Veterans' Health Care: Chicago Efforts to Improve System Efficiency
(Letter Report, 05/29/98, GAO/HEHS-98-118).

Pursuant to a congressional request, GAO reviewed: (1) what impacts the
Veterans Affairs (VA) Chicago Health Care System (VACHCS) had on
veterans, employees, and medical schools in the Chicago area; (2)
VACHCS' integration process; (3) the integration decisions made; and (4)
dollar savings for these decisions.

GAO noted that: (1) the VACHCS integration process, which began in 1996,
included 28 work groups that studied administrative, patient support,
and direct care services and made recommendations to an Integrated
Coordinating Committee (ICC); (2) the ICC reviewed, reworked, and
modified work group recommendations; (3) work group recommendations
approved by ICC were sent to the VACHCS director for review, approval,
and implementation; (4) recommendations involving changes to clinical
services were also reviewed and approved by the Great Lakes network
director and the Veterans Health Administration Under Secretary for
Health; (5) VACHCS involved stakeholders in its integration process; (6)
the VACHCS integration: (a) unified the management of 16 services; (b)
reengineered 23 services by standardizing operating policies, practices,
and databases or by establishing more efficient practices; and (c)
consolidated parts of eight services in a single location; (7) the
integration appears to have had a small but positive impact on veterans,
employees, and medical schools; (8) VACHCS officials report that they
have maintained the level of service to veterans and, in some instances,
even improved access and quality while minimizing the hardship on VA
employees by not dismissing any current employees; (9) medical school
affiliations remain largely unchanged, and medical education continues
to be provided at both hospitals, using the same management structure
and operating practices; (10) the VACHCS integration saved about $7
million; and (11) VACHCS saved about $4 million by eliminating 80
positions, of which 74 were vacant, and approximately $2 million by
avoiding the purchase of duplicate equipment and related construction.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-98-118
     TITLE:  Veterans' Health Care: Chicago Efforts to Improve System 
             Efficiency
      DATE:  05/29/98
   SUBJECT:  Medical education
             Veterans hospitals
             Reengineering (management)
             Health services administration
             Health care cost control
             Health resources utilization
             Medical schools
IDENTIFIER:  VA Chicago Health Care System
             Chicago (IL)
             
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Cover
================================================================ COVER


Report to Congressional Requesters

May 1998

VETERANS' HEALTH CARE - CHICAGO
EFFORTS TO IMPROVE SYSTEM
EFFICIENCY

GAO/HEHS-98-118

VA's Integration of Chicago Hospitals

(406131)


Abbreviations
=============================================================== ABBREV

  ICC - Integration Coordinating Committee
  SAG - Stakeholders Advisory Group
  VA - Department of Veterans Affairs
  VACHCS - VA Chicago Health Care System
  VHA - Veterans Health Administration

Letter
=============================================================== LETTER


B-274869

May 29, 1998

The Honorable Carol Moseley-Braun
United States Senate

The Honorable Luis V.  Gutierrez
House of Representatives

The Honorable Lane Evans
House of Representatives

The Department of Veterans Affairs' (VA) health care system is one of
the nation's largest direct health care delivery systems.  VA
operates 173 hospitals, over 400 outpatient clinics, 133 nursing
homes, and 40 domiciliaries organized into 22 service networks,
covering specific geographic areas that reflect patient referral
patterns and the availability of medical services.  Facility
integrations are part of VA's nationwide strategy to restructure its
health care delivery system to improve the access to and the quality
and efficiency of care provided to U.S.  veterans.  These
integrations reflect, in large part, changes that have been under way
in the private sector.  Profound changes in health care brought
about, in part, by technological advances and the rise of managed
health care, among other things, have caused a dramatic shift away
from inpatient care and a corresponding move to outpatient care. 
Toward this end, VA has been increasing the number of ambulatory care
access points, emphasizing primary care, decentralizing
decision-making, and integrating facilities. 

In June 1996, the Secretary of Veterans Affairs announced the
integration of two Chicago hospitals--Lakeside and West Side
hospitals--under one director; these hospitals became the VA Chicago
Health Care System (VACHCS) within the Great Lakes network.  The
Great Lakes network includes portions of Illinois, Indiana,
Wisconsin, and Michigan and operates 8 hospitals and 12 outpatient
clinics. 

Lakeside and West Side are tertiary care hospitals, providing acute
inpatient medical, surgical, and psychiatric care, and are located
about 6 miles apart in downtown Chicago.  VACHCS spent over $212
million, employed 2,257 staff, and served over 41,000 veterans in
fiscal year 1997.  Both hospitals are affiliated with medical
schools, Lakeside with Northwestern University and West Side with the
University of Illinois at Chicago. 

The VACHCS integration began at a time when VA was experiencing
dramatic decreases in its staffing levels nationwide.  Since fiscal
year 1996, VA has reduced staffing by about 19,500.  During this
period, the Great Lakes network reduced staff by over 2,000, and
VACHCS reduced staffing by 573.  VACHCS staffing reductions are
similar to the cuts nationwide and at the other hospitals within the
Great Lakes network that were not undergoing integrations. 

You asked what impacts the VACHCS integration has had on veterans,
employees, and medical schools in the Chicago area.  As a result of
discussions with your offices, we agreed to describe (1) VACHCS's
integration process; (2) the integration decisions made; (3) the
impacts on veterans, employees, and medical schools; and (4) dollar
savings for these decisions.  In addition to this report, we have
issued two other reports\1 related to VA medical facility
integrations.  We reported that VA could serve all veterans in the
Chicago area in three hospitals instead of four and also reported
that VA facility integration processes can be improved by adopting
comprehensive planning and completing planning before implementation
begins. 

To identify integration impacts, we reviewed all documents of the
Integration Coordinating Committee and working groups involved in the
integration process.  In addition, we interviewed chiefs of services
or chairpersons of the work groups to obtain the implementation
status of each integration recommendation and its potential impact on
veterans, employees, medical schools, and dollar savings. 

We performed our review between November 1997 through April 1998 in
accordance with generally accepted government auditing standards. 


--------------------
\1 VA Health Care:  Closing a Chicago Hospital Would Save Millions
and Enhance Access to Services (GAO/HEHS-98-64, Apr.  16, 1998) and
VA Health Care:  Lessons Learned From Medical Facility Integrations
(GAO/T-HEHS-97-184, July 24, 1997). 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

VACHCS' integration process, which began in 1996, included 28 work
groups that studied administrative, patient support, and direct care
services and made recommendations to an Integration Coordinating
Committee (ICC).  The ICC reviewed, reworked, and modified work group
recommendations.  Work group recommendations approved by the ICC were
sent to the VACHCS director for review, approval, and implementation. 
Recommendations involving changes to clinical services were also
reviewed and approved by the Great Lakes network director and the
Veterans Health Administration (VHA) Under Secretary for Health. 
VACHCS involved stakeholders, such as Members of Congress, medical
school and veterans' organization representatives, and labor unions
and community groups, in its integration process, including them in
work groups or on committees. 

The VACHCS integration (1) unified the management of 16 services; (2)
reengineered 23 services by standardizing operating policies,
practices, and databases or by establishing more efficient practices;
and (3) consolidated parts of 8 services in a single location.  Also,
a new joint (medical school) deans' committee has been established to
make future integration recommendations to the VACHCS director
concerning 12 services, including medicine, surgery, and
psychiatry--the largest, most significant, and most difficult
services to integrate. 

The integration appears to have had a small but positive impact on
veterans, employees, and medical schools.  The direct-care services,
such as medicine, surgery, and psychiatry, continue to be provided at
both Lakeside and West Side.  VACHCS officials report that they have
maintained the level of service to veterans and, in some instances,
even improved access and quality while minimizing the hardship on VA
employees by not dismissing any current employees.  Instead,
unstaffed positions were eliminated.  Medical school affiliations
remain largely unchanged, and medical education continues to be
provided at both hospitals, using the same management structure and
operating practices.  In addition, the VACHCS integration saved about
$7 million.  VACHCS saved about $4 million by eliminating 80
positions, of which 74 were vacant, and approximately $2 million by
avoiding the purchase of duplicate equipment and related
construction.  Other savings resulted from decisions such as
standardizing drug formularies. 


   VA CHICAGO HEALTH CARE SYSTEM'S
   INTEGRATION PROCESS
------------------------------------------------------------ Letter :2

The Great Lakes network director established the VACHCS integration
process.  This separate and temporary process involved an ICC, a
Stakeholders Advisory Group (SAG), and service-specific work groups. 
(See app.  I for an illustration of VACHCS' integration process.) The
network director, the VACHCS director, service chiefs, and
stakeholders determined the membership of the committees and the
groups participating in the VACHCS integration process. 

The Chief of Staff, VA New Jersey Health Care System, chaired the
ICC, which consisted of 15 members.  The other 14 members included
representatives from the Great Lakes network, unions, VACHCS
employees, Chicago medical schools, and the veterans service
organizations (see app.  II for a list of ICC members).  The ICC held
its first meeting in October 1996 and established service-specific
work groups to review services and propose recommendations for
integration.  Between October 1996 and October 1997, the ICC held
nine meetings to review, rework, and modify work group
recommendations.  Work group recommendations approved by the ICC were
forwarded to the VACHCS director for review, approval, and
implementation.  Any integration recommendations having an impact on
network initiatives were reviewed and approved by the network
director.  The VHA Under Secretary for Health reviewed and approved
integration recommendations affecting clinical services and programs. 

The service-specific work groups had responsibility for conducting
analyses and proposing integration recommendations to the ICC.  Work
group participants included VACHCS staff, representatives of
affiliated medical schools, unions, community groups, and veterans'
representatives. 

The service-specific work groups fell into three categories: 
administrative, direct patient care, and patient support.  Five work
groups reviewed administrative services, such as engineering,
information resource management, and medical administration services. 
Fourteen work groups reviewed direct patient care services, such as
medical, surgical, psychiatric, and dental.  The remaining nine work
groups analyzed patient support services, such as chaplain, nutrition
and food, and pathology and laboratory services.  (App.  III contains
a list of the services, by category.)

The Stakeholders Advisory Group provided input and advice to the ICC
regarding work group activities and proposed integration
recommendations.  The SAG consisted of 17 members, including
representatives of elected officials, affiliated medical schools,
community groups, labor unions, and veterans service organizations
(see app.  IV for a list of members).  It met seven times over a
12-month period. 

In addition, the ICC, the SAG, the network director, and the VACHCS
director determined that voluntary, recreational therapy, and payroll
services did not require work groups.  The VACHCS director made
integration decisions for these three services. 


   INTEGRATION DECISIONS
------------------------------------------------------------ Letter :3

The VACHCS integration process produced a total of 200 integration
recommendations.  Forty-six recommendations maintain the status quo
or will not be implemented; therefore, no changes occurred within the
services as a result of those recommendations.  Thirty-eight
recommendations have been deferred to the VACHCS director or the
deans' committee for further consideration.  The remaining 116
integration recommendations are in various stages of implementation,
with 90 percent either having been or in the process of being
implemented, as table 1 shows. 



                          Table 1
          
               Status of Integration Decision
            Implementation, by Service Category

                          Implementati  Implementati
Service     Implementati         on in        on not  Tota
category     on complete       process       started     l
----------  ------------  ------------  ------------  ----
Administra            19             8             3    30
 tive
Direct                12            21             2    35
 care
Patient               28            17             6    51
 support
==========================================================
Total                 59            46            11   116
----------------------------------------------------------
Source:  Service chiefs provided this information between November
1997 and March 1998. 

Most integration decisions will reengineer services, while the least
number of decisions will consolidate services, as table 2 shows. 



                          Table 2
          
            Number of Integration Decisions, by
             Service Category and Decision Type

                        Reengineer
Service        Unified          ed
category    management    services  Consolidations   Total
----------  ----------  ----------  --------------  ------
Administra           5          22               3      30
 tive
Direct               4          27               4      35
 care
Patient              7          41               3      51
 support
==========================================================
Total               16          90              10     116
----------------------------------------------------------
Source:  Service chiefs provided this information between November
1997 and March 1998. 

When unifying management, VACHCS eliminated a chief of service
position at one of the two hospitals.  For example, before the
integration, a service, such as medical administration, had two
chiefs of service--one at each hospital.  By unifying management, one
chief assumed responsibility for the service at both hospitals, and
the chief's position at one hospital was eliminated. 

Reengineering may involve either standardizing VACHCS policies,
procedures, and databases within a service for both hospitals or
establishing more effective or efficient approaches for conducting
business.  Before the integration, each service at each hospital had
its own policies and procedures.  Several chiefs of service told us
they adopted the best policy or procedure from one hospital and
created a standard to be used at both hospitals.  For example, the
nursing service standardized the professional standards boards for
registered and licensed practical nurses at both hospitals.  The
medical administration service created a more efficient approach to
its transcription activity by negotiating one transcription contract,
which resulted in enhanced productivity and consistency for discharge
summaries and other patient-related reports. 

Consolidation may involve moving an entire service, or some part of a
service, to a single location.  VACHCS decisions consolidated parts
of a service, not an entire service.  For example, the VACHCS
director consolidated payroll, within the fiscal service, by
transferring five employees from West Side Hospital to Lakeside
Hospital.  In addition, specific testing is now done at one hospital
within the pathology and laboratory service. 

Although the VACHCS ICC has completed its work, future integration
recommendations for 12 services have been deferred to the newly
created joint deans' committee.  (See app.  V for a list of these
services.) Integration recommendations to unify management and to
reengineer and consolidate the largest services, such as medicine,
surgery, and psychiatry, could be the most significant and most
difficult to accomplish. 


   IMPACTS OF INTEGRATION
------------------------------------------------------------ Letter :4

The VACHCS integration decisions affected veterans, employees, and
medical schools.  Most of the integration decisions affected the
administrative and patient support services.  Integration decisions
affecting the direct patient care services, such as medicine,
surgery, and psychiatry, have been deferred.  These services continue
to be provided at both hospitals. 


      IMPACT ON VETERANS
---------------------------------------------------------- Letter :4.1

VACHCS integration appears to have had a small but positive impact on
veterans.  Veterans continue to obtain medical, surgical, and
psychiatric services at the same hospitals as they have in the past. 
VACHCS officials reported that the level of service to veterans is
being maintained while some changes enhance access and quality of
care.  For example, the pharmacy service reported reducing patient
prescription waiting time from 90 minutes to 20 minutes by expanding
its hours of operation and using new technology to fill
prescriptions.  Also, VACHCS officials stated that veterans' access
to the social work service improved by transferring some
administrative activities to the medical administration service, thus
giving social workers more time to spend with patients.  In addition,
a greater percentage of nurses are spending more time with patients,
thus enhancing the quality of care, according to VACHCS officials. 

Three VACHCS consolidation decisions affected veterans.  As a result,
the number of veterans who may be inconvenienced by traveling to
either Lakeside Hospital or West Side Hospital for such care is
small, as shown in table 3. 



                                Table 3
                
                 Annual Number of Veterans Treated Who
                         May Be Inconvenienced

                                                                Number
                                                                    of
                                                                vetera
Consolidation decisions                                             ns
--------------------------------------------------------------  ------
Nuclear medicine: bone density studies and in vitro assays          25
Nuclear medicine: myocardial perfusion imaging                     430
Prosthetics: amputee clinic                                          2
======================================================================
Total                                                              457
----------------------------------------------------------------------
Source:  Service chiefs provided this information between November
1997 and March 1998. 

Although there were seven other consolidation decisions, they will
not affect where veterans receive their care.  For example,
consolidation of flow cytometry within the pathology and laboratory
service at Lakeside will not affect veterans because only the blood
sample is sent to Lakeside for analysis.  The veteran can have blood
drawn at West Side, if that is more convenient, and the sample will
be sent to the laboratory at Lakeside. 


      IMPACT ON VA EMPLOYEES
---------------------------------------------------------- Letter :4.2

The VACHCS integration affected employees in three ways.  First, it
eliminated 80 positions; however, only 6 positions were staffed at
the time of their elimination.  The remaining 74 positions were
unstaffed, as table 4 shows. 



                                Table 4
                
                 Number of Positions Eliminated by the
                              Integration

                                                  Number of
                                                  positions
                                                  eliminated
                                                --------------
                                                Unstaf  Staffe
Service category                                   fed       d   Total
----------------------------------------------  ------  ------  ------
Administrative                                      26       1      27
Direct care                                          7       1       8
Patient support                                     41       4      45
======================================================================
Total                                               74       6      80
----------------------------------------------------------------------
Source:  Service chiefs provided this information between November
1997 and March 1998. 

In anticipation of the integration of the Lakeside and West Side
hospitals, vacancies created by attrition were left unstaffed with
the expectation that a smaller number of employees would be required,
according to the VACHCS director.  By eliminating unstaffed
positions, VACHCS minimized the hardship on currently employed staff. 

Second, employees from one hospital were transferred to the other
hospital.  VACHCS officials reported transferring about 29 employees. 
For example, 5 employees performing payroll functions were
transferred from West Side to Lakeside, and 10 employees performing
medical care cost recovery functions were transferred from Lakeside
to West Side. 

Third, employees will travel intermittently to each hospital to
perform work.  For example, 14 single chiefs of service told us they
will shuttle the 6 miles between the Lakeside and West Side hospitals
to perform their duties. 


      IMPACT ON MEDICAL SCHOOLS
---------------------------------------------------------- Letter :4.3

VACHCS integration appears to have had a positive impact on the
affiliated medical schools.  Clinical services, such as medicine,
surgery, and psychiatry remain unchanged.  These services and medical
education continue to be provided at both hospitals using the same
management structure and operating procedures.  However, educational
opportunities for residents and research opportunities for staff have
been enhanced in limited instances by integrating the two hospitals,
according to VACHCS officials.  For example, the goal of the new
joint deans' committee is to offer privileges to residents at both
hospitals.  This will provide affiliates with greater diversity in
their education and research programs. 


   INTEGRATION SAVINGS
------------------------------------------------------------ Letter :5

VACHCS officials estimated that integration decisions will result in
savings of several million dollars, although it is not possible to
estimate the full magnitude of savings at this time.  This is because
most savings involved reengineering decisions.  These savings, by
their nature, are difficult to estimate in terms of the extent of
efficiencies that will be realized. 


      MEASURABLE SAVINGS
---------------------------------------------------------- Letter :5.1

At present, VACHCS officials estimate that a savings of at least $4.9
million annually and about $2.25 million in one-time savings can be
attributed to the integration.  Most of the recurring savings
generated came from decisions to reengineer patient support services,
as table 5 shows. 



                          Table 5
          
             Estimates of Recurring Savings, by
             Service Category and Decision Type

Service        Unified  Reengineered  Consolidat
category    management      services        ions     Total
----------  ----------  ------------  ----------  --------
Administra    $228,990      $857,940           0  $1,086,9
 tive                                                   30
Direct         193,086       831,654      $2,000  1,026,74
 care                                                    0
Patient        446,534     2,357,669           0  2,804,20
 support                                                 3
==========================================================
Total         $868,610    $4,047,263      $2,000  $4,917,8
                                                        73
----------------------------------------------------------
Source:  Service chiefs provided this information between November
1997 and March 1998. 

Given that hospitals are service providers and are labor intensive,
most recurring savings generated came from eliminating personnel
positions.  Of the estimated $4.9 million, about $3.7 million of the
savings are attributed to eliminating 74 unstaffed positions and 6
staffed positions.  Other savings resulted from decisions such as
standardizing drug formularies and reducing the need for contracting
by performing activities in-house. 

The VACHCS integration generated one-time savings of about $2.25
million.  For example, the network director approved replacement of
only one angiography suite for VACHCS, resulting in a one-time cost
avoidance of $1.25 million.  In addition, VACHCS officials said that
by replacing only one of two cameras in the nuclear medicine service,
VACHCS avoided spending $500,000.  Furthermore, it refrained from
spending another $500,000 by sharing one computer system and thus
eliminating the need to upgrade a second system. 


      OTHER POTENTIAL SAVINGS
---------------------------------------------------------- Letter :5.2

VACHCS officials reported that the integration will likely lead to
additional savings but that the annual savings were not measurable at
this time.  For example, the Lakeside and West Side hospitals will be
jointly purchasing supplies and equipment.  VACHCS officials believe
that this joint purchasing will result in lower costs, but they were
unable to estimate the amount of the savings.  Overall, the officials
who reported nonmeasurable savings also indicated that the amounts
would be insignificant compared with the measurable savings. 


   AGENCY COMMENTS
------------------------------------------------------------ Letter :6

We provided copies of a draft of this report for review and comment
to VA, the University of Illinois College of Medicine, and
Northwestern University Medical School, and we received comments from
each of them.  These comments are summarized in the following
sections.  The comments in their entirety are in appendixes VI, VII,
and VIII, respectively. 


      DEPARTMENT OF VETERANS
      AFFAIRS
---------------------------------------------------------- Letter :6.1

The VHA Under Secretary for Health reviewed the report and
acknowledged that it will be of interest to the Great Lakes network
in its future planning as well as to other networks contemplating
integrations of their facilities.  In this regard, he noted that the
report will be provided for consideration in the planned contractor
study of health care delivery in the Great Lakes network.  This study
is being done in response to our recent report, VA Health Care: 
Closing a Chicago Hospital Would Save Millions and Enhance Access to
Services (GAO/HEHS-98-64, Apr.  16, 1998). 


      UNIVERSITY OF ILLINOIS
      COLLEGE OF MEDICINE
---------------------------------------------------------- Letter :6.2

The Dean of the University of Illinois College of Medicine commented
that our report accurately reflects the recent VACHCS integration
process and decisions to date.  He emphasized that future integration
recommendations are being evaluated by the deans' committee, which is
expected to assist VACHCS in realizing further operational
efficiencies, preserving high-quality care for U.S.  veterans, and
maintaining the educational and research environment afforded by the
VA health care system.  He noted that the goal of the new deans'
committee is to offer privileges to residents at both hospitals, thus
providing affiliates with greater diversity in their education and
research programs.  Finally, he stated that the deans' committee
should be given sufficient time to complete its work and have its
performance evaluated before future changes are considered.  He noted
that integration recommendations to unify management of, reengineer,
and consolidate the largest services, such as medicine, surgery, and
psychiatry, could be the most significant and most difficult to
accomplish.  These areas have yet to be considered by the deans'
committee. 


      NORTHWESTERN UNIVERSITY
      MEDICAL SCHOOL
---------------------------------------------------------- Letter :6.3

The Dean of Northwestern University Medical School commented that the
report accurately describes the VACHCS structure and integration
process.  He stated that the integration structure and process
allowed veterans, employees, health care providers, and affiliated
institutions an effective voice in the deliberations.  Collaboration
between the leadership of the affiliated medical schools and the
management of each facility has produced a more efficient health care
delivery system for veterans without sacrificing quality, he said. 
He provided assurance that as the joint deans' committee considers
and implements integration decisions on the remaining major services,
the issues of access and quality of care for veterans will be at the
forefront of its deliberations. 

The Dean highlighted a positive impact of the integration that
received brief mention in the report.  While the integration's
predominant goal of achieving cost savings has been and will continue
to be realized, the integration process has created a level of
cooperation between all involved institutions that is expected to
provide benefits to veterans' health care in Chicago for years to
come.  In addition, the integration process is building new
relationships between the two medical schools that could lead to
future collaboration on many levels.  Though nearly impossible to
quantify, these ancillary benefits are important, he said. 

Finally, the Dean commented that with respect to efficiencies and
cost savings, additional savings are expected to be realized as
decisions about major services are made.  He stated that a thorough
analysis of the integration process and its benefits cannot be done
until all integration decisions have been implemented and the
integrated facilities have had sufficient time to absorb the changes
and produce results. 


---------------------------------------------------------- Letter :6.4

As agreed with your offices, copies of this report are being sent to
the Secretary of Veterans Affairs, interested congressional
committees, and other interested parties.  Copies will be made
available to others upon request. 

Please contact me on (202) 512-7101 if you have any questions about
this report.  Other GAO contacts and staff acknowledgments for this
report are listed in appendix IX. 

Stephen P.  Backhus
Director, Veterans' Affairs
 and Military Health Care Issues


VA CHICAGO HEALTH CARE SYSTEM
INTEGRATION PROCESS
=========================================================== Appendix I



   (See figure in printed
   edition.)

Source:  Great Lakes network director. 


MEMBERS OF THE INTEGRATION
COORDINATING COMMITTEE
========================================================== Appendix II

Chairman: 

Chief of Staff, VA New Jersey Health Care System

Members: 

Dean, Northwestern University Medical School
Dean, Chicago Medical School
Dean, University of Illinois at Chicago College of Medicine
Dean, Loyola University of Chicago Stritch School of Medicine
President, Local 73, Service Employees International Union
Director, Advisory Council on Veterans Affairs, City of Chicago
Chief, Nursing Service, VACHCS, Lakeside division
Chief, Medical Administration, VACHCS, West Side division
Department Service Officer, Veterans of Foreign Wars
Chief, Medical Service, VACHCS, Lakeside division
Chief, Medical Service, VACHCS, West Side division
Chief, Engineering Service, VACHCS, Lakeside division
Nursing Education, Illinois Nurses Association Representative,
VACHCS,
 West Side division
Clinical Services Manager, Great Lakes network


SERVICES IDENTIFIED AS
ADMINISTRATIVE, DIRECT PATIENT
CARE, AND PATIENT SUPPORT
========================================================= Appendix III

                                    Services
Category                            ----------------------------------
Administrative                      Engineering

                                    Environmental management

                                    Information resource management

                                    Medical administration

                                    Police and security

Direct patient care                 Ambulatory care

                                    Anesthesiology

                                    Audiology and speech pathology

                                    Dental

                                    Diagnostic radiology

                                    Home-based primary care program

                                    Medicine

                                    Neurology

                                    Nuclear medicine

                                    Nursing

                                    Psychiatry

                                    Psychology

                                    Surgery

                                    Therapeutic radiology

Patient support                     Chaplain

                                    Education

                                    Library

                                    Nutrition and food

                                    Pathology and laboratory

                                    Pharmacy

                                    Prosthetics

                                    Research

                                    Social work
----------------------------------------------------------------------
Notes:  Payroll (administrative), recreational therapy (direct care),
and voluntary (patient support) services did not have work groups. 

The physical medicine and rehabilitation service (direct care) work
group did not provide a report by October 1, 1997. 


MEMBERS OF THE STAKEHOLDERS
ADVISORY GROUP
========================================================== Appendix IV

Chairman: 

Assistant Director, Illinois Department of Veterans Affairs

Members: 

Office of Senator Richard J.  Durbin
Office of Senator Carol Moseley-Braun
Office of Congressman Stephen E.  Buyer
Office of Congressman Danny K.  Davis
Office of Congressman Lane Evans
Office of Congressman Luis V.  Gutierrez
Office of Congressman Peter J.  Visclosky
President, Strategic Planning Analysts, Inc.
Executive Director, Vaughan Chapter Paralyzed Veterans of America
Chairman, Minority Veterans Steering Committee, Montford Point Marine
 Association
Associate Dean for Administration and Planning, Northwestern
University  Medical School
Director of Services, Disabled American Veterans
Senior Associate Dean, College of Medicine, University of Illinois at
  Chicago
National Service Officer, Paralyzed Veterans of America
Illinois Medical District Commission
Vice President for Planning, Northwestern Memorial Hospital


SERVICES DEFERRED TO JOINT DEANS'
COMMITTEE
=========================================================== Appendix V

                                    Services
Category                            ----------------------------------
Direct patient care                 Ambulatory care

                                    Anesthesiology

                                    Diagnostic radiology

                                    Medicine

                                    Neurology

                                    Nuclear medicine

                                    Physical medicine and
                                    rehabilitation\a

                                    Psychiatry

                                    Surgery

Patient support                     Education

                                    Pathology and laboratory

                                    Research
----------------------------------------------------------------------
\a This service was deferred to the joint deans' committee after the
ICC completed its work. 




(See figure in printed edition.)Appendix VI
COMMENTS FROM THE DEPARTMENT OF
VETERANS AFFAIRS
=========================================================== Appendix V




(See figure in printed edition.)Appendix VII
COMMENTS FROM THE UNIVERSITY OF
ILLINOIS COLLEGE OF MEDICINE
=========================================================== Appendix V



(See figure in printed edition.)




(See figure in printed edition.)Appendix VIII
COMMENTS FROM NORTHWESTERN
UNIVERSITY MEDICAL SCHOOL
=========================================================== Appendix V



(See figure in printed edition.)


GAO CONTACTS AND STAFF
ACKNOWLEDGMENTS
========================================================== Appendix IX

GAO CONTACTS

Paul Reynolds, Assistant Director, (202) 512-7109
Walter Gembacz, Senior Evaluator

STAFF ACKNOWLEDGMENTS

In addition to those named above, Lesia Mandzia and John Borrelli
collected and analyzed information about the status and impacts of
the integration recommendations.  Joan Vogel provided technical
support. 


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