AYM1 SERVICE PLAN BRIEF

Service Plan Brief for

Ophthalmology Services

Andrea Cox BSN, RN

Western Governors University

Pattie Sunderhaus, DNP, EdD, MS, RN

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AYM1 SERVICE PLAN BRIEF

Service Plan Brief for Ophthalmology Services

Service Idea

The proposed service plan is the initiation of Ophthalmology services at the Beckley, WV

VA Medical Center. This plan will significantly increase the complexity and volume of clinical

workload both in the outpatient clinic setting and the Operating Room.

The addition of an ophthalmologist will expand the eye clinic services by providing the

ability to perform ocular surgeries including but not limited to cataract surgery, glaucoma

surgery, and basic oculoplastic treatment. Additional benefits of access to a staff

ophthalmologist include increased diagnostic and treatment capacity as well as increased

availability of eye care personnel to treat emergent conditions.

The chief reasons for adding an ophthalmologist to the eye clinic staff are (1) to increase

the number of eye care services provided to the local veteran population, (2) to provide services

to veterans who must otherwise obtain those services from sources either outside the VA

system or at locations that are great distances from their homes, (3) to reduce the significant

wait times presently experienced due to poor availability of those services, and (4) reduce the

amount of money flowing out of the VA system via Care in the Community, and other sources

by establishing the ability to perform those services within the Beckley VAMC.

Care in the Community poses many problems with continuity of care. Tracking initial

referrals are difficult, following up care aftercare was received, and accessing outside records.

This creates reluctance of VA providers to refer Veterans to Care in the Community (Nevedal et

al., 2019).

In FY 2010 the Beckley VAMC spent $1,055,863 on community sourced eye care. In FY

2020 the number rose to $2,029,769. The increase between 2019 and 2020 was the result of

many factors including cost of care increases and an increase in the number of patients

examined at the hospital. However, a significant portion of the increase was due to the no

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AYM1 SERVICE PLAN BRIEF

availability of secondary VA hospitals to receive Beckley patients. Cataract patients were

traditionally referred to Salem, Durham, and Clarksburg VAMCs. Due to ever-increasing

backlogs at those locations, they were forced to stop receiving cataract referrals from Beckley,

thus forcing our facility to utilize community resources. Further, the closure of the Salem retina

clinic and the severe backlog at the Durham retina clinic again forced Beckley to refer its retina

patients to community providers.

It is evident that by providing at least some of those services at the Beckley VAMC, a

large amount of money will be retained within the facility rather than being channeled to non-VA

facilities.

The addition of an ophthalmologist to the Beckley VAMC staff will improve the quality of

care and provide multiple benefits to the veteran population. These include but are limited to

the following:

Vastly increased access to care. At present, the delay in receiving cataract surgery is

greater than 90 days. This delay is caused by the severe backlog or even no availability of

cataract surgery at the traditional referral facilities. Also, many of the local providers to whom

patients are referred have a substantial backlog, often reaching three or more months. The

ability to provide cataract surgery at this facility will reduce the backlog to only weeks. The

benefits of increased access to care are obvious to veterans, the hospital, the VISN, and the

greater Veteran's Administration.

Reduced travel requirement for veterans. Presently the nearest VA medical center with

the potential to provide cataracts and other surgeries is located four hours from Beckley

(Durham VAMC; presently not accepting cataract patients from Beckley). Providing cataract

surgeries at this location will significantly improve patient safety and satisfaction.

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AYM1 SERVICE PLAN BRIEF

Increased knowledge base for the Beckley eye clinic. Adding an ophthalmologist to the

eye care staff will have the inherent benefit of bringing additional knowledge and experience to

the clinic, resulting in a broader base of understanding from which to make accurate diagnoses

and provide appropriate treatments. This naturally will also serve to increase patient safety and

satisfaction.

Market Analysis

Target population:

The Beckley VA Medical Center currently services approximately 12,000 Veterans within

8 counties in West Virginia.

The increasing enrollment of Vietnam-era Veterans is resulting in an increased incidence

of age-related eye and vision conditions. Age-related macular degeneration (AMD), diabetic

retinopathy, and glaucoma are major causes of visual impairment and blindness. In younger

Veterans, trauma (both military and non-military) is a frequent cause of eye/vision problems.

Accordingly, Veterans need cost-effective, readily accessible, and comprehensive eye and

vision care services (United States Department of Veterans Affairs, 2019a).

Potential referral bases:

The goal of adding Ophthalmology services at the Beckley VA Medical Center is to

become a referral hub for Veterans in need of cataract surgery from other VA facilities within

West Virginia. Once these referral patterns are established and successful the Beckley VA can

become a referral source for other VA facilities outside of the VISN but within a 1–2-hour drive

time for the Veteran.

Potential competitors for planned service:

Currently, the competitor for the planned service is the Veteran's choice to use Care in

the Community if they meet one of the six eligibility requirements. However, the Veteran may be

assessed a co-pay based on their eligibility, income on file in the VA health care system, or

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AYM1 SERVICE PLAN BRIEF

whether the condition they were seen for is related to a service condition rated 10% or higher.

This alone could be a deterrent to the use of Care in the Community (United States Department

of Affairs, 2021).

SWOT Analysis

Strengths Weaknesses
Executive Leadership support Physician Recruitment (Surgical sub-
specialists)
Highly experienced OR staff Space

Highly functioning sterile processing service Budget

Robust Optometry program Lack of access at other VISN facilities that

have Ophthalmology services

Opportunities Threats
VISN referral center for Ophthalmology Physician Recruitment (Surgical sub-
specialists)
Increase in VERA funding and third-party Rural community
reimbursement
Decrease Care in the Community costs Recruitment of certified ophthalmology
technicians
Decrease travel time for Veterans Budget

The SWOT analysis is used to identify internal strengths and weaknesses and external

opportunities and threats. This information is used to determine the strategies the facility should

pursue. The facility can respond either offensively or defensively to the results by developing

strategies that capitalize on external opportunities, minimize the impact of potential threats, take

advantage of strengths, and/or improve on weaknesses (Davis et al., 2019).

To maximize the opportunities, adding in-house Ophthalmology services will vastly

increase access to care. At present, the delay in receiving cataract surgery is greater than 90

days. This delay is caused by the severe backlog or even no availability of cataract surgery at

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AYM1 SERVICE PLAN BRIEF

the traditional referral facilities. Also, many of the local providers to whom patients are referred

have a substantial backlog, often reaching three or more months. The ability to provide

cataract surgery at this facility will reduce the backlog to only weeks. The benefits of increased

access to care are obvious to veterans, the hospital, the VISN, and the greater Veteran's

Administration.

Also, it will reduce travel requirements for veterans. Presently the nearest VA medical

center with the potential to provide cataracts and other surgeries is located four hours or an

average of 191 miles one way from Beckley, WV.

The costs of referrals to the community will decrease drastically. In fiscal year (FY) 2019

the Beckley VAMC spent $1,055,863 on community sourced eye care. In FY 2020 the number

rose to $2,029,769. The increase between 2019 and 2020 was the result of many factors

including cost of care increases and an increase in the number of patients examined at the

hospital. However, a significant portion of the increase was due to the no availability of

secondary VA hospitals to receive Beckley patients. Cataract patients were traditionally

referred to Salem, Durham, and Clarksburg VAMCs. Due to ever-increasing backlogs at those

locations, they were forced to stop receiving cataract referrals from Beckley, thus forcing our

facility to utilize community resources. Further, the closure of the Salem retina clinic and the

severe backlog at the Durham retina clinic again forced Beckley to refer its retina patients to

community providers.

It is evident that by providing at least some of those services at the Beckley VAMC, a

large amount of money will be retained within the facility rather than being channeled to non-VA

facilities. Besides, for each patient seen within the facility who is vested, the facility receives a

certain dollar amount for that patient based on the Veterans Equitable Resource Allocation

(VERA) system.

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AYM1 SERVICE PLAN BRIEF

To mitigate threats the facility will work with a national recruiter to obtain resumes for

Ophthalmologists and technicians. Also, the job postings for the Ophthalmologist and

Ophthalmic technician were revised to include the tourism opportunities West Virginia has to

offer.

Regarding the budgetary threats, the return on investment for keeping the care within

the VA is approximately $8,552,397 after personnel and non-personnel costs for the first-year

projection.

Service Plan Feasibility

Cost-Benefit Analysis

Category Description of the Service Plan Costs

The Organization Salary Costs
Equipment Costs
Space Renovations
Operations Travel pay to Veterans
The clinic, OR, and SPS supplies
Additional office supplies
The Time away from work
Client/Patient Co-pays, if applicable
Prescription costs
The Staff Uniforms
Licensure
Health Insurance
Technology Increased IT support
Additional network connections
Additional computers/printers

Category Description of Service Plan Benefits

The Organization Increased VERA funding
Decreased Care in the Community costs
Distinguished center for referrals
Operations Improved patient outcomes
Improved patient satisfaction
Improvement in performance measures related to
access
The Client/Patient Improved patient experience
Improved access to care
Less travel time

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The Staff Improved employee satisfaction

Opportunities for training and education to broaden the
knowledge base
Participation in invasive procedures outside of the
operating room
Technology EMR that can be accessed across all VA facilities
nationally
Gold standard equipment that feeds images and results
directly into the EMR
Equipment with built in patient safety mechanisms to
prevent patient harm

Risk Assessment

Overall Results and Strategies for Minimizing the

Risks
Cost disposable
instruments versus
reusable instruments
Recruitment of an
Ophthalmologist
Wrong-site surgery (i.e.
wrong eye for cataract
surgery, a wrong
intraocular implant placed
on the wrong eye)
Appropriate labeling and
storage of ophthalmic
medications in the clinic
setting
Incorrect intraocular lens
calculations
Risks
Results of Risk Assessment: Low Risk, High Volume
Strategies for mitigation: Disposable instruments result
in less use of equipment and supplies and manpower
needed to reprocess reusable instruments through the
Sterile Processing Services.
Results of Risk Assessment: High Risk, Low Volume
Strategies for mitigation: The job posting for the
Ophthalmologist will be revised to include the tourism
opportunities West Virginia has to offer. Also, the facility
will work with a national recruiter to obtain resumes for
Ophthalmologists.
Results of Risk Assessment: High Risk, High Volume
Strategies for mitigation: For Intraocular Lens Implants a
modified policy to ensure double-check of preprocedural
calculations and implant read-back (Neilly et al., 2018).
Results of Risk Assessment: High Risk, High Volume
Strategies for mitigation: Pre-made labels with an open
and expiration date will be purchased and a hospital-grade
medication refrigerator placed in the clinic for appropriate
medication storage.
Results of Risk Assessment: High Risk. High Volume
Strategies for mitigation: Purchase of auto-calculating
lensometer that removes the factor of human error.

Financial Projections

Approximately 90% of the budget for the VA is funded through the Veterans Equitable

Resource Allocation (VERA) system. This system assigns a specific dollar amount that the

facility will receive per vested patient each year for 3 years. This dollar amount is determined

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based on specific diagnoses and where they fall on the VERA hierarchy. The other 10% is

received through 3rd party billing or private insurance.

Visual impairment diagnoses place patients in price group 4 on the VERA 2020 Patient

Classification Hierarchy (Advanced Appropriation Prices. Based on the enrollment priority group

the patient is placed in the facility can receive $13,752 to $15,643 per vested patient each year

for 3 years (United States Department of Veterans Affairs, 2020). This data will be utilized to

project financial revenue since it accounts for 90% of the annual VA facility budget.

The number of patients sent through Care in the Community for cataract surgery during

FY19 was 322 patients and 486 in FY2020. There is a projected 34% increase for FY2021,

totaling 651 patients.

Based on the VERA price groups stated above, the first-year projection for

reimbursement by adding Ophthalmology services would be approximately $8,952,552 to

$10,183,593 depending on the priority group.

vera reimbursement projections

VERA Reimbursement

$14,947,357

$12,174,945

$9,568,072

1-year Projection 2-year Projection 3-year Projection

There is an estimated 25% increase for the two- and three-year projections compared to

the 34% increase for the one-year projection due to the aging Veteran population.

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AYM1 SERVICE PLAN BRIEF

Patients needing Ophthalmology Care

Number of Patients

3-Year Projection 1017

2-year Projection 814

1-year Projection 641

Operational Expense Budget

Category Description of Each Type of Expense

Personnel Expenses (1) Ophthalmologist with an average salary of $270,900
(2) Ophthalmic Technician with an average of $43,313
(2) OR Registered Nurses with an average salary of $71,490
(1) Sterile Processing Technician with an average salary of $32,200
Other-than-Personnel Surgical Equipment $250,787
(OTP) Expenses Outpatient Clinic Equipment $209,245
Sterile Processing Equipment $ 22,937
(Salary.com, n.d.)

Expenses

Non-Personnel;
482969; 48%
Personnel; 532706;
52%

Personnel Non-Personnel

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AYM1 SERVICE PLAN BRIEF

Key Performance Indicators (KPIs)

Service Plan KPIs Measurement and Frequency

Structure: The OR nurse manager will monitor the number of

10 cataract surgeries per week for the firstcataract cases every week. Fallouts will be analyzed
8 weeks, increasing in increments of 10 for trends, with actions developed to address any
every 8 weeks until 30 surgeries per week identified trends. This information will be reported to
are performed. the Chief of Surgery who will report weekly to
Executive Leadership via morning report.
Process: Ophthalmology clinic wait times will be monitored by
Ophthalmology clinic wait times will the Specialty Clinic nurse manager every week
remain 30 days or less from the creation using the Appointment Cube through VSSC. Outliers
date. will be addressed by the development of actions to
sustain improvement. This information will be
reported to the Chief of Specialty Care who will
report weekly to the Executive Leadership via
morning report.
Outcome: The patient advocate will monitor the rating of
The rating of Surgical sub-specialty Surgical sub-specialty providers through SAIL every
providers (i.e., Ophthalmology) will remain quarter. If a decrease in the rating is identified the
in the 95th percentile within SAIL. patient advocate will report to the Chief of Specialty
care who will analyze the data to identify outliers.
Actions will be developed and monitored. This
information will be reported quarterly to the Quality,
Safety, Value Council.

The KPI for structure can guide future decisions related to OR utilization. Once analyzed

the data could show inefficiencies in the wheels into wheels out times for cataract cases, thus

creating barriers to the successful performance of the stated goal of 10 surgeries per week. This

data could be used to guide decisions for adding additional OR rooms or additional blocks of

time for ophthalmic surgical procedures.

The KPI for the process can guide future decisions regarding staffing. If clinic wait times

routinely exceed the 30-day threshold after the use of successful strategies, this information

could be formulated into a justification for adding Ophthalmologists and support staff. Adding

additional staff provides an increase in clinic availability, directly impacting clinic wait times.

The KPI for outcome guides future decisions regarding patient satisfaction with the new

program. If the patient's experience is negative, whether, in the clinic setting or the OR setting,

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the patient may refuse to receive their Ophthalmic care within the VA and resort to Care in the

Community. This negatively impacts the goal to decrease Care in the Community costs and

decreased the potential VERA reimbursement for that patient.

Strategies to improve staff performance and interprofessional collaboration are

discussed below.

Pay for performance can be tied to the overall rating of surgical sub-specialty

providers to remain in the 95th percentile or better. Pay for a performance motivates employees’

in-role task performance. It is a vital component of an organization’s compensation strategy.

Pay for performance increases individual and collective performance at the team, unit, or

organization levels (He et al., 2021). This performance measure is a result of surveys completed

by patients and employees. When incentivized and compliance in the 95th percentile or better

the interprofessional collaboration between the physician, patients, and coworkers improves.

Wait time measures are designed to help reduce the number of appointments with long

waits. SAIL reports new patient specialty care appointments completed within 30 days of

creation date (United States Department of Veterans Affairs, 2019b). A strategy to improve

clinic wait times is the implementation of Care Coordination Referral teams. These teams review

all referrals to determine if the appropriate diagnostic testing was ordered per the Care

Coordination Agreements. When these diagnostic tests are ordered and completed before the

surgical sub-specialty appointment, it eliminates the need for unnecessary return appointments

for test results. This improves clinic wait times by increasing clinic availability.

This strategy improves staff performance concerning productivity. Physician productivity

increases when they can see more new patient consults and perform surgeries in the Operating

Room because of efficient patient scheduling and improved clinic wait times.

Interprofessional collaboration is improved when care coordination agreements are

jointly developed and approved by providers across multiple services. These agreements when

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utilized as intended create a culture of collaboration and respect among physicians and

providers, eliminating silos and the lack of continuity in care.

Care coordination opens interprofessional communication that fosters conversations for

proactive strategies that prevent patient deterioration and unnecessary use of inappropriate

health services (Brooks et al., 2020).

Service Plan Start-Up Tasks and Timelines

Task Task Owner Timeline

Recruitment of a staff Ophthalmologist Chief of Surgery 6 months

Recruitment of certified Ophthalmic technicians RN Manager Specialty 6 months

Clinics
Recruitment of registered nurses for the OR RN Manager OR 6 months

Blueprint for space renovations Chief of Facilities 2 months

Management
Clinic supply needs list RN Manager Specialty 4 months
Clinics
Clinic equipment needs list RN Manager Specialty 4 months
Clinics
OR supply needs list RN Manager OR 4 months

OR equipment needs list RN Manager OR 4 months

Review of pending Care in the Community Chief of Care in the 2 months

Ophthalmology consults Community
Creation of clinic and OR schedules RN Manager Specialty 6 months
Clinics and OR

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Executive Summary

The chief reasons for adding an ophthalmologist to the eye clinic staff are (1) to increase

the number of eye care services provided to the local veteran population, (2) to provide services

to veterans who must otherwise obtain those services from sources either outside the VA

system or at locations that are great distances from their homes, (3) to reduce the significant

wait times presently experienced due to poor availability of those services, and (4) reduce the

amount of money flowing out of the VA system via Care in the Community, and other sources

by establishing the ability to perform those services within the Beckley VAMC.

The target population is the 12,000 Veterans served by the Beckley VA Medical Center

who need comprehensive eye care. The goal of adding Ophthalmology services at the Beckley

VA Medical Center is to become a referral hub for Veterans in need of cataract surgery from

other VA facilities within West Virginia and for other VA facilities outside of the VISN but within a

1–2-hour drive time for the Veteran. Currently, the competitor for the planned service is the

Veteran's choice to use Care in the Community if they meet one of the six eligibility

requirements.

The SWOT analysis determined initiating Ophthalmology services will vastly increase

access to care, reduce travel times for Veterans, decrease Care in the Community costs thus

increasing VERA funding by keeping the care within the VA system.

The benefits of the service plan significantly outweigh the costs associated. The plan will

decrease Care in the Community costs which will increase VERA reimbursement, which

occupies 90% of the facility's annual budget. The facility will benefit from improvements in

patient outcomes, patient experience, and performance measures related to access.

The major potential for risk associated with the proposed service plan is wrong-site

surgeries and incorrect intraocular lens calculations. These are high risk, high volume risks with

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AYM1 SERVICE PLAN BRIEF

mitigation strategies such as a modified policy to ensure double-check of preprocedural

calculations and implant read-back (Neilly et al., 2018) and purchasing of auto-calculating

lensometers that remove the factor of human error.

References

Salary.com. (n.d.). Salary Research.

https://salary.com/research

David, F. R., Creek, S. A., & David, F. R. (2019). What is the Key to Effective SWOT Analysis,

AQCD Factors. SAM Advanced Management Journal (07497075), 84(1), 25–35.

http://www.samnational.org
United States Department of Veterans Affairs. (2019a). VHA Directive 1121 Eye and Vision
Care.
https://www.va.gov/OPTOMETRY/docs/1121_D_2019-10-02.pdf
United States Department of Veterans Affairs. (2021). Community Care Copayments.
https://www.va.gov/COMMUNITYCARE/revenue_ops/copays.asp
United States Department of Veterans Affairs. (2020). Allocation Resource Center VERA 2020
Hierarchy.
https://vaww.arc.med.va.gov/reports/vera/vera2020/vera20_reports/
VERA20_AA_Hierachy.htm
Neily, J., Chomsky, A., Orcutt, J., Paull, D., Mills, P., Gilbert, C., Hemphill, R., Gunnar, W.
(2018). Examining Wrong Eye Implant Adverse Events in the Veterans Health
Administration With a Focus on Prevention: A Preliminary Report. Journal of Patient
Safety, 14(1), 49-53.
https://doi.org/10.1097/PTS.0000000000000170
He, W., Li, S.-L., Feng, J., Zhang, G., & Sturman, M. C. (2021). When Does Pay for

Performance Motivate Employee Helping Behavior? The Contextual Influence of

Performance Subjectivity. Academy of Management Journal, 64(1), 293–326.

https://doi.org/10.5465/amj.2018.1408

United States Department of Veterans Affairs. (2019b). Quality of Care.

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AYM1 SERVICE PLAN BRIEF

https://www.va.gov/QUALITYOFCARE/measure-up/SAIL_definitions.asp

Brooks, E. M., Winship, J. M., & Kuzel, A. J. (2020). A “Behind-the-Scenes” Look at

Interprofessional Care Coordination: How Person-Centered Care in Safety-Net Health

System Complex Care Clinics Produce Better Outcomes. International Journal of

Integrated Care (IJIC), 20(2), 1–10.

https://doi.org/10.5334/ijic.4734

Nevedal, A. L., Ellerbe, L. S., Wagner, T. H., Asch, S. M., & Koenig, C. J. (2019). A Qualitative

Study of Primary Care Providers’ Experiences with the Veterans Choice Program. JGIM:

Journal of General Internal Medicine, 34(4), 598.

https://doi.org/10.1007/s11606-018-4810-2

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