VA Health Care:
Processes to Evaluate, Implement, and Monitor Organizational Structure Changes Needed
GAO-16-803: Published: Sep 27, 2016. Publicly Released: Oct 27, 2016.
The Veterans Health Administration (VHA) is in the midst of its largest geographic realignment in more than 20 years. The realignment resulted in some staff redundancies—2 or more staff doing the same job, also called "double-encumbered" positions. Regional network directors told us they were frustrated with the lack of guidance from VHA's central office about how to resolve this and other challenges they faced.
Department of Veterans' Affairs (VA) Veterans Health Administration (VHA) Regional Map, Post-Realignment
Map showing VHA's realigned regions for health care service delivery.
What GAO Found
Recent internal and external reviews of Veterans Health Administration (VHA) operations have identified deficiencies in its organizational structure and recommended changes that would require significant restructuring to address, including eliminating and consolidating program offices and reducing VHA central office staff. However, VHA does not have a process that ensures recommended organizational structure changes are evaluated to determine appropriate actions and implemented. This is inconsistent with federal standards for internal control for monitoring, which state that management should remediate identified internal control deficiencies on a timely basis. GAO found instances where VHA actions in response to recent recommendations for organizational structure changes were incomplete, not documented, or not timely. For example, VHA chartered a task force to develop a detailed plan to implement selected recommendations from the independent assessment of VHA's operations required by the Veterans Access, Choice, and Accountability Act of 2014; according to VHA, the assessment cost $68 million. It found, among other things, that VHA central office programs and staff had increased dramatically in recent years, resulting in a fragmented and “silo-ed” organization without any discernible improvement in business or health outcomes. It recommended restructuring and downsizing VHA's central office. The task force of 18 senior Department of Veterans Affairs (VA) and VHA officials conducted work over about 6 months, but did not produce a documented implementation plan or initiate implementation of recommendations. Without a process that documents the assessment, approval, and implementation of organizational structure changes, VHA cannot ensure that it is making appropriate changes, using resources efficiently, holding officials accountable for taking action, and maintaining documentation of decisions made.
VHA central office's monitoring of the Veterans Integrated Service Networks (VISN) realignment—a recent and significant organizational structure change—has been limited, and the office has provided little implementation guidance. In October 2015, VHA began to implement a realignment of its VISN boundaries, which involves decreasing the number of VISNs from 21 to 18 and reassigning some VA medical centers (VAMC) to different VISNs. VHA officials anticipate this process will be completed by the end of fiscal year 2018. VHA officials on the task force implementing the realignment told GAO they thought VISNs could implement the realignment independently without the need for close monitoring. VHA also did not provide guidance to address VISN and VAMC challenges that could have been anticipated, including challenges with services and budgets, double-encumbered positions (two officials in the same position in merging VISNs), and information technology. Further, VHA officials said they do not have plans to evaluate the realignment. VHA's actions are inconsistent with federal internal control standards for monitoring (management should establish monitoring activities, evaluate results, and remediate identified deficiencies) and risk assessment (management should identify, analyze, and respond to changes that could affect the system). Without adequate monitoring, including a plan for evaluating the VISN realignment, VHA cannot be certain that the changes being made are effectively addressing deficiencies; nor can it ensure lessons learned can be applied to future organizational structure changes.
Why GAO Did This Study
GAO and others have expressed concerns about VHA's management of its health care system. In response, VA initiated a new regional framework to improve internal coordination and customer service, and VHA initiated an effort to realign its VISNs.
GAO was asked to review VHA's organizational structure—the operating units, processes, and other components used to achieve agency objectives. This report examines the extent to which (1) VHA has a process for evaluating recommended organizational structure changes to determine actions needed and implementing them as appropriate; and (2) VHA monitored and provided guidance for implementing the VISN realignment. GAO reviewed VHA documents, reviewed internal and external assessments of VHA, and interviewed officials from VHA central office and all VISNs. GAO evaluated VHA's actions against relevant federal standards for internal control.
What GAO Recommends
GAO recommends that VHA (1) develop a process to ensure that organizational structure recommendations are evaluated for implementation; and (2) evaluate the implementation of the VISN realignment to determine and correct deficiencies, and apply lessons learned to future organizational structure changes, such as possible changes to VISN staffing models. VA concurred with GAO's recommendations.
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Recommendations for Executive Action
Comments: VHA concurred with this recommendation and has provided regular updates on its progress in implementing it. In July 2017, VHA told us that a Rapid Design and Implementation functional assessment of VHA Central Office and VISN organizations had been completed, which included a survey, interviews with central office and VISN officials, and other meetings. In November 2017, VHA reported that in October it awarded a contract to conduct an independent assessment of the VISN consolidation experience and to make recommendations for future actions. The independent assessment is expected to be completed in January 2018. VHA also reported in November 2017 that the Rapid Design and Implementation functional assessment process yielded a high-level organizational concept that is being used by teams to develop recommendations for consolidations within VHA, and that these recommendations will be submitted to VHA leadership in January 2018. In our recommendation, we stated that lessons learned from evaluating the VISN realignment need to be applied to future organizational structure changes. It is difficult to determine at this time how lessons learned from the VISN realignment's evaluation can be incorporated into new organizational structure changes if such changes are being drafted for VHA leadership approval at the same time that the evaluation is underway. As of December 2017, this recommendation remains open pending further updates from VHA.
Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to conduct an evaluation of the implementation of the VISN realignment to determine whether deficiencies exist that need corrective actions, and apply lessons learned from the evaluation to future organizational structure changes, such as possible changes to VISN staffing models or actions to implement Commission on Care recommendations.
Agency Affected: Department of Veterans Affairs
Status: Closed - Implemented
Comments: VHA concurred with this recommendation and has provided regular updates on its progress in implementing it. In November 2017, VHA reported that the Acting Under Secretary for Health approved a new procedure for documenting and implementing organizational changes on July 12, 2017, and provided a copy. The standard operating procedure contains specific instructions and mechanisms for proposing, evaluating, promulgating, and implementing organizational changes, including the designation of officials responsible for reviewing and approving such changes. In March 2018, VHA reported using the procedure as part of current efforts to implement central office organizational structure changes as part of implementing VHA's Modernization Initiative. As such, we are closing this recommendation as implemented.
Recommendation: The Secretary of Veterans Affairs should direct the Under Secretary for Health to develop a process to ensure that organizational structure recommendations resulting from internal and external reviews of VHA are evaluated for implementation. This process should include the documentation of decisions and assigning officials or offices responsibility for ensuring that approved recommendations are implemented.
Agency Affected: Department of Veterans Affairs