100VA10NS10

Categories of individuals covered by the system:
The records include information concerning individual patients, veterans who have applied for care, their friends, their families, VA healthcare providers and members of the community. Members of the community include congressional liaisons, veterans service organizations and attorneys.

Categories of records in the system:
The records may include information maintained in paper records, and entered into the Veterans Health Information Systems and Technology Architecture (VistA), related to concerns and complaints regarding an individual's medical care, VA benefits, and/or encounters with healthcare facility personnel. The records include information that is compiled to review, investigate, and resolve these issues.

Authority for maintenance of the system:
Title 38, United States Code, chapter 73, section 7301 (b).

Purpose(s):
The records may be used for such purposes as producing various management and patient follow-up reports; responding to patient and other inquiries; conducting healthcare-related studies, statistical analysis, and resource allocation planning; providing clinical and administrative support to patient medical care; audits, reviews and investigations conducted by the staff of the healthcare facility, VISN, VHA Headquarters, and VA's Office of Inspector General (OIG); law enforcement investigations; quality improvement reviews and investigations; personnel management and evaluation; employee ratings and performance evaluations; employee disciplinary or other adverse action, including discharge; advising healthcare professional licensing or monitoring bodies or similar entities or activities of VA and former VA healthcare personnel; accreditation of a facility by an entity such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO); and, notifying medical schools of medical students' performance. The information is integrated into the overall quality improvement plans and activities of the facility and used to improve services and communications, as well as, to track categories of complaints and the locations of complaints in order to improve the delivery of healthcare.

Routine uses of records maintained in the System Including categories of users and the purposes of such uses:

1. Disclosure may be made to a Congressional office from the record of an individual in response to an inquiry from the Congressional office made at the written request of that individual.
2. Disclosure may be made to the National Archives and Record Administration (NARA) for records management inspections conducted under authority of Title 44, United States Code.
3. Disclosure may be made to the Department of Justice and United States Attorneys in defense or prosecution of litigation involving the United States, and to Federal agencies upon their request in connection with review of administrative tort claims filed under the Federal Tort Claims Act, 28 U.S.C. 2672.
4. Disclosure may be made to any facility regarding the hiring, performance, or other personnel-related information with which there is, or there is proposed to be, an affiliation, sharing agreement, contract, or similar arrangement for purposes of establishing, maintaining, or expanding any such relationship.
5. Disclosure may be made to a Federal agency or to a State or local government licensing board and/or to the Federation of State Medical Boards or a similar non-government entity which maintains records concerning individual employment histories or concerning the issuance, retention or revocation of licenses, certifications, or registration necessary to practice an occupation, profession or specialty, in order for the Department to obtain information relevant to a Department decision concerning the hiring, retention or termination of an employee or to inform Federal agencies, licensing boards or the appropriate non-government entities about the healthcare practices of employees who resigned, were terminated, or retired and whose professional healthcare activity so significantly failed to conform to generally accepted standards of professional medical practice as to raise reasonable concern for the health and safety of patients receiving medical care in the private sector or from another Federal agency. These records may also be disclosed as part of an ongoing computer-matching program to accomplish these purposes.
6. For program review purposes and the seeking of accreditation and/or certification, disclosure may be made to survey teams of JCAHO, College of American Pathologists, American Association of Blood Banks, and similar national accreditation agencies or boards with whom VA has a contract or agreement to conduct such reviews, but only to the extent that the information is necessary and relevant to the review.
7. Disclosure may be made to a State or local government entity or national certifying body which has the authority to make decisions concerning the issuance, retention or revocation of licenses, certifications or registrations required to practice a healthcare profession, when requested in writing by an investigator or supervisory official of the licensing entity or national certifying body for the purpose of making a decision concerning the issuance, retention or revocation of the license, certification or registration of a named healthcare professional.
8. Disclosure of information to the Federal Labor Relations Authority (FLRA) (including its General Counsel) when requested in connection with the investigation and resolution of allegations of unfair labor practices, in connection with the resolution of exceptions to arbitration awards when a question of material fact is raised, in connection with matters before the Federal Service Impasses Panel, and to investigate representation petitions and conduct or supervise representation elections.
9. Disclosure of relevant information may be made to individuals, organizations, private or public agencies, etc., with whom VA has a contract or agreement to perform such services as VA may deem practicable for the purposes of laws administered by VA, in order for the contractor or subcontractor to perform the services of the contract or agreement.
10. Disclosure may be made to a Federal agency, in response to its request, in connection with the hiring or retention of an employee, the issuance of a security clearance, the reporting of an investigation of an employee, the letting of a contract, or the issuance of a license, grant, or other benefit by the requesting agency, to the extent that the information is relevant and necessary to the requesting agency's decision on the matter.
11. Disclosure may be made to a Federal, State or local agency maintaining civil, criminal or other relevant information such as current licenses, if necessary to obtain information relevant to any agency decision concerning the hiring or retention of an employee, the issuance of a security clearance, the letting of a contract, or the issuance of a license, grant or other health, educational or welfare benefit.
12. Disclosure of information may be made to the next-of-kin and/ or the person(s) with whom the patient has a meaningful relationship to the extent necessary and on a need-to-know basis consistent with good medical-ethical practices.
13. A record containing the name(s) and address(es) of present or former members of the armed services and/or their dependents may be disclosed under certain circumstances: (1) To any non-profit organization if the release is directly connected with the conduct of programs and the utilization of benefits under Title 38 U.S.C.; and (2) to any criminal or civil law enforcement governmental agency or instrumentality charged under applicable law with the protection of the public's health or safety, if a qualified representative of such organization, agency or instrumentality has made a standing written request that such name(s) or address(es) be provided for a purpose authorized by law; provided that the record(s) will not be used for any purpose other than that stated in the request and that organization, agency or instrumentality is aware of the penalty provision of 38 U.S.C. 5701(f).
14. VA may disclose on its own initiative any information in this system, except the names and home addresses of veterans and their dependents, which is relevant to a suspected or reasonably imminent violation of law, whether civil, criminal or regulatory in nature and whether arising by general or program statute or by regulation, rule or order issued pursuant thereto, to a Federal, State, local or foreign agency charged with the responsibility of investigating or prosecuting such violation, or charged with enforcing or implementing the statute, regulation, rule or order. On its own initiative, VA may also disclose the names and addresses of veterans and their dependents to a Federal agency charged with the responsibility of investigating or prosecuting civil, criminal or regulatory violations of law, or charged with enforcing or implementing the statute, regulation, rule or order issued pursuant thereto.

Policies and practices for storing, retrieving, accessing, retaining and disposing of records in the system:

Storage:
Records are maintained on paper, magnetic tape, disk, or laser optical media. Information on automated storage media includes record information stored in the VistA system. In most cases, copies of back-up computer files are maintained at off-site locations.

Retrievability:
Records are retrieved by the names and social security numbers or other assigned identifiers of the individuals on whom they are maintained.

Safeguards:

1. Access to VA working and storage areas is restricted to VA employees on a ``need-to-know'' basis; strict control measures are enforced to ensure that disclosure to these individuals is also based on this same principle. Generally, VA file areas are locked after normal duty hours and the facilities are protected from outside access by the Federal Protective Service or other security personnel.
2. Access to VistA at healthcare facilities is generally limited by appropriate locking devices and restricted to authorized VA employees and vendor personnel. Peripheral devices are placed in secure areas (areas that are locked or have limited access) or are otherwise protected. Information in the VistA system may only be accessed by authorized VA employees and vendor personnel. Access to file information is controlled at two levels: the systems recognize authorized employees by series of individually unique passwords/codes as part of each data message, and the employees are limited to only that information in the file which is needed in the performance of their official duties. Information that is downloaded from VistA and maintained on personal computers is afforded similar storage and access protections as the data that is maintained in the original files. Access to information stored on automated storage media at other VA locations is controlled by individually unique passwords/ codes.
3. Data maintained at the AAC can only be updated by authorized AAC personnel. Access is limited to authorized employees by individually unique access codes that are changed periodically. Physical access to the AAC is generally restricted to AAC staff, VA Headquarters' employees, custodial personnel, Federal Protective Service and authorized operational personnel through electronic locking devices. All other persons gaining access to the computer rooms are escorted.

Retention and disposal:
Paper records and information stored on electronic storage media are maintained and disposed of in accordance with the records disposition authority approved by the Archivist of the United States.

System manager(s) and address:
Official responsible for policies and procedures: Program Manager, National VA Patient Representation Program (10NS10), VA Medical Center, 1900 E. Main, Danville, Illinois 61832. Officials maintaining the system: Director at the facility where the individuals made contact.

Notification procedure:
Individuals who wish to determine whether this system of records contains information about them should contact the VA facility location where they made or have contact. Inquiries should include the person's full name, social security number, date(s) of contact and return address.

Record access procedures:
Individuals seeking information regarding access to and contesting of records in this system may write, call or visit the VA facility location where they made contact.

Record source categories:
The patient, family members, and friends, employers or other third parties when otherwise unobtainable from the patient or family; Patient Medical Records--VA (24VA136); private medical facilities and healthcare professionals; State and local agencies; other Federal agencies; VISNs, Veterans Benefits Administration automated record systems (including Veterans and Beneficiaries Identification and Records Location Subsystem--VA (38VA23) and the Compensation, Pension, Education and Rehabilitation Records--VA (58VA21/22); and various automated systems providing clinical and managerial support at VA healthcare facilities.

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