VA Real Property:

Improvements in Facility Planning Needed to Ensure VA Meets Changes in Veterans' Needs and Expectations

GAO-19-440: Published: Jun 13, 2019. Publicly Released: Jun 13, 2019.

Additional Materials:

Contact:

Andrew Von Ah
(202) 512-2834
vonaha@gao.gov

 

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

 

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

VA provides medical services to a veteran population that is growing older and more diverse. These demographic shifts will drive changes in veterans’ needs and expectations, and require adjustments to VA medical facilities. We looked at how VA is incorporating these changes into its planning efforts.

We found that:

VA is not fully assessing veterans' changing expectations

Local VA planners do not fully trust or use VA estimates on future space needs for their medical facilities

We recommended that VA work to better incorporate veterans' changing needs and expectations into its facilities planning efforts.

One of 172 VA Medical Centers

A VA Medical Center

A VA Medical Center

Additional Materials:

Contact:

Andrew Von Ah
(202) 512-2834
vonaha@gao.gov

 

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

 

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

What GAO Found

The Department of Veterans Affairs (VA) analyzes demographic trends to assess veterans' future health-care needs, such as the need for more long-term care or women's health care services. VA does not, however, systematically collect data concerning whether demographic groups differ in their expectations for how they will receive care, such as whether some groups expect different levels of privacy. VA officials said they gauge expectations by surveying veterans and talking to veterans service organizations. GAO's review, however, found the amount of information VA collected through these methods is limited. Without robust data about veterans' expectations and assessing how changes would affect facilities' space needs, VA cannot readily anticipate and adapt to meet veterans' changing expectations—a goal in its FY 2018–2024 Strategic Plan .

In addition to identifying meeting veterans' changing needs and expectations as a national strategic goal, VA defined a national set of VA-delivered core medical services called “foundational health services” to, in part, meet veterans' expectations of consistent care offerings across VA medical centers (VAMC) and also to focus VA's resources on its highest priority services. However, based on GAO's survey of VAMCs and discussions with selected facility-planning officials, GAO found that VA did not clearly instruct VAMCs in how to apply VA's strategic goal or foundational health services to facility planning. Accordingly, more than three quarters of VAMC facility-planning officials responding to GAO's survey indicated additional instruction from VA for the strategic goal and foundational health services would be useful. Without providing clear instruction, VA increases its risk that its strategic goal and foundational health services are not meeting their objective to incorporate veterans' changing needs and expectations.

Most facility-planning officials had concerns with using estimated space needs derived from VA's Strategic Capital Investment Planning (SCIP) process, which converts estimated needs for veterans' health care into future space needs for the VAMCs. Specifically, the officials (1) did not understand how the SCIP process converts health care needs into physical space and (2) questioned how accurately the space estimates reflected the future health-care needs for local facilities. For example, 72 percent of facility-planning officials responding to GAO's survey reported that at least one of SCIP's 12 space category estimates was “generally inaccurate” at reflecting projected space needs for their facility. As a result, instead of relying on SCIP's space estimates as a starting point to incorporate veterans' changing needs into facility planning, VAMC facility planners told GAO that they may instead use locally identified health care needs and priorities to determine space needs. Without a process for VA to understand and address concerns about the SCIP process, VAMCs may spend time and resources on capital projects that do not necessarily meet veterans' future needs as VA intended. This approach may therefore impede VA's ability to respond to veterans needs as this population changes.

Why GAO Did This Study

VA provides for care to over 9-million veterans in its health care system, including 172 VAMCs. As veterans' demographics shift, such as by age or gender, their needs for health care and their expectations for how they receive that care may also change. Along with the VA MISSION Act of 2018, which requires VA to assess its facilities for realignment and modernization, these changes could have implications for VA's capital-planning efforts.

GAO was asked to review how VA incorporates veterans' changing needs and expectations into facility planning. This report examines: (1) VA's efforts to assess trends in veterans' future needs and expectations; (2) VA's efforts to help VAMCs address these changes through facility planning; and (3) how VAMCs use VA's process for identifying facilities' future space needs.

GAO surveyed all VAMCs, visited nine VAMCs, reviewed VA's planning documents and data, and interviewed officials from VA and veterans service organizations. GAO's survey response rate was 99 percent.

What GAO Recommends

GAO recommends VA: (1) assess changes in veterans' expectations; (2) instruct facility planners on how to incorporate veterans' changing needs and expectations; (3) clarify foundational health services implementation; and (4) assess concerns with the SCIP process and make needed adjustments. VA agreed with GAO's recommendations.

For more information, contact Andrew Von Ah at (202) 512-2834 or vonaha@gao.gov, or Debra A. Draper at (202) 512-7114 or draperd@gao.gov.

Recommendations for Executive Action

  1. Status: Open

    Comments: VA concurred with this recommendation, but noted that it had already developed and implemented effective systems for obtaining Veterans' input in facility planning. However, we found that the information VA collects through these efforts may be limited based on our review of VA's surveys, including VSignals and the Survey of Enrollees, as well as our discussions with several Veterans Service Organizations. For example, we found that VA's efforts were limited because they either focused on overall veteran expectations without a means of assessing how they differed by demographics, or they focused on veteran satisfaction with their past experiences. Moreover, satisfaction with past experiences, as operationalized by VA for the surveys we reviewed, measured how someone is with what they received--while "expectations," as defined by VA, would measure or gain insight into what it is that someone would want, and which may or may not be what they are receiving. Thus, while satisfaction, as operationalized by VA, can be an indicator of an expectation, as defined by VA, the two are not synonymous. Although VA considers this recommendation closed, we are working with them to identify ways that expectations, as VA has defined the term, can be measured.

    Recommendation: To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations develop and implement a process to assess veterans' changing expectations and disseminate this information to VAMCs. (Recommendation 1)

    Agency Affected: Department of Veterans Affairs

  2. Status: Open

    Priority recommendation

    Comments: VA agreed with the recommendation and indicated that it would instruct users on what data to use in planning and updates, which would help ensure veterans' input is incorporated where appropriate. As of its fiscal year 2021 budget justification, VA still had not provided this guidance to the VAMCs, but noted that it would provide it in scheduled facility planning calls that were expected to start in the second quarter of fiscal year 2020.

    Recommendation: To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations instruct VAMCs on how to meet VA's strategic goal of incorporating veterans' changing needs and expectations into facility planning, such as by identifying certain resources or tools and directing VAMCs to use them. (Recommendation 2)

    Agency Affected: Department of Veterans Affairs

  3. Status: Open

    Comments: VA concurred with this recommendation and noted that it would clarify prior guidance on the foundational health services for VAMCs, which it expected to complete in June 2019. In November 2019, VA told us that it had reviewed this prior guidance from August 2017 that had defined foundational services, and has rescinded it. However, we are working with VA to determine if this decision to rescind the prior guidance was distributed to VAMCs.

    Recommendation: To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations provide additional instruction to VAMCs on how to incorporate the concept of foundational health services into facility planning. (Recommendation 3)

    Agency Affected: Department of Veterans Affairs

  4. Status: Open

    Priority recommendation

    Comments: VA agreed with this recommendation and indicated that it would update its training instructions to facility planners by adding an explanation of how SCIP space estimates are derived. In addition, VA noted that it would survey facility planners about their concerns with the SCIP space estimates, and use these results to either address the concerns or make improvements to SCIP. As of November 2019, VA had not completed the training or the survey, but noted that they are in the process of updating training materials for the FY22 SCIP planning process--which was targeted to start 2019. We will work with VA to obtain relevant documentation of these efforts.

    Recommendation: To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations systematically gather feedback from facility planners and address (as necessary) their concerns with the reliability of the SCIP process, including providing additional information on how SCIP's space estimates are derived. (Recommendation 4)

    Agency Affected: Department of Veterans Affairs

 

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