Disabled Veterans' Care: Better Data and More Accountability Needed to
Adequately Assess Care (Letter Report, 04/21/2000, GAO/HEHS-00-57).
Pursuant to a congressional request, GAO reviewed the Department of
Veterans Affairs' (VA) compliance with the requirements to maintain
capacity and access for veterans with special disabilities, focusing on:
(1) the accuracy of the conclusions in VA's fiscal year (FY) 1998 annual
capacity report; and (2) challenges facing VA in managing its special
disability programs.
GAO noted that: (1) VA concluded in its annual report for FY 1998 that
it had maintained its capacity to treat veterans with special
disabilities; (2) however, VA's data are not sufficient to support that
conclusion because of extensive data problems, such as the use of
unreliable proxy measures to identify veterans with special
disabilities; (3) moreover, VA based its conclusion on national
statistics that indicated more special disability veterans were served
with fewer resources expended in 1998 than in 1996; (4) however, there
is considerable variability among the Veterans Integrated Service
Networks (VISN), and, in fact, some VISNs reported serving fewer
veterans; (5) in addition, VA attributes reduced expenditures and the
use of fewer resources to efficiency gains--however, because it lacks
outcome measures, VA cannot tell whether it has maintained, enhanced, or
diminished quality of care; (6) VA faces challenges in maintaining its
capacity to serve special disability populations; and (7) in particular,
the lack of a single VA headquarters unit accountable for ensuring
compliance with the capacity legislation may have caused delays in: (a)
monitoring and investigating locations where capacity appears to have
declined; and (b) fully implementing congressionally mandated
performance standards for VA employees responsible for allocating and
managing special disability program resources.
--------------------------- Indexing Terms -----------------------------
REPORTNUM: HEHS-00-57
TITLE: Disabled Veterans' Care: Better Data and More
Accountability Needed to Adequately Assess Care
DATE: 04/21/2000
SUBJECT: Veterans
Data integrity
Health care services
Persons with disabilities
Accountability
Health care cost control
Rehabilitation programs
Veterans benefits
Performance measures
IDENTIFIER: VA Veterans Integrated Service Network
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GAO/HEHS-00-57
Appendix I: VA Definitions of Six Special Disabilities
22
Appendix II: Performance and Access Monitors
23
Appendix III: Comments From the Department of Veterans Affairs
34
Table 1: Change in Number of Special Disability Veterans Served and Dollars
Spent Between Fiscal Years 1996 and 1998 8
Table 2: Change in Number of Special Disability Veterans Served in Inpatient
and Outpatient Settings Between Fiscal Years 1996
and 1998 9
Table 3: Change in FTE Employees and Beds for Spinal Cord
Dysfunction and Blind Rehabilitation Between Fiscal Years
1996 and 1998 10
BROS blind rehabilitation outpatient specialist
CDR cost distribution report
DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
FTE full-time-equivalent
PTSD post-traumatic stress disorder
SCI spinal cord injury
SCI&D spinal cord injury and disorder
SMI serious mental illness
TBI traumatic brain injury
VA Department of Veterans Affairs
VHA Veterans Health Administration
VISN Veterans Integrated Service Network
Health, Education, and
Human Services Division
B-283462
April 21, 2000
The Honorable Lane Evans
Ranking Democratic Member
Committee on Veterans' Affairs
House of Representatives
Dear Mr. Evans:
In 1996, the Congress expressed concern that budgetary pressures and ongoing
reorganization within the Department of Veterans Affairs (VA) health care
system could make VA's specialized programs for disabled veterans vulnerable
to inappropriate cost cutting. Section 104 of the Veterans Health Care
Eligibility Reform Act of 1996 (P.L. 104-262) requires the Secretary of VA
to (1) ensure that VA's systemwide capacity to provide specialized treatment
and rehabilitative services to veterans with spinal cord dysfunction,
blindness, amputations, or mental illness is not reduced below October 1996
levels and (2) provide veterans with reasonable access to needed specialized
care and services. VA is required to report to the House and Senate
Committees on Veterans' Affairs annually from 1997 through 2001 about its
systemwide capacity to provide this specialized care.
Although the legislation directed VA to preserve capacity and to ensure
reasonable access for veterans with special disabilities, it did not define
capacity or access or specify how each was to be measured. After
consultation with stakeholders,1 VA defined capacity as the number of
individual veterans treated within specialized inpatient units and clinics
and the dollars expended for their care. VA included number of beds and
staffing levels as additional measures of capacity for spinal cord
dysfunction and blind rehabilitation. Access was defined as timeliness in
providing services to veterans for their specialized needs. In addition, VA
planned to implement outcome measures within 2 to 3 years to evaluate
program effectiveness, regardless of resources expended, by measuring
treatment results.
This report responds to your request that we review VA's compliance with the
requirements to maintain capacity and access for veterans with special
disabilities.2 Specifically, we provide the results of our review of (1) the
accuracy of the conclusions in VA's fiscal year 1998 annual capacity report
and (2) challenges facing VA in managing its special disability programs. In
addition, we assessed whether VA has complied with section 903 of the
Veterans Programs Enhancement Act of 1998 (P.L. 105-368), which directed the
Under Secretary for Health to prescribe, by January 1, 1999, job performance
standards for employees responsible for allocating and managing special
disability program resources.
To develop this information, we met with VA officials responsible for
developing and analyzing information on the disability programs; VA
officials responsible for managing the special disability programs at the
national level; officials at Veterans Integrated Service Networks (VISN) in
Durham, N.C., Atlanta, Ga., and San Francisco, Calif.; officials at
facilities in Durham, N.C., Richmond, Va., Decatur and Augusta, Ga., and
Palo Alto and San Francisco, Calif.; and representatives from veterans'
service organizations and advisory committees with which VA is required to
consult in responding to the 1996 legislation. We also reviewed relevant VA
and advisory committee reports, policies, manuals, and publications. We
performed our work between October 1998 and January 2000 in accordance with
generally accepted government auditing standards.
VA concluded in its annual report for fiscal year 1998 that it had
maintained its capacity to treat veterans with special disabilities.
However, VA's data are not sufficient to support that conclusion because of
extensive data problems, such as the use of unreliable proxy measures to
identify veterans with special disabilities. Moreover, VA based its
conclusion on national statistics that indicated more special disability
veterans were served with fewer resources expended in 1998 than in 1996.
However, there is considerable variability among the VISNs, and, in fact,
some VISNs reported serving fewer veterans. In addition, VA attributes
reduced expenditures and the use of fewer resources to efficiency gains;
however, because it lacks outcome measures, VA cannot tell whether it has
maintained, enhanced, or diminished quality of care.
VA faces challenges in maintaining its capacity to serve special disability
populations. In particular, the lack of a single VA headquarters unit
accountable for ensuring compliance with the capacity legislation may have
caused delays in (1) monitoring and investigating locations where capacity
appears to have declined and (2) fully implementing congressionally mandated
performance standards for VA employees responsible for allocating and
managing special disability program resources. In order to ensure compliance
with the capacity legislation, we are recommending that VA designate a
single office to be accountable for fully implementing the mandate to
maintain capacity in special disability programs.
Since 1995, VA has taken significant steps to transform its health care
system from a hospital- and specialist-based system to a
prevention-oriented, community-based system with primary care as its
foundation. To accomplish this transition, VA moved from a management
structure based on 172 hospitals to one based on VISNs in 22 separate
geographic areas. These VISNs have substantial operational autonomy and are
responsible for making basic budgetary, planning, and operational decisions
to meet the health care needs of veterans living within the 22 geographic
areas. Each VISN oversees between 5 and 11 large hospital facilities, as
well as clinics and other delivery locations.
The Veterans Health Care Eligibility Reform Act of 1996 authorized new
eligibility rules for outpatient treatment that permit VA to provide medical
care in the most appropriate settings. Eligibility reform was intended to
reduce inappropriate admissions and denial of care to many veterans who were
ineligible under the old rules for outpatient treatment. In addition, VA
proposed a plan to operate within the same annual appropriation for VA
health care through 2002.3 As a result, VISN and facility managers had
strong incentives to reengineer delivery systems to offset rising health
care costs.
In this environment of shifting service delivery from inpatient to
outpatient settings, system reorganization, and no-growth budgets, section
104 of the Veterans Health Care Eligibility Reform Act directed VA to
protect services and resources committed to veterans with spinal cord
dysfunction, blindness, amputations, or mental illness. After discussions
with stakeholders, as required by the act, VA added two more special
disabilities--traumatic brain injury and post-traumatic stress disorder
(PTSD)--to this list. For the purpose of the capacity requirement, VA
limited the definition of mental illness to refer to only those veterans
with serious mental illness and created two subcategories: veterans disabled
as a result of a disorder related to substance abuse and homeless veterans
disabled as a result of serious mental illness.
House Report 104-690, which accompanied the 1996 legislation, noted that the
special disability programs constitute a vital core of VA's mission, tend to
be high-cost efforts, and are unmatched in scope and quality in the private
sector. The six special disabilities were targeted because of their close
association with service-related illnesses and the likelihood of
progressively worsening disability in the absence of specialized treatment
or rehabilitation. VA must carry out the requirements of the legislation in
consultation with the Advisory Committee on Prosthetics and Special
Disabilities Programs and the Committee on the Care of Severely Chronically
Mentally Ill Veterans,4 and VA has done so.
Although the legislation directed VA to preserve capacity and to ensure
reasonable access for veterans with special disabilities, it did not specify
how capacity and access were to be defined or measured. VA defined capacity
as the number of individual veterans treated within specialized inpatient
units and clinics and the dollars expended for the care of these veterans.
VA intends to use outcome measures, when they become available, to measure
the effectiveness of its specialized programs. At the insistence of
veterans' service organizations, number of beds and staffing levels were
included as additional measures of capacity for spinal cord dysfunction and
blind rehabilitation. VA defined access as timeliness in providing services
to veterans for their specialized needs. Although VA considered other
measures of access, the data necessary to develop these measures, primarily
the number and location of the universe of veterans with each disability,
are not generally available.
Has Been Maintained
VA's fiscal year 1998 annual capacity report concluded that VA's capacity to
treat special disability groups nationwide had been generally maintained.
This conclusion was based on national statistics that indicated that more
special disability veterans were served in 1998 than in 1996. However,
measurement results varied among VISNs, with some showing a decrease in
veterans served. In our view, the available data are insufficient to support
any conclusions because VA's workload and resource data are inaccurate. In
addition, reliable outcome measures are not available to assess whether the
quality of care provided to special disability populations has changed or is
satisfactory.
VA has asserted that capacity to treat veterans with special disabilities
has been maintained because the number of veterans treated in special
disability programs increased from fiscal year 1996 to fiscal year 1998 by 8
percent, or 28,141 individuals. However, during that same period, spending
for these programs decreased by 8 percent, or approximately $184 million.
Veterans with a serious mental illness accounted for 81 percent of the
special disability veterans served and 84 percent of the dollars spent in
the special disability categories. The number of veterans with special
disabilities served during the period increased or remained relatively
constant for all conditions except amputations. VA reported the decline in
the number of veterans with amputations as a favorable outcome of successful
efforts to prevent amputations in diabetic patients. VA expenditures
decreased for amputations, serious mental illness, and PTSD. Analysis of
expenditures for two subcategories of serious mental illness shows a
decrease of 29 percent for veterans with a disorder related to substance
abuse and an increase of 23 percent for veterans who were homeless.
Expenditures also increased for spinal cord dysfunction, traumatic brain
injury, and blind rehabilitation. (See table 1.)
Table 1: Change in Number of Special Disability Veterans Served and Dollars
Spent Between Fiscal Years 1996 and 1998
Veterans served Dollars spent (in thousands)
Disability Change Change
FY 1996 FY 1998 FY 1996 FY 1998
(percentage) (percentage)
Spinal cord
dysfunction 8,598 9,252 +654 (+8) $199,848 $202,878 +$3,030 (+2)
Blindness 9,726 11,930 +2,204 (+23) 43,855 53,935 +10,080
(+23)
Traumatic
brain injury176 189 +13 (+7) 4,439 4,906 +467 (+11)
Amputations 4,765 4,549 -216 (-5) 5,953 5,286 -667 (-11)
Serious
mental 269,009 290,961 +21,952 (+8) 2,080,240 1,900,938 -179,302
illnessa (-9)
Substance -168,568
abuse 107,074 106,599 -475 (-0.4) 575,902 407,334 (-29)
Homeless 24,539 27,201 +2,662 (+11) 75,071 92,614 +17,543
(+23)
PTSD 39,653 43,187 +3,534 (+9) 101,882 84,112 -17,770
(-17)
Total 331,927 360,068 +28,141(+8) $2,436,217 $2,252,055 -$184,162
(-8)
aThe total for serious mental illness is more than the sum of the
subcategories listed under it because the category includes, but is not
limited to, veterans who are substance-abusing or homeless.
Source: VA's 1998 capacity report to the Congress: Maintaining Capacity to
Provide for the Specialized Treatment and Rehabilitative Needs of Disabled
Veterans (VA, June 1999).
VA's fiscal year 1998 capacity report was an improvement over its previous
reports because it included for the first time a breakout of veterans served
in both inpatient and outpatient settings. Between 1996 and 1998, the number
of veterans served in inpatient settings increased for blindness, traumatic
brain injury, the homeless subcategory of serious mental illness, and PTSD.
The shift from inpatient to outpatient care was most evident in the broad
category of serious mental illness and its subcategory of substance abuse.
The number of seriously mentally ill veterans treated in an inpatient
setting declined by approximately 19 percent, while the number of seriously
mentally ill veterans with substance abuse disorders who received inpatient
care declined by approximately 41 percent. The number of special disability
veterans treated in outpatient settings increased for all conditions with
the exception of amputations. (See table 2.)
Table 2: Change in Number of Special Disability Veterans Served in Inpatient
and Outpatient Settings Between Fiscal Years 1996 and 1998
Veterans served
Disability/Setting Percentage change
FY 1996 FY 1998
Spinal cord dysfunction
Inpatient 5,185 5,117 -1
Outpatient 6,599 7,576 +15
Blindness
Inpatient 1,607 1,976 +23
Outpatient 9,345 11,560 +24
Traumatic brain injurya
Inpatient 176 189 +7
Amputationsa
Outpatient 4,765 4,549 -5
Serious mental illness
Inpatient 117,088 95,068 -19
Outpatient 251,216 278,674 +11
Substance abuse
Inpatient 50,628 30,021 -41
Outpatient 90,916 99,337 +9
Homeless
Inpatient 5,273 7,072 +34
Outpatient 21,913 23,763 +8
PTSD
Inpatient 4,312 4,694 +9
Outpatient 37,768 41,224 +9
aData were not reported for both inpatient and outpatient settings.
Source: VA 1998 capacity report (VA, June 1999).
For veterans disabled by spinal cord dysfunction or blindness, capacity was
also measured by staff resources--full-time-equivalent (FTE) employees--and
the number of specialized beds dedicated to veterans with these
disabilities. From 1996 to 1998, VA reported that staffing levels dropped by
12 percent (267 FTE employees) for spinal cord dysfunction and increased by
1 percent (3 FTE employees) for blind rehabilitation. Numbers of beds
declined in both areas: 15 percent (180 beds) for spinal cord dysfunction
and 7 percent (15 beds) for blind rehabilitation. (See table 3.) Veterans'
service organizations have questioned the accuracy of these numbers on the
basis of surveys they have conducted at VA facilities and have concluded
that capacity reductions have been even greater: 18 percent fewer spinal
cord care beds and 32 percent fewer spinal cord care staff resources. In
addition, the Advisory Committee on Prosthetics and Special Disabilities
Programs has questioned whether VA inappropriately included unstaffed spinal
cord and blind rehabilitation beds in the capacity report. Two of the
facilities we visited reported delays in transferring veterans with acute
care needs to a specialized spinal cord injury unit. In addition, the
national average waiting time for admission to an inpatient blind
rehabilitation program increased slightly, from 31.8 weeks in fiscal year
1996 to 33.4 weeks in fiscal year 1998. Moreover, outreach efforts by the
facility-based Visual Impairment Services Team, which provides coordinated
services to legally blind veterans, continued to increase the already
lengthy waiting lists for blind rehabilitation programs. The delays in
admission to spinal cord care beds in some areas and the lengthy waiting
times for blind rehabilitation indicate that the reduction in bed levels may
be affecting access to these services.
Table 3: Change in FTE Employees and Beds for Spinal Cord Dysfunction and
Blind Rehabilitation Between Fiscal Years 1996 and 1998
Disability/Measure FY 1996 FY 1998 Percentage change
Spinal cord dysfunction
FTE employees 2,175.8 1,909.3 -12
Beds 1,209 1,029 -15
Blindness
FTE employees 414.5 417.3 +1
Beds 228 213 -7
Source: VA 1998 capacity report (VA, June 1999).
While VA stated that it had maintained capacity nationally, some VISNs
appeared to be maintaining workloads and expenditures for special disability
populations, while others showed declines in veterans served and
expenditures. For example, only two VISNs maintained or increased their
workloads for all six disabilities. Another two VISNs served fewer veterans
in at least four of the six special disability groups. VA's Committee on the
Care of Severely Chronically Mentally Ill Veterans stated in its response to
the capacity report that because the measure of maintenance of clinical
effort (dollars expended) had actually decreased, VA should scrutinize those
VISNs with the largest reductions in capacity. The committee further stated
that many VISNs showed substantial increases in the numbers of veterans
treated (up to 17 percent) with relatively constant expenditures, while
other networks showed decreases in veterans treated and decreases in funds
expended. VA provided no data to show that decreased demand for services
accounted for the decrease in veterans treated.
The information management systems currently used by VA are not precise
enough to capture the information necessary to accurately calculate workload
and expenditure statistics for the special disability populations. As a
result, VA developed a complex process using eight different databases to
compile VISN and national workload and resource data for the six disabling
conditions. This process used inpatient diagnostic information, when
available, and a set of proxy measures to infer a likely condition when
diagnostic information was not available. For example, because VA's
outpatient care database does not currently include diagnostic information,5
VA identified additional patients as belonging to a special disability group
on the basis of information regarding the number of visits to specific
clinics. Thus, veterans who visited certain psychiatric/mental health
clinics at least six times were counted as disabled by serious mental
illness. Because of the lack of diagnostic information and the sometimes
inappropriate proxies used, we are not confident that the workload figures
and subsequent expenditure amounts are accurate. Stakeholders have voiced
similar concerns. For example, the cochair of the Committee on the Care of
Severely Chronically Mentally Ill Veterans stated during testimony in 1998
that "the currently available data is inadequate to comprehensively and
reliably monitor the Veterans Health Administration's efforts to maintain
capacity for these disabling conditions."
Our visits to selected field locations helped confirm the validity of our
concerns about the accuracy of VA's workload and resource data. We were
unable to validate workload and resource data contained in the capacity
report using information maintained at VA facilities because data were not
routinely available under the definitions developed for the disabling
conditions (see app. I).6 Several clinicians told us that the definitions
used in the capacity report had no clinical basis when it came to treating
patients. For example, as defined by VA's capacity report, seriously
mentally ill veterans represented about 81 percent of the universe of
veterans with special disabilities in fiscal year 1998. Yet the seriously
mentally ill category would not be tracked at the facility level because it
does not represent a meaningful grouping of patients who would receive
similar medical care.
Our site visits also found that despite 3 years of requirements to report on
capacity, management staff at VA facilities generally did not know the
definitions used by VA headquarters to identify veterans with special
disabilities or the methodology used to develop workload data for their
facilities. For example, one facility offered substance abuse treatment in a
day treatment program instead of a traditional substance abuse clinic. The
capacity report indicated that this facility experienced a 17-percent
decline in the treatment of seriously mentally ill patients with substance
abuse disorders and a 9-percent decline in expenditures for this population.
Facility officials believed that the capacity report understated workload
for seriously mentally ill patients with substance-related disorders because
VA's methodology did not include the day treatment clinic as a program
serving this special disability population.
We also identified deficiencies in the accuracy of VA's resource measures
(that is, expenditures for all programs and staffing levels and beds for
spinal cord care and blind rehabilitation). Moreover, veterans' service
organizations have reported discrepancies between the cost distribution
report (CDR), which is the data system used by VA to allocate costs, and
information reported by special disability program officials. The
information in the CDR is suspect because it relies on subjective judgments
to allocate the distribution of staff time and dollars spent in each
inpatient unit and outpatient care area. VA's Inspector General found that
service-level managers have broad discretion in selecting and applying cost
allocation techniques, leading to inconsistency, infrequent updates, and
disparate treatment of similar cost accounting issues.7 Clinical staff told
us that vacancies were at times deliberately hidden through the reallocation
of staff to special disability programs in the CDR or filled with
individuals possessing less skill and ability. Thus, these staff believe
that the CDR can be easily manipulated to create the appearance that
staffing and expenditure levels in the special disability program have been
maintained.
VA acknowledged that its data systems need improvement, and in December 1998
the Veterans Health Administration (VHA) held a Data Quality Summit to
identify issues related to the collection and use of data in VHA. Multiple
data quality issues were identified, including the completeness,
reliability, validity, and timeliness of ambulatory care data. Recognizing
problems with the data used to prepare the annual capacity report, VA used a
verification and data correction process to improve the accuracy and
reliability of data for the fiscal year 1998 report to the Congress. VA
headquarters shared preliminary data with medical centers, VISNs, and
program offices to identify problems. In addition, the most recent capacity
report reflects a closer working relationship among VA, its advisory
committees, and interested veterans' service organizations. According to VA,
this collaboration has resulted in data improvements. While the steps taken
by VA to improve its data quality are commendable, we believe that these
efforts will not bear fruit in the short term because of the myriad people
and processes at the facility, VISN, and national levels that make data
collection at VA so cumbersome.
The primary basis for VA's conclusion that it has maintained capacity is the
increased number of veterans served by the special disability programs.
However, of the five special disability programs that reported serving more
veterans, two experienced a decrease in expenditures and two a reduction in
dedicated beds. Without outcome measures, the effect of these changes on the
appropriateness and effectiveness of treatment is unclear. For example,
although the number of veterans treated for serious mental illness increased
by 8 percent from 1996 to 1998, expenditures decreased by 9 percent.
Similarly, the number of veterans treated for PTSD increased by 9 percent,
while expenditures declined by 17 percent. VA generally attributed
expenditure reductions to increases in efficiency as outpatient or
domiciliary care replaced more costly hospital inpatient treatment. Other
stakeholders review the same data and conclude that reduced expenditures
have eroded comprehensiveness and quality of care.
Facility managers we contacted were primarily concerned with maintaining
operations given the constraints of constant budgets, staff reductions, and
increasing workloads. These managers implemented various strategies to
improve efficiency while maintaining services to all veterans, including
those served in the special disability programs. These strategies included
the use of service lines,8 "hoptel" beds,9 making referrals to
community-based service providers, and shifting care to outpatient settings.
Facility officials generally believed that newly developed alternative care
settings were appropriate for special disability populations, although no
clear evidence exists to support this position.
While facility officials believed that they were meeting the demand for
special disability services, they expressed concern that additional cost
reductions might adversely affect quality of care. One facility was able to
reduce the number of inpatient psychiatric beds from over 400 to fewer than
100. Officials at this location were confident that the community
infrastructure was adequate for most veterans. VA case managers were
assigned to patients, and staff members were working with the community to
develop additional capacity as needed. In contrast, officials from another
facility stated that their community had few suitable alternatives, a
situation that led the facility's chief of staff to question the strategy of
deinstitutionalizing patients with mental illness.
Assessment of patient care outcomes for VA's special disability populations
would be a major asset in interpreting VA data and trends that showed more
veterans served with fewer resources. Although outcome measures are
difficult to develop and are not generally available in private sector
health care systems either, VA made a commitment in 1997 to develop within 2
years comprehensive and reliable measures of treatment outcome for the six
disability groups.
The fiscal year 1998 capacity report contains performance "monitors" that
are a mixture of outcome and process measures related to the care provided
to the six disability groups. The 18 performance monitors VA identified are
designed to assess quality, functional status, and patient satisfaction.
According to VA, these measures will be revised as more appropriate ones are
identified.
Data were unavailable for 7 of the 18 performance monitors identified in the
fiscal year 1998 capacity report, and information was unavailable for the 3
years from 1996 through 1998 for 15 monitors (see app. II). Some performance
monitors, such as continuity of care for previously hospitalized patients
and changes in functional status, appear to be useful indicators of quality.
However, others are more process-oriented and do not support an assessment
of possible improvements resulting from the care provided. For example, the
performance monitor for the care of veterans with serious mental illness is
a process measure of the percentage of patients who are assessed on a
one-time basis for their level of functioning, not an outcome measure of
their improvement. Furthermore, some monitors are limited to a small segment
of the population or address populations broader than the special disability
populations. For example, performance monitors for the spinal cord
dysfunction population include only those patients discharged after
inpatient treatment (about 55 percent of all spinal cord dysfunction
patients served), and measures for the serious mental illness category
include all psychiatric patients, and not just those with serious mental
illnesses.
Both advisory committees questioned the validity of VA's performance
monitors and expressed concern that insufficient progress has been made in
the development of comprehensive and valid measures of treatment outcome as
VA transitions to greater reliance on outpatient delivery systems. While
VA's development of performance monitors is a step in the right direction,
more research is needed to determine whether these measures are adequate to
assess whether the care provided to veterans in the special disability
programs is as comprehensive as, and equal in quality to, the care provided
in 1996.
Programs
Special disability services are delivered at the facility level, where VISN
and facility officials face the need to become more efficient to meet the
needs of more veterans with fewer resources. The alternative to increased
efficiency is decreased services. Accountability for maintaining capacity in
the special disability programs is currently fragmented among several
organizational units in VA, and performance standards mandated by statute
have not been fully implemented for those managing resources or allocating
them to special disability programs. VA indicated in its fiscal year 1998
capacity report that it was monitoring situations in which capacity appeared
to have declined, but VA did not respond to our repeated requests that it
identify who was responsible for this monitoring.
Organizational Units
Responsibility for implementing the mandate to maintain capacity in special
disability programs is divided among several headquarters units, including
the Office of Policy and Planning, the Chief Network Office, and the Office
of Patient Care Services. The Office of Policy and Planning is responsible
for developing the annual capacity report. This office coordinates the
development of capacity statistics and program definitions, oversees the
verification and validation process,10 and consults with internal and
external stakeholders in finalizing the capacity report. The Chief Network
Officer is the primary point of contact for the VISNs and provides
operational direction and supervision to the field through the 22 VISN
directors. The Office of Patient Care Services houses the clinically related
headquarters programs that support the delivery of patient care services in
the field. This office develops patient care policies and guidelines, acts
as program consultant to the special disability programs, and provides
advice and consultation to VISN and facility directors.
After contacting these three headquarters units, we concluded that none of
them was responsible for monitoring field locations whose capacity to serve
special disability populations appears to have declined. Each of the units
denied responsibility for monitoring and referred us to one of the other
offices as the potentially responsible unit. Despite VA's data problems,
enhanced monitoring and follow-up could be useful in mitigating the
limitations of VA's current capacity measures and performance monitors. In
addition to helping identify data reliability issues, such monitoring
efforts could bring to light legitimate concerns about the provision of
services to special disability populations in alternative care settings.
To improve accountability for maintaining capacity in the special disability
programs, the Congress, through the Veterans Programs Enhancement Act,
required VA to develop job performance standards for employees responsible
for allocating and managing resources for serving veterans with special
disabilities. The law also required that the standards include measures of
workload, allocation of resources, and quality of care indicators, and that
the standards be implemented by January 1, 1999.
As of January 2000, VA had implemented at least one quality of care
performance standard, or monitor, in each of the six special disability
programs. The 2000 VISN directors' performance agreement states that part of
the performance evaluation will be based on the results of the monitors of
capacity for special populations. The agreement includes 12 monitors related
to the disability populations. Achievement goals for VISN directors have
been established for the 2 spinal cord care monitors, but not for the
remaining 10 monitors. Without stated goals, it is unclear what would be
considered acceptable performance.
Also, the performance agreement is silent on the measurement of workload and
allocation of resources, which is required by the law. The mandatory job
performance standards cannot be considered fully implemented without
measures of workload and allocation of resources.
VA has demonstrated that measurable performance standards for key management
officials can promote change. For example, by including in the VISN
directors' performance agreements a requirement to decrease the number of
days inpatients spent in acute care in fiscal year 1998, VA reduced these
acute-bed-days from 3,430 per 1,000 veterans served in fiscal year 1994 to
1,333 per 1,000 veterans served in fiscal year 1998, a 61-percent decrease.
While questions remain about the accuracy of VA's workload and resource
data, VA has committed to work with stakeholders and veterans' service
organizations to improve the accuracy and reliability of the data. VA has
also committed itself to developing measures of quality of care in special
disability programs in order to ensure that quality is maintained or
improved. However, in view of the difficulty of developing and validating
outcome measures, it is unlikely that VA will be able to develop measures
across all special disability programs in the near future. In the meantime,
the annual capacity report can be a valuable tool for identifying specific
locations with potential problems in service delivery to special disability
populations. Enhanced monitoring of such locations could be used to augment
VA's current limited capacity measures and performance monitors.
Responsibility for managing VA's response to the capacity requirement is
dispersed among several of VA's organizational components, and none of them
has taken responsibility for investigating apparent declines in capacity or
quality of services for veterans with special disabilities. Designating a
single organization as responsible for these functions would help focus
accountability for maintaining capacity. In addition, the accountable office
could be charged with fully implementing the congressional requirement to
develop job performance standards for employees responsible for allocating
and managing resources used to serve veterans with special disabilities.
To help ensure compliance with the law, we recommend that the Secretary of
Veterans Affairs direct the Under Secretary for Health to assign lead
responsibility to a headquarters unit for
� initiating efforts to monitor and determine the causes for apparent
declines in capacity and
� developing job performance standards for employees who are responsible for
allocating and managing the resources used to serve veterans with special
disabilities.
In commenting on the draft report, VA generally agreed with our findings and
recommendations. VA intends to take an approach to ensuring compliance with
the law that is different from assigning lead responsibility to a
headquarters unit. VA said it would renew its commitment to using existing
coordination and issue resolution mechanisms to address compliance with the
law. We continue to believe that assigning responsibility to one office
would better ensure that capacity is accurately measured and appropriately
maintained. The coordination mechanisms have not accomplished this in the
past, and focusing one office's attention on the issue is, in our opinion,
more likely to ensure accountability in the future. VA said that a new
management structure would have to be created if it designated a single
office as responsible for ensuring compliance with the law. We believe that
a new management structure is not required and that designating an office as
accountable for compliance with the law would be sufficient. VA has tasked a
working group, the 3-year-old Performance Management Work Group, with the
development of job performance standards. This action should emphasize and
delineate responsibility for the timely completion of the job performance
standards.
VA also commented that it believes that measuring the full continuum of
care, not just the numbers of beds and FTE staff, is the most appropriate
measure of access to care. We agree with VA, but, as we have discussed in
the report, VA does not have the data or processes available to consider the
full continuum of care. In this regard, we support VA's efforts to develop
outcome measures.
VA expressed concern that the draft report placed emphasis on the
maintenance of capacity at the VISN level, noting that the law states that
capacity should be maintained at the national level. As discussed in the
report, we included information by VISN because the nationwide data hid the
variability across the VISNs. Moreover, VA stated in its 1998 capacity
report that it was monitoring situations in which capacity appeared to have
declined in particular VISNs; however, we were unable to identify who was
responsible for this monitoring. We support VA's initiative to monitor
declines in capacity at the VISN level, knowing that such an effort exceeds
the statutory requirement to maintain capacity nationally.
As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days from
the date of the report. At that time, we will send copies of this report to
the Honorable Togo D. West, Jr., Secretary of Veterans Affairs; appropriate
congressional committees; and other interested parties. We will also make
copies available to others upon request.
Please contact me on (202) 512-7101 if you or your staff have questions
about the report or need additional assistance. George Poindexter, Linda
Diggs, Marcia Mann, and William Stanco made key contributions to this
assignment.
Sincerely yours,
Stephen P. Backhus
Director, Veterans' Affairs and
Military Health Care Issues
VA Definitions of Six Special Disabilities
Disability VA capacity report definition
Veterans with neurological deficit lesions
involving the spinal cord, including but not
limited to traumatic spinal cord injuries;
intraspinal neoplasms resulting in
Spinal cord injury and neurological deficit; vascular insults to
disorders (SCI&D) the spinal cord; cauda equina syndrome;
inflammatory disease of the spinal cord; and
diseases such as multiple sclerosis,
unstable traumatic lesions of the spinal
cord, and degenerative spine diseases are
considered to have SCI&D.
Veterans are considered disabled by
blindness when the best corrected central
visual acuity with ordinary eyeglasses or
contact lenses is 20/200 or less in the
Blindness better eye, or when the best corrected
visual acuity in the better eye is better
than 20/200 but visual field defects exist
that produce a useful visual field dimension
of 20 degrees or less.
Veterans who have sustained brain trauma,
including from iatrogenic causes, and who
have motor or cognitive impairments as a
result of the brain injury for at least 3
months, are considered to have a TBI. These
individuals either require rehabilitative
services, such as acute intervention of
Traumatic brain injury (TBI) speech pathology and cognitive
rehabilitation, in the first several months
or are so severely impaired that their
rehabilitative potential is objectively so
low that rehabilitative services are not
appropriate. These patients may require
chronic life support measures, such as
mechanical ventilation.
Amputation applies to veterans who have a
full or partial amputation of a limb,
Amputation including neurologic loss of a limb (except
from stroke) and loss of the use of a limb
from injuries to the brain, spinal cord, or
peripheral nerves.
Veterans who have within the past year had a
diagnosed mental, behavioral, or emotional
disorder of sufficient duration to result in
a disability that meets the Diagnostic and
Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV),a criteria are
considered to have an SMI. Disability is
Serious mental illness (SMI) defined as a functional impairment that
substantially interferes with or limits one
or more major life activities, such as
bathing, dressing, managing money, or taking
prescribed medication. Two subcategories
include veterans who have a diagnosed DSM-IV
substance-related disorder and homeless
veterans who have a disability as a result
of mental illness.
Veterans who meet the diagnostic criteria
for PTSD include those who
have been exposed to a catastrophic or
traumatic event involving actual or
threatened death or injury, or a threat to
the physical integrity of self or others,
and who have a subjective response of
intense fear, helplessness, or horror;
have intrusive recollections or
reexperiences of the event;
Post-traumatic stress
disorder (PTSD) persistently avoid stimuli associated with
the trauma and have generally numbed
responsiveness;
have persistent symptoms of increased
arousal;
have symptoms that last 1 month or longer;
and
experience clinically significant distress
or impairment in social, occupational, or
other important areas of functioning.
a DSM-IV is the standard handbook for psychodiagnosis employed by clinicians
and researchers in the United States.
Performance and Access Monitors
Continued
Indicator
Access or type Portion of
Disability performance Indicator (processa population Method of data Results Comments
monitor or covered collection reported
outcomeb)
Only SCI&D
patients needing
urgent admission
to an SCI center Acute condition
are included in means care is
the measurement, required by newly
which covers all injured veterans
Admission to a newly injured or by veterans
spinal cord injury veterans and a with SCI who need
(SCI) center portion of the FY 96--41% urgent care
within 1 day of SCI&D populationSurvey of SCI because of
SCI&D Access request for Process with older centers by the FY 97--91% medical
patients needing injuries. VA SCI&D Strategic complications or
acute, inpatient treats Health Group FY 98--100% surgical needs.
specialty care approximately Results are
(average) 400 newly reported as a
injured patients percentage of SCI
per year. The centers that met
newly injured the requirements
make up 8% of established by
the SCI&D the indicator.
population
treated as
inpatients.
Results are
SCI clinic Covers those FY 96--87% reported as a
patients seen inSurvey by the percentage of SCI
SCI&D Access appointment within Process SCI clinics at SCI&D Strategic FY 97--100% centers that met
7 days of referral
(average) facilities with Health Group the requirements
an SCI center FY 98--100% established by
the indicator.
Only veterans
discharged from Of the 23 SCI
an SCI center centers, 16 had
can potentially fewer than 30
be included in respondents to
SCI inpatients the denominator. the survey;
Patient FY 97--55%
SCI&D Performance rating VA care as Outcome Of the 5,117 satisfaction according to VA,
"very good" to patients such small
"excellent" discharged in FYsurvey results FY 98--55% samples are
1998, only 550, regarded as
or 10%, of the unreliable and of
patients were questionable
included in the validity.
survey results.
VA states that
discharge to
noninstitutional
community living
Includes "could be" viewed
National
Discharge from SCI veterans Patient Care as positive.
admitted for FY 97--95% Outcome does not
SCI&D Performance bed unit to Outcome rehabilitation Database on necessarily
noninstitutional patients
community living and other discharged from FY 98--95% relate to quality
purposes, such of care received
as annual exams SCI bed unit during inpatient
treatment and may
be the result of
socioeconomic
factors.
Measures time
only for FY 96--31.8
Average waiting patients weeks
time for admission actually Self-reporting Measures
Blindness Access to inpatient blind Process admitted to by blind FY 97--32.2 admissions during
rehabilitation program, not rehabilitation weeks a 6-month period
program those on waitingcenters
list who decline FY 98--33.4
admission weeks
The number of
veterans served
Number and There was a 36% is not the best
percentage change increase in the FY 97--873 measure of
in the number of number of access. A
veterans seen by FY
Blindness Access veterans served by Process a BROS, BROS semiannual 98--1,191 numerator and a
blind reports denominator are
rehabilitation representing an needed to
outpatient increase from % change: determine
specialists (BROS) 7.4% in 1997 to +36 accessibility of
10% in 1998.
the program for
veterans.
Patients The survey
Inpatients of admitted to a VA response rate in
blind blind 1998 was 38%,
rehabilitation rehabilitation Blind which was an
rehabilitation FY 97--98% improvement over
Blindness Performance program reporting Outcome program, which customer 1997. Two of the
being "satisfied" accounts for 17%
or "completely of the blinded satisfaction FY 98--98% nine blind
satisfied" with VA veteran survey rehabilitation
care population centers had less
seeking care than 30 responses
to the survey.
Impossible to FY 96--3
determine days
Average waiting without There is no
TBI Access time for admission Process numerators and Survey of TBI FY 97--2 indication of the
to a designated denominators, centers days size of the
TBI bed which were not survey sample.
provided in the FY 98--2
report days
Impossible to FY 96--6
Average waiting determine days
time for without There is no
TBI Access first-time TBI Process numerators and Survey of TBI FY 97--5 indication of the
outpatient denominators, centers days size of the
appointment which were not survey sample.
provided in the FY 98--7
report days
Discharge of
"first-admission" Only percentages
TBI patients from were provided,
Measures only VA Functional with a footnote
TBI Performance TBI network Outcome first-admission Status Outcome FY 98---68% stating that some
medical
rehabilitation TBI patients Database were based on a
beds to the very small number
community of discharges.
Measures much
more than
patient
Delayed prosthetic population with National FY 96--1.3%
Amputation Access orders Process amputations and delayed
(cumulative) was deleted fromprosthetic FY 97--0.7%
the list of order report
access measures
by VA for FY
1998
The number of
inpatient
rehabilitation
units has
Discharge of lower Unable to decreased and, as
extremity amputees determine what VA Functional FY 96--82% a result, the way
care is delivered
Amputation Performance from inpatient Outcome percentage of Status and FY 97--77% to veterans
rehabilitation amputees the Outcome
units to community data provided byDatabase undergoing
setting VA represent FY 98--77% amputations has
also changed,
making
comparisons by
fiscal year
difficult.
Indicator
included in
Patients at risk External peer Veterans
for foot review Integrated
Sample of
Amputation Performance amputation who Process diabetic program--data Data not Service Network
were referred to a collected by available. (VISN) directors'
foot care patients outside performance
specialist contractor. measures under
clinical practice
guidelines
Patient
satisfaction with Survey to be
Amputation Performance VA-issued lower Outcome administered to National survey Data not
extremity lower extremity of patients available.
prosthetic limb amputees
Indicator
includes only
those veterans
discharged from The indicator for
a general veterans with a
psychiatry unit psychiatric
Veterans seen in (approximately FY 96--52% diagnosis who
any psychiatric 33% of the Patient were seen within
SMI Access outpatient clinic Process veterans treatedTreatment File FY 97--53% 30 days of
within 30 days for SMI); unableand outpatient discharge is part
after discharge to determine if files FY 98--58% of the FY 2000
this includes VISN directors'
all discharges performance
from psychiatry measures.
or just patients
determined to
have an SMI.
Indicator
includes only
those veterans
discharged from
a general
psychiatry unit FY 96--34
days
Average time to (approximately Patient
33% of the
SMI Access first outpatient Process veterans treatedTreatment File FY 97--32
visit following and outpatient days
discharge for SMI); unablefiles
to determine if
this includes FY 98--31
all discharges days
from psychiatry
or just patients
determined to
have an SMI.
Patients with at
least one Global Would need
Assessment of Includes all comparison of
Functioning score patients seen in functional scores
if seen in any a psychiatric to measure
SMI Performance Veterans Health Process inpatient or Mental health Data not outcome of
Administration outpatient package available. treatment, which
mental health setting, not VA intends to
inpatient or just those with accomplish in FY
outpatient setting SMI 1999.
in FY 1998
The majority of
substance abuse
care is now
delivered in an
outpatient
Veterans seen in setting. This
any substance measure includesPatient FY 96--38%
SMI--substance abuse outpatient only the 28% of Treatment File
abuse Access clinic within 30 Process veterans treatedand outpatient FY 97--41%
days after for substance files
discharge abuse in an FY 98--41%
inpatient
setting and
includes more
than SMI
patients.
The majority of
substance abuse
care is now
delivered in an
outpatient FY 96--27
Average time to setting. This days
first outpatient measure includesPatient
SMI--substance visit for veterans only the 28% of Treatment File FY 97--28
abuse Access discharged from Process veterans treatedand outpatient days
substance abuse for substance files
programs abuse in an FY 98--27
inpatient days
setting and
includes more
than SMI
patients.
Covers veterans
Patients receiving
(percentage) that inpatient or
demonstrate outpatient care
SMI--substance improvement in the and would Mental health Data not
abuse Performance drug and alcohol Outcome potentially package available.
use scores in the include more
Addiction Severity than SMI
Index patients in the
sample
Because of the
closure of
VA had not substance abuse
developed an and general
access indicator Not determined Not determined psychiatry beds,
at the time the at the time the VA did not
SMI--homeless Access for the homeless Process FY 1998 capacityFY 1998 Data not include access
subcategory of SMI available.
at the time the FY report was capacity report data for these
1998 report was published was published patients and may
published. not include them
in the future
because of small
sample sizes.
May include
veterans without
Veterans who SMI when looking
acquired living at homeless
arrangements at population
discharge from a discharged from
Domiciliary Care a Domiciliary FY 96--51%
for Homeless Care for Northeast Sample size was
SMI--homeless Performance Veterans program Outcome Homeless Program FY 97--52% not provided in
or Health Care for Veterans programEvaluation report.
Homeless Veteran or Health Care Center files FY 98--52%
community-based for Homeless
contract Veteran
residential care community-based
program contract
residential care
program
May include
veterans without
Veterans who SMI if looking
obtained at homeless
employment at population
discharge from a discharged from FY 96--49%
Domiciliary Care a Domiciliary Northeast Sample size was
SMI--homeless Performance for Homeless Outcome Care for Program FY 97--52% not provided in
Veterans program Homeless Evaluation report.
or community-based Veterans programCenter files FY 98--54%
contract or
residential care community-based
program contract
residential care
program
Veterans with May include
mental illness veterans without
(including SMI if looking
substance abuse) at homeless
who had a population
follow-up mental discharged from 1999 data to be
health outpatient a contract collected and
summarized by
SMI--homeless Performance visit within 30 Process Domiciliary Carethe Northeast Data not
days of discharge for Homeless available.
from a contract Veterans programProgram
Domiciliary Care or Evaluation
for Homeless community-based Center.
Veterans program residential care
or community-based program
residential care
program
Covers PTSD
Veterans with a population who
primary diagnosis received FY 96--64%
of PTSD seen in inpatient care, Patient
PTSD Access any psychiatric Process which accounts Treatment File FY 97--65%
outpatient clinic for and outpatient
within 30 days approximately files FY 98--68%
after discharge 11% of the
population
Covers PTSD
FY 96--30
Average time to population who days
first outpatient received Patient
inpatient care,
PTSD Access visit for veterans Process which accounts Treatment File FY 97--28
discharged with a and outpatient days
primary PTSD for files
diagnosis approximately FY 98--26
11% of the
population days
Veterans
(percentage)
treated for PTSD VA is using
in specialized Covers PTSD functional scores
PTSD programs with population to determine the
PTSD Performance at least one Process treated in both Mental health Data not number of
Global Assessment inpatient and package available. veterans disabled
of Functioning outpatient by PTSD for FY
score programs 1998.
Change in PTSD
symptoms on the FY
short form of the Covers PTSD The Northeast 96--39.05
Mississippi Scale population Program
Evaluation FY
PTSD Performance from admission to Outcome admitted to a Center is using 97--37.19
follow-up 4 months specialized
after discharge intensive PTSD a
(national average program self-reporting % change:
for adjusted mean survey.
scores) -1.86
Change in alcohol
abuse symptoms as
measured by the FY
Alcohol Abuse The Northeast 96--0.169
Composite of the Covers PTSD Program
Addiction Severity population Evaluation FY
PTSD Performance Index from Outcome admitted to a Center is using 97--0.137
admission to specialized a
follow-up 4 months intensive PTSD self-reporting % change:
after discharge program survey.
(national average -0.032
for adjusted mean
scores)
Change in drug
abuse symptoms as
measured by the FY
Drug Abuse The Northeast 96--0.071
Composite of the Covers PTSD Program
Addiction Severity population Evaluation FY
PTSD Performance Index from Outcome admitted to a Center is using 97--0.059
admission to specialized a
follow-up 4 months intensive PTSD self-reporting % change:
after discharge program survey.
(national average -0.012
for adjusted mean
scores)
Change in
occupational
functioning as
measured by the
number of days the Covers PTSD The Northeast
veteran has been population Program
Evaluation
PTSD Performance employed during Outcome admitted to a Center is using Data not
the past 30 days specialized available.
at admission and intensive PTSD a
follow-up 4 months program self-reporting
after discharge survey.
(national average
for adjusted mean
scores)
Veterans FY
successfully Process Covers PTSD The Northeast 96--62.7%
contacted for (step to population Program
PTSD Performance outcome assessment collect admitted to a Evaluation FY
after discharge data for specialized Center's 97--66.6%
from an intensive an outcome intensive PTSD response rate
PTSD program measure) program for survey % change:
+3.9
aA measure that focuses on a process that leads to a certain outcome and
that, when executed well, will increase the probability of achieving a
desired outcome.
bA measure that indicates the result of the performance or nonperformance of
a function(s) or process(es).
Comments From the Department of Veterans Affairs
(406174)
Table 1: Change in Number of Special Disability Veterans Served and Dollars
Spent Between Fiscal Years 1996 and 1998 8
Table 2: Change in Number of Special Disability Veterans Served in Inpatient
and Outpatient Settings Between Fiscal Years 1996
and 1998 9
Table 3: Change in FTE Employees and Beds for Spinal Cord
Dysfunction and Blind Rehabilitation Between Fiscal Years
1996 and 1998 10
1. Stakeholders included members of the Advisory Committee on Prosthetics
and Special Disabilities Programs and the Committee on the Care of Severely
Chronically Mentally Ill Veterans.
2. We provided preliminary information on the results of our review in a
briefing to your staff on May 24, 1999.
3. Nevertheless, VA's fiscal year 2000 budget appropriation for health care
was increased by $1.7 billion over the fiscal year 1999 budget
appropriation.
4. The members of the Advisory Committee on Prosthetics and Special
Disabilities Programs are from veterans' service organizations,
universities, and private sector health care providers. In accordance with
the Veterans Health Care Eligibility Reform Act, members of the Committee on
the Care of Severely Chronically Mentally Ill Veterans must be employees of
the Veterans Health Administration with expertise in the care of the
chronically mentally ill and must be appointed by VA's Under Secretary for
Health.
5. VA has begun implementation of a Decision Support System that will
capture diagnostic information for outpatient clinic visits and will provide
cost accounting information.
6. Other groups, such as the minority staff of the Senate Committee on
Veterans' Affairs, were also unable to verify workload and resource data
because of problems in obtaining reliable or comparable data across
facilities. See Minority Staff Review of VA Programs for Veterans With
Special Needs , prepared for Senator John D. Rockefeller IV, July 27, 1999.
7. VA Office of Inspector General, Evaluation of Medical Center Investment
in Ambulatory Care Infrastructure , Report Number 9AY-A19-078 (Washington,
D.C.: VA, Mar. 31, 1999).
8. A service-line model is a health care organizational model based upon
providing a comprehensive set of clinical and administrative services to
meet the needs of a particular segment of the market (for example, veterans
with mental illness or spinal cord dysfunction). Budgetary, personnel, and
reporting authorities vary in the different service-line models.
9. Hoptels are temporary lodging, usually within facilities, that provide a
cost-effective alternative to inpatient admissions.
10. VA refers to this as the error detection and correction process in its
fiscal year 1998 capacity report.
*** End of document. ***