Fast Facts

The Veterans Health Administration expects to provide medical care to more than 7 million veterans this year. It uses 18 regional networks to manage its 172 medical centers.

We found that VHA does not ensure its networks have the appropriate staff in place to effectively operate the network and to ensure medical centers are providing veterans timely access to quality care.

We recommended that VHA develop a process to assess the performance of its networks and ensure that they are appropriately staffed.

VA health care has been on our High Risk List since 2015.

 

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Highlights

What GAO Found

The Veterans Health Administration’s (VHA) oversight of its regional health care networks is limited. Within VHA, these networks—known as Veterans Integrated Service Networks (VISN)—manage the day-to-day functions of medical centers and also provide administrative and clinical oversight of medical centers. VHA’s approach for overseeing VISNs does not include an assessment of each VISN as a whole. Instead, to assess VISN operations, VHA primarily relies on performance assessments of individual VISN directors, which are based in part on medical center performance data. VHA officials acknowledged that a VISN director’s individual performance is not always indicative of the VISN’s performance as a whole. VHA supplements these assessments with periodic meetings with VISN leadership, including quarterly reviews on specific topics, such as patient quality assurance metrics and best practices. However, GAO found that these quarterly reviews do not typically include discussion of VISN-level performance measures, or how VISNs manage and oversee medical centers. By establishing a process for assessing the overall performance of VISNs in managing and overseeing medical centers, VHA would be better able to determine if a VISN’s performance is positive, if it is functioning poorly, or if it requires remediation.

VHA also lacks a comprehensive policy to define VISN roles and responsibilities. VHA and VISN officials told GAO they have several documents they believe help VISNs understand these roles and responsibilities. However, these documents either focus on specific policies and programs, or are tied to individuals. The lack of clearly defined roles and responsibilities at the VISN level makes it difficult for VHA to develop an effective oversight process that ensures adequate monitoring of VISN activities.

VHA primarily oversees VISN staffing by using standardized staffing levels and positions, but does not ensure VISNs adhere to them. VHA has a standardized VISN organizational chart, which includes recommended staffing levels for each of the 18 VISNs—63 to 66 full-time-equivalent staff—and 28 key positions, including a chief medical officer and mental health lead, to be in place at each VISN. VHA officials told GAO they expect VISNs to adhere to the standardized chart, and that they conducted a one-time review that included checking that VISNs’ total full-time equivalents were within the allotted allowance. However, VHA’s review did not ensure that VISN organizational charts always included the 28 key positions laid out on the standardized chart. GAO found one to five key positions were not listed on the organizational charts of more than a third of VISNs, among those with organizational charts that VHA had reviewed and approved. For example, one VISN was missing both the primary care and geriatrics positions on its organizational chart. VISN officials provided various reasons for the positions not being listed on the organizational charts, including that these responsibilities were being performed as a collateral duty for VISN or medical center staff. Without effective oversight, VHA leadership cannot provide reasonable assurance that VISNs are appropriately staffed, which may hinder implementation of programs, and ultimately, the care veterans receive.

Why GAO Did This Study

VHA operates one of the nation's largest health care systems with 18 regional networks—VISNs—that manage and oversee 172 medical centers within defined geographic areas. VHA expects to provide care to more than 7 million veterans in fiscal year 2019, and demand for its services is expected to grow over time.

GAO was asked to conduct a review of VISNs, including VHA's oversight of VISNs. This report examines (1) the extent to which VHA oversees VISNs’ management and oversight of medical centers and (2) how VHA oversees VISN staffing.

GAO reviewed VHA policies, guidance, and staffing data regarding VISNs. GAO also interviewed officials from VHA, all 18 VISNs, and four medical centers selected for variation in geography, urban or rural location, and complexity.

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Recommendations

GAO recommends that VHA (1) develop a process to assess the overall performance of VISNs in managing and overseeing medical centers, (2) establish a comprehensive policy that clearly defines VISN roles and responsibilities for managing and overseeing medical centers and (3) establish a process to routinely oversee VISN staffing. VHA concurred with the first and third recommendations, and concurred in principle with the second.

Recommendations for Executive Action

Agency Affected Recommendation Status
Office of the Under Secretary for Health 1. The Under Secretary for Health should develop a process to assess the overall performance of VISNs in managing and overseeing medical centers. (Recommendation 1)
Open
VHA concurred with our recommendation. In December 2019, VHA reported efforts to modernize its governance structure with a newly created VHA Governance Board. In February 2020, VHA reported additional efforts to charter governance councils to support the VHA Governance Board and work continues to develop these councils and responsibilities. In August 2020, VHA reported that VHA's new leadership team and Governance Board are examining options for a policy that defines management and governance roles and responsibilities. VHA's targeted completion date is September 2021. For closure, VHA will need to provide documentation that shows the process developed to assess the overall performance of VISNs in managing medical centers. Providing documentation explaining how these governance structures plan to assess overall VISN performance, including any metrics or tools that would be used as a part of this process, would be useful in determining if this recommendation can be considered for closure.
Office of the Under Secretary for Health
Priority Rec.
This is a priority recommendation.
2. The Under Secretary for Health should establish a comprehensive policy that clearly defines VISN roles and responsibilities for managing and overseeing medical centers. (Recommendation 2)
Open
VHA concurred in principle with our recommendation. In December 2019, VHA told us they were working to streamline reporting structures at all levels, focusing on governance and workflow, including defining consistent levels of authority. In February 2020, VHA told us they were realigning Central Office in addition to making changes to the governance structure to support clarity of roles and responsibilities. In August 2020, VHA established new leadership positions that included the Assistant Under Secretary for Health for Operations to oversee the VISNs. VHA reported that redesign work would continue for fiscal year 2021. The new leadership team and Governance Board plan to examine policy options that define management and governance roles and responsibilities including VISNs' roles and responsibilities for managing and overseeing medical centers. VHA's targeted completion date for this work is September 2021. Following completion of VHA's efforts to streamline Central Office and ensure reporting structures are in place, VHA will need to provide policy documentation that clearly outlines VISN roles and responsibilities, including how these governance structures plan to define the VISN's roles and responsibilities. While governance and reporting structures are a first step, it is important for roles and responsibilities to be clearly outlined in a policy vehicle, as VHA requires the use of policy to assign responsibilities for executing a course of action to individuals or groups.
Office of the Under Secretary for Health 3. The Under Secretary for Health should establish a process to routinely oversee VISN staffing, to include ensuring VISNs are consistent with VHA's standardized VISN staffing levels and positions, and documenting the rationale for approving staffing that does not adhere to VHA's standardized approach. (Recommendation 3)
Closed - Implemented
VHA concurred with our recommendation and provided regular updates on its progress in implementing it. In August 2020, VHA provided final documentation of its efforts to establish a process to routinely oversee VISN staffing. VA issued VA Directive 5010, which established Manpower Management as the office responsible for organizational structure. The Manpower Standard Operating Procedure, which accompanies Directive 5010, identifies VHA Manpower as the oversight office for VISN organizational structure. The VHA Manpower office reviews VISN organizational structure, including staffing levels and positions, annually in September, using the January 2020 Revised VISN Organizational Chart. The Revised Organizational Chart serves as guidance for VISN staffing approved by VHA. This standard operating procedure includes a process for documenting any hiring or staffing change request decisions, as well as changes that occur outside of the annual review period.

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