2007.07.25: July 25, 2007: Headlines: Congress: Legislation: Senate Foreign Relations Committee: Statement by David Kotz, Inspector General of the Peace Corps
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2007.07.25: July 25, 2007: Headlines: Congress: Legislation: Senate Foreign Relations Committee: Statement by David Kotz, Inspector General of the Peace Corps
Statement by David Kotz, Inspector General of the Peace Corps
This study that our office is conducting is the first of its kind, and also marks the first time that the Peace Corps has received the Office of Management and Budget approval to reach out to a subsection of the general public, applicants who entered the Medical Screening Process but did not become Peace Corps Volunteers, to survey them about their experiences in the medical screening process. The Office of Inspector General recognizes that this population of former applicants is a rich and untapped resource for identifying strengths and weaknesses in the Medical Clearance System. Through their responses, we hope to gather data unique to this group of applicants, which will yield findings and recommendations that will improve Peace Corps’ applicant retention during the Medical Clearance System.
And perhaps of greatest concern, our study has found that several of our recommendations for improvements to the Medical Clearance System were recommended in prior reports dating back to 1992, were accepted by the Agency but were never implemented.
We applaud Senator Dodd’s office for the concern with applicants’ ability to obtain information on their likelihood of being medically qualified by the Peace Corps before they spend significant sums of their own money on required medical exams and tests. We also agree wholeheartedly with the concerns that have been expressed regarding the out-dated nature of the Medical Screening guidelines. These guidelines must be reviewed at a minimum annually to ensure that they represent the most currently available medical evidence. However, posting the Medical Screening guidelines online is not the best solution to providing applicants with answers to their medical screening concerns, nor it is necessarily the best in our opinion. The medical screening guidelines are a tool for making complex medical decisions used by medical professionals. If the medical screening guidelines were posted online, it could lead to applicants without medical backgrounds misinterpreting their eligibility and actually lead to more confusion on the part of applicants. It also has the possibility of resulting in the Agency unnecessarily dissuading perfectly able, healthy and productive applicants from becoming Volunteers. Further, telling the applicants the answers they need to give in order to be medically cleared may encourage and invite fraud, which would, in the end, jeopardize their health and safety in the field. In our view, applicants would receive the most accurate answer of whether or not their particular condition will preclude them from serving in the Peace Corps by having the opportunity to speak to a screening nurse, rather than by reviewing the information online.
We applaud Section 306(b) of the Bill that increases whistleblower protection for Volunteers reporting the misconduct of Peace Corps staff as we feel that as much protection as possible should be provided to these whistleblowers. Because of their status as Volunteers and not employees, currently Volunteers are not afforded significant protection from retaliation for their whistleblower claims. Whistleblowers provide a great deal of critical information to our office with respect to the inner workings of the Agency and we need to make sure Volunteers are protected when they provide this important information. Very often, our information comes from whistleblowers and complaints and our Office would not be able to prevent waste, fraud and abuse in the Agency without the help and support of Volunteers acting as whistleblowers.
We also applaud the Committees’ efforts to give the Volunteers a larger role in evaluating various aspects of the Peace Corps. When the Office of Inspector General conducts evaluations, we focus entirely on the opinions and viewpoints of the Volunteers, as they are the life blood of the Agency, and we uniformly uncover critical information regarding their sites, programs, projects and the abilities of the Peace Corps staff in country. We believe that Office of Inspector General inspections should not be the only mechanism for Volunteers to share their view and provide feedback concerning activities at post. It is our opinion that the Agency should become even more Volunteer-centric and provide more opportunities for the Volunteers to be involved in the decision-making process. Encouraging the use of the Volunteer Advisory Committee is an excellent idea. We also concur with the Bill’s efforts to provide more Volunteer involvement in site selection and personnel aspects of a post. The Volunteers’ viewpoints and feedback must be considered when the Agency makes important decisions concerning site selection, training curriculum and personnel evaluation at post. Within Section 201 of the Bill, there is a provision that these upward reviews and surveys of Volunteers be provided to various Agency officials. We concur with a proposal expressed by others that our office also receive the results of the upward reviews conducted by Volunteers on senior staff and programs. We too believe that this will be a source of valuable information and enhance the effectiveness of the Inspector General’s Office in improving Peace Corps management and programs.
Statement by David Kotz, Inspector General of the Peace Corps
Testimony of H. David Kotz
Inspector General of the Peace Corps
Before the U.S. Senate Foreign Relations Subcommittee on Western Hemisphere, Peace Corps, and Narcotics Affairs
Wednesday, July 25, 2007
9:30 a.m.
Photo: Courtesy of the office of Senator Dodd taken by Adam Wells
Introduction
Good morning. I am honored to testify today before this Committee on the subject of the Peace Corps Volunteer Empowerment Act as the Inspector General of the Peace Corps. The purpose of the Office of Inspector General is to prevent and detect fraud, waste, abuse, and mismanagement and to promote economy, effectiveness, and efficiency in government. I appreciate Chairman Dodd, as well as the other members of the Committee, for their interest in and commitment to the Peace Corps. I believe the Committee’s and Congress’ involvement in the Peace Corps is helpful to our office, in strengthening the accountability and effectiveness of the Peace Corps. By introducing this Bill and expressing interest in the Peace Corps, Congress is helping the Peace Corps Office of Inspector General identify the necessary changes and improvements in the Peace Corps. Through the Committee’s commitment to improving the Peace Corps, whether through legislation or continued dialogue, Congress and the Office of Inspector General can help ensure that these critical improvements are implemented by the Agency.
It is my hope that the Committee remains committed to the issues raised in the legislation and the continued improvements to the Peace Corps in the future.
Description of the Medical Clearance System Study
I plan to address several of the items in the Bill; however, the matters that I will devote most of my time to relate to the Medical Clearance process. The Office of Inspector General is currently undertaking a comprehensive eight-month study of the Peace Corps Medical Clearance System and process.
It is important to point out to the Committee, that in the course of conducting this study of the Medical Clearance System, we are systematically analyzing many of the same issues that the Peace Corps Volunteer Empowerment Act also addresses: the adequacy of the screening review process and policies; the medical screening guidelines; the screening review timeframe; guidance to applicants; transparency; interoffice communication; customer service; staff training; the appeals process; and the reimbursement fee schedule. Our study is on-going and should be issued shortly.
This study that our office is conducting is the first of its kind, and also marks the first time that the Peace Corps has received the Office of Management and Budget approval to reach out to a subsection of the general public, applicants who entered the Medical Screening Process but did not become Peace Corps Volunteers, to survey them about their experiences in the medical screening process. The Office of Inspector General recognizes that this population of former applicants is a rich and untapped resource for identifying strengths and weaknesses in the Medical Clearance System. Through their responses, we hope to gather data unique to this group of applicants, which will yield findings and recommendations that will improve Peace Corps’ applicant retention during the Medical Clearance System.
One of the goals of our study is to determine whether frustrations with the Medical Clearance System have become a barrier to service in the Peace Corps or have otherwise contributed to applicants’ decision to discontinue their Peace Corps applications. The Office of Inspector General has reached out to 3,330 Volunteers and applicants in our survey and to date has collected detailed responses on the Medical Clearance System from 864 individuals. We are analyzing responses from those applicants who withdrew their application and particularly with respect to the question, “At what stage did you withdraw your application?” Our results to date show that 82% of the respondents withdrew their application during the Medical Clearance process. Our results also show that when asked why they withdrew from the application process, the four most frequently cited reasons out of the 19 provided, which included reasons such as “Returning to school” or “Personal/familial reasons” were “Medical Screening took too much time,” “Burdensome medical costs,” “Burdensome dental costs,” and “Poor communication with Medical Screening.”
When asked the question, “Were you satisfied with the Peace Corps Medical Clearance process?” 63% of applicants who applied but did not serve, answered that they were not at all satisfied or minimally satisfied. However, 19% said they were more or less satisfied and only 12% stated they were very satisfied or extremely satisfied.1 When the same question was asked to current Volunteers (those who persevered through the process and served), “Were you satisfied with the Peace Corps Medical Clearance process?” 28% said they were not at all satisfied or minimally satisfied and nearly half of the Volunteers (49%) said they were more or less satisfied with the Medical Clearance process. For the last five years, the number of applicants the Office of Medical Services has medically qualified for service has exceeded the number of Volunteers requested by Peace Corps posts.2 Therefore, if your measure of the effectiveness of the Medical Clearance System is whether the Agency is able to medically screen in the number of Volunteers requested by Peace Corps posts, then, yes, it would appear that the Medical Clearance System is working. However, our preliminary results show that the Medical Clearance System and process has, in fact turned away numerous individuals from continuing their application process, and that an overwhelming percentage of those who withdrew their application withdrew at the medical screening stage and expressed negative views on the Medical Screening System demonstrates that while the Medical Clearance System may not be entirely broken, it is certainly in need of repair.
In addition to our survey, our evaluation of the Medical Clearance System includes a case study portion requesting electronic journals and teleconferences with current 50-plus applicants and extensive face-to-face interviews with Peace Corps staff including screening staff, screening nurses, Office of Medical Services managers, and policy makers. Our office has been working with the Agency, the 50-plus Initiative Work Group that the Agency has put together, and the National Peace Corps Association to understand how the Medical Clearance process can be improved. We look forward to sharing more information with the Committee and Chairman Dodd when the study is completed and working together to improve the process for applicants and the Agency.
Medical Clearance System Problems List and Description
While the study is not complete and I am somewhat reluctant to present definitive information, we have identified the following issues with the Medical Clearance System:
1. Quality Improvement in the Office of Medical Services has been lacking. The Quality Improvement unit within the Peace Corps’ Office of Medical Services has not been proactive in developing performance measures, leading quality improvement initiatives, or collecting staff feedback to analyze and track screening performance in order to identify areas for improvement, nor have they systematically updated the Medical Screening Guidelines or the Country Health Resources database as required. As a result, screening nurses have developed their own, additional criteria, based on research they collected about medical conditions and advances in medical diagnosis. The Quality Improvement unit is currently working with the screening nurses to incorporate their research into the new Medical Screening Guidelines. In addition, the posts have not been required to annually update their information in the Country Health Resources database and therefore, the list of countries who can accept Medical Accommodations has not been updated in real time and applicants are being restricted from serving in countries that could have accommodated them.
2. Peace Corps has identified but has not prioritized or implemented technological improvements that would have a host of benefits to applicants including streamlining the Medical Clearance process, improving transparency and communication with applicants, and improving medical records management and storage. These technological enhancements are critical to improving numerous aspects of the medical clearance process including reducing screening time. For example, while 75% to 80% of the Peace Corps applications are submitted online, the Medical Kit, a packet with examination forms and instructions for the applicant and the medical or dental provider, is in a paper format which must be collated and mailed to the applicant. Screening nurses reported that approximately 95% of the Medical Kits they receive are missing required documentation and that is a major reason why medical screening is delayed. Although the Office of Medical Services has requested that the Agency’s Information Technology Group place the Medical Kit online as far back as several years ago, as of this date, this has not occurred.
3. Numerous applicants reported that they and their health care providers found the Medical Kit Guidance and Instructions to be confusing. Other applicants reported that they were overwhelmed by the Medical Kit Guidance because it is presented in a 32 page book. One Volunteer wrote:
The way it was organized took many times to read and reread to figure out which doctor needed what. It wasn’t completely unclear, because obviously I’m here, but I remember it took several times to read it to make sense of it for me, and then even my doctors had some questions about what was needed. Certain tests I thought might be unnecessary, because I knew I hadn’t any of those diseases, but my doctor was afraid not to run them, so I paid for them anyway! In the dental forms I didn’t realize you needed a certain x-ray exam, so I had to go back to see the dentist twice (out of my own pocket). My gynecologist was unclear even about some of the paper work.
Other Volunteers wrote:
Some of the instructions were partially repeated, forms were called by a variety of names, and in one case I felt it was necessary to cut a portion out of the booklet based on the instructions. Those items to be filled out by the applicant need to be organized and clearly separated.
Information had inconsistencies, and was often confusing. Calling the help telephone numbers did no good as you seldom got through, messages you left were usually not returned, but, most frustrating, whenever you did reach a person they usually told you they couldn't help you and would transfer you to another department, who would then tell you they couldn't help you and transfer you right back.
4. Medical Screening customer service needs to be significantly improved. Applicants reported that despite calling the 800 number multiple times to reach a screening nurse, they were unable to reach a customer service representative and sometimes unable to even leave a voicemail message because the voicemail was full. In addition, some applicants who did reach a customer service representative, reported that they were rude or unhelpful.
One of the current 50-plus applicants who is participating in the case study had this to say about calling with a medical screening question:
I left a message on the nurse line yesterday (June 11), and have not received a response yet. I just tried again to call (June 12, 11:45 am), and wasn’t able to leave a call-back message, as the voice-mail box was full. I never received a call back this time.
Another 50-plus applicant wrote:
I sent a fax on Saturday afternoon, July 7, asking for clarification of what was wanted. As of Monday evening, July 9, I had not received a reply. This morning, July 10, I still hadn’t received a reply, and I needed to know because I’m having blood drawn for another purpose soon. So I called the nurse station. I think this was the first time I’ve called there that a person picked up, and she then transferred me directly to the Screening Nurse and I was able to get my answer. She told me my fax was probably in a pile of about 20 that she had to deal with, now in their busy season.
One applicant who did not serve had this to say about Medical Screening customer service:
I don't know where to begin here, since my experience was so negative. For one thing, you have to have live people available, and you MUST get back to people and answer their voicemail and e-mails in a timely fashion. You must be clear and specific about your objections, and please try to be helpful and supportive rather than cold and distant during this difficult process.
Our evaluation intends to make several recommendations that will affect the customer service provided to applicants during the Medical Clearance process.
5. Numerous Peace Corps staff and applicants reported that Veterans Affairs Hospitals do not have the resources to adequately screen applicants for Peace Corps medical clearance. The Veterans Affairs Hospitals are highlighted as a resource for applicants to get free physical exams covered by Peace Corps; however, many applicants are unaware of this resource. Other applicants reported that Veterans Affairs physicians’ were rude, did not honor their appointments, and that the physical exam was not complete. This required applicants to spend hundreds of dollars to complete follow-up tests and exams.
One applicant who did not serve wrote:
Provide a facility in order to do the medical clearance process much like the one that is done for the armed forces.
Another Volunteer provided the following feedback:
Misinformation about availability of using government/military medical facilities. I was denied this option when I tried. Also, unnecessary tests were required as follow-up for conditions or past procedures, which were not medically indicated and furthermore were not reimbursed by PC.
6. 50-plus applicants take nearly twice as long to clear medical screening compared to applicants under 50 years of age. According to the Office of Medical Services Executive Summary Reports, it takes approximately 34 days to medically qualify an applicant under the age of 50, whereas it takes between 68-73 days to medically qualify an applicant over the age of 50. Additionally, as a group, 50-plus applicants are more likely to appeal their case if they are deemed Medically Not Qualified. The 50-plus population comprises 5% of the total Volunteer population; however, they make up 25% of the cases reviewed by the Medical Screening Appeals Board. The 50-plus applicant population does have a different medical screening experience and therefore, it is critical for significant improvement to be made to the Peace Corps Medical Clearance System in order for the Director’s laudable goal of significantly increasing the percentage of 50-plus Volunteers to be achieved.
7. In 2006, the average Federal Employees’ Compensation Act claim amount paid to 50-plus Volunteers was $9,109 compared to $5,667 paid to under 50 Volunteers. In 2006, 29% of the 50-plus population in the field became a Federal Employees’ Compensation Act claimant, compared to 12% of the under 50 population. An effective screening process protects Volunteer’s health and safety and saves the Agency and taxpayer’s money by resulting in fewer medical evacuations and Federal Employees’ Compensation Act claims.
8. The five-year rule is a significant detriment, not a benefit to the Medical Clearance System and Office of Medical Services screening unit. Where experience and a comprehensive knowledge base of Peace Corps post conditions and medical accommodations are indispensable to screening applicants efficiently, productively, and safely, the effect of the five-year rule is to essentially force the most experienced and dedicated nurses to leave the Agency. These nurses are replaced with new nurses who require extensive training and who only reach acceptable levels of efficiency screening applicants after one year. The turnover caused by the five-year rule also reduces all screening teams’ productivity and creates an unnecessary bottleneck in the application process.
9. Applicants and Office of Medical Services staff uniformly report that the applicant reimbursement fee schedule for required medical, dental and eye examinations is not adequate and should be increased. According to the preliminary results of our survey, 21% of applicants and Volunteers did not have health insurance when they applied to the Peace Corps with the majority spending $101-$500 in out-of-pocket expenses for required medical exams and lab work.3
One Volunteer wrote:
Tell us in advance that we'll probably have to have (and pay for) follow-up examinations or tests. The reimbursement is inadequate for most situations, even at a public health clinic.
10. And perhaps of greatest concern, our study has found that several of our recommendations for improvements to the Medical Clearance System were recommended in prior reports dating back to 1992, were accepted by the Agency but were never implemented. An evaluation conducted by McManis Associates, entitled “Report on the Screening and Medical Clearance Process” issued in 1992 gave the recommendation that:
A process needs to be established to institutionalize and standardize the procedures for updating and revising medical screening guidelines and medical screening policy.
Discussion to develop a process for reviewing and updating the Medical Screening Guidelines was proposed in 2005, begun in October 2006 and is anticipated to be completed by October 2007; this is 15 years after the problem was identified. Additionally, several Office of Medical Services staff cited the 2002 Pugh Ettinger McCarthy External Evaluation of the Volunteer Health System as an excellent evaluation of the Medical Clearance System and agreed with its recommendations including, the need for collecting applicant and Volunteer feedback, development of quality performance controls and indicators, and noting the effect the five-year rule has had in “challeng[ing] succession planning in management and limit[ing] organizational memory”.
In light of our preliminary findings from our comprehensive Medical Screening System survey, we conclude that the Medical Clearance System is in need of significant improvement. Particularly in light of the 50-plus Initiative, the Peace Corps needs to fix the Medical Screening Process. In a number of cases, the problems with the Medical Screening Process are not new, and in fact, some changes have been suggested by Peace Corps employees and prior studies, but these changes have not been implemented.
High Level Recommendations for Improvements to the Medical Clearance System.
The Medical Screening System is a critical aspect of the Volunteer Delivery process. The Medical Screening System is responsible for striking the delicate balance between medically screening in and screening out applicants in order to provide overseas posts with healthy, able and productive Volunteers. While again our study has not been completed, our office has worked with the Medical Screening System Agency stakeholders and has identified specific action items for fixing the issues with the Medical Screening System:
We recommend that the Quality Improvement unit work with Office of Medical Service managers to develop performance measures and staff feedback mechanisms to systematically identify, justify to the Agency, and implement improvements to the Medical Clearance System.
Some of the performance measures identified are the following:
Employee and staff:
* % of Office of Medical Services employees that rate their job satisfaction as excellent
Timeliness and Flow:
* % of screenings with decision made within 90 days of receipt
Timeliness and Flow:
* % of incomplete medical records
Timeliness and Flow:
* % of requests for records not delivered in 48 hours
Efficiency and accuracy:
* Cost per screening
Effectiveness:
* % of Peace Corps Volunteers with accommodations that complete 27 months of service
Effectiveness:
* rate of mental health Early Terminations
In addition, the Quality Improvement unit within the Office of Medical Services should take a more proactive role in leading quality assurance and quality control initiatives. Quality Improvement should be conducted on two tiers, operational on a day-to-day process level and on a strategic level. Office of Medical Services staff reported that our Office’s current evaluation of the Medical Clearance System was one of the first opportunities in which a Peace Corps staff member was asked their opinion on systems and processes. We recommend that the Quality Improvement unit develop quality improvement feedback mechanisms for Office of Medical Services staff to identify areas and processes in the medical screening process that can be improved and suggest improvements. Discussion and data analysis will identify the best ways to make these process and strategic improvements. Quality Improvement leadership and staff should undergo quality improvement training to better equip the unit with the tools and knowledge to implement this recommendation.
To ensure Agency accountability to the Medical Clearance System, we recommend that performance measures and other indicators developed by the Quality Improvement unit and Office of Medical Services managers be written in an annual report that tracks the efficiency, effectiveness and productivity of the Medical Clearance System. We further recommend that this report be included in the Office of Medical Services report “Health of the Volunteer.”
We also recommend that the Quality Improvement unit in the Office of Medical Services lead the effort in reviewing the medical screening guidelines at a minimum annually or as updates are required.
We applaud Senator Dodd’s office for the concern with applicants’ ability to obtain information on their likelihood of being medically qualified by the Peace Corps before they spend significant sums of their own money on required medical exams and tests. We also agree wholeheartedly with the concerns that have been expressed regarding the out-dated nature of the Medical Screening guidelines. These guidelines must be reviewed at a minimum annually to ensure that they represent the most currently available medical evidence. However, posting the Medical Screening guidelines online is not the best solution to providing applicants with answers to their medical screening concerns, nor it is necessarily the best in our opinion. The medical screening guidelines are a tool for making complex medical decisions used by medical professionals. If the medical screening guidelines were posted online, it could lead to applicants without medical backgrounds misinterpreting their eligibility and actually lead to more confusion on the part of applicants. It also has the possibility of resulting in the Agency unnecessarily dissuading perfectly able, healthy and productive applicants from becoming Volunteers. Further, telling the applicants the answers they need to give in order to be medically cleared may encourage and invite fraud, which would, in the end, jeopardize their health and safety in the field. In our view, applicants would receive the most accurate answer of whether or not their particular condition will preclude them from serving in the Peace Corps by having the opportunity to speak to a screening nurse, rather than by reviewing the information online.
We respectfully suggest that since the underlying reason that the authors of the Bill may have recommended the posting of the medical screening guidelines online relates to the high levels of frustration that applicants feel with regard to the customer service element of the Medical Screening System, our evaluation will make several recommendations that address needed customer service improvements and that will make screening nurses more accessible to applicants.
We recommend the Agency strategically use technology to streamline the Medical Clearance System. As the Bill correctly points out, the Peace Corps can use the internet and technology to streamline the Medical Clearance System and provide more transparency and accessibility to applicants. We strongly support those aspects of the Bill. Improvements in technology that we have identified that will improve the Medical Clearing System are:
o Immediate scanning of applicant’s paper medical records prior to review by the screening nurses. This change in the Medical Screening System will help segue the department toward a full electronic medical records system and will remedy the current administrative problems of inadequate storage and the difficulty sometimes faced locating and processing paper files.
o Posting the Medical Kit online.
We recommend Peace Corps use its online presence to post information to improve transparency and communication with applicants about the Medical Clearance
System. We recommend that the following measures be put into place to improve transparency and communication for applicants:
o Create an Online Toolkit Medical Screening Checklist.
o Expand Status Checks and Incorporate Automated E-mail Messaging to Applicants every time an applicant’s status is changed.
o Publish the “Comprehensive Medical and Dental Package” online.
o Modify the Health Status Review to include timeframes for questions regarding family counseling.
o Consolidate location of instructions and forms.
o Communicate a detailed description of the Medical Screening process and the country placement process.
o Post the most typical conditions for which the Agency does not normally accept applicants, 2) medically accommodates applicants, and/or 3) delays an applicant’s entry into duty and update this list on a routine basis and as needed.
We agree with the Bill’s Section 301(4), that a detailed description of the medical screening process applicable to Peace Corps applicants, including definitions of all applicable terms, should be posted on the Peace Corps website and on My Toolkit. We strongly concur that there should be a more detailed description of the Medical Clearance process that helps set applicant expectations for the amount of time the medical clearance will take including scheduling doctors appointments, waiting for test results, completing follow-up tests and review of medical documentation by a screening nurse. We also strongly agree with providing more information on the medical dispositions that can result from the screening process and improving information regarding the implications of a failure to disclose medical information as indicated in Section 301(5) of the Bill.
We concur with Section 301(1) of the Bill, that a list of medical conditions that typically disqualify individuals from serving, and a list of conditions that typically lead to medically accommodating a Volunteer should be provided to all applicants, and note that this list is currently posted on the Peace Corps application site and is included in recruitment kits sent out to applicants. However, more detailed information should be provided and the list should be updated on a continuous basis. We recommend that the Office of Medical Services continually update the list of medical conditions. Numerous applicants stated that the online document does not list all conditions, and the following quote from one of the Volunteers who responded to our current survey highlights the importance of providing this information to applicants:
Did not know that getting PRK/LASIK eye enhancement surgery would delay my medical clearance for a year. This was not known to me and was the reason I did not finish my medical clearance.
We agree with the Bill in that the Peace Corps can and should do a better job at providing medical clearance information to applicants. We do however, agree with the Agency that if some of the Peace Corps Volunteer Empowerment Act provisions for the Medical Clearance System were implemented without an understanding of the interwoven systems of recruitment, medical screening, legal screening and placement, the result could actually lengthen the medical screening process and could result in Volunteers being placed in countries that cannot provide the resources needed to accommodate their health conditions. However, upon the conclusion of our study, we plan to recommend specific improvements that address the majority of the concerns that are raised in the Peace Corps Act Volunteer Empowerment Act: transparency, communication and customer service.
We recommend that the Office of Medical Services improve the Medical Kit instructions by eliminating contradictory guidance and by highlighting the most critical information.
We recommend that the Office of Medical Services recognize customer service as a core value of the screening process, the importance of coaching applicants through the Medical Clearance System, and that the Office of Medical Services implement “Coaching through Clearance,” for applicants.
In addition, the following specific improvements will improve customer service, communication and transparency for applicants:
o Establish customer service training and customer service standards.
o Establish mechanisms for customer service feedback.
o Establish a Screening Nurse email address that can be checked by Screening Assistants and forwarded onto the proper screening nurse.
o The direct telephone extension of the screening assistant should be included in the Medical Kit.
o Improve the Medical Clearance System customer service line so that the line always rolls to another phone until a live person is reached.
We recommend that the regional recruiters cease providing applicants with information about Veterans Affairs Hospitals as a convenient and financial resource for completing the physical exam requirements of the Medical Kit.
We recommend that the Agency exempt several positions in the Office of Medical Services from the five-year rule to the extent allowed under the law. Peace Corps is unique in that it hires and extensively trains experienced and knowledgeable nurses but then by virtue of the five-year rule, it loses that experience and knowledge prematurely. This practically has the effect of increasing the likelihood of errors in medical judgment, causing potential harm to Peace Corps Volunteers. If one combines the drastic effect of the five-year rule with the nationwide nursing shortage, for example, and the present-day reality that trained, experienced, and passionate screening nurses are becoming increasingly more difficult to recruit and retain, the overall impact is substantial. While there are legislative impediments to wholesale exemption of positions in the Office of Medical Services from the five-year rule, our final report will outline specific positions that we believe should be exempted from the five-year rule and the statutory and regulatory bases for these exemptions.
We recommend that the reimbursement fee schedule be increased to meet average doctor bill rates for physical examinations, dental examinations, and eye glasses. We wholeheartedly endorse the concern expressed in the Bill in Section 301(6), about the insufficiency of the reimbursement fee schedule for physical examinations, dental examinations, and eye glasses. One of the questions on our survey is, “What one thing would you do to make the Medical Clearance process better?”; a high percentage of respondents cited changes to the reimbursement fee schedule. This is somewhat surprising in light of the survey’s results that 59% of applicants who did not serve and 32% of Volunteers did not even submit a reimbursement claim.
While we agree with the Agency that full reimbursement for medical tests required by Peace Corps is not attainable without a significant increase in appropriation dollars, we strongly recommend that the reimbursement schedule be increased. The justifications are two-fold; the current schedule has not been increased on a routine basis to account for inflation and does not take into account new clearance requirements, such as immunizations, that have been added to the Medical Kit. In addition to immediately increasing the reimbursement fee schedule, the Agency should review the reimbursement schedule annually and determine increases to the reimbursement schedule if either 1) new requirements are added to the Medical Kit and/or 2) already required tests and exams have increased in cost. Aside from annual reimbursement review and general increase of the reimbursement schedule, the current dental reimbursement amount of $60 should be increased to $100 or more because the costs of dental exams and x-rays is increasingly higher and fulfilling the requirements for dental clearance is one of the most burdensome components of the medical screening process.
Our office feels strongly about this recommendation because not only does the current reimbursement schedule frustrate Volunteers and deter desirable and qualified Volunteers from completing medical screening, but the reimbursement schedule may also act as an unintended barrier to recruiting Volunteers from diverse socioeconomic levels. There is a correlation between people of lower socioeconomic levels not having access to health insurance, increasing the cost burden for this demographic and further preventing them from finishing the application process or even applying to Peace Corps. If the Committee and the Peace Corps are seeking to increase recruitment efforts for minorities and older Americans, removing the impediment of an inadequate reimbursement schedule is an important step.
We also would like to provide the following additional comments about specific aspects of the Volunteer Empowerment Act’s medical screening provision that we have not already addressed above.
We have certain concerns with the Bill’s provision in Section 301(1b) that providing a list of countries available to accept Volunteers with medical accommodations may lead to false expectations on where these Volunteers may serve and result in misinformation and more confusion. In addition, the list of medical accommodation countries is maintained by the Office of Medical Services, but is constantly changing and posting that information may not achieve the desired result of providing more accurate information to applicants.
With regard to Section 301(2) of the Bill that requires the establishment of a process for applicants and other interested parties to propose changes to the Medical Screening Guidelines, we note that while it is important to provide mechanisms that give voice to applicants’ feedback and concerns, questioning the medical validity of screening guidelines may actually lead to even longer and costlier processing lengths. Screening nurses could potentially be overburdened by the tenacity of Volunteers to seek other medical opinions that would medically qualify them. In addition, medical opinions provided by other physicians unfamiliar with the health conditions and standards necessary in foreign posts could pose serious health risks to that Volunteer. Finally, screening nurses need a standard of medical criteria to base their decisions in evaluating an applicant’s medical qualification. Changing this system fosters an environment of relativity and inconsistency as each screening nurse will have differing methods and criteria for qualifying applicants, which may in effect, compromise medical screening transparency.
We very much concur with the intention of Section 301(3), of the Bill that would require a process to allow Volunteers to appeal rejections on medical grounds, and note that we have determined that there is an appeals process in place which provides applicants an opportunity to provide more data empowering the Volunteer to advocate for themselves using new medical information. With respect to the right to base an appeal on the inadequacy of the medical screening guidelines, there is a process in place to update the medical screening guidelines that will be completed by October 2007. We endorse this effort and note that it is long overdue. Given that this review is underway, we do not think it is necessary to include the right to base an appeal on the inadequacy of the medical screening guidelines in the overall appeals process.
Comments on Other Sections of the S.732 Volunteer Empowerment Act
As I indicated, our analysis is focused on the Medical Clearance System. With respect to certain other aspects of the Bill, I have the following opinions.
We wholeheartedly concur with the laudable goal of doubling the number of Peace Corps Volunteers by December 2009, but would caution that significantly increased appropriations are an absolute necessity to achieve this goal, as in some cases, the Peace Corps is stretched too thin today. In our view, it would be unwise to continue to expand posts without the resources to ensure that Volunteers are properly supported.
We applaud Section 306(b) of the Bill that increases whistleblower protection for Volunteers reporting the misconduct of Peace Corps staff as we feel that as much protection as possible should be provided to these whistleblowers. Because of their status as Volunteers and not employees, currently Volunteers are not afforded significant protection from retaliation for their whistleblower claims. Whistleblowers provide a great deal of critical information to our office with respect to the inner workings of the Agency and we need to make sure Volunteers are protected when they provide this important information. Very often, our information comes from whistleblowers and complaints and our Office would not be able to prevent waste, fraud and abuse in the Agency without the help and support of Volunteers acting as whistleblowers.
We also applaud the Committees’ efforts to give the Volunteers a larger role in evaluating various aspects of the Peace Corps. When the Office of Inspector General conducts evaluations, we focus entirely on the opinions and viewpoints of the Volunteers, as they are the life blood of the Agency, and we uniformly uncover critical information regarding their sites, programs, projects and the abilities of the Peace Corps staff in country. We believe that Office of Inspector General inspections should not be the only mechanism for Volunteers to share their view and provide feedback concerning activities at post. It is our opinion that the Agency should become even more Volunteer-centric and provide more opportunities for the Volunteers to be involved in the decision-making process. Encouraging the use of the Volunteer Advisory Committee is an excellent idea. We also concur with the Bill’s efforts to provide more Volunteer involvement in site selection and personnel aspects of a post. The Volunteers’ viewpoints and feedback must be considered when the Agency makes important decisions concerning site selection, training curriculum and personnel evaluation at post. Within Section 201 of the Bill, there is a provision that these upward reviews and surveys of Volunteers be provided to various Agency officials. We concur with a proposal expressed by others that our office also receive the results of the upward reviews conducted by Volunteers on senior staff and programs. We too believe that this will be a source of valuable information and enhance the effectiveness of the Inspector General’s Office in improving Peace Corps management and programs.
Concluding Remarks
In conclusion, we applaud Senator Dodd and the Committee’s interest in the Peace Corps. We plan to finalize our comprehensive Medical Clearance System study shortly and aggressively encourage the Agency to implement our recommendations to repair a medical clearance process that needs a great deal of improvement. We also plan to follow-up with many of the additional good measures provided by this Bill. While we support aspects of the Bill, we also feel that with Congress’ support, these measures can be implemented without legislation. We hope to continue our excellent dialogue with Senator Dodd’s office and other offices to ensure that the necessary improvements are made to the Medical Clearance System and other aspects of the Peace Corps.
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Headlines: July, 2007; Congress; Legislation; Peace Corps Library; Peace Corps Directory; Peace Corps History; Bulletin Board; Recent Peace Corps News
When this story was posted in July 2007, this was on the front page of PCOL:
Peace Corps Online The Independent News Forum serving Returned Peace Corps Volunteers
| Dodd issues call for National Service Standing on the steps of the Nashua City Hall where JFK kicked off his campaign in 1960, Presidential Candidate Chris Dodd issued a call for National Service. "Like thousands of others, I heard President Kennedy's words and a short time later joined the Peace Corps." Dodd said his goal is to see 40 million people volunteering in some form or another by 2020. "We have an appetite for service. We like to be asked to roll up our sleeves and make a contribution," he said. "We haven't been asked in a long time." |
| Public diplomacy rests on sound public policy When President Kennedy spoke of "a long twilight struggle," and challenged the country to "ask not," he signaled that the Cold War was the challenge and framework defining US foreign policy. The current challenge is not a struggle against a totalitarian foe. It is not a battle against an enemy called "Islamofascism." From these false assumptions flow false choices, including the false choice between law enforcement and war. Instead, law enforcement and military force both must be essential instruments, along with diplomacy, including public diplomacy. But public diplomacy rests on policy, and to begin with, the policy must be sound. Read more. |
| Ambassador revokes clearance for PC Director A post made on PCOL from volunteers in Tanzania alleges that Ambassador Retzer has acted improperly in revoking the country clearance of Country Director Christine Djondo. A statement from Peace Corps' Press Office says that the Peace Corps strongly disagrees with the ambassador’s decision. On June 8 the White House announced that Retzer is being replaced as Ambassador. Latest: Senator Dodd has placed a hold on Mark Green's nomination to be Ambassador to Tanzania. |
| Peace Corps Funnies A PCV writing home? Our editor hard at work? Take a look at our Peace Corps Funnies and Peace Corps Cartoons and see why Peace Corps Volunteers say that sometimes a touch of levity can be one of the best ways of dealing with frustrations in the field. Read what RPCVs say about the lighter side of life in the Peace Corps and see why irreverent observations can often contain more than a grain of truth. We'll supply the photos. You supply the captions. |
| PCOL serves half million PCOL's readership for April exceeded 525,000 visitors - a 50% increase over last year. This year also saw the advent of a new web site: Peace Corps News that together with the Peace Corps Library and History of the Peace Corps serve 17,000 RPCVs, Staff, and Friends of the Peace Corps every day. Thanks for making PCOL your source of news for the Peace Corps community. Read more. |
| Suspect confesses in murder of PCV Search parties in the Philippines discovered the body of Peace Corps Volunteer Julia Campbell near Barangay Batad, Banaue town on April 17. Director Tschetter expressed his sorrow at learning the news. “Julia was a proud member of the Peace Corps family, and she contributed greatly to the lives of Filipino citizens in Donsol, Sorsogon, where she served,” he said. Latest: Suspect Juan Duntugan admits to killing Campbell. Leave your thoughts and condolences . |
| Warren Wiggins: Architect of the Peace Corps Warren Wiggins, who died at 84 on April 13, became one of the architects of the Peace Corps in 1961 when his paper, "A Towering Task," landed in the lap of Sargent Shriver, just as Shriver was trying to figure out how to turn the Peace Corps into a working federal department. Shriver was electrified by the treatise, which urged the agency to act boldly. Read Mr. Wiggins' obituary and biography, take an opportunity to read the original document that shaped the Peace Corps' mission, and read John Coyne's special issue commemorating "A Towering Task." |
| Chris Dodd's Vision for the Peace Corps Senator Chris Dodd (RPCV Dominican Republic) spoke at the ceremony for this year's Shriver Award and elaborated on issues he raised at Ron Tschetter's hearings. Dodd plans to introduce legislation that may include: setting aside a portion of Peace Corps' budget as seed money for demonstration projects and third goal activities (after adjusting the annual budget upward to accommodate the added expense), more volunteer input into Peace Corps operations, removing medical, healthcare and tax impediments that discourage older volunteers, providing more transparency in the medical screening and appeals process, a more comprehensive health safety net for recently-returned volunteers, and authorizing volunteers to accept, under certain circumstances, private donations to support their development projects. He plans to circulate draft legislation for review to members of the Peace Corps community and welcomes RPCV comments. |
| He served with honor One year ago, Staff Sgt. Robert J. Paul (RPCV Kenya) carried on an ongoing dialog on this website on the military and the peace corps and his role as a member of a Civil Affairs Team in Iraq and Afghanistan. We have just received a report that Sargeant Paul has been killed by a car bomb in Kabul. Words cannot express our feeling of loss for this tremendous injury to the entire RPCV community. Most of us didn't know him personally but we knew him from his words. Our thoughts go out to his family and friends. He was one of ours and he served with honor. |
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Story Source: Senate Foreign Relations Committee
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