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Veterans Health Administration: Regional Networks Need Improved Oversight and Clearly Defined Roles and Responsibilities

GAO-19-462 Published: Jun 19, 2019. Publicly Released: Jun 19, 2019.
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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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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.


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 The Under Secretary for Health should develop a process to assess the overall performance of VISNs in managing and overseeing medical centers. (Recommendation 1)
Closed – Implemented
VHA concurred with our recommendation and has provided updates on its progress toward implementation. VHA reported efforts to modernize its governance structure with a newly created VHA Governance Board. Additionally, VHA reported that improved oversight of the overall performance of VISNs and medical centers will be achieved through the current reorganization of the Healthcare Operations Center (HOC). The HOC supports Senior VA Leadership by providing authoritative data, allowing them to assess performance of each medical center and VISN. In December 2023, VHA reported that it had revamped and expanded its enterprise-wide daily leadership briefing, which is attended by VHA senior leaders and program offices and VISN leadership. VHA reported that three times per week, regional network leadership teams present their metrics, challenges, and best practices during the daily leadership briefing. This includes weekly presentations of the following: (1) Enterprise-wide balanced scorecard with a deep dive into each network-specific balanced scorecards. VHA provided documentation of the enterprise-wide balanced scorecard that includes acute care, outpatient access, and other metrics. On a weekly basis, VHA reported that the HOC presents enterprise data followed by presentations by VISN leadership on their VISN metrics (often supplemented with facility-level data) to VHA senior leaders and program office leaders, which allows for VHA oversight and support to improve VISN performance. (2) A weekly deep dive into a rotation of the six VHA priorities and associated key actions and outcome measures. According to VHA, this includes a weekly deep dive into at least one outcome measure presented by VISN leadership with proactive engagement by the associated VHA program office(s). For example, VHA provided documentation that one key action, outcome measure, is to increase the number of veterans who use Whole Health services at all VA facilities including virtual care, community care, and collaborative opportunities. VHA tracks veteran utilization percentage for each of its VISNs. (3) A weekly deep dive into access. VISN leadership present their access challenges, action plans for solution(s), and provide updates to VHA senior leadership. According to VHA, the Integrated Veteran Care team provides enhanced monitoring, oversight, and support for field improvements in access. We consider this recommendation implemented.
Office of the Under Secretary for Health
Priority Rec.
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)
VHA concurred in principle with our recommendation and provided regular updates on its progress in implementing it. 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. In December 2020, VHA reported continued development of the policies to clarify organizational roles and responsibilities. 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. The timeline was extended due to COVID-19. In September 2021, VHA issued Directive 1217.01 which outlined the roles, responsibilities, and decision rights for the VHA Governance Board. This directive outlined delegated authority and defined Governance Board responsibilities. In May 2023, VHA reported this directive is currently under review to include the roles and responsibilities of VISNs and medical centers as part of a set of core functions tailored to differentiate the authority and span of control for all VHA operational units to include management and oversight responsibilities. In February 2024, VHA reported that publication of the directive is projected for October 2024. Additionally, VHA reported that in April 2023 a VISN Organizational Structure Workgroup was chartered to enhance the effectiveness of VHA oversight and governance. This workgroup will evaluate current inconsistencies across VISNs and propose unified recommendations for realignment to ensure standardized execution of the VHA mission, strategies, goals, and objectives. VHA's target completion date is March 2024. For closure, VHA will need to provide documentation that shows the policy (e.g., Directive 1217.01) that outlines VISN level responsibilities for management and oversight of medical centers.
Office of the Under Secretary for Health 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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