VA Health Care: Additional Guidance, Training, and Oversight Needed to Improve Clinical Contract Monitoring
What GAO Found
All 12 contracts GAO reviewed from the four Department of Veterans Affairs' (VA) medical centers (VAMC) visited contained performance requirements consistent with VA acquisition policy. However, the performance requirements lacked detail in six categories: type of provider or care; credentialing and privileging; clinical practice standards; medical record documentation; business processes; and access to care. GAO identified these categories from reviews of VA acquisition regulations, VA policies, and hospital accreditation standards; and VA officials verified that these six categories were an accurate reflection of performance requirements that should be in VA clinical contracts. GAO found, for example, one VAMC cardiothoracic contract that had detailed performance requirements while another VAMC's cardiothoracic contract did not contain a statement describing the contract provider's responsibilities for reporting and responding to adverse events and patient complaints. GAO also found that contracting officials lack tools, such as standard templates, that provide examples of the performance requirements that should be included in common types of clinical contracts. Such tools would help ensure consistency in requirements across contracts.
Contracting officer's representatives (COR) cited two main challenges in monitoring contract providers' performance--too little time to monitor clinical contractors' performance effectively and inadequate training. Most of the 40 CORs at the four VAMCs in GAO's review said that their clinical contract monitoring duties were a collateral duty and that they had other primary responsibilities, such as serving as a business manager or administrative officer for a specialty clinic within the VAMC. GAO found that, on average, each of these 40 CORs spent about 25 percent of their time monitoring an average of 12 contracts. CORs said the demands of their primary positions at times prevented them from fully monitoring contract providers' performance. Further, VA's current guidance related to COR responsibilities does not include any information on how VAMCs are to determine the feasibility of whether a COR's workload--including both COR and primary position responsibilities--will allow them to carry out their tasks as CORs for monitoring contract provider performance. GAO also found that current VA COR training programs focus on contracts that buy goods, not clinical services, and include little information on monitoring responsibilities. CORs questioned the usefulness of the COR training VA uses to prepare them for monitoring clinical contracts.
VA Central Office conducts limited oversight of COR and contract monitoring activities. VA Central Office reviews of COR clinical contractor monitoring activities are limited to a small number of annual file reviews that focus on verifying the presence of required documentation only and do not assess the quality of CORs' monitoring activities. Since implementing the program in March 2013 these reviews have been conducted in 4 of 21 network contracting offices and as of August 2013 none of the 4 offices has received feedback on these reviews. Without a robust monitoring system, VA cannot ensure that all CORs in its VAMCs are properly monitoring, evaluating, and documenting the performance of contract providers caring for veterans.
Why GAO Did This Study
VA must frequently contract with non-VA health care providers so that clinical providers are available to meet veterans' health care needs. While recent studies have disclosed problems with VA's development of contracts for clinical services, there has been little scrutiny of how VA monitors and evaluates the care contract providers give to veterans.
GAO was asked to review VA's efforts to monitor clinical contractors working in VA facilities. This report examines the extent to which VA establishes complete performance requirements for contract providers, challenges VA staff encounter in monitoring contract providers' performance, and the extent to which VA oversees VAMC staff responsible for monitoring contract providers.
GAO reviewed VA acquisition regulations and other guidance. In addition, GAO visited four VAMCs that varied in geographic location and selected a nongeneralizable sample of three types of clinical contracts from each of the four VAMCs to review. GAO discussed how VAMC and VISN staff monitor and oversee these contracts and reviewed contract monitoring documentation.
GAO recommends that VA develop and disseminate standard templates that provide examples of performance requirements for clinical contracts, revise guidance for CORs to include workload information, modify COR training, and improve the monitoring and oversight of clinical contracts. VA concurred with GAO's recommendations.
Recommendations for Executive Action
|Department of Veterans Affairs||To improve the monitoring and oversight of clinical contracts, the Secretary of Veterans Affairs should direct the Under Secretary for Health to develop and disseminate tools, such as standard templates, for the most common types of clinical contracts in VA's health care system. Such tools should include performance requirement statements covering key categories of VA health care policy and guidance--such as credentialing and privileging, provider qualifications, and expectations for compliance with critical VA policies and medical record documentation requirements.||
The Department of Veterans Affairs (VA) developed standard templates for the documentation required develop several types of clinical contracts. These templates include standard formats and language for performance requirements.
|Department of Veterans Affairs||To improve the monitoring and oversight of clinical contracts, the Secretary of Veterans Affairs should direct the Under Secretary for Health to develop and issue guidance on the performance standards that could be included in common types of clinical contracts--including Community-Based Outpatient Clinic, specialty, and temporary clinical provider contracts--to ensure that these performance standards are clearly stated in the contracts and have measurable targets for assessing contract provider performance.||
The Department of Veterans Affairs (VA) developed standard templates for several common types of clinical contracts that include standardized performance standards and formats for developing and communicating performance targets to contractors.
|Department of Veterans Affairs||To improve the monitoring and oversight of clinical contracts, the Secretary of Veterans Affairs should direct the Under Secretary for Health to revise current standard operating procedures for CORs to provide guidance on the number of contracts, based on size and complexity, each COR should manage to ensure that all CORs maintain a workload that allows them to fulfill their duties as a COR and their primary position responsibilities.||
In December 2015, VHA issued revised standard operating procedures to include new instructions for staff to consider certain factors when nominating a contracting officer representative (COR) and for determining the number of contracts each COR should manage. VHA also revised the COR nomination memorandum to reflect these considerations.
|Department of Veterans Affairs||To improve the monitoring and oversight of clinical contracts, the Secretary of Veterans Affairs should direct the Under Secretary for Health to modify existing COR training to ensure it includes examples and discussion of how to develop and monitor service contracts--including contracts for the provision of clinical care in VAMCs.||
The Department of Veterans Affairs (VA) developed several training modules for contracting officer's representatives that included information on developing and monitoring clinical contracts.
|Department of Veterans Affairs||To improve the monitoring and oversight of clinical contracts, the Secretary of Veterans Affairs should direct the Under Secretary for Health to increase Service Area Office and VA Central Office oversight of Contracting Officers and CORs by ensuring that post-award contracting files are regularly reviewed for all network contracting offices.||
In October 2013, we recommended that the Veterans Health Administration increase its oversight for all network contracting offices. In June 2016 the Veterans Health Administration reported that the agency had completed reviews for all it network contracting offices for fiscal year 2016 and had a schedule in place for fiscal year 2017.