Veterans Health Care:

Additional Actions Could Further Improve Policy Management

GAO-17-748: Published: Sep 22, 2017. Publicly Released: Sep 22, 2017.

Additional Materials:

Contact:

Debra A. Draper
(202) 512-7114
draperd@gao.gov

 

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

How does the Veterans Health Administration ensure that its 170 medical centers are providing timely, high-quality care to veterans? VHA uses national policies and guidance that cover all aspects of health care delivery, such as purchasing community care and scheduling outpatient appointments.

We looked at how VHA defines and communicates its national policy and guidance and collects information on local implementation challenges. Among the issues we found was that VHA does not consistently solicit input from the local level before issuing policy or after implementing it.

We made 6 recommendations to address this and other challenges.

 

Photo of the Department of Veterans Affairs.

Photo of the Department of Veterans Affairs.

Additional Materials:

Contact:

Debra A. Draper
(202) 512-7114
draperd@gao.gov

 

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

What GAO Found

The Veterans Health Administration (VHA)—within the Department of Veterans Affairs (VA)—is taking steps to align existing national policy documents with newly revised definitions that streamline and clarify document use. According to the new definitions in its June 2016 directive on policy management, directives and notices are now the sole documents for establishing national policy; other types of documents, such as program office memos, are considered guidance. VHA is reviewing about 800 existing national policy documents to eliminate those that no longer meet its new definitions, and to rescind or recertify those that are outdated. At this time, VHA is not planning to review guidance documents, such as program office memos and standard operating procedures, to assess whether they align with its updated directive, because there is no central repository for these documents and it would be too resource intensive to locate all of them. Further, GAO's review found—contrary to VHA's updated directive—that program offices are continuing to use memos to issue policy. The continued use of program office memos to establish national policy undermines VHA's efforts to improve its policy management.

VHA has a standard process for making national policy documents accessible to VA medical centers (VAMC) and the Veterans Integrated Service Networks (VISN) to which the medical centers report, but lacks a process for making guidance documents accessible. VHA makes national policy documents accessible to all organizational levels through a publications website and e-mail distribution list as outlined in its June 2016 directive. However, GAO found that VHA has not established a similar process for program offices to make guidance documents accessible at the local level. Specifically, there is no central repository, such as a publications website, for guidance documents, and the program offices do not track or consistently disseminate the guidance documents they issue. Without a standard process for consistently maintaining and disseminating guidance, VHA lacks assurance that staff receive and follow the same guidance, as intended.

VHA does not routinely collect information on local challenges with national policy implementation or on exemption waivers. The four VISNs and eight VAMCs in GAO's review reported various challenges they face when implementing national policy, such as resource constraints and undefined time frames. In instances where VAMCs cannot meet policy requirements, program offices may approve policy exemption waivers on an ad hoc basis. However, GAO found that VHA lacks complete information on approved policy exemption waivers because it does not have a standard process for approving, tracking, and reassessing them. In recognition of this issue, VHA established a committee to develop a waiver process in June 2017.

VISNs and VAMCs in GAO's review develop and maintain various local policies, but VHA does not ensure that they align with national policies. Specifically, GAO found that VHA does not have a process for program offices to systematically ensure that local policies align with national policies. Without such a process, VHA may continue to experience inconsistent policy implementation across its health care system.

Why GAO Did This Study

GAO was asked to conduct a management review of VHA; this is the sixth report in the series. In this review of VHA's policy management, GAO examines the extent to which (1) VHA has implemented its new definitions for national policy and guidance documents; (2) VHA ensures that national policy and guidance documents are accessible to VISNs and VAMCs; (3) VHA collects information on local challenges with implementing national policy, including the exemptions granted when policy requirements cannot be met; and (4) local policies are developed and maintained by VISNs and VAMCs, and whether they are aligned with national policies.

GAO reviewed agency documentation, including VHA's revised directive on policy management. GAO also interviewed VHA officials involved with policy improvement efforts, as well as officials from a nongeneralizable sample of four national program offices, four VISNs, and eight VAMCs selected to provide geographic variation, among other factors.

What GAO Recommends

GAO is making six recommendations to VHA, which include clarifying national policy and guidance documents, ensuring access to guidance documents, incorporating local feedback into national policy, establishing a process to approve and track policy exemption waivers, and ensuring alignment of local and national policy. VHA generally concurred with GAO's recommendations.

For more information, contact Debra A. Draper at (202) 512-7114 or draperd@gao.gov.

Recommendations for Executive Action

  1. Status: Open

    Priority recommendation

    Comments: VA agreed with our recommendation. In June 2018, VHA reported taking a number of steps to better understand which guidance documents are currently used as policy, such as creating a repository of 10N memos it had identified. VHA plans to incorporate these memos into present policy or new directives, and rescind the remaining documents. In October 2018, VHA further noted that it is in the process of developing an interim policy notice on memo use by the end of December 2018, and updating its national policy directive by the end of June 2019. To fully implement this recommendation, VHA needs to provide us with the finalized version of the recertified VHA Directive 6330, which should include clarified guidance on the use of national policy and guidance documents as well as their recertification requirements. For guidance documents, this should include the use, vetting, and recertification of all types of memos, including but not limited to 10N memos.

    Recommendation: The Under Secretary for Health should further clarify when and for what purposes each national policy and guidance document type should be used, including whether guidance documents, such as program office memos, should be vetted and recertified. (Recommendation 1)

    Agency Affected: Department of Veterans Affairs: Veterans Health Administration

  2. Status: Open

    Comments: VA agreed with our recommendation. VHA reported that it added a 10N memo section to its internal publications website in November 2017, and began uploading 10 years of 10N memos with links from each memo to national policy. VHA anticipates that it will complete the 10N memo upload by December 2018. VHA also reported that it plans to build and maintain a comprehensive repository that centralizes all guidance on one website in order to co-locate program office guidance with the corresponding VHA policy. To fully implement this recommendation, VHA should provide documentation of its final process for maintaining and disseminating guidance documents to VHA program offices, VISNs, and VAMCs.

    Recommendation: The Under Secretary for Health should develop standard processes for consistently maintaining and disseminating guidance documents to each level of the organization. (Recommendation 2)

    Agency Affected: Department of Veterans Affairs: Veterans Health Administration

  3. Status: Open

    Comments: VA agreed with our recommendation in principle and cited that the recommendation was no longer needed because VHA had already instituted new policy development processes that allow VHA employees and program offices to provide feedback on national policy prior to issuance or recertification. We noted that the recommendation was still needed because VHA had not yet implemented its pre-policy form that will serve as a mechanism to systematically collect information about national policies prior to issuance and will require program offices to provide information on a policy's purpose, whether it conflicts with other VHA policy, implementation metrics, resources needed, a cost analysis, and a communications plan for VISNs and VAMCs. In October 2018, VHA reported that it was using a preliminary pre-policy form for each national policy, and was assessing the effectiveness of the form and collecting feedback on its usefulness through various mechanisms. To fully implement this recommendation, VHA should provide documentation of the finalized pre-policy form and that it has been implemented.

    Recommendation: The Under Secretary for Health should systematically obtain information on potential implementation challenges from VISNs and VAMCs and take the appropriate actions to address challenges prior to policy issuance. (Recommendation 3)

    Agency Affected: Department of Veterans Affairs: Veterans Health Administration

  4. Status: Open

    Comments: VA agreed with our recommendation. In June 2018, VHA reported that it had formed a Field Advisory Workgroup to provide continuing advice on national policy. VHA reported its findings and recommendations from the first workgroup meeting in December 2017 to senior leadership, and held another series of interviews in Summer 2018 to gain additional feedback about how national policy changes affect local facilities. In October 2018, VHA noted that it is in the process of rewriting VHA Directive 6330 based on feedback from the field. To fully implement this recommendation, VHA should provide documentation of the mechanism by which program offices systematically obtain feedback from VISNs and VAMCs on national policy after implementation and how it will take the appropriate actions.

    Recommendation: The Under Secretary for Health should establish a mechanism by which program offices systematically obtain feedback from VISNs and VAMCs on national policy after implementation and take the appropriate actions. (Recommendation 4)

    Agency Affected: Department of Veterans Affairs: Veterans Health Administration

  5. Status: Open

    Comments: VA agreed with our recommendation. In October 2018, VHA reported that it had collected information on the waiver procedures and areas of improvement that exist at both the national and local levels. Based on this information, VHA's Waiver Workgroup is finalizing its recommendations for implementing a formal waiver process. To fully implement this recommendation, VHA should provide us with documentation of a process that standardizes policy exemptions waivers, including tracking and monitoring those that are approved.

    Recommendation: The Under Secretary for Health should establish a standard policy exemption waiver process and centrally track and monitor approved waivers. (Recommendation 5)

    Agency Affected: Department of Veterans Affairs: Veterans Health Administration

  6. Status: Open

    Comments: VA agreed with our recommendation. In June 2018, VHA reported that a future update to its Directive 6330 will regulate local policies for the first time. VHA also reported that it had identified approximately 55,000 local policies and included them in a SharePoint database, which will serve as a baseline for removing redundant or conflicting local policy. In October 2018, VHA noted its plans to determine who is responsible for monitoring implementation of national and local policy, as well as the alignment between these levels of policy. To fully implement this recommendation, VHA should provide us with documentation of a finalized version of the standard process it develops for ensuring the alignment of local and national policies, including designated roles and responsibilities.

    Recommendation: The Under Secretary for Health should establish a standard process, including designated oversight roles, to periodically monitor that local policies established by VISNs and VAMCs align with national policies. (Recommendation 6)

    Agency Affected: Department of Veterans Affairs: Veterans Health Administration

 

Explore the full database of GAO's Open Recommendations »

Aug 7, 2019

Aug 2, 2019

Jul 17, 2019

Jun 19, 2019

Jun 17, 2019

Jun 13, 2019

May 22, 2019

Apr 30, 2019

Looking for more? Browse all our products here