Veterans Health Care: Additional Actions Could Further Improve Policy Management
How does the Veterans Health Administration ensure that its 170 medical centers are providing timely, high-quality care to veterans? VHA uses national policies and guidance that cover all aspects of health care delivery, such as purchasing community care and scheduling outpatient appointments.
We looked at how VHA defines and communicates its national policy and guidance and collects information on local implementation challenges. Among the issues we found was that VHA does not consistently solicit input from the local level before issuing policy or after implementing it.
We made 6 recommendations to address this and other challenges.
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What GAO Found
The Veterans Health Administration (VHA)—within the Department of Veterans Affairs (VA)—is taking steps to align existing national policy documents with newly revised definitions that streamline and clarify document use. According to the new definitions in its June 2016 directive on policy management, directives and notices are now the sole documents for establishing national policy; other types of documents, such as program office memos, are considered guidance. VHA is reviewing about 800 existing national policy documents to eliminate those that no longer meet its new definitions, and to rescind or recertify those that are outdated. At this time, VHA is not planning to review guidance documents, such as program office memos and standard operating procedures, to assess whether they align with its updated directive, because there is no central repository for these documents and it would be too resource intensive to locate all of them. Further, GAO's review found—contrary to VHA's updated directive—that program offices are continuing to use memos to issue policy. The continued use of program office memos to establish national policy undermines VHA's efforts to improve its policy management.
VHA has a standard process for making national policy documents accessible to VA medical centers (VAMC) and the Veterans Integrated Service Networks (VISN) to which the medical centers report, but lacks a process for making guidance documents accessible. VHA makes national policy documents accessible to all organizational levels through a publications website and e-mail distribution list as outlined in its June 2016 directive. However, GAO found that VHA has not established a similar process for program offices to make guidance documents accessible at the local level. Specifically, there is no central repository, such as a publications website, for guidance documents, and the program offices do not track or consistently disseminate the guidance documents they issue. Without a standard process for consistently maintaining and disseminating guidance, VHA lacks assurance that staff receive and follow the same guidance, as intended.
VHA does not routinely collect information on local challenges with national policy implementation or on exemption waivers. The four VISNs and eight VAMCs in GAO's review reported various challenges they face when implementing national policy, such as resource constraints and undefined time frames. In instances where VAMCs cannot meet policy requirements, program offices may approve policy exemption waivers on an ad hoc basis. However, GAO found that VHA lacks complete information on approved policy exemption waivers because it does not have a standard process for approving, tracking, and reassessing them. In recognition of this issue, VHA established a committee to develop a waiver process in June 2017.
VISNs and VAMCs in GAO's review develop and maintain various local policies, but VHA does not ensure that they align with national policies. Specifically, GAO found that VHA does not have a process for program offices to systematically ensure that local policies align with national policies. Without such a process, VHA may continue to experience inconsistent policy implementation across its health care system.
Why GAO Did This Study
GAO was asked to conduct a management review of VHA; this is the sixth report in the series. In this review of VHA's policy management, GAO examines the extent to which (1) VHA has implemented its new definitions for national policy and guidance documents; (2) VHA ensures that national policy and guidance documents are accessible to VISNs and VAMCs; (3) VHA collects information on local challenges with implementing national policy, including the exemptions granted when policy requirements cannot be met; and (4) local policies are developed and maintained by VISNs and VAMCs, and whether they are aligned with national policies.
GAO reviewed agency documentation, including VHA's revised directive on policy management. GAO also interviewed VHA officials involved with policy improvement efforts, as well as officials from a nongeneralizable sample of four national program offices, four VISNs, and eight VAMCs selected to provide geographic variation, among other factors.
GAO is making six recommendations to VHA, which include clarifying national policy and guidance documents, ensuring access to guidance documents, incorporating local feedback into national policy, establishing a process to approve and track policy exemption waivers, and ensuring alignment of local and national policy. VHA generally concurred with GAO's recommendations.
Recommendations for Executive Action
|Veterans Health Administration||
Priority Rec.The Under Secretary for Health should further clarify when and for what purposes each national policy and guidance document type should be used, including whether guidance documents, such as program office memos, should be vetted and recertified. (Recommendation 1)
VA agreed with our recommendation. On March 29, 2022, VHA issued a recertified national policy directive that clarifies the use of policy and guidance documents at both the national and local levels. For example, VHA now requires that program office memos (also known as "operational memos") be published on VHA's internal publications page or face rescission. These memos may also be rescinded upon written request. Operational memos must also be reviewed by VHA's national policy office prior to publication to ensure they conform with existing national policy. VHA stated that operational memos that do not have mandatory actions, such as those announcing a site visit or requesting volunteers, are not subject to these requirements. However, VHA expects that the majority of operational memos will be subject to the requirements established in its national policy directive.
|Veterans Health Administration||The Under Secretary for Health should develop standard processes for consistently maintaining and disseminating guidance documents to each level of the organization. (Recommendation 2)||
VA agreed with our recommendation. VHA reported that it added a program office memo (also known as "operational memo") section to its internal publications website in November 2017. Uploading operational memos to this website allowed VHA to identify 327 outdated documents that it has since rescinded, as well as numerous other documents that may require rescission. In June 2021, VHA required all operational memos to be maintained on its publications website and established a process to review and disseminate program office memos. VHA also provided an August 2021 example of the weekly list of published program office memos it disseminates to email groups that include regional leadership and administrative contacts.
|Veterans Health Administration||The Under Secretary for Health should systematically obtain information on potential implementation challenges from VISNs and VAMCs and take the appropriate actions to address challenges prior to policy issuance. (Recommendation 3)||
VA agreed with our recommendation in principle and cited that the recommendation was no longer needed because VHA had already instituted preliminary policy development processes that allow VHA employees and program offices to provide feedback on national policy prior to issuance or recertification. In November 2019, VHA provided documentation of the finalized process it uses to assess potential implementation challenges. Specifically, VHA systematically collects information about national policies prior to issuance through an online form that includes resource implications (e.g., staffing) and factors that may impede implementation. On a weekly basis, VHA staff receive an email about policies open for review. The VHA program office responsible for the policy then provides a response to each comment received.
|Veterans Health Administration||The Under Secretary for Health should establish a mechanism by which program offices systematically obtain feedback from VISNs and VAMCs on national policy after implementation and take the appropriate actions. (Recommendation 4)||
VA agreed with our recommendation. In December 2020, VHA provided documentation of the mechanisms it uses to systematically obtain national policy implementation feedback from the local level. For example, VHA disseminates a monthly digest with the previous month's published documents. The digest encourages recipients to report policy-related inconsistencies, inaccuracies, or improvements. VHA also noted that it has a mail group to receive feedback from the local level, which it typically responds to in less than 48 hours or escalates the issue as appropriate. VHA then uses a tracker to capture feedback on policy issues, which includes the method of communication in which the feedback was received and the steps taken to address the feedback. Finally, VHA policy staff conduct at least two site visits to VAMCs and VISNs annually to examine policy implementation at the local level. Following the site visits, VHA policy staff prepare reports documenting the discussion and policy issues raised by local staff.
|Veterans Health Administration||The Under Secretary for Health should establish a standard policy exemption waiver process and centrally track and monitor approved waivers. (Recommendation 5)||
VA agreed with our recommendation. In December 2020, VHA issued an interim policy notice describing its plans to publish all policy waivers on an internal website and report to senior leadership on a regular basis. In June 2021, VHA provided a screenshot of the internal website, with a number of published waivers. VHA also indicated that it developed guidance on the policy waiver process, including notifying VA medical facilities to provide past policy waivers to publish on the internal website. VHA noted that it would use this information as part of its first policy waiver report to VHA senior leadership in July 2021. In October 2021, VHA provided further documentation of its developed guidance. For example, VHA captured its policy waiver process in a flow chart with the time frames for key reporting and roles and responsibilities at the local and national levels.
|Veterans Health Administration||The Under Secretary for Health should establish a standard process, including designated oversight roles, to periodically monitor that local policies established by VISNs and VAMCs align with national policies. (Recommendation 6)||
VA agreed with our recommendation. In June 2018, VHA reported that it had identified approximately 55,000 local policies and included them in a SharePoint database, which will serve as a baseline for removing redundant or conflicting local policy. In November 2019, VHA issued an interim policy that established business rules for oversight and monitoring local policy development at the VISN and VAMC levels. Specifically, VHA will assess the number of local policies every 6 months as well as identify patterns of non-compliance. In addition, the interim policy includes standardized templates, a recertification requirement of 5 years to mirror the national policy requirement, and restricts VHA program offices from creating requirements for local policy development. In December 2020, VHA provided the tracker it uses for assessing local policies, including the number of local policies in each VISN and VAMC from February and July 2020. In addition, VHA provided a March 2020 report where it assessed local policy management at five VAMCs of varying complexity levels and geographic locations to identify common barriers, trends, and opportunities for standardizing local policies.