Veterans Health Administration (VHA) Numbered Administrative Issue Documents Program Guide

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1 Veterans Health Administration (VHA) Numbered Administrative Issue Documents Program Guide Department of Veterans Affairs Veterans Health Administration Office of Regulatory and Administrative Affairs 810 Vermont Avenue, N.W. Washington, DC 20420

2 Contents VHA Numbered Administrative Issue Documents Program Guide PARAGRAPHS PAGE 1. Informal Review Guide to the ORAA (10B4) Initial Substantive and Technical Review Guide to the Formal Concurrence Process Accelerated Concurrence Process Ensuring Appropriate Labor Management Relations (LMR) Review... 9 APPENDICES A. Justification for Proposed VHA Issue (VA Form )... A-1 B. Chief of Staff Briefing Note (VHA Form )... B-1 C. Basic Guidelines for 508 Compliance... C-1 i

3 1. INFORMAL REVIEW PROCESS: The informal review process for input from 10N, 10P, and 10A is optional. Program offices are encouraged to seek input from other offices informally as needed. 2. GUIDE TO THE ORAA (10B4) INITIAL SUBSTANTIVE AND TECHNICAL REVIEW PROCESS: a. Background. This is a guide to the initial substantive and technical review process that replaces the informal review process recommended in the February 2013 Policy Task Force Report. New or significantly revised policy documents may still be developed in accordance with the Task Force Report s pre-work recommendations. The initial substantive and technical review process should be used only after any prework development has occurred. NOTE: The initial substantive and technical review process should be conducted entirely through . Send requests to VHA CO 10B4 Actions. b. Purpose. The purpose of the initial substantive and technical preview process is to ensure adequate opportunity for review and comment before a document is put into VA s official e-concurrence system (VAIQ). The Task Force believed that this will reduce or eliminate problems including signatures becoming outdated; version control issues; and other complications and delays that arise when negotiating edits using the official system instead of using and other informal communications. c. Drafting and Section 508. Documents submitted to 10B4 for substantive and technical review need not conform fully to the requirements of Section 508. However, originating program offices are encouraged to be mindful of those requirements while drafting policy documents, and 10B4 will return to that office any document which is likely to require substantial additional work before it can meet those requirements. The originating program office will be responsible for obtaining certification of compliance from the Section 508 office for the version to be published. See paragraph 3.b.(4) below and Appendix C. d. Process. The review process is as follows: (1) Step 1. After appropriate pre-work development concludes (as the originating program office determines is needed, see above), the originating program office s the policy to VHA CO 10B4 ACTIONS. NOTE: If amending an existing policy, originating program office should communicate major changes. (2) Step 2. 10B4 reviews, suggests edits and comments and discusses incorporation of such edits or comments with originating program office. (3) Step 3. After 10B4 and the originating program office agree on a final version, 10B4 provides originating program office with a clean version of the policy document for the originating program office to put in formal concurrence. NOTE: There are no prescribed timeframes in which to conduct this initial substantive and technical review; however, 10B4 strives to complete this review within 20 business days. 1

4 VHA PROGRAM GUIDE April 8, 2015 FLOW PROCESS DIAGRAM FOR INITIAL SUBSTANTIVE AND TECHNICAL REVIEW PROCESS Originating VHA Program Office s policy document to VHA CO 10B4 Actions. Office of Regulatory and Administrative Affairs (10B4) reviews, suggests edits or comments, and works with PO to incorporate edits and comments. Office of Regulatory and Administrative Affairs (10B4) sends clean VAIQ ready version to originating Program Office. Originating Program Office proceeds to Formal Concurrence Process. 2

5 3. GUIDE TO THE FORMAL CONCURRENCE PROCESS: a. This is a guide to the formal concurrence process recommended in the February 2013 Policy Task Force Report. It should be used only after the policy document has been through the initial substantive and technical review process. The formal concurrence process must be conducted in the e-concurrence system (i.e., VAIQ). NOTE: If significant changes are made during formal concurrence from the VAIQ ready version prepared by 10B4 during the informal review process, the originating program office should advise 10B4 as soon as possible to minimize or avoid unnecessary delay in obtaining any re-concurrences that may be required. b. The review process is as follows: (1) Step 1 (Days 1-10). (a) Originating program office assigns the document concurrently to 10N and 10P. (b) 10N and 10P assign to affected subordinate offices, as needed. NOTE: Originating program office may make individual assignments to subordinate offices, but only 10N and 10P concurrences are mandatory. (c) 10N and 10P upload signed concurrence to VAIQ within 10 days after receipt of assignment. (2) Step 2 (Days 11-20). (a) Originating program office assigns the document to 10A. (b) 10A assigns to affected subordinate offices, as needed. NOTE: Originating program office may make individual assignments to subordinate offices, but only 10A concurrence is mandatory. (c) 10A uploads signed concurrence to VAIQ within 10 days after receipt of assignment. NOTE to Steps 1 and 2: 10A, 10N, and 10P must consolidate their respective subordinate office concurrences on one VA Form and ensure program office and subordinate offices concurrences are uploaded to VAIQ within 10 days after receipt of assignment. (3) Step 3 (Days 21-60). (a) Originating program office assigns the document to 10B4. (b) 10B4 reviews document and s the final, formatted version to originating program office for their approval (voting ). (c) Originating program office approves the final copy. 3

6 VHA PROGRAM GUIDE April 8, 2015 (d) 10B4 obtains formal concurrence from OGC (if determined necessary pursuant to OGC/VHA Memorandum of Agreement). (e) OGC uploads signed concurrence to VAIQ, after receipt of assignment within: (f) No less than 15 days after receipt of assignment for non-complex policy documents. (g) No less than 30 days for complex policy documents. NOTE: The originating program office, 10B4, and OGC will work through any resulting edits or comments. Depending on the changes required by OGC, the originating program office may need to request fresh concurrences from 10N, 10P, and/or 10A. (h) 10B4 assigns to LMR; LMR either: 1. Concurs. 2. Concurs with comments. NOTE: After USH signs, originating Program Office must send 10 copies of the signed policy to LMR. 3. Concurs with conditions. NOTE: Document will not be signed at mail call; USH will approve the document and it will be returned to originating Program Office, who will provide 10 copies of the unsigned document to LMR, who will engage in bargaining. (4) Step 4. (a) 10B4 s the final version of the document to the originating program office. (b) The originating program office completes 508 compliance requirements in accordance with VA Section 508 guidance (see Appendix C) and submits the document to the VA Section 508 office for verification. The program office must not make substantive changes to the document. (c) The Section 508 office will return the document and the conformance report to the originating program office. (d) Once the document is certified as 508 compliant, the program office sends the document and conformance report to 10B4 for final processing. (e) 10B4 concurs and presents document to Under Secretary for Health for review and/or signature (dependent on LMR concurrence). NOTE: If document is subject to bargaining, 10B4 will return assignment to originating program office, which will reassign to 10B4 after bargaining is complete. 4

7 FLOW PROCESS DIAGRAM FOR FORMAL CONCURRENCE PROCESS DUSH for Operations and Management (10N) and DUSH for Policy and Services (10P) Originating Program Office assigns to: 10N and 10P assign to subordinate offices STEP 1 Day: N and 10P concur Originating Program Office assigns to: Principal DUSH 10A 10A assigns to subordinate offices STEP 2 Day: A concurs Originating Program Office assigns to: Office of Regulatory and Administrative Affairs (10B4) 10B4 reviews document and s green sheet ( final version ) to originating program office for approval 10B4 alerts PO if OGC makes substantive changes or if LMR concurs with comments (FYI to union) or concurs with conditions (bargaining) Originating Program Office assigns to: Office of General Counsel (OGC) - 02 (if required) (15-30 days) 10B4 assigns to Labor Management Relations (LMR) 10B4 10B4 returns the final document to the originating program office for 508 compliance and verification VA Section 508 Office section508@va.gov STEP 3 Day: STEP 4 Under Secretary for Health Review / Signature 5

8 VHA PROGRAM GUIDE April 8, ACCELERATED CONCURRENCE PROCESS: a. This is a guide to the accelerated concurrence process recommended in the February 2013 Policy Task Force Report. It should be used only for existing policies that need to be recertified or amended with minor or merely technical changes. b. The review process is as follows: (1) Step 1 (Day 1-10). (a) Originating Program Office s a tracked changes version of an existing policy document that requires only minor or technical changes to the VHA CO 10B4 Actions. NOTE: 10B4 will return to the program office any document that, upon cursory review, will not comply with basic VHA Section 508 requirements. (b) 10B4 reviews legal authority to determine whether more significant changes are required. (c) 10B4 s VAIQ ready version of the document to the originating program office to begin formal review / concurrence within 10 days after receipt of request. (2) Step 2 (Days 11-15). (a) Originating program office assigns the document concurrently to 10N and 10P. (b) 10N and 10P assign to affected subordinate offices, as needed. NOTE: Originating program office may make individual assignments to subordinate offices, but only 10N and 10P concurrences are mandatory. (c) 10N and 10P upload signed concurrence to VAIQ within 5 days after receipt of assignment. (3) STEP 3 (Days 16-20). (a) Originating program office assigns the document to 10A. (b) 10A assigns to affected subordinate offices, as needed. NOTE: Originating program office may make individual assignments to subordinate offices, but only 10A concurrence is mandatory. (c) 10A uploads signed concurrence to VAIQ within 5 days after receipt of assignment. NOTE to Steps 1 and 2: 10A, 10N, and 10P must consolidate their respective subordinate office concurrences on one VA Form and ensure Program Office and subordinate offices concurrences are uploaded to VAIQ within 10 days after receipt of assignment. (4) Step 4 (Days 21-40). 6

9 (a) Originating program office assigns the document to 10B4. (b) 10B4 reviews and assigns to OGC, if appropriate. (c) 10B4 s green sheet (final, formatted version) to originating program office for their approval, after OGC concurs (when applicable). (d) Originating program office approves green sheet. (e) 10B4 assigns to LMR; LMR either: 1. Concurs. 2. Concurs with comments. NOTE: After USH signs, originating Program Office must send 10 copies of the signed policy to LMR. 3. Concurs with conditions. NOTE: Document will not be signed at mail call; USH will approve the document and it will be returned to originating Program Office, who will provide 10 copies of the unsigned document to LMR, who will engage in bargaining. (5) Step 5: (a) 10B4 s the final version of the document to the originating program office. (b) The originating program office completes 508 compliance requirements in accordance with VA Section 508 guidance (see Appendix C) and submits the document to the VA Section 508 office for verification. The program office must not make substantive changes to the document. (c) The Section 508 office will return the document and the conformance report to the originating program office. (d) Once the document is certified as 508 compliant, the program office sends the document and conformance report to 10B4 for final processing. (e) 10B4 concurs and presents to Under Secretary for Health for review and/or signature (dependent on LMR concurrence). NOTE: If document is subject to bargaining, 10B4 returns assignment to originating program office, which will reassign to 10B4 after bargaining is complete. 7

program office to address all comments / edits and 10B4 sends VAIQ ready version of document to originating program office STEP 1 Day: 1-10 Originating Program Office assigns (in VAIQ) to:

10 VHA PROGRAM GUIDE April 8, 2015 FLOW PROCESS DIAGRAM FOR ACCELERATED CONCURRENCE PROCESS Originating program office s tracked changes version to 10B4 10B4 s tracked changes version to: Originating program office to address all comments / edits and 10B4 sends VAIQ ready version of document to originating program office STEP 1 Day: 1-10 Originating Program Office assigns (in VAIQ) to: Originating Program Office assign to 10N and 10P (Uploads VAIQ ready version to correspondence document STEP 2 Day: Originating Program Office assigns (in VAIQ) to: Originating Program Office assigns to 10 (After 10N and 10P concurs) STEP 3 Day: Originating Program Office assigns (in VAIQ) to: Office of Regulatory and Administrative Affairs (10B4)10B4 reviews document and s green sheet ( final version ) to originating program office for approval 10B4 alerts PO if OGC makes substantive changes or if LMR concurs with comments (FYI to union) or concurs with conditions (bargaining) Originating Program Office assigns to: Office of General Counsel (OGC) - 02 (if required) (15-30 days) 10B4 assigns to Labor Management Relations (LMR) 10B4 10B4 returns the final document to the originating program office for 508 compliance and verification VA Section 508 Office section508@va.gov STEP 3 Day: STEP 4 Under Secretary for Health Review / Signature 8

11 5. ENSURING APPROPRIATE LMR REVIEW OF VHA POLICY DOCUMENTS: a. Refine concurrence process to ensure that VHA policies with potential impact on bargaining unit employees are flagged for review by LMR and the VHA Labor Relations (10A2A1A) section of the Workforce Management & Consulting (WMC) Office (10A2A). The Federal Service Labor-Management Relations Statute (5 U.S.C. Chapter 71) and Collective Bargaining Agreements with our unions require that in certain circumstances VA submit formal notice to the unions and allow the unions an opportunity to bargain prior to initiating new policies or changing existing policies. The Office of Labor Management Relations (LMR) is responsible for ensuring that timely notice of proposed changes is provided to the unions. b. Key Points. (1) Program offices may not correctly identify policies with potential and significant impact to Bargaining Unit (BU) employees. (2) WMC will assist program offices by identifying those policies that likely meet the requirement for review by labor representatives, but the final decision rests with LMR. (3) LMR and WMC should be included in the concurrence process for new and changed policies. A policy that requires union review will be sent to the unions once all the concurrences are final and the policy is in final version, but before USH signature and final implementation. (4) Executive Order 13522, Creating Labor-Management Forums to Improve Delivery of Government Services, requires VA management officials to include the unions pre-decisionally in all workplace matters to the fullest extent practicable. The term pre-decisional involvement typically involves inviting the unions to participate in task forces or work groups developing policy prior to any change being initiated. At the national level, LMR would send such invitations to the union national officials via the National Partnership Council. NOTE: Pre-Decisional involvement can be achieved by inviting the unions to participate in task forces or work groups developing policy during the informal pre-concurrence review (see Step One below). LMR would send such invitations to the unions, via the National Partnership Council. c. Process. To formalize the inclusion of LMR, 10B4 must make an assignment to LMR for concurrence on all documents. When revisions have been made to update or replace an existing VHA policy, the changes between the preceding policy and the updated policy must be adequately identified by the VHA program office. The changes should be easily identifiable for LMR and union review, using tracked changes (including strikethroughs for deletions of existing language and underlining insertions or new language). The assignment to LMR should be made after OGC has concurred in the document to ensure that the document meets legal standards. The chart below defines what possible concurrence responses LMR may make and what actions must be taken depending on the nature of LMR s concurrence. 9

12 VHA PROGRAM GUIDE April 8, 2015 (1) Process is as follows: If Then And Handling 1. LMR concurs (without comment or condition) No union notice required Note in COS Briefing Sheet that USH can sign without delay Normal document processing 2. LMR concurs with COMMENT that the unions must be given copies FYI Union notice is required only for information; no delay in implementation Note in COS Briefing Sheet that USH can sign without delay Normal document processing but 10 copies of signed document must be provided to LMR after the USH signs; LMR provides to unions FYI 3. LMR provides a CONDITIONAL concurrence that unions must be given time to review and make demand for bargaining Policy may not be implemented until time expires without demand to bargain OR demand to bargain is made but time for bargaining expires without union proposals OR demand is made and negotiations conclude Note in COS Briefing Sheet that USH may NOT sign until time expires without demand OR demand is made and negotiations conclude 10 copies of final document signature must be provided to LMR before the USH signs; LMR will advise when document may be signed. 10 (2) Processing of document continues as normal until USHs Mail Call: (a) If LMR concurrence is either 1 or 2 in chart above, USH can sign as normal. After final document is prepared, program office must send 10 copies of final, signed document to LMR to be provided FYI to unions.

13 (b) If LMR concurrence is 3 in chart above, labor has between 20 and 30 business days, depending on labor contract, to demand to bargain on the content of the policy that impacts the employees the union represents. LMR will track the timeframe for a response from labor representatives. During this time, the policy concurrence folder is retained in 10B4; the program office will provide LMR with 10 copies of the unsigned final version of the document. If the unions do not make a demand to bargain within the allotted time, LMR will notify 10B4 and the program office that the policy may be signed by USH. (c) If the unions demand to bargain, USH signature and implementation must await the outcome of the negotiation. Negotiation can be a lengthy process. LMR will track the timeframe for a response from labor representatives. 10B4 will continue to hold the concurrence folder until the negotiations are complete. Once bargaining is complete, LMR will notify 10B4 and the program office that bargaining is complete and will update the LMR concurrence in VAIQ. (d) 10B4 will update the COS Briefing Note to reflect that LMR s conditional concurrence is cleared and present the folder to VHA COS for the USH signature. 11

14 VHA PROGRAM GUIDE April 8, 2015 Accommodating LMR Review of VHA Policy Documents Mail Call LMR Concur with COMMENTS; Union FYI only LMR CONDITIONAL CC; Unions get chance to bargain LMR CONCURS; No union input Under Secretary for Health review/approve but DO NOT SIGN Document returned to PO via 10B4 with instruction to provide to LMR PO provides 10 copies to LMR LMR Alerts PO that there is NO demand to bargain Unions have 30 days to demand to Bargain Demand to Bargain 10B4 updates document (dates) & prepares for Under Secretary for Health signature LMR alerts PO that bargain complete; MOU signed. LMR enters new concurrence (no conditions) Under Secretary for Health Signs If LMR =FYI: PO provides 10 copies of signed document to LMR Publish 12

15 APPENDIX A VA Form , Justification for Proposed VHA Issue is accessible via ORAA s web site: and VA Forms web site: A-1

16 APPENDIX B VA Form , VHA Chief of Staff Briefing Note is accessible via ORAA s web site: and VHA Forms and Publication Web site: B-1

17 BASIC GUIDELINES FOR 508 COMPLIANCE APPENDIX C 1. OVERVIEW: Please reference this formatting guide to help guide you with Section 508 compliance. Please note that there are some inconsistencies between VHA Handbook and what is described below. Please use the guidance below to ensure basic 508 standards are met. 2. FONT: Arial font, size 12 point. 3. PARAGRAPH NUMBERING: If only one paragraph follows a heading, the text follows the heading on the same line. If a subheading is used (a., (1), etc.) there must be subsequent paragraphs to follow (b., (2), etc.). Paragraphs in policy documents should model the following multi-level structure: Adjust number position as follows for appropriate list levels (See Figure 1): 1. BOLD: This is known as the Title (Heading 1). a. Bold + Underlined. (Number position.25 ) This is also known as a main numbered paragraph. (Heading 2) (1) Bold. (Number position.25 ) (a) Underlined. (Number position.25 ) 1. Regular. (Number position.4 ) a. Regular. (Number position.4 ) (1) Regular. (Number position.55 ) (a) Regular. (Number position.55 ) NOTE: Automatic number formatting should be utilized to create a Section 508 compliant document. Continued on next page C-1

18 VHA PROGRAM GUIDE April 8, 2015 APPENDIX C Figure 1. Adjusting the number position. 4. HEADINGS: When crafting a document, create headings using Microsoft Word Styles. Use Headings 1 & 2 (and Style Separator if necessary) in Appendices as well. DO NOT create heading styles for any headings other than the Title (Heading 1) and main numbered paragraphs labeled a.,b.,c., etc. (Heading 2). Reference adjust number position example in par. 1, Paragraph Numbering. NOTE: This is just a quick tip GUIDANCE: Guidance for VA Section 508 is contained in the following links: a. VA Section 508 Home Page. b. Guidance and Tutorials- VA Section 508 elearning Support. c. Training Options. d. Creating Accessible Documents Training (Schedule). e. VA Conformance Certification (Conformance Validation Statement). f. Contact: Section 508 Support Section508Support@va.gov C-2

Department of Defense INSTRUCTION

Department of Defense INSTRUCTION SUBJECT: DoD Directives Program References: See Enclosure 1 NUMBER 5025.01 October 28, 2007 Incorporating Change 2, July 1, 2010 DA&M 1. PURPOSE. This Instruction: a.