VA Health Care:

Improved Guidance and Oversight Needed for the Patient Advocacy Program

GAO-18-356: Published: Apr 12, 2018. Publicly Released: Apr 12, 2018.

Additional Materials:

Contact:

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

 

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

The Veterans Health Administration has designated patient advocates at each VA medical center to receive and document feedback from veterans.

Amid concerns about veterans’ ability to receive timely and quality care, we reviewed the VHA patient advocacy program.

We found that VHA is beginning to address governance, staffing, training, and other issues, including directing a workgroup to provide recommendations by spring of 2018. However, the recommendations are only for consideration and deadlines have slipped in the past.

We recommended 6 actions to improve guidance for and oversight of the program.

A VA patient advocacy program sign

This is a photo of a sign that includes contact numbers and says

This is a photo of a sign that includes contact numbers and says "How are we doing? We want to know."

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) provided limited guidance to Department of Veterans Affairs (VA) medical centers (VAMC) on the governance of its patient advocacy program and its guidance, a program handbook, has been outdated since 2010. VAMCs are still expected to follow the outdated handbook, which does not provide needed details on governance, such as specifying the VAMC department to which patient advocates should report. Officials from most of the VAMCs that GAO reviewed noted that the VAMC department to which patient advocates report can have a direct effect on the ability of staff to resolve veterans' complaints. The lack of updated and complete guidance may impede the patient advocacy program from meeting its expectations, to receive and address complaints from veterans in a convenient and timely manner.

VHA also has provided limited guidance to VAMCs on staffing the patient advocacy program. VHA's handbook states that every VAMC should have at least one patient advocate and appropriate support staff; however, it did not provide guidance on how to determine the number and type of staff needed. Officials at all but one of the eight VAMCs in GAO's review stated that their patient advocacy program staff had more work to do than they could accomplish. This limited guidance on staffing could impede VAMCs' efforts to ensure that they have the appropriate number and type of staff to address veterans' complaints in a timely manner.

Further, VHA has recommended training for patient advocates, but it has not developed an approach to routinely assess their training needs or monitored training completion. VHA officials stated that they relied on VAMC and Veterans Integrated Service Network (VISN) staff to conduct these activities. However, GAO found that for the eight VAMCs in its review, the training needs of patient advocates were not routinely assessed, and training completion was not always monitored. Without conducting these activities, VHA increases its risk that staff may not be adequately trained to advocate on behalf of veterans.

Finally, VHA has not monitored patient advocacy program data-entry practices or reviewed the data to assess program performance. VHA officials stated that they relied on VISN and VAMC officials to ensure that all complaints were consistently entered into VHA's Patient Advocate Tracking System (PATS). However, GAO identified inconsistencies in the extent to which VAMC officials did so. VHA's lack of monitoring may pose a risk that not all complaints are entered into this tracking system—a goal of the program. Additionally, VHA officials stated they did not systemically review data in the system to assess program performance and identify potential system-wide improvements because VHA considered this the responsibility of VAMCs. As a result, VHA officials may miss opportunities to improve veterans' experiences.

VHA is beginning to address many of these governance, staffing, training, and data issues, including directing a workgroup to provide recommendations by spring of 2018. However, because the recommendations will be advisory, and because program deadlines have slipped in the past, the nature and timing of the actions needed to resolve these issues remain unclear.

Why GAO Did This Study

VHA has designated patient advocates at each VAMC to receive and document feedback from veterans or their representatives, including requests for information, compliments, and complaints. In recent years, the importance of a strong patient advocacy program has taken on new significance given concerns with VHA's ability to provide veterans timely access to health care, among other issues.

The Comprehensive Addiction and Recovery Act of 2016 included a provision for GAO to review VHA's patient advocacy program. This report examines the extent to which VHA has (1) provided guidance on the governance of the program; (2) provided guidance on staffing the program; (3) assessed the training needs of patient advocates and monitored training completion; and (4) monitored patient advocacy program data-entry practices and reviewed program data. GAO reviewed VHA and VAMC documents, including summaries of program data. GAO interviewed VHA officials about the program, as well as officials from a non-generalizable selection of eight VAMCs and five VISNs selected based on the volume of veteran complaints and other factors. GAO also compared VHA policies and practices to federal internal control standards.

What GAO Recommends

GAO is making 6 recommendations to improve guidance for and oversight of the patient advocacy program, focusing on governance, staffing, training, and PATS data entry and assessment. VA 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

    Comments: VHA concurred with this recommendation and has provided regular updates on its progress in implementing it. As of April 2019, VHA's Office of Patient Advocacy (OPA) partnered with VA's Center for Healthcare Organization and Implementation Research (CHOIR) to better understand the current state of patient advocacy services in VHA, focusing on position descriptions, grade levels, and reporting structures. VA medical center staff completed questionnaires about the patient advocacy program in January 2019 and VHA analyzed the results. CHOIR officials are conducting site visits to interview key staff directly to identify the benefits and opportunities for improvements with patient advocacy services, including reporting structure. Upon completion of site visits to validate questionnaire findings, CHOIR will present their final recommendations to OPA. OPA will develop reporting structure guidance and work with workforce management and VHA senior leaders to communicate and implement the guidance. VHA's target completion for these efforts is December 2019.

    Recommendation: The VHA Undersecretary for Health should provide updated guidance to VAMCs on the governance of the patient advocacy program, including clear definitions of reporting lines. (Recommendation 1)

    Agency Affected: Department of Veterans Affairs: Veterans Health Administration

  2. Status: Open

    Comments: VHA concurred with this recommendation and has provided regular updates on its progress in implementing it. As of April 2019, VHA's Office of Patient Advocacy (OPA) partnered with VA's Center for Healthcare Organization and Implementation Research (CHOIR) and VHA's Workforce Management to develop an evidence-based patient advocacy staffing model that accounts for facility size, complexity and geographic region. A set of questions was distributed to all VAMCs in December 2018. Responses to these questions have been analyzed by CHOIR, and on-site interviews at select facilities are in progress to validate the report findings. VHA's Workforce Management is working with CHOIR and OPA to use the results to develop a recommended and validated staffing model. This guidance will also be incorporated in the future revision of the VHA directive. The target completion of these efforts is December 2019.

    Recommendation: The VHA Undersecretary for Health should assess and provide guidance to VAMCs on appropriately staffing the patient advocacy program, including guidance on how to determine the appropriate number and type of staff. (Recommendation 2)

    Agency Affected: Department of Veterans Affairs: Veterans Health Administration

  3. Status: Closed - Implemented

    Comments: VHA concurred with this recommendation and has provided regular updates on its progress in implementing it. As of April 2019, VHA's Office of Patient Advocacy (OPA) collected feedback on training needs for patient advocates from Veterans Integrated Service Network (VISN) coordinators and patient advocates. At the end of fiscal year 2018, OPA reviewed the training needs identified and developed a training plan. OPA then convened a workgroup to revise and update the training curriculum for new patient advocates. Lastly, OPA hired a Training Specialist who will conduct an annual assessment of the training needs of patient advocates moving forward.

    Recommendation: The VHA Undersecretary for Health should develop an approach to routinely assess the training needs of patient advocates. (Recommendation 3)

    Agency Affected: Department of Veterans Affairs: Veterans Health Administration

  4. Status: Closed - Implemented

    Comments: VHA concurred with this recommendation and has provided regular updates on its progress in implementing it. As of April 2019, VHA's Office of Patient Advocacy (OPA) worked with officials from VA's Employee Education System (EES) to incorporate patient advocacy training modules into VA's Talent Management System (TMS). OPA officials monitored the completion of training for patient advocates using TMS reports. Further, OPA hired a training specialist to review TMS reports on an annual basis moving forward.

    Recommendation: The VHA Undersecretary for Health should monitor the completion of training for patient advocates. (Recommendation 4)

    Agency Affected: Department of Veterans Affairs: Veterans Health Administration

  5. Status: Open

    Comments: VHA concurred with this recommendation and has provided regular updates on its progress in implementing it. As of April 2019, VHA's Office of Patient Advocacy (OPA) receives a weekly report from both the Patient Advocate Tracking System (PATS) and PATS-Replacement (PATS-R) Systems reporting on the number of new cases entered at every VA medical center (VAMC). With development of the PATS-R web-based tool, OPA, the Veterans Experience Office and the PATS-R developers have conducted a review of existing codes and are currently working with various VHA program offices to standardize codes across various data systems. VA plans to develop an auditing toolkit to ensure standardized, timely documentation of complaints, including accurate coding within PATS. The target completion date for these efforts is December 2019.

    Recommendation: The VHA Undersecretary for Health should monitor PATS data-entry practices to ensure all complaints are entered into PATS and that veterans' feedback is coded consistently. (Recommendation 5)

    Agency Affected: Department of Veterans Affairs: Veterans Health Administration

  6. Status: Open

    Comments: VHA concurred with this recommendation and has provided regular updates on its progress in implementing it. As of April 2019, VHA's Office of Patient Advocacy (OPA) has conducted quarterly reviews of PATS data at the national level to ensure trends are identified and ensure performance improvement is implemented. VHA's Patient Advocacy Tracking System-Replacement (PATS-R) team provides updates on monthly Patient Advocacy community of practice calls and weekly calls with the PATS-R pilot sites to discuss the development of reports that will strengthen monitoring, auditing and reporting of data. VHA plans to continue processes to improve Patient Advocacy Tracking System (PATS) data tracking, trending and monitoring, which will continue to support identification of system-wide improvements. The target completion date for these efforts is December 2019.

    Recommendation: The VHA Undersecretary for Health should systematically review PATS data to assess program performance and identify potential system-wide improvements. (Recommendation 6)

    Agency Affected: Department of Veterans Affairs: Veterans Health Administration

 

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