Veterans Health Care:
Improvements Needed in Operationalizing Strategic Goals and Objectives
GAO-17-50: Published: Oct 21, 2016. Publicly Released: Nov 21, 2016.
How will VHA provide quality health care to veterans?
The Veterans Health Administration provided health care to 6.7 million veterans in fiscal year 2015. However, changes in the veteran population (such as more female veterans) could affect VHA's current strategies to provide quality health care. Effective strategic planning—such as identifying goals and methods to achieve them—can help VHA respond to the changing health care needs of veterans.
We reviewed VHA's strategic planning process and recommended that it clarify the responsibilities of VA's medical centers, and develop an oversight process.
Timeline of Factors that Have Affected or May Affect the Veterans Health Administration’s Strategic Goals and Objectives, during Fiscal Years 2013 – 2018
Timeline showing 13 reports, events, and strategic plans that may have affected VHA's goals.
What GAO Found
The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) uses a multi-step strategic planning process to develop its strategic goals and objectives, which includes two key steps—(1) identifying and assessing factors that may affect health care delivery, which is referred to as environmental scanning, and (2) holding the annual National Leadership Council (NLC) Strategic Planning Summit—according to officials. VHA officials told GAO that they leverage VA's environmental scanning results in making decisions regarding VHA's strategic goals and objectives and that VA's central office has historically had a role in aspects of VHA's strategic planning process—such as participating in the NLC summit.
VHA relies on the VA medical centers (VAMC) that directly provide care to veterans and the Veterans Integrated Service Networks (VISN), regional entities to which the VAMCs report, to operationalize its strategic goals and objectives. However, certain limitations in VHA's processes hinder VISNs' and VAMCs' efforts in operationalizing these goals and objectives. Specifically,
VHA has not specified VAMCs' role and responsibilities in its strategic planning guidance, as it has for VISNs. For example, VHA's directive for VISNs clearly states how VISN directors are to operationalize VHA's operational plans; no such directive exists for VAMC officials. Similarly, VHA provided VISNs a strategic planning guide for operationalizing its current strategic plan, but did not provide a similar guide to the VAMCs.
VHA has not developed detailed strategies for VISNs and VAMCs to use in operationalizing all of its strategic goals and objectives. According to leading practices for strategic planning, strategies should describe how strategic goals and objectives are to be achieved, including a description of the operational processes, staff skills, technology and other resources required. In September 2014, VHA published the Blueprint for Excellence to provide strategies for transforming VHA health care service delivery in response to concerns regarding the VHA wait-time crisis that year. However, it did not develop similar strategy documents for other years or for the other goals and objectives in its strategic plan.
VHA does not have an effective oversight process for ensuring and assessing the progress of VISNs and VAMCs in meeting VHA's strategic goals and objectives. According to VHA officials, VHA relies on two methods for assessing performance towards meeting selected strategic goals and objectives. Specifically, VHA uses VISN and VAMC directors' individual annual performance plans, as well as veteran survey information, to assess VHA's performance towards meeting certain metrics, such as improving veterans' access. However, it is unclear how these specific metrics are linked to assessing overall progress towards VHA's strategic goals and objectives. As a result, VHA may not know to what extent VISNs' and VAMCs' efforts to operationalize its goals and objectives are adequately addressing top management concerns or department-wide strategic goals.
Why GAO Did This Study
Veterans' health care needs may change due to changes in veteran demographics and other factors. Strategic planning, including identifying mission, vision, goals, and objectives, and operationalizing strategies to achieve those goals and objectives are essential for VHA to establish its strategic direction to respond to these changing demands and provide care in a dynamic environment.
GAO was asked to review VHA's strategic planning. This report examines (1) VHA's strategic planning process and (2) the extent to which VHA operationalizes its strategic goals and objectives. GAO reviewed VHA strategic planning documents; and interviewed officials from VA and VHA central office, three VISNs selected to provide variation in geographic location, and nine VAMCs within these VISNs selected to provide variation in factors such as geographic location and facility complexity. GAO evaluated VHA's actions against federal standards for internal control and leading practices for strategic planning.
What GAO Recommends
GAO recommends that VHA (1) specify VAMCs' roles and responsibilities in operationalizing its strategic goals and objectives, (2) develop detailed strategies to operationalize its goals and objectives, and (3) develop an oversight process to assess progress made. VA concurred with GAO's recommendations.
For more information, contact Debra A. Draper at (202) 512-7114 or firstname.lastname@example.org.
Recommendations for Executive Action
Comments: According to officials, VHA's Office of Policy and Planning continues to routinely communicate that all components of the organization should align their activities and resources to VA's 2014-2020 strategic goals and objectives, the MyVA Priority and Management Initiatives, and to the five VHA Priorities for Strategic Action. VHA's Office of Policy and Planning has also developed and disseminated Strategic Principals for Operational and Programmatic Decision Making, which was intended to provide a set of unifying principles for operational and programmatic decision-making. In its September 2017 update, VHA provided GAO with a copy of its draft FY 2018-2019 Operational and Modernization Plan. VHA is also in process of developing an Operational Planning Worksheet that is intended to provide instructions, definitions and examples to help create meaningful tactics, identify accountable leads, and document relevant interdependencies and requirements across the organization for VAMCs, VISNs and Program Offices. In its September 2017 update, VHA also noted that the National Leadership Council Strategic Planning Summit was held in June 2017, and that the focus of the summit was to ensure a clear understanding of the five VA/VHA priorities and how to operationalize the priorities at all levels of the organization. According to officials, VHA also held its National Planning Training (NPT) in August 2017 and the training was designed around the five VA/VHA priorities with a significant emphasis on clarifying the roles and responsibilities of VA Health Care Systems, VISNs and Program Offices in operationalizing the five priorities. According to officials, presentations incorporated the five priorities and a discussion on the various operational roles across the organization. VHA also noted that an online discussion board was opened at the conclusion of each NPT session with discussion questions specific to clarifying implementation responsibilities for the five VA/VHA priorities and other strategic initiatives. GAO has requested that VHA provide documentary evidence of these activities to support closure of this recommendation.
Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to define the roles and responsibilities of VAMCs in operationalizing VHA's strategic goals and objectives; this could be accomplished by establishing roles and responsibilities for VAMCs similar to how VHA defines roles and responsibilities for VISNs in VHA Directive 1075 and by developing guidance for VAMCs similar to guidance developed for VISNs.
Agency Affected: Department of Veterans Affairs
Comments: According to officials, VHA held its annual National Leadership Council Strategic Planning Summit in June 2017, during which NLC members and other strategic thinkers representing Program Office and VA Health Care Systems identified a set of strategies and milestones that link to and support operationalizing the five VA/VHA priorities. According to officials, these 16 strategies and milestones serve as the initial framework for operational planning at the VA Health Care System, VISN, and Program Office levels. VHA has provided evidence that it is currently developing its 2018 modernization and operational planning guidance, which is expected to link VA's strategic goals and objectives to the modernization plan and the five VA/VHA priorities. The guidance is also expected to require program offices, VISNs, and VAMCs to submit plans that articulate tactics and milestones and identify requirements that clearly link organizational activities back to operationalizing strategies and accomplishing priorities and goals. According to officials, the next phase of operational planning will occur at the VA Senior Leaders' Business Meeting, during which VA Health Care System, VISN, and Program Office leaders will further detail plans by identifying the tactics and requirements each will implement to operationalize the strategies and achieve the priorities, including identifying individuals that will be responsible for leading implementation of tactics. According to officials, VHA will initiate the final phase of operational planning following this meeting. During this final phase, VHA expects to disseminate its operational plan, and guidance, to VISNs and Program Offices with guidance to work with their subcomponents (VAMCs and other divisions) to finalize details in support of the operational plan. Following, the VISNs and Program Offices are expected to return their plans to VHA's Office of Policy and Planning to be incorporated into VHA's final modernization and operational plan. According to officials, VHA's Office of Policy and Planning has also continued to work very closely with the VA Office of Enterprise Integration to link VHA's strategies and measures with VA's draft 2018-2024 goals, objectives, strategies and measures to ensure consistency and alignment in planning and operationalization. According to officials, these linkages will enable VHA and VA to monitor and report progress on achieving the five VA/VHA priorities.
Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to consistently develop strategies that can be used by VISNs and VAMCs to operationalize VHA's goals and objectives, ensuring that they clearly link directly to VHA's goals and objectives.
Agency Affected: Department of Veterans Affairs
Comments: In its 60-day update, VHA notified GAO that performance plans for senior executives will be updated to include requirements to provide oversight to assure that day-to-day activities on initiatives and programs are consistent with organizational goals, objectives and priorities. Furthermore, VHA informed GAO that executive performance, and performance of the organizations they lead, will be assessed using periodic review of performance against established organizational metrics associated with priorities, and annual performance plans of senior executives. In its 60 day update, VHA also notified GAO that VHA's Office of Policy and Planning will monitor implementation on a periodic basis to identify when initiatives or programs are progressing appropriately or at risk of not achieving goals and objectives in accordance with priorities. In VHA's August 2017 update on open recommendations, officials noted that VHA has also developed an internal Healthcare Operations Dashboard--which provides immediate and daily information regarding veterans' health care access, including wait times, productivity, and utilization--and an externally-facing Access and Quality in VA Healthcare web site--which provides veterans, caregivers, and other stakeholders with tools to view access and quality performance for specific VA facilities. According to VHA officials, both VA and VHA are monitoring strategic programs and activities to identify barriers that may impede progress towards the achievement of goals and objectives, which can then be elevated to leadership, as appropriate. In VHA's September 2017 update, officials also noted that VHA's Office of Policy and Planning and Office of Strategic Integration are coordinating the monitoring and quarterly reporting of progress on achievements related to the five VA/VHA priorities and the supporting strategies. According to officials, Priority and Strategy leads have been identified and are responsible for reporting operational progress and for managing any challenges that slow or prevent operationalization. According to officials, progress on all strategies and priorities is being reported at the VHA senior leaders morning meeting on a routine basis. GAO has requested that VHA provide documentary evidence of these activities to support closure of this recommendation.
Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to develop an oversight process to assess progress made in meeting VHA's strategic goals and objectives, including feedback on how well activities and programs are contributing to achieving these goals and objectives.
Agency Affected: Department of Veterans Affairs