Veterans Health Care: VA's Medical Support Role in Emergency	 
Preparedness (23-MAR-05, GAO-05-387R).				 
                                                                 
Since the terrorist attacks on September 11, 2001, the Department
of Veterans Affairs (VA) has increased its efforts to plan for	 
and respond to national emergencies, including acts of terrorism 
and natural disasters. Additionally, in August 2004, the Federal 
Bureau of Investigation and the Department of Homeland Security  
announced that military and VA medical facilities were potential 
terrorist targets. In light of military casualties from conflicts
in Afghanistan and Iraq and continued threats of terrorist	 
incidents, Congress asked us to review VA's medical support role 
in emergency preparedness. Specifically, we agreed to provide	 
information on the following questions: (1) What is VA's role in 
providing medical support within the U.S. to military personnel  
in wartime and during national emergencies? (2) What actions has 
VA taken to improve its internal emergency preparedness to ensure
that it is ready to maintain continuity of operations and	 
provision of medical services to veterans? (3) What is VA's role 
in participating in emergency medical response measures with	 
other federal, state, and local agencies?			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-05-387R					        
    ACCNO:   A19978						        
  TITLE:     Veterans Health Care: VA's Medical Support Role in       
Emergency Preparedness						 
     DATE:   03/23/2005 
  SUBJECT:   Emergency medical services 			 
	     Emergency preparedness				 
	     Employee training					 
	     Facility security					 
	     Health care personnel				 
	     Health care services				 
	     Health centers					 
	     Intergovernmental relations			 
	     Internal controls					 
	     Military personnel 				 
	     National preparedness				 
	     Veterans hospitals 				 
	     National Response Plan				 

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GAO-05-387R

United States Government Accountability Office Washington, DC 20548

March 23, 2005

The Honorable Steve Buyer
Chairman
The Honorable Lane Evans
Ranking Democratic Member
Committee on Veterans' Affairs
House of Representatives

The Honorable Christopher H. Smith
House of Representatives

Subject: 	Veterans Health Care: VA's Medical Support Role in Emergency
Preparedness

Since the terrorist attacks on September 11, 2001, the Department of
Veterans Affairs (VA) has increased its efforts to plan for and respond to
national emergencies, including acts of terrorism and natural disasters.
Additionally, in August 2004, the Federal Bureau of Investigation and the
Department of Homeland Security announced that military and VA medical
facilities were potential terrorist targets. In light of military
casualties from conflicts in Afghanistan and Iraq and continued threats of
terrorist incidents, you asked us to review VA's medical support role in
emergency preparedness.

Specifically, we agreed to provide information on the following questions:
(1) What is VA's role in providing medical support within the U.S. to
military personnel in wartime and during national emergencies? (2) What
actions has VA taken to improve its internal emergency preparedness to
ensure that it is ready to maintain continuity of operations and provision
of medical services to veterans? (3) What is VA's role in participating in
emergency medical response measures with other federal, state, and local
agencies?

To answer these questions, we reviewed the laws that establish VA's
emergency preparedness responsibilities, VA policies and procedures
relating to emergency preparedness, and our past reports on VA's medical
support role in emergency preparedness. In addition, we observed a VA
crisis response team meeting and a continuity of operations exercise. We
also interviewed officials responsible for VA's emergency preparedness
programs. Our work was performed from September 2004 through February 2005
in accordance with generally accepted government auditing standards.

In summary, Public Law 97-174 authorizes VA to provide inpatient medical
care to active duty members of the armed services during or immediately
following their involvement in armed conflicts during wartime and national
emergencies. According to VA, while the Department of Defense (DOD) has
never requested priority care from VA based on this law; VA has routinely
reported to the Congress and DOD the number of inpatient beds available
for military personnel. We also found that VA has taken numerous actions
to improve emergency preparedness, such as developing educational and
training materials for its staff, training staff at 134 VA medical
centers, and increasing security at its facilities by requiring a minimum
of two patrolling VA police officers on duty at all times. Other
activities, such as developing a systemwide strategy for protecting its
facilities and acquiring decontamination equipment, are still in progress.
Finally, VA participates in emergency medical response measures with other
federal, state, and local agencies by providing assistance in seven
support functions outlined in the Department of Homeland Security's
National Response Plan. For example, if requested, the types of support VA
would provide include public health and medical services, emergency
management, and public safety and security. Enclosure I contains briefing
slides on our findings.

We provided a draft of this report to VA for comment. In its written
comments, VA concurred with the report's findings. VA also provided
technical comments, which we incorporated were appropriate. (See encl. II
for a copy of VA's comments.)

The information contained in this report was provided to your staff on
December 2,
2004. As discussed with your staff during that briefing, we agreed to
issue a report to
you containing the information we provided. We also are sending copies of
this
report to the Chairman and Ranking Minority Member, Senate Committee on
Veterans' Affairs, the Secretary of Veterans Affairs, and other interested
parties. We
will also make copies available upon request. In addition, the report will
be available
at no charge on GAO's Web site at http://www.gao.gov.

If you or your staffs have any questions about this report, please contact
me at (202)
512-7101 or Michael T. Blair, Jr., Assistant Director, at (404) 679-1944.
Cherie' Starck,
Cynthia Forbes, and Julianna Williams made key contributions to this
report.

Cynthia A. Bascetta
Director, Health Care-Veterans'

Health and Benefit Issues

Enclosures - 2

                      The Department of Veterans Affairs'
                       Medical Support Role in Emergency
                                  Preparedness

                        Briefing Slides for the Staff of
                           The Honorable Steve Buyer
                                    Chairman
                                      and
                            The Honorable Lane Evans
                           Ranking Democratic Member
                     House Committee on Veterans' Affairs,
                                      and
                       The Honorable Christopher H. Smith
                            House of Representatives

The Department of Veterans Affairs' Medical Support Role in Emergency
Preparedness

o  Introduction

o  Key Questions

o  Background

o  Scope and Methodology

o  Results in Brief

o  Answers to Key Questions

                                  Introduction

During national emergencies, the Department of Veterans Affairs' (VA)
primary responsibilities are to ensure that eligible veterans have
continuing access to health care and to safeguard VA employees, patients,
and visitors within its medical centers and properties. VA also has a role
in supporting the military medical system within the U.S. and in
participating in emergency medical response measures with other federal
agencies and with state and local governments.

                                 Key Questions

1.	What is VA's role in providing medical support within the U.S. to
military personnel in wartime and during national emergencies?

2.	What actions has VA taken to improve its internal emergency
preparedness to ensure that it is ready to maintain continuity of
operations and provision of medical services to veterans?

3.	What is VA's role in participating in emergency medical response
measures with other federal, state, and local agencies?

                                   Background

VA's expenditures for its medical emergency preparedness activities for
fiscal year 2003 were about $37 million. Estimated total amounts for
fiscal years 2004 and 2005 are approximately $44 million and $50 million,
respectively. These expenditures would be less than 1/10 of 1 percent of
VA's annual budget.

                                   Background

Two main entities within VA are responsible for emergency preparedness.

o 	The Office of Operations and Readiness, under VA's Office for Policy,
Planning, and Preparedness, is responsible for emergency preparedness
activities VA-wide and serves as VA's primary liaison with the Department
of Homeland Security and other federal agencies.

o 	The Emergency Management Strategic Health Care Group (EMSHG), under
VA's Veterans Health Administration (VHA),1 is responsible for providing
guidance and support to VA medical facilities for emergency preparedness
activities including coordination and planning with state and local
entities. EMSHG staff are located in VA headquarters and medical centers
throughout the country.

1VHA's primary responsibility is the delivery of health care to veterans.
VHA operates 157 VA medical centers and more than 800 outpatient clinics.
In fiscal year 2004, VHA provided care to over 4.7 million veterans.

Background

On January 6, 2005, the Department of Homeland Security issued its
National Response Plan.2 The purpose of this plan is to provide a
consistent nationwide framework to standardize management practices and
procedures to ensure that federal, state, and local governments can work
together effectively and efficiently to prepare for, respond to, and
recover from domestic incidents, including acts of terrorism, major
natural disasters, or man-made emergencies.

2Prior to the National Response Plan, the federal government had a Federal
Response Plan that outlined the roles of federal agencies in a national
emergency. Unlike the National Response Plan, this plan did not
incorporate the roles of state and local governments.

                                   Background

o 	One component of the National Response Plan is the NationalDisaster
Medical System (NDMS), which is a joint effort of thefederal and private
sectors to provide backup to state and local health care resources in the
event of disasters producing masscasualties.

o 	As part of the National Response Plan, the nation alsomaintains
strategically placed stockpiles of drugs and medical supplies (pharmacy
caches) to be used in emergencies. VA procures and maintains some of these
caches for the Department of Homeland Security and the Department of
Health and Human Services' Centers for Disease Control and Prevention.

o 	VA also maintains pharmacy caches for the internal use of its medical
centers.

                             Scope and Methodology

To do our work, we interviewed VA staff from offices with responsibility
for emergency preparedness, including the

o  Office of Operations and Readiness,

o  Office of Security and Law Enforcement,

o  Office of Public Health and Environmental Hazards,

o  Emergency Management Strategic Health Care Group, and

o  Office of Facilities Management.

                             Scope and Methodology

We also

o 	reviewed laws that establish VA's emergency preparedness
responsibilities, including Public Law 97-174 (VA and Department of
Defense (DOD) Health Resources Sharing and Emergency Operations Act),
Public Law 93-288, as amended (Robert T. Stafford Disaster Relief and
Emergency Assistance Act), and Public Law 107-188 (Public Health Security
and Bioterrorism Preparedness and ResponseAct of 2002);

o 	reviewed VA directives, guidebook, handbooks, and a manual relating to
emergency preparedness activities;

o 	observed a crisis response team meeting and a continuity of operations
exercise; and

o 	reviewed the standard operating procedures for maintaining aVA pharmacy
cache.

                             Scope and Methodology

Our review was conducted from September 2004 through February 2005 in
accordance with generally accepted government auditing standards.

                                Results in Brief

o 	VA's primary role to support the military medical system during wartime
and national emergencies is to provide inpatient medical care in the U.S.
for military personnel. VA routinely reports to DOD the number of VA beds
available for active duty casualties. VA's role is outlined in a
memorandum of understanding (MOU) between the two departments.

                                Results in Brief

o 	VA has taken numerous actions to improve emergency preparedness for its
medical facilities. Actions include the development of an Emergency
Management Program Guidebook, educational and training materials, and a
Continuityof Operations Plan (COOP). VA has also established internal
pharmacy caches, developed medical center decontamination programs,
trained staff from 134 VA medical centers on decontamination procedures,
and increased security at its facilities by requiring a minimum of two
patrolling VA police officers on duty at all times. Other activities, such
as developing a systemwide strategy for protecting its facilities and
acquiringdecontamination equipment, are still in progress.

                                Results in Brief

o 	VA participates in emergency medical response measures with other
federal, state, and local agencies by providing the support for seven
functions outlined in the National Response Plan. For example, if
requested and resources are available, the types of support VA could
provide include public health and medical services, emergency management,
and public safety and security.

Question 1: VA's Role in Providing Medical Support within the U.S. to
Military Personnel

Public Law 97-174 authorizes VA to provide medical services to members of
the armed forces during wartime or national emergencies. This law, enacted
in May 1982, was intended for use in the event DOD has insufficient
resources to take care of military casualties. Under the law, the
Secretary of VA is authorized to give active duty personnel responding to
or involved in a war or national emergency a higher priority for medical
services than all veterans, except those with a service-connected
disability. According to VA officials, DOD has never requested priority
care from VA based on this law.

Question 1: VA's Role in Providing Medical Support within the U.S. to
Military Personnel (continued)

o 	In December 1982, VA and DOD signed an MOU outlining each agency's
responsibilities pertaining to wartime or national emergencies under the
law. On the basis of the MOU, VA projects the number and types of beds
available for active duty personnel. In accordance with the MOU, the types
of beds reported include critical care, medical/surgical, and psychiatric.

o 	Every other month, and upon request, VA reports to DOD the number of
beds that could immediately be made available for active duty casualties
within 24 hours. Annually, VA also reports to the Congress and DOD the
number of beds likely to be available in 24 hours, 72 hours, and in 30
days. In developing estimates, VA takes into account the number of
veterans that could be discharged or transferred to other VA medical
centers.

Question 1: VA's Role in Providing Medical Support within the U.S. to
Military Personnel (continued)

In August 2004, VA reported that, as of January 1, 2004, the following
numbers of beds were available for military personnel3

o  2,945 in 24 hours,

o  4,618 in 72 hours, and

o  6,035 in 30 days.

3VA's National Bed Control System reports that a total of about 18,500
hospital beds were available in the VA health care system on September 30,
2004.

Question 2: VA's Actions to Improve Its Internal Emergency Preparedness

VA has taken numerous actions to improve its internal emergency
preparedness, including

o  developing an Emergency Management Program Guidebook,

o 	developing educational and training materials for health care
providers,

o  developing a COOP,

o  establishing pharmacy caches at 143 VA medical centers,

o  developing a VA medical center decontamination program, and

o  improving physical security at VA facilities.

Question 2: VA's Actions to Improve Its Internal Emergency Preparedness
(continued)

VHA has issued an Emergency Management Program Guidebook for developing an
emergency preparedness program. The guidebook is intended to

o 	provide VA medical centers with a uniform approach to develop,
implement, and evaluate an emergency preparedness program;

o 	provide VA medical centers with "best practice" templates that can be
modified to meet local needs; and

o 	help ensure compliance with the Joint Commission on Accreditation of
Healthcare Organizations' (JCAHO)4 emergency management standards.

4JCAHO is an independent not-for-profit organization and the nation's
predominant standards-setting and accrediting body in health care. Its
standards set performance expectations for activities that affect the
safety and quality of patient care.

Question 2: VA's Actions to Improve Its Internal Emergency Preparedness
(continued)

VA developed a series of educational and training modules for health care
professionals on the medical response to a potential attack with weapons
of mass destruction. The training materials include information on

o  the role of clinical leadership at a local VA facility,

o  chemical warfare agents,

o  biological warfare agents,

o  radiological warfare agents,

o  blast and explosive weapons, and

o  potential effects of weapons of mass destruction on mental health.

Question 2: VA's Actions to Improve Its Internal Emergency Preparedness
(continued)

VA developed an agencywide COOP so that it can maintain essential services
to veterans during emergencies. The COOP includes

o 	a Readiness Operations Center that operates 24 hours a day, 7 days a
week to monitor and respond to emergencies;

o 	a succession plan that identifies personnel that can replace key VA
management if they are unavailable in an emergency; and

o 	two alternate command locations that can be used to house and support
key VA management in the event VA operations cannot be managed from
headquarters in Washington, D.C.

In addition, each VA medical center developed a site-specific COOP.

Question 2: VA's Actions to Improve Its Internal Emergency Preparedness
(continued)

VA established pharmacy caches at 143 VA medical centers.

o 	In an emergency, these caches would be used for short-term treatment of
veterans, VA staff, and visitors at the VA facility.

o 	Caches come in two sizes, which provide drugs and supplies to treat
either 1,000 or 2,000 patients for 48 hours.

o 	The contents of all caches are managed centrally through adatabase in
Hines, Illinois. However, each VA medical center must follow standard
operating procedures for cache management. For example, VA medical centers
must regularlyverify that the cache is stored and secured in a manner
consistent with VA policy and that its contents are accounted for,
current, and available for use. EMSHG staff are also required toinspect
the caches annually.

Question 2: VA's Actions to Improve Its Internal Emergency Preparedness
(continued)

VA developed and funded a decontamination program that includes training
staff, purchasing equipment, and conducting drills at 134 VA medical
centers.5 VA has recently hired a program manager to provide oversight of
the decontamination program across its medical centers.

o 	As of September 2004, staff from all 134 VA medical centers had
completed decontamination training at either North Little Rock, Arkansas,
or Bay Pines, Florida. Each VA medical center usually sent four staff to
the training.

o 	VA Medical centers that have received their equipment are required to
conduct two decontamination drills per year.

5Not all VA medical centers require their own decontamination program. For
example, some medical centers may receive decontamination services from
DOD or nearby affiliated hospitals.

Question 2: VA's Actions to Improve Its Internal Emergency Preparedness
(continued)

As of January 2005,

o 	57 VA medical centers had ordered and received decontamination
equipment,

o 	48 VA medical centers had ordered and were waiting for decontamination
equipment, and

o 	29 VA medical centers were in the process of submitting an order for
decontamination equipment.

Question 2: VA's Actions to Improve Its Internal Emergency Preparedness
(continued)

VA created a physical security assessment methodology and between July2003
and July 2004 assessed physical security vulnerability at 118 sites that
VA has determined to be most critical to its missions.

o 	Facilities critical to VA's missions were identified and ranked based
on criteria such as location and importance to VA's operations.

o 	Almost all of the sites were VA medical centers; others included VA
regional offices, data centers, and a cemetery.

o 	VA systemwide strategies for protecting its facilities are currently
beingdeveloped in response to the findings from these initial assessments.

o  Further assessments are planned for additional sites and new
facilities.

Question 2: VA's Actions to Improve Its Internal Emergency Preparedness
(continued)

VA has also increased security at VA medical centers by requiring a
minimum of two patrolling VA police officers on duty at all times.

Question 3: VA's Role in Participating in Emergency Response Measures with
other Federal, State, and Local Agencies

o 	43 VA medical centers are designated as NDMS federal coordinating
centers. EMSHG staff at these centers are responsible for coordinating and
reporting on resources available for NDMS efforts, such as patient
reception, transportation, and communication plans.

o 	VA is participating in emergency medical response measures with other
federal, state, and local agencies as outlined in the National Response
Plan.

o 	Under the plan, VA has a support role in seven emergency support
functions.

Question 3: VA's Role in Participating in Emergency Response Measures with
other Federal, State, and Local Agencies (continued)

Emergency support functions that VA would provide if requested include

o 	Public Works and Engineering-provide engineering personnel and support
for repair, construction, and restoration of facilities;

o 	Emergency Management-provide coordination of management efforts,
including financial and human capital resources;

o 	Mass Care, Housing, and Human Services-provide food preparation,
medical supplies and personnel, and facilities suitable for mass shelter;

Question 3: VA's Role in Participating in Emergency Response Measures with
other Federal, State, and Local Agencies (continued)

o 	Resource Support-provide technical assistance in identifying and
procuring medical supplies and other medical services;

o 	Public Health and Medical Services-provide medical support to state and
local governments and assistance in managing human remains;

o 	Public Safety and Security-provide security planning and traffic and
crowd control; and

o 	External Affairs-provide emergency public information, as well as media
and community relations.

                                    (290408)

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