Veterans Archives - Charles F. Mullen

Proposed Clinical Optometrist Qualification Standard (COQS)

Introduction

Despite notable advances in optometry clinical practice, board certification programs, specialization and advanced student and resident training, the Clinical Optometrist Qualification Standard (COQS) for appointment and promotion of VA optometrists has remained unchanged for 38 years. In addition, changes to state optometry licensing laws have accelerated since 1978 that have significantly expanded the patient care responsibilities of optometrists that recast their eligibility for optometry clinical privileges in the VA.

Drs Myers and Mullen, former VA Optometry Service Directors, sent a letter and the following draft of an updated COQS to the Secretary, Department of Veterans Affairs on March 27, 2017 which includes their key recommendation to incorporate the board certifications established by the profession of optometry in the past ten years by utilizing them as quantifiable, national benchmarks of clinical competence in both general and specialty optometry practice.

Proposed Clinical Optometrist Qualification Standard (COQS) (.doc)
Proposed Clinical Optometrist Qualification Standard (COQS) (.pdf)

Veterans Health Administration (VHA) Clinical Optometrist Qualification Standard (COQS) Needs to be Revised

The Proposal

Proposed Clinical Optometrist Qualification Standard (COQS) (.doc)
Proposed Clinical Optometrist Qualification Standard (COQS) (.pdf)

Background

Following the creation of the VHA Optometry Service (PL 93-541) in 1976, VHA optometrists were transferred from the Civil Service personnel system into the independent physician-dentist personnel-salary system utilized by VHA under the authority of Title 38 of the U.S. Code.

That transfer was delayed two years, until 1978, while a Clinical Optometrist Qualification Standard (COQS) was established specifying requirements for appointment-promotion of optometrists into the VHA personnel system.

That first COQS has been reissued many times since 1978 for changes in technical and administrative language but its written requirements for appointment-promotion have remained unchanged, word-for-word, as written in 1978 and are now 39 years old.

We believe those requirements must be brought up-to-date to reflect the significant changes that have taken place to the training, licensure, credentialing and clinical responsibilities of optometrists in the past 39 years.

Changes in the Optometry Profession

Since 1978 when the COQS was first issued, the clinical training, credentialing and patient care responsibilities of optometrists have expanded significantly.

The Veterans Health Administration has played, and continues to play, the leadership role in these changes through its establishing the first hospital training programs for optometry students and the first hospital residency training programs for optometry school graduates and its clinical teaching affiliations with the schools and colleges of optometry beginning in 1973. As those affiliations spread, a VA Optometry Service was established to recruit residency-trained optometrists as VA medical staff. Today, VA operates the largest optometry training program and optometry patient care system in the United States with over 700 full-time optometrists treating more than 1.4 million unique enrolled patients per year. Over seventy percent of optometry students now serve a VA extern rotation prior to graduation and VA residency programs have grown to 86 that train over 215 residents each year in the specialties of medical optometry and low vision rehabilitation.

We believe the VHA training programs for optometrists have become a national treasure that deserve better recognition and a new COQS.

Also since 1978:

Expansions in state licensing laws have significantly broadened the medical prescribing responsibilities of optometrists and standards which they must meet.

The appointment of optometrists to the medical staffs at Joint Commission accredited federal and state health organizations, authorized in 1986, requires optometrists be credentialed following the same process and standards as physicians and dentists and has, along with VHA, fostered the specialty of hospital optometry practice.

Board certification programs have more recently become available for credentialing optometrists in general practice and the specialty of medical optometry. At this time there are three recognized, independent national board certifications available for credentialing and each has a companion Maintenance of Competence programs (two for general practice, one for the specialty of medical optometry).

Medical optometry and low vision rehabilitation training that originated within VA residency training programs have emerged as optometry specialties. While once there were no optometry specialty residency programs, today 24% of optometry school graduates elect to serve a specialty residency accredited by the American Council on Optometric Accreditation, and VHA operates the great majority of those specializing in medical optometry or low vision rehabilitation (for example VICTORS and Blind Rehabilitation centers).

Current COQS Must Be Updated

As a result of these significant changes to optometry training and the rise of specialization and Board Certification credentialing (attributable, to a large degree, to the VA) cited above, the Clinical Optometrist Qualification Standard (COQS) issued 39-years ago in 1978 no longer reflects current optometry training, credentialing and patient responsibilities; especially of those optometrists practicing within VA medical facilities.

For example, today’s optometrists are held to the same standards of care required of physicians providing that same care.

In addition, VA and other Joint Commission accredited facilities now utilize the same application-credentialing review committees once only used to credential physicians and dentists and the Centers for Medicare and Medicaid hold optometrists to the same credentialing standards by placing them within its group of “Medicare Physicians”.

The 1978 COQS paid little attention to optometry residency training (1), expanded state licensing laws and board certifications in general and specialty optometry practice did not then exist.

We believe an updated COQS furthers the appointment and promotion of only well qualified, board eligible and board certified optometrists to Senior and Chief Grades and meets current standards of best-practices and credentialing. It also requires supervision/mentoring of inexperienced junior-grade (Associate and Full Grade) optometrists entering VHA service.

This supervision of junior-level optometrists is very important for the maintenance of one-level-of-care since eye patient presentations at VHA eye clinics are typically more prevalent, serious, complex and organic in cause than those encountered in private practice and, in our experience, recent graduates without hospital residency training are not fully prepared for hospital practice; to provide patient care unsupervised; to understand hospital procedures; or facilitate the close cooperation between disciplines required for appropriate, timely referrals and co-management of VA eye patients.

It was for these reasons that VHA optometry residencies were created in 1975 to prepare optometrists to practice within medical facilities as a member of their medical staffs.

Recommendations

Revise the 1978 COQS written requirements for appointment/promotion to the five levels of clinical patient care and teaching responsibility because their wording has remained unchanged since first issued in 1978 and are now seriously dated.

A suggested new COQS utilizes national clinical board certifications adopted by the profession for benchmarks of clinical competence for general and hospital optometry practice; requires supervision of inexperienced junior optometrists and adds other proxies for competence not available in 1978 that include Diplomate status in the American Academy of Optometry and/or election to other learned optometry societies.

This model COQS is more rigorous and specific to the unique demanding requirements for optometrists serving as VHA medical staff members.

Notes

(1) Optometry hospital residency training programs did not exist in our profession until VA created them in 1975 followed by VA residencies in low vision rehabilitation, both highly important to VHA patient care. The 1978 COQS could not foresee the importance these specialty residents would have to VHA patient care.

(2) Changes to the COQS since 1978 have been limited to only technical and conforming administrative updates while its standards for each clinical grade have remained identical for 39 years.

(3) The 1978 COQS had insufficient provisions for recognition of future credentialing of optometry specialists, which have three levels of credentialing; 1.Completion of residency training, 2. Passage of a national specialty examination, 3.Specialty board certification. Stages 2 and 3 did not exist in 1978.

(4) VA was first to establish a hospital optometry residency program and led the development of it and other optometry specialties in the profession.

(5) VASF 171, OMB #2900-0205. (Application for VHA appointment).

(6) It is highly recommended that in the future, passage of specialty examinations and specialty board certifications become one necessary qualification for appointment/promotion to Senior and Chief Grades respectively.

Proposed Clinical Optometrist Qualification Standard (COQS) (.doc)
Proposed Clinical Optometrist Qualification Standard (COQS) (.pdf)

Charles F. Mullen, O.D.
Director, Optometry Svc.
1990-96

Kenneth Myers, Ph.D., O.D.
Director, Optometry Svc.
1974-89

New England College of Optometry’s Tribute to the Department of Veterans Affairs Optometry Service (Video & Transcript)

Thank you President Scott for your gracious remarks.

I am deeply honored to be awarded the New England College of Optometry’s Presidential Medal in recognition of my tenure as Director of the VA Optometry Service.

It is also a distinct privilege to join my distinguished colleagues and long time friends — Drs. Myers and Haffner in this evening’s tribute to the VA Optometry Service.

As an educator, I am grateful to the VA for its enormous contribution to the clinical training of this country’s optometry students and residents.

And as a veteran I am most appreciative of the excellent eye care VA optometrists provide each year to over one million of our most deserving citizens, the Nation’s veterans.

The comprehensive eye care provided to veterans by VA optometrists in collaboration with ophthalmologists is clearly among the best in the United States.

Optometry clinics are among the busiest of VA services, providing 1.5 million eye care visits annually.

The VA Optometry Service was the first in the country to develop and implement an effective model of interdisciplinary eye care in a large national system.

VA optometrists lead the profession in the management of patients with age related macular degeneration, diabetic retinopathy and glaucoma.

Prestigious professional journals are replete with publications by VA optometrists affirming VA’s leadership in advancing ophthalmic care.

During my tenure as Director, I witnessed the growing importance of VA optometry in the provision of primary eye care and low vision rehabilitation services.

However, my experience pales in comparison to the dramatic increase, over the past 12 years, in optometry staff, students and residents including numerous quality improvement initiatives.

The VA’s Eye Care Quality Improvement Program is recognized as one of the most comprehensive and effective in health care.

It is a unique system of checks and balances.

For overall guidance, the VA adopted the clinical practice guidelines of the American Optometric Association and the American Academy of Ophthalmology, the recognized standards for both professions.

The VA’s clinical credentialing and privileging process is precise and meticulously applied ensuring that every clinician’s education, clinical training and licensure are appropriate for the clinical privileges granted.

A robust system of clinical reviews, practice evaluations and peer review programs ensure that every veteran receives the highest quality eye care.

The quality, timeliness and seamless provision of eye care services by 675 VA optometrists and over 175 residents and fellows is now often cited as the gold standard for optometric care.

In addition to primary eye care, optometrists provide rehabilitative care in VA special programs such as low vision clinics, VICTORS programs and blind rehabilitation centers.

65 additional low vision optometric specialists have been appointed in recent years and placement of mid level and advanced low vision programs, in each of the 21 nation-wide VA Integrated Service Networks, is planned.

The Department of Defense-VA, Center of Excellence is an outstanding program for the management of servicemen and women who have sustained significant eye injuries as well as vision problems resulting from traumatic brain injury. At this center, optometrists, ophthalmologists and rehabilitation specialists ensure seamless transition for the patient from military service to the VA.

The innovative Boston VA based Teleretinal Imaging Program has already assessed 700,000 veterans for the risk of vision threatening disorders. Another example of optometry’s leadership and of effective collaboration among eye care providers, primary care physicians and IT personnel.

A special note of acknowledgement to my VA colleagues for your commitment to excellence in eye care and for your dedicated service to our Nation’s Veterans.

Thank you for recognizing my service as Director. It was an honor to have served with so many outstanding optometrists.

Changes in the Department of Veterans Affairs and Their Implications for Optometric Education

In the coming years the veterans’ health care system will be affected by powerful societal and health care industry dynamics. These factors will influence the manner in which the VA accomplishes its mission and they provide the context in which it must operate.

My discussion of the future of the veterans’ health care system is based on the following assumptions:

The role of the federal government in American society will continue to be reevaluated, and competition for federal government funding will become even more intense.
Most health care in the United States will continue to be provided by the private sector.
There will continue to be marked turmoil among and consolidation of medical groups, hospitals, health maintenance organizations, and other elements of the private sector.
Managed care within integrated delivery systems will become the most common mode of health care delivery in the United States.
Medical and scientific information will continue to grow at an astonishing rate.
Technological innovations will continue to revolutionize clinical practice. In addition, the trend of providing care in nonhospital settings will continue, and even accelerate, as concern about health care costs continues.
Advances in information and communication technology, and imaging systems in particular, will open up many new opportunities for improving the delivery of health care.
Integrated information systems will be the key to success for future health care systems.
Nonphysician providers will be increasingly used in health care systems of the future.
Health care organizations will be increasingly expected to prevent disease and promote community wellness, in addition to treating individual cases of illness.
There will be increased demand for accountability in health care and increased emphasis on health care outcomes and measurements.
While the rate of increase of health care costs has diminished in recent years, health care costs will continue to be a major driving force in the industry. Nonetheless, quality of care and customer service will become more important issues.
The veteran population eligible for care at VA facilities will continue to age and decrease. However, the need for both acute and long-term care services for this aging population will rise disproportionately to the decrease in users due to greater health care needs associated with aging.
In addition to the “macro” issues, there will be local and regional dynamics impacting individual VA facilities and networks.

In envisioning the veterans’ health care system of the 21st century, it is assumed that the future is unpredictable and that the VA must be flexible enough to rapidly respond to unforeseen circumstances.

The mission of the veterans’ health care system is to serve the needs of America’s veterans by providing specialized care for service-connected veterans, primary care, and related medical and social support services.

To accomplish its mission, the Veterans Health Administration (VHA) should be a comprehensive, integrated health care system that provides excellence in health care value, excellence in service as defined by its customers, and excellence in education and research. It also should be an organization characterized by exceptional accountability.

There are numerous changes underway in the VA which specifically affect optometric education and they present both challenges and opportunities – opportunities for significant gains if optometric institutions are proactive and significant losses if they are passive. The VA is currently:

Reengineering the operational and management structure of the veterans health care system.
Implementing the Veterans Integrated Service Network (VISN) management structure. This new structure has resulted in a shift of operational control and some policy development to the local level.
Management Assistance Councils consisting of external advisors are either operational or being established in all Networks.
Restructuring VHA headquarters.
Implementing multidisciplinary “service line” rather than discipline-specific clinical care in recognition of the Transdimensional nature of health care today. Optometry and ophthalmology have been placed in the HQ Primary and Ambulatory Care Strategic Health Group forming the eye care program. This is likely to be emulated in VA field facilities.
Standardizing clinical processes (e.g., with nationally developed clinical guidelines) and delegating clinical care responsibility to nonphysician providers.
Exploring ways of improving the accessibility, quality, and cost-effectiveness of VA’s special emphasis programs, e.g., VICTORS.
Increasing the proportion of the VA’s work force providing primary care.
Developing tailored training/retraining programs in primary care.
Reducing the variation in professional staffing that exists among facilities and services having similar missions and work loads.

Although we may experience reductions at certain facilities, overall continued growth in optometry is projected. Since 1990, VA Optometry Service has added 86 FTEE staff and residents. This growth has facilitated our involvement in the following activities:

Increased sharing of activities with academic affiliates and the Department of Defense.
Promoting a VHA culture of ongoing quality improvement that is predicated on providing health care value.
Establishing a VA clinical “Centers of Excellence” program to celebrate and disseminate best practices and to foster studies that identify organizational characteristics that lead to performance excellence.
Promulgating customer service standards and ensuring that they are known by both staff and patients, e.g., 30 days maximum wait for eye care.
Decreasing waiting times for appointments. Although reduced from over 100 days in 1990 to the current level of 47, it still is far from acceptable.
Ensuring the VHA’s educational offerings emphasize areas of greatest societal need and are responsive to the needs of veterans today and in the future.
Convening Residency Realignment Advisory Committees for physicians and other health professionals to provide guidance in ensuring the VA’s postgraduate training programs are responsive to the needs of the VA and the nation. Possible overall reduction in optometry positions could result from general downsizing. Also, the lack of formal requirements for optometric residency training increases the vulnerability of the program. Most likely there will be a reduction in multiple resident placements.
Increasing the proportion of trainees in primary care disciplines.
VA facilities are reevaluating their affiliation(s) in light of VHA’s restructuring and vision of the “new VA,” and the present educational role of VA. Affiliation agreements should defend the prerogatives of VA, control the use of VA resources, and protect the interest of VA patients.
Initiating review and renegotiation of all academic affiliation agreements.
Reassessing the role and function of Deans Committees in light of today’s changed health educational environment and effect changes where needed.
Academic affiliations and residents are likely to be negotiated on a Network basis.
Clinical credentialing and privileging will probably be conducted on a Network basis.

The VA’s Current Contributions to Optometric Education

There are currently 155 academic affiliation agreements at 103 facilities. Five hundred thirty optometry students annually rotate through VA facilities. Seventy-five residents and 9 WOC are currently funded at 44 program sites. A significant increase in requests for “without compensation placements” (WOC) has been noted. There is a potential of 400,000 annual clinical teaching encounters. Research opportunities abound with currently over 7.0 million in funded optometric research.

There is a corps of well-qualified clinical preceptors with some VA optometrists released to teach at affiliates. VA clinicians are also active contributors to the literature and national continuing education programs.

What Can Individual Schools and Colleges Do to Preserve VA Affiliations?

Above all, be an active partner.
Assist VA facilities with Quality Improvement activities.
Assist VA facilities in improving staff productivity and reducing waiting times for appointments. Low productivity will likely result in loss of residency funding and possibly staff FTEE. Chronic long waiting times could result in local frustration and contracting out to commercial providers. This is already a reality in one Network.
Seek appointment of school-based optometric faculty as consultants at VA facilities.
Enter into contractual “sharing’ arrangements, e.g., VICTORS, Eye Care Centers of Excellence.
Seek appointments to Network Management Assistance Councils. Already, Drs. Haffner, Hopping, and Walls have been appointed and I have received positive feedback on their contributions.
Increase awareness of VA affiliations by publicizing your institution’s activities.
Seek new academic affiliations within your Network.
Prepare thoroughly for COE accreditation visits and address problems before COE visits. Less than full accreditation will likely result in loss of VA funding.
Seek cooperative research projects with VA affiliates.
Consider WOC residency programs as a means to initiate new programs.
Understand the new JCAHO accreditation standards and survey process and their implications to optometry.

What Can ASCO Do Collectively?

ASCO should implement the recommendations agreed to in the 1992 AOA/ASCO/NAVAO Strategic Plan. For example:

In cooperation with the VA, assist in the development of and implementation of a system wide Total Quality Improvement Program.
Improve management of affiliations programs by: participation on Network Management Assistance Councils. (Originally the Deans’ Committees.)
Stimulate research proposals in cooperation with VA medical centers.
Review faculty appointment procedures and benefits for VA preceptors and enhance them wherever permitted by institutional governance.
Residency expansion in VA should be carefully managed to assure well-balanced clinical educational programs nationwide.
ASCO should endeavor to publicly promote its relationship with the VA, increasing positive support of VA activities and accomplishments and increasing the public and the government’s knowledge of optometry.
Monitor affiliations through the ASCO Committee on Residencies and Externships and through COE reports.

This is a time of great change in the VA. It presents many challenges, but also many opportunities. The shift of control to the Networks (local) level makes it more important than ever that every affiliated optometric institution be an active partner with its VA affiliated facilities and Network leadership. There is the possibility for significant gains if there is local initiative and likewise the possibility for significant losses if the schools and colleges of optometry are inactive.

At the time this article was written, Dr. Mullen was Director of the Optometry Service, Veterans Health Administration. This article is based on the VA’s new strategic plan entitled Prescription for Change. Dr. Mullen is currently the president of the Illinois College of Optometry.

The Journal of the Association of Schools and Colleges of Optometry.
Optometric Education, Volume 22, Number 3. Spring 1997.
Charles F. Mullen, O.D.