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Highlights

What GAO Found

Geographic shifts in the veteran population, changes in health care delivery, and an aging infrastructure affect the Department of Veterans Affairs' (VA) efforts to align its services and real property portfolio to meet the needs of veterans. For example, a shift over time from inpatient to outpatient care will likely result in underutilized space once used for inpatient care. In such instances, it is often difficult and costly for VA to modernize, renovate, and retrofit existing facilities given the challenges associated with these older facilities.

VA relies on the Strategic Capital Investment Planning (SCIP) process to plan and prioritize capital projects, but SCIP's limitations—including subjective narratives, long time frames, and restricted access to information—undermine VA's ability to achieve its goals. Although VA acknowledges many of these limitations, it has taken little action in response. Federal standards for internal control state that agencies should evaluate and determine appropriate corrective action for identified limitations on a timely basis. Without doing so, VA lacks reasonable assurance that its facility-alignment reflects veterans' needs.

A separate planning process—VA Integrated Planning (VAIP)—was designed to supplement SCIP and to provide planners with a more strategic vision for their medical facilities through the creation of facility master plans. However, GAO found limitations with this ongoing effort, which VA estimated to cost $108 million. Specifically, the facility master plans assume that all future growth in services will be provided directly through VA facilities without considering alternatives, such as purchasing care from the community. However, VA's use of care in the community has increased to an obligated $10.1 billion in fiscal year 2015. Federal capital-acquisition guidance identifies inefficient spending as a risk of not considering other options for delivering services. This consideration is particularly relevant as VA's data project that the number of enrolled veterans will begin to fall after 2024. Officials who oversee the VAIP process said that they were awaiting further analyses required by recently released VA guidance on the proportion of care and types of services to obtain from the community. As a result of this and other limitations, some local VA officials said that they make little use of the VAIP facility master plans and contract for their own facility master plans outside the VAIP process.

Although VA instructs local VA officials to communicate with stakeholders, its guidance is not detailed enough to conform to best practices. VA has not consistently followed best practices for effectively engaging stakeholders in facility consolidation efforts—such as in utilizing two-way communication early in the process and using data to demonstrate the rationale for facility alignment decisions. GAO found that when stakeholders were not always engaged consistently with best practices, VA's efforts to align facilities with veterans' needs were challenged. Also, VA officials said that they do not monitor or evaluate these communications efforts and, therefore, have little assurance that the methods used effectively disseminate information to stakeholders. This approach runs counter to federal standards for internal control, which instruct agencies to monitor and evaluate activities, such as communications methods.

Why GAO Did This Study

VA operates one of the largest health care systems in the United States, with 168 VA medical centers and more than 1,000 outpatient facilities. Many of these facilities are underutilized and outdated. A previous effort aimed at modernizing and better aligning facilities was not fully implemented.

GAO was asked to review the current alignment of VA medical facilities with veterans' needs. This report examines: (1) the factors that affect VA facility alignment with veterans' needs, (2) the extent to which VA's capital-planning process facilitates the alignment of facilities with the veteran population, and (3) the extent to which VA has followed best practices by integrating stakeholders in facility alignment decisions. GAO reviewed VA's facility- planning documents and data, and interviewed VA officials in headquarters and at seven medical facilities selected for their geographic location, population, and past alignment efforts. GAO also evaluated VA's actions against federal standards for internal control and best practices for capital planning.

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Recommendations

GAO made four recommendations, including that: VA improve SCIP's scoring and approval process among other limitations and discontinue or improve the utility of the VAIP facility master plans, and improve guidance to effectively communicate facility alignment decisions with stakeholders and to evaluate these efforts. VA partially concurred with the first recommendation and fully concurred with the other recommendations. GAO believes the recommendations are sound, as described in the report.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Veterans Affairs To improve VA's ability to plan for and facilitate the alignment of its facilities with veteran needs, the Secretary of Veterans Affairs should direct the appropriate offices and administrations to address identified limitations to the SCIP process, including limitations to scoring and approval, and access to information.
Closed - Implemented
VA has taken actions to address the SCIP limitations, including limitations to access to information, time frames, and the scoring and approval process. Regarding access to information limitations, for the Fiscal Year 2021 SCIP process (which takes place in 2019), VA made a list of all projects under consideration for the current budget planning year accessible for planners to review the projects in proximate locations to ensure there is no duplication in plans. Regarding time frame limitations, VA made changes to the SCIP process so that planners would learn the results of the prior year's scoring of SCIP projects prior to the deadline to develop and submit the next year's business cases. VA also made several changes to address the limitations to the SCIP scoring and approval process. First, VA updated its Fiscal Year 2021 SCIP process to clarify to planners that projects are not to be submitted if they rely on another project being completed prior to its award. This addressed concerns about the visibility and prioritization of sequenced projects. Second, VA revised its training for the Fiscal Year 2021 SCIP process and reformatted the business case questions in an effort to reduce subjectivity. For example, VA held multiple training sessions in May 2019 that focused on explanations about how to answer specific questions within the business case form. Third, VA revised its Fiscal Year 2021 SCIP process to note that planners are not allowed to submit projects that are not intended for execution must not be entered into SCIP in an effort to get credit for closing a service gap. VA has clarified that these activities were a result of our recommendation.
Department of Veterans Affairs To improve VA's ability to plan for and facilitate the alignment of its facilities with veteran needs, the Secretary of Veterans Affairs should direct the appropriate offices and administrations to assess the value of VAIP's facility master plans as a facility-planning tool. Based on conclusions from the review, either 1) discontinue the development of VAIP's facility master plans or 2) address the limitations of VAIP's facility master plans.
Closed - Implemented
In its 60-day letter dated August 3, 2017, VA noted that its VAIP facility master plans have been discontinued while VA pursues a congressionally-directed National Realignment Strategy, which will last a minimum of 18 months. VA will be evaluating service delivery opportunities in each contiguous United States (CONUS) market, to improve the networks of complementary community care providers, best coordinate Veteran healthcare, and move certain components of care into the community when appropriate. Once a National Realignment Plan is submitted and approved by Congress, future facility master plans will be adjusted accordingly, and incorporate pertinent information. Such information will include community care realignment opportunities. VA also confirmed that these actions were a result of our recommendation.
Department of Veterans Affairs To improve VA's ability to plan for and facilitate the alignment of its facilities with veteran needs, the Secretary of Veterans Affairs should direct the appropriate offices and administrations to develop and distribute guidance for Veterans Integrated Service Networks (VISNs) and facilities using best practices on how to effectively communicate with stakeholders about alignment change.
Closed - Implemented
In its 60-day letter dated August 3, 2017, VA noted that to ensure consistency in stakeholder engagement efforts, VHA Office of Communications developed a standard operating procedure (SOP) for all VISN and facility public affairs officers to follow when planning/implementing a facility mission change and/or realignment. The SOP directs that the template communications plan, including timeline for notifications, target audiences, and example key messaging, will be utilized. A mechanism for sharing best practices has been established for implementation in moving forward with local communications. The SOP was launched and discussed on the June 28, 2017 monthly Public Affairs Officers (PAO) conference call. In addition, further dissemination of the SOP occurred through an email from the VHA Deputy Under Secretary for Health for Operations and Management to facility and VISN leadership on June 30, 2017. VA has clarified that these activities were a direct result of our recommendation.
Department of Veterans Affairs To improve VA's ability to plan for and facilitate the alignment of its facilities with veteran needs, the Secretary of Veterans Affairs should direct the appropriate offices and administrations to develop and implement a mechanism to evaluate VISN and facility communication efforts with stakeholders to ensure that these communication efforts are working as intended and align with guidance and best practices.
Closed - Implemented
VA has created a standard operating procedure (SOP) to follow when planning/implementing a facility mission change and/or realignment. The SOP provided guidance for facilities to implement evaluation tools to measure the return on their communications investment in sharing information with stakeholders, including after action reports, media monitoring tools, and direct feedback from target audiences. In addition, through the SOP, a mechanism for evaluate VISN and facility communication efforts with stakeholders was created. Specifically, the SOP including a directive to use measurement to track the progress of these communication and outreach effort and to evaluate these efforts through tools, including after action reporting. Through the SOP, a mechanism for sharing these evaluation efforts and best practices was also established for moving forward with stakeholder communications. Specifically, a discussion room has been set up on an internal VA site to share best practices with all public affairs officers for implementation in moving forward with local communications. As of September 14, 2017, close to 100 VISN/facility public affairs specialists have joined this site. In addition, VHA uploaded three after action reports to the site as examples of best practices related to facility mission changes.

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