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    Subject Term: "Health care policies"

    4 publications with a total of 9 open recommendations including 2 priority recommendations
    Director: Debra A. Draper
    Phone: (202) 512-7114

    3 open recommendations
    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: Department of Veterans Affairs
    Status: Open

    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 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: Department of Veterans Affairs
    Status: Open

    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 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: Department of Veterans Affairs
    Status: Open

    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.
    Director: Emrey Arras, Melissa H
    Phone: (617)788-0534

    1 open recommendations
    Recommendation: To better balance the benefits of expedited rulemaking procedures with the benefits of public comments that are typically part of regular notice-and-comment rulemakings, and improve the quality and transparency of rulemaking records, the Director of OMB, in consultation with the Chairman of Administrative Conference of the United States (ACUS), should issue guidance to encourage agencies to respond to comments on final major rules, for which the agency has discretion, that are issued without a prior notice of proposed rulemaking.

    Agency: Executive Office of the President: Office of Management and Budget
    Status: Open

    Comments: In comments on the draft report, OMB disagreed with GAO's recommendation. OMB stated that it did not believe it was necessary to issue guidance on this topic at that time. In July 2014, OMB said that it had no further comments on this recommendation. As of June 2017, OMB had not provided any additional responses to GAO's requests for an update on the status of this recommendation.
    Director: Williamson, Randall B
    Phone: (206)287-4860

    3 open recommendations
    including 2 priority recommendations
    Recommendation: To ensure that servicemembers have equitable access to the military services' wounded warrior programs, including the RCP, and to establish central accountability for these programs, the Secretary of Defense should establish or designate an office to centrally oversee and monitor the activities of the military services' wounded warrior programs to include the following: (1) Develop consistent eligibility criteria to ensure that similarly situated recovering servicemembers from different military services have uniform access to these programs; (2) Direct the military services' wounded warrior programs to fully comply with the policies governing care coordination and case management programs and any future changes to these policies; (3) Develop a common mechanism to systematically monitor the performance of the wounded warrior programs--to include the establishment of common terms and definitions--and report this information on a biannual basis to the Armed Services Committees of the House of Representatives and the Senate.

    Agency: Department of Defense
    Status: Open
    Priority recommendation

    Comments: DOD did not concur with our part (1) of our recommendation to develop consistent eligibility criteria, explaining that the three military department secretaries should have the ability to control entrance criteria into their wounded warrior programs and that varying eligibility criteria have not resulted in noticeable differences in access to these programs by recovering servicemembers or their families. In attachments to a memo dated April 8, 2014, DOD provided an update on progress made to implement parts (2) and (3) of the DOD-specific recommendation made in GAO-13-5. Regarding part (2), DOD reported that budget constraints had delayed its plan to conduct oversight visits to 63 service sites over a 12-month period to ensure that military wounded warrior programs were operating in compliance with DOD Recovery Coordinator Program policy. DOD stated that the Warrior Care Policy office, in coordination with the military service branches, had intended to begin these oversight visits and interviews in September 2013; that as of March 2014, five sites had been reviewed; and that results of the compliance visits would be available upon completion. Regarding part (3) of the recommendation, DOD's memo stated that DOD and VA continue work on developing policies on clinical and non-clinical care coordination. It also noted that interagency metrics for monitoring complex care coordination performance were under development by the DOD/VA Interagency Care Coordination Committee. Further, DOD stated that because the Joint Executive Council publishes an annual report, that reporting the progress in developing common terms and definitions used by wounded warrior programs to congressional committees would be of limited value. As of October 2016, when we determine what additional steps the agency has taken to implement this recommendation, we will update this information.
    Recommendation: To ensure that persistent challenges with care coordination, disability evaluation, and the electronic sharing of health records are fully resolved, the Secretaries of Defense and Veterans Affairs should ensure that these issues receive sustained leadership attention and collaboration at the highest levels with a singular focus on what is best for the individual servicemember or veteran to ensure continuity of care and a seamless transition from DOD to VA. This should include holding the Joint Executive Council accountable for (1) ensuring that key issues affecting recovering servicemembers and veterans get sufficient consideration, including recommendations made by the Warrior Care and Coordination Task Force and the Recovering Warrior Task Force; (2) developing mechanisms for making joint policy decisions; (3) involving the appropriate decision-makers for timely implementation of policy; and; (4) establishing mechanisms to systematically oversee joint initiatives and ensure that outcomes and goals are identified and achieved.

    Agency: Department of Defense
    Status: Open
    Priority recommendation

    Comments: As of October 2016, under the joint DOD/VA Interagency Care Coordination Committee, the departments have made progress to improve nonclinical care coordination procedures, primarily through the development of two initiatives?the Lead Coordinator initiative (in which a single care coordinator serves as the primary point of contact for a recovering servicemember) and through the use of a single, interagency care plan (ICP) for each recovering servicemember. As of March 2016, the departments were continuing the national rollout of the Lead Coordinator initiative and had trained nearly 3,700 DOD and VA personnel on the new process. In addition, DOD and VA continued the development of the ICP initiative, which will depend upon their ability to electronically exchange the information needed to implement servicemembers' care plans. In December 2015, DOD awarded a contract to support the ICP and to create electronic interoperability with VA. The departments anticipate testing their ability to exchange information digitally in June 2016 and achieving full operational capability by September 2016. We will continue to monitor progress to implement the joint Lead Coordinator and the ICP care coordination initiatives.
    Recommendation: To ensure that persistent challenges with care coordination, disability evaluation, and the electronic sharing of health records are fully resolved, the Secretaries of Defense and Veterans Affairs should ensure that these issues receive sustained leadership attention and collaboration at the highest levels with a singular focus on what is best for the individual servicemember or veteran to ensure continuity of care and a seamless transition from DOD to VA. This should include holding the Joint Executive Council accountable for (1) ensuring that key issues affecting recovering servicemembers and veterans get sufficient consideration, including recommendations made by the Warrior Care and Coordination Task Force and the Recovering Warrior Task Force; (2) developing mechanisms for making joint policy decisions; (3) involving the appropriate decision-makers for timely implementation of policy; and; (4) establishing mechanisms to systematically oversee joint initiatives and ensure that outcomes and goals are identified and achieved.

    Agency: Department of Veterans Affairs
    Status: Open

    Comments: As of October 2016, under the joint DOD/VA Interagency Care Coordination Committee, the departments have made progress to improve nonclinical care coordination procedures, primarily through the development of two initiatives?the Lead Coordinator initiative (in which a single care coordinator serves as the primary point of contact for a recovering servicemember) and through the use of a single, interagency care plan (ICP) for each recovering servicemember. As of March 2016, the departments were continuing the national rollout of the Lead Coordinator initiative and had trained nearly 3,700 DOD and VA personnel on the new process. In addition, DOD and VA continued the development of the ICP initiative, which will depend upon their ability to electronically exchange the information needed to implement servicemembers' care plans. In December 2015, DOD awarded a contract to support the ICP and to create electronic interoperability with VA. The departments anticipate testing their ability to exchange information digitally in June 2016 and achieving full operational capability by September 2016. We will continue to monitor progress to implement the joint Lead Coordinator and the ICP care coordination initiatives.
    Director: Dicken, John E
    Phone: (202)512-7043

    2 open recommendations
    Recommendation: To address state agency practices and external pressure that may compromise survey accuracy, the Administrator of CMS should reestablish expectations through guidance to state survey agencies that noncitation practices--official or unofficial--are inappropriate, and systematically monitor trends in states' citations.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: September 2017: HHS reported CMS is working to address this recommendation. We will update the status of this recommendation when we receive further information. September 2016: CMS has not yet provided additional information. GAO will update the recommendation, as appropriate, when information is received. July 2015: CMS indicated it will provide GAO with updated actions in early 2016. May 2014: Though the best method to address external pressures on State Agencies was not identified, CMS is continuing to address the consistency, effectiveness, and integrity of the survey process through the following activities: reviewing citation patterns for the nursing home surveys; systematically identifying and testing opportunities to make the survey process more efficient and effective; and holding monthly CO and RO calls to address consistencies in the survey and enforcement process. CMS Regional Offices also routinely hold conference calls (e.g., monthly) with the State Survey Agencies in their region to address survey, enforcement and certification issues and conduct the federal validation survey of the state's findings. CMS is looking to review specific regulatory deficiencies for trends and areas where additional guidance is needed. Anticipated completion date of October 31, 2014. June 2013: Though the best method to address external pressures on State Agencies was not identified. CMS is continuing to address the consistency, effectiveness, and integrity of the survey process through the following activities: reviewing citation patterns for the nursing home surveys; systematically identifying and testing opportunities to make the survey process more efficient and effective; and holding monthly CO and RO calls to address consistencies in the survey and enforcement process. CMS Regional Offices also routinely hold conference calls (e.g., monthly) with the State Survey Agencies in their region to address survey, enforcement and certification issues and conduct the federal validation survey of the state's findings. September 2010: CMS held a State/Federal meeting in April 2010. The discussion with the State/Federal meeting did not shed light on best method to address possible external pressures on State Agencies. Some expressed that poor documentation/inadequate investigation may cause deficiencies to be dropped and not necessarily external pressure. They will continue to work on developing next steps.
    Recommendation: To address state agency practices and external pressure that may compromise survey accuracy, the Administrator of CMS should establish expectations through guidance to state survey agencies to communicate and collaborate with their CMS regional offices when they experience significant pressure from legislators or the nursing home industry that may affect the survey process or surveyors' perceptions.

    Agency: Department of Health and Human Services: Centers for Medicare and Medicaid Services
    Status: Open

    Comments: September 2017: HHS reported CMS is working to address this recommendation. We will update the status of this recommendation when we receive further information. September 2016: CMS has not yet provided additional information. GAO will update the recommendation, as appropriate, when information is received. July 2015: CMS indicated it will provide GAO with updated actions in early 2016. May 2014: CMS has undertaken a broader review of both the QIS and traditional survey processes, and the extent to which the methodology and guidance result in an effective and efficient survey process. In August 2012, CMS convened a broad group of surveyors to address these issues and make recommendations which have resulted in continuing work to develop and test alternative guidance and processes. CMS is looking to review specific regulatory deficiencies for trends and areas where additional guidance is needed. Anticipated Completion date of December 31, 2014. June 2013: Though the best method to address external pressures on State Agencies was not identified. CMS is continuing to address the consistency, effectiveness, and integrity of the survey process through the following activities: reviewing citation patterns for the nursing home surveys; systematically identifying and testing opportunities to make the survey process more efficient and effective; and holding monthly CO and RO calls to address consistencies in the survey and enforcement process. CMS Regional Offices also routinely hold conference calls (e.g., monthly) with the State Survey Agencies in their region to address survey, enforcement and certification issues and conduct the federal validation survey of the state's findings. September 2010: CMS held a State/Federal meeting in April 2010. The discussion with the State/Federal meeting did not shed light on best method to address possible external pressures on State Agencies. CMS will continue to work on developing next steps.