Managing Risks and Improving VA Health Care

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Since our 2019 High-Risk Report, the rating for the capacity criterion improved from not met to partially met, and ratings for the other four criteria remain unchanged.

As the new VA leadership team sets its priorities, it is critical that a senior leader with sufficient positional authority to drive organizational action is charged with addressing high-risk concerns.

This is particularly important as VA has made limited progress since 2015 in fully developing an action plan, although significant resources and time have been devoted to developing one.

The action plan VA approved in October 2020 included key components for most areas of concern; however, we identified deficiencies with these components. The action plan also lacked thorough integration with VA’s modernization initiatives.

Without a clear roadmap, VA cannot effectively monitor its efforts or demonstrate progress. We have made 432 recommendations related to VA health care since 2010, 129 of which remained open as of December 2020.

Section 7007 of the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020, enacted in January 2021, requires VA to submit to Congress a plan addressing certain high-risk areas and provide annual updates on its progress, which provides an important oversight mechanism for VA’s high-risk efforts.

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Since our 2019 High-Risk Report, ratings for one criterion—capacity—improved and the other four remain unchanged.

Leadership commitment: partially met. VA has continued to establish policy management initiatives at its Veterans Health Administration (VHA), such as the process VHA finished implementing in November 2019 to obtain feedback on national policy from all levels of the organization including the local level. With the many modernization efforts under way that will realign agency roles and responsibilities, such as VHA’s central office reorganization, it is critical that VHA’s policy management initiatives continue to receive support from senior leadership to ensure effective change management.

Capacity: partially met. VA has improved in this criterion due to the policy procedures VHA has established and maintained since 2017, such as eliminating 64 program office memos on access to care that do not conform to national policy requirements. To help accomplish its policy management initiatives, VHA uses a contract—$7.2 million in fiscal year 2020—to support its capacity needs, such as the use of professional policy writers to assist program offices. VHA relies on the continuation of this contractor support to make progress in this area of concern and to maintain the policy procedures it has established.

Action plan: partially met. VA’s action plan includes key components to address ambiguous policies and inconsistent processes, but we identified a number of deficiencies with these components. For example, the action plan does not provide interim steps or milestones for several actions listed as “in progress,” such as identifying responsibilities for policy implementation by the end of fiscal year 2021.

Monitoring: not met. In its action plan, VA described monitoring activities for this area of concern, but did not link those activities to performance measures. In addition, VA noted that it is establishing monitoring procedures, such as plans for collecting documentation of demonstrated progress for each area of concern.

Demonstrated progress: not met. VA cannot show that it is addressing root causes, because its action plan does not include all critical actions or milestones. Our work has indicated continuing policy management issues, and since 2019, we have made 20 recommendations to address these issues. For example, in June 2019, we found that VHA does not have a comprehensive policy defining the roles and responsibilities of the regional networks that manage and oversee VA medical facilities, which makes it difficult to ensure adequate monitoring of the activities of these regional networks.

We recommended that VHA develop such a policy to ensure that it can adequately monitor these regional networks. VA concurred in principle with this recommendation, which remains open.

Inadequate Oversight and Accountability

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Since our 2019 High-Risk Report, ratings for two criteria regressed and three remain unchanged.

Leadership commitment: not met. Since 2019, VA has regressed in this criterion as the Under Secretary for Health position has remained unfilled; instead, VA has had an Executive-in-Charge leading VHA, including its high-risk efforts and major modernization initiatives. Turnover in the senior executives leading high-risk efforts that occurred after root causes and outcomes were established makes leadership commitment in this area of concern unclear.

Capacity: not met. VA had taken steps to establish initial compliance, internal audit, and risk management activities (central components of the agency’s oversight and accountability model) prior to 2019. However, VA’s action plan indicates it has made minimal progress since that time to further develop these activities, and VA has not clearly identified capacity needs for most outcomes in this area of concern.

Action plan: not met. Since 2019, VA has regressed in this criterion as it has not developed the key components of an action plan. Specifically, the action plan did not include thoroughly developed critical actions, milestones, or performance measures to reach its stated outcomes. For example, the action plan states that VHA governance will ensure accountability with its requirements by the end of fiscal year 2020. However, the plan only included one critical action—that its high-risk workgroup identify and collaborate with relevant stakeholders. VA also did not establish any performance measures or metrics. As a result, it is unclear how VA intends to achieve this outcome.

Monitoring: not met. In its action plan, VA included a few monitoring activities for this area of concern, such as reviewing corrective actions. However, the action plan does not say who is responsible for these activities or how VA will track progress on them.

Demonstrated progress: not met. VA cannot show that it is addressing root causes due to the lack of details in its action plan. Our work has indicated continuing oversight and accountability issues, and since 2019, we have made 30 recommendations to address these issues. For example, in September 2020, we found that VA does not have a full understanding of the prevalence and nature of on-campus suicides, hindering its ability to address them. We made three recommendations for VA to obtain accurate data and to complete comprehensive analyses to better understand on-campus suicides. VA agreed with two of our three recommendations, all of which remain open.

Also in September 2020, we found that the Veterans Community Care Program (implemented by VA in June 2019) has metrics to assess the timeliness of appointment scheduling that are inconsistent with scheduling guidance VA staff are instructed to follow. This deficiency limits VA’s ability to determine the effectiveness of the Veterans Community Care Program in improving access to care.

We made three recommendations to address timely access to the Veterans Community Care Program, including that VA align its monitoring metrics with the time frames established for the program’s scheduling process. VA did not concur that it should align metrics with its scheduling process because it already monitors the timeliness of key steps. Because VA’s response does not fully address our recommendation, such as establishing time frames to account for the entire appointment scheduling process, this recommendation remains open. We maintain that VA should implement the recommendation in order to achieve its goal of reducing veterans’ wait times.

Information Technology Challenges

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Since our 2019 High-Risk Report, ratings for two criteria improved and three remain unchanged.

Leadership commitment: partially met. VA has improved in this criterion due to leadership stability in the Chief Information Officer position. VA has a number of information technology initiatives under way to address VHA’s critical business needs, such as electronic health record modernization, community care, and legacy systems. Therefore, it is critical that VA maintain leadership support to prioritize and meet VHA’s information technology needs, including electronic health record modernization efforts delayed in early 2020 and then again due to the COVID-19 pandemic, affecting the implementation of this $16.1 billion initiative. This leadership support is particularly important during the administration transition as the Chief Information Officer position must be appointed.

Capacity: partially met. VA has improved in this criterion due to the significant funding and staff resources provided to electronic health record modernization, with initial deployment of the system taking place in late October 2020 at the first of over 100 locations. However, this effort and the resources needed are still in the early stages.

Action plan: partially met. VA’s action plan includes key components to address information technology challenges, but we identified a number of deficiencies with these components. For example, the action plan states that VA will reduce the number of duplicative information technology systems, but does not establish milestones or a target by which to measure progress toward this outcome. The action plan also states that VA intends to work with internal stakeholders and workgroups on information technology system modernization, but does not provide details on how it will do so.

Monitoring: not met. In its action plan, VA described monitoring activities for most outcomes in this area of concern, but did not link those activities to performance measures. In addition, VA noted that it is establishing monitoring procedures, such as plans for collecting documentation of demonstrated progress for each area of concern.

Demonstrated progress: not met. VA cannot show that it is addressing root causes, because its action plan does not include all critical actions or milestones. Our work has indicated a number of information technology issues, and since 2019, we have made five recommendations to address these issues. For example, in June 2020, we found that VA did not always involve all relevant stakeholders in system configuration decisions for its future electronic health record. Stakeholders, including medical facility clinicians and staff, need to be involved in these decisions to ensure the system will meet their needs.

We recommended that VA take steps to clarify terminology and include adequate detail in descriptions of local workshop sessions for implementation at future facilities. VA agreed with our recommendation, which remains open.

Inadequate Training for VA Staff

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Since our 2019 High-Risk Report, ratings for two criteria improved and three remain unchanged.

Leadership commitment: partially met. VA has improved in this criterion due to leadership stability since March 2019 in the Chief Learning Officer position and the governance structures it has maintained, such as learning councils made up of program office training staff. However, VA still lacks an enterprise-wide annual training plan, a central initiative for achieving the agency’s identified outcomes.

Capacity: partially met. VA has improved in this criterion due to the working groups and task forces with specific responsibilities VHA has established and maintained for carrying out its training initiatives. These initiatives are highly reliant on organization-wide collaboration, such as from contracting, finance, and policy offices. VA also relies on contracts to support its training initiatives—$1.18 million in fiscal year 2020—that it included as a key capacity item to ensure progress toward its outcomes.

Action plan: partially met. While key components were included for this area of concern in VA’s action plan, we identified a few deficiencies. For example, VA’s critical actions are not linked to its performance measures, making it unclear which activities will enable it to assess progress toward meeting its outcomes.

In addition, the majority of milestones VA included for this area of concern were for activities projected to be completed in fiscal year 2020 or 2021, which may not provide a realistic time frame for what VA is able to accomplish or provide a sufficient roadmap for how VA plans to proceed.

Monitoring: not met. In its action plan, VA described monitoring activities for this area of concern, but did not link those activities to performance measures. In addition, VA noted that it is establishing monitoring procedures, such as plans for collecting documentation of demonstrated progress for each area of concern.

Demonstrated progress: not met. VA cannot show that it is addressing root causes, because its action plan does not contain realistic milestones or align performance measures with critical actions. Our work has identified a number of training issues, and since 2019, we have made six recommendations to address these issues.

For example, in July 2020, we found that VA had not sufficiently trained compliance officers or independent auditors on reviewing disbursement agreements for its Graduate Medical Education program, which reimburses academic affiliates for medical and dental residents’ salaries and benefits. Insufficient training puts VHA at increased risk of making improper payments in this program.

We recommended that VHA develop training for both oversight mechanisms that includes general information on Graduate Medical Education programs and disbursement agreement oversight, as well as detailed information about how each review should be conducted. VA agreed with our recommendations, both of which remain open.

Unclear Resource Needs and Allocation Priorities

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Since our 2019 High-Risk Report, ratings for one criterion improved—capacity—and the other four remain unchanged.

Leadership commitment: partially met. VA has maintained senior leadership in the Chief Financial Officer position and has established workforce policies. VHA has paused its financial management modernization efforts until other initiatives related to electronic health records and supply chain are further along, affecting a key organizational change for determining resource needs.

Capacity: partially met. VA has improved in this criterion as it has completed hiring VHA Office of Finance senior leadership and is in the process of hiring regional network-level analysts for workforce resource activities. VA is also establishing budget submission procedures, but has not clearly identified this effort’s needed resources.

Action plan: partially met. VA’s action plan includes key components to address unclear resource needs and allocation priorities, but we identified a number of deficiencies with these components. For example, over half of VA’s actions in this area of concern were “in planning” or “in progress” with a projected completion date, but the plan did not provide any interim steps or milestones of how VA would make progress toward those dates. In addition, the majority of milestones VA included were for short-term activities mostly occurring in fiscal year 2020 that, while important, do not provide a sufficient roadmap for all that needs to be accomplished and how VA plans to proceed.

Monitoring: not met. In its action plan, VA described monitoring activities for this area of concern, but did not link those activities to performance measures. In addition, VA noted that it is establishing monitoring procedures, such as plans for collecting documentation of demonstrated progress for each area of concern.

Demonstrated progress: not met. VA cannot show that it is addressing root causes, because its action plan does not include all critical actions or milestones. Our work has identified a number of issues with resource allocation, and since 2019, we have made 11 recommendations to address these issues.

For example, in September 2020, we found that VA processes for actuarial modeling—used to estimate resources for providing health care services in the community—lack steps for communicating all relevant information on data quality and overall uncertainty associated with community care budget estimates.

We recommended that VA communicate information on data quality to its actuarial consultant and assess and communicate overall uncertainty associated with actuarial projections to stakeholders. VA agreed with our recommendations, both of which remain open.