VA Health Care:

Actions Needed to Improve Oversight of Community-Based Outpatient Clinics

GAO-18-375: 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

Community-based outpatient clinics are an increasingly important part of the Department of Veterans Affairs’ health care system, providing millions of veterans with services like primary and mental health care. Most of them are operated by VA, but others are operated by contractors.

We found weaknesses in VA's oversight of community-based outpatient clinics, leading us to make four recommendations to help ensure veterans receive the same standard of care regardless of whether a clinic is operated by VA or by a contractor.

 

Exterior plaque at Department of Veterans Affairs headquarters building with department seal and mission statement

Exterior plaque at Department of Veterans Affairs headquarters building with department seal and mission statement

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

Community-based outpatient clinics (CBOC) are an important part of the Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) health care delivery system. These clinics are geographically separate from VA medical centers (VAMC) and provide outpatient services, including primary care and mental health care. GAO found weaknesses in VHA's oversight of CBOCs:

Incomplete policy implementation. VHA has not implemented certain CBOC oversight requirements as outlined in its policy. Specifically, VHA has not developed guidelines for monitoring the quality and comprehensiveness of care in CBOCs and officials said they have no plans to do so. Officials told GAO they believe the requirement was met as part of their regular oversight of Veterans Integrated Service Networks (VISN)—regional networks responsible for oversight of VAMCs and CBOCs. However, VHA may miss CBOC performance problems that are not identifiable in VISN-level data. Further, although policy requires VHA central office officials to review CBOC performance as part of quarterly VISN performance reviews, officials said they do not specifically do so unless the VISN identifies a problem. Officials from three of the four VISNs in GAO's review said they largely delegate CBOC oversight to VAMCs, and do not separately review clinic performance unless a VAMC identifies a problem.

An inaccurate and incomplete CBOC Report. VHA's CBOC Report is prepared by VHA central office and distributed to VISNs and VAMCs quarterly and at year-end. The CBOC Report could be useful to compare clinical quality of care between VHA-operated and contracted CBOCs, but it is inaccurate and incomplete. Specifically, VHA officials have used their judgment to classify certain sites as CBOCs in the report, rather than use the official classifications in policy. GAO found that 22 percent of sites were incorrectly classified as CBOCs when they were other types of sites, including VAMCs. As a result, the report is of limited usefulness to VHA as an oversight tool.

Lack of guidance or training on the CBOC Report. VHA central office officials do not provide guidance or training specific to understanding the CBOC Report to assist VISNs and VAMCs in their oversight of CBOCs. GAO found that in several places in the report, shorthand text and acronyms were used, but not defined. In addition, several VISN and VAMC officials stated that guidance or training would be helpful.

No requirement to use the CBOC Report. VHA officials told GAO that VAMCs and VISNs are expected to use the CBOC Report as an oversight tool, but GAO found that VHA lacks a requirement that they do so. Officials from three of the four VISNs and three of the four VAMCs in GAO's review were not using the report.

These weaknesses potentially lead to inconsistent oversight and create a risk that VHA is not providing one standard of care that is of high quality to veterans across VHA-operated and contracted CBOCs.

Why GAO Did This Study

In fiscal year 2016, VHA's 733 CBOCs provided care to more than 3 million veterans at a cost of $5.3 billion. Although most of these clinics are VHA-owned and -operated, 101 are operated through contracts with non-VHA organizations. VHA policy states that CBOCs, whether VHA-operated or contracted, must provide one standard of care that is of high quality.

GAO was asked to review VHA's use of contracts to carry out core functions. This report examines, among other issues, the extent to which VHA oversees CBOC operations.

To conduct this work, GAO reviewed VHA's policies and CBOC Report. GAO also interviewed officials from VHA's central office and from a nongeneralizable sample of eight CBOCs and their four respective VAMCs and VISNs. The CBOCs were selected for variation in factors such as contract status and geographic area.

What GAO Recommends

GAO recommends that VHA (1) implement oversight requirements that align with existing policy; (2) establish a process to ensure the CBOC Report is accurate and complete; (3) provide guidance or training to VISNs and VAMCs on how to use the CBOC Report; and (4) require use of the CBOC Report as an oversight tool. VA concurred with all of GAO's recommendations and identified actions it is taking to implement them.

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

Recommendations for Executive Action

  1. Status: Open

    Comments: VA concurred with this recommendation, and in June 2018 reported that it was taking actions to implement it. Specifically, VA stated that it assembled a workgroup of staff from the offices of the Principal Deputy Under Secretary for Health; Deputy Under Secretary for Health for Operations and Management, Assistant Deputy Under Secretary for Health for Clinical Operations, Performance Measurement, and Primary Care Operations to discuss guidance to be issued to VISNs and VAMCs. VA plans for this guidance to take the form of a memorandum to VISNs and VAMCs, and plans to include a requirement to add the review of the CBOC Report as part of regular quality monitoring for VISNs and VAMCs. VA stated that this memo would be distributed in June 2018. In November 2018, VHA reported that the memo had been sent November 8, 2018, and subsequently rescinded on November 21. VHA plans to issue new guidance, and once we have received information about further actions, we will update the status of this recommendation.

    Recommendation: The VHA Undersecretary for Health should implement oversight requirements that align with VHA's existing policy, including developing guidelines for monitoring quality of care in CBOCs. (Recommendation 1)

    Agency Affected: Department of Veterans Affairs: Office of the Under Secretary for Health

  2. Status: Open

    Comments: VA concurred with this recommendation, and in June 2018 reported that it was taking actions to implement it. Specifically, VA stated that it assembled a workgroup of staff from the offices of the Principal Deputy Under Secretary for Health; Deputy Under Secretary for Health for Operations and Management, Assistant Deputy Under Secretary for Health for Clinical Operations, Performance Measurement, and Primary Care Operations to discuss the current process for updating the VA Site Tracking (VAST) application. Representatives from the offices of Primary Care Operations and the Office of the Assistant Deputy Under Secretary for Health for Policy and Planning will collaborate to assess the current frequency with which VAST application data are validated for accuracy and completion. It is not clear, however, whether ensuring that the VAST application is up to date will result in a more accurate and complete list of CBOCs in the CBOC Report. As we stated in our report, the site classifications in the CBOC Report are based, in part, on officials' judgment in addition to the classifications in VAST, resulting in a report that does not present accurate information on CBOCs across VHA and is therefore of limited usefulness. VA needs to ensure that the list of CBOCs in the CBOC Report is consistent with VHA's established site classifications. We will update the status of this recommendation once we receive updated information from VA.

    Recommendation: The VHA Undersecretary for Health should establish a process for regularly updating the CBOC Report to ensure it contains an accurate and complete list of CBOCs that is consistent with VHA's established site classifications. (Recommendation 2)

    Agency Affected: Department of Veterans Affairs: Office of the Under Secretary for Health

  3. Status: Closed - Implemented

    Comments: VA concurred with this recommendation and in June 2018 reported its actions to implement it. Specifically, the VHA Office of Performance Measurement's Office of Reporting, Analytics, Performance, Improvement, and Deployment (RAPID) provided guidance regarding the availability and use of the CBOC Report during its monthly Performance Measurement Office Hours National Call on May 9, 2018. Officials could not confirm exact VISN/VAMC attendance, but believe the call included good representation from VISNs and VAMCs as officials at those levels are invited to the calls. In addition, the Assistant Deputy Under Secretary for Health for Clinical Operations, supported by Performance Measurement, provided guidance and training on the use of the CBOC Report during a quarterly Face to Face Conference on May 17-18, 2018 for national and VISN-level clinical leadership. Finally, officials noted that information on RAPID's calls and presentations are accessible on internal webpages. We also found that in the updated CBOC Report VHA sent, RAPID had updated the documentation of the CBOC Report's methodology to include more details about the sources used. We stated in our report that the methodology previously did not make it clear that the measures in the report are derived from a standardized dataset that officials could receive training on. There are now links to provide more information about these data sources in the methodology section. Because of these actions, we consider this recommendation implemented.

    Recommendation: The VHA Undersecretary for Health should ensure that VISNs and VAMCs receive guidance or training on how to use the CBOC Report. (Recommendation 3)

    Agency Affected: Department of Veterans Affairs: Office of the Under Secretary for Health

  4. Status: Open

    Comments: VA concurred with this recommendation, and in June 2018 reported that it plans to issue a memorandum to VISNs and VAMCs from the Office of the Assistant Deputy Under Secretary for Health for Clinical Operations requiring them to use the CBOC Report as an oversight tool. In November 2018, VHA reported that the memo had been sent November 8, 2018, and subsequently rescinded on November 21. VHA plans to issue new guidance, and once we have received information about further actions, we will update the status of this recommendation.

    Recommendation: The VHA Undersecretary for Health should require the use of the CBOC Report as an oversight tool for ensuring one standard of care that is of high quality across VHA-operated and contracted CBOCs. (Recommendation 4)

    Agency Affected: Department of Veterans Affairs: Office of the Under Secretary for Health

 

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