Recommendation: The Undersecretary for Health should consistently collect sexual orientation data in VHA's health record system, which could include adding a field for providers to input veterans' sexual orientation. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Undersecretary for Health should analyze veterans' sexual orientation data in order to assess health care outcomes for lesbian, gay, and bisexual veterans. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Undersecretary for Health should consistently collect veterans' self-identified gender identity data within and across record systems. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Undersecretary for Health should analyze veterans' self-identified gender identity data in order to assess health care outcomes for transgender veterans. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Under Secretary for Health should establish steps for communicating to VA's actuarial consultant information on data quality, including any limitations, used in the actuarial modeling that informs VA's community care budget estimates. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Under Secretary for Health should establish further steps for assessing and communicating to stakeholders the degree of overall uncertainty associated with actuarial projections for community care that inform the community care budget estimates. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: Congress should consider requiring VA to establish an overall wait-time performance measure for veterans to receive care under the VCCP that will permit VA to measure and monitor the timeliness of VCCP appointments and compare timeliness to that of VA medical facilities. (Matter for Consideration 1)

Agency: Congress
Status: Open

Comments: When we determine what steps the Congress has taken, we will provide updated information.

Recommendation: The Under Secretary of Health should align its monitoring metrics with the time frames established in the VCCP scheduling process. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Under Secretary of Health should conduct a review of community provider enrollment and use of the HSRM to include identifying and taking steps to remove any challenges to community provider enrollment and use; and, if determined appropriate, establish a requirement for community providers to use the HSRM; and (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Under Secretary of Health should direct VAMC leadership to assess their community care staffing and resource needs, and develop a plan to address any identified risks to their ability to schedule appointments in a timely manner, including strategies to adjust staff levels and address recruitment and retention challenges as needed. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Secretary of Veterans Affairs should ensure that the Office of Enterprise Integration develops a plan—including milestones and roles and responsibilities for OEI, VBA, and VHA—to address identified challenges that have hindered research on the health care outcomes for service-connected conditions of veterans receiving disability compensation. To align VA's efforts with the goals of its 2018-2024 Strategic Plan, VA's development of this plan should be completed and ready for implementation by June 1, 2020. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with this recommendation. VA stated that the Office of Enterprise Integration (OEI) will coordinate with VBA and the Veterans Health Administration (VHA) to create an operational plan that addresses challenges that have hindered research on health care outcomes for service-connected conditions of veterans receiving disability compensation. As of March 2020, VA anticipates completing this plan by June 2020. We will consider closing the recommendation when that effort is complete.

Recommendation: The Under Secretary for Benefits should develop and implement a periodic analysis of program management data for trends in the individual service-connected conditions being reevaluated as well as data on the outcomes of reevaluations. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA stated in March 2020 that it plans to develop requirements to augment its capacity to analyze reevaluation trends. According to officials, VA has determined the necessary requirements for the data needed to analyze the outcomes of reevaluations. VBA will review 12 months of data to assess trends and make recommendations based on the review. VA plans to complete the trend analysis by the end of June 2020 and will establish a process for periodic analysis of data trends. We will consider closing this recommendation when VA has analyzed multiple data points to assess trends in reevaluations on a periodic basis.

Recommendation: The Under Secretary for Benefits should implement the two recommendations in VBA's May 2018 consistency study to provide training on how to determine when a reevaluation is needed and review reevaluation decisions for accuracy at the lowest-scoring offices and take corrective action as needed. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

Comments: In November 2019, VA stated that VBA provided a reminder to all regional offices about the availability of training resources on how to determine when a reevaluation is needed. VA also stated that VBA conducted another consistency study on this issue in August 2019 and plans to use that study's results to guide its review of the lowest-scoring regional offices. This study recommended inspecting claims processed at the two lowest-scoring offices, because they may have high numbers of errors related to reevaluation requirements. VA stated that VBA would devise a statistically valid sample of claims based on the August 2019 study. In April 2020, VA provided information from national accuracy reviews and individual claims processor quality reviews for these two offices. However, these reviews were not specifically designed to assess the quality of decisions on reevaluations, and as such, do not provide generalizable information on all reevaluations decided by these two offices. To help close this recommendation, VA should take steps to focus its review on claims with reevaluations, in order to identify and correct root causes of any deficiencies, such as through additional training or the improvement of training. Using the results of both the 2018 and 2019 studies would allow VBA to more fully assess this issue.

Recommendation: The Under Secretary for Benefits should clarify guidance in its procedures manual regarding the knowledge, skills, and abilities needed to make decisions on whether to reevaluate veterans for changes in their service-connected conditions. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with this recommendation in principle, acknowledging the importance of having appropriately skilled and trained employees to process reevaluations and other claims. VA stated that it believes the procedures outlined in its manual accurately describe the steps necessary for claims adjudicators to make the decision whether to reevaluate veterans for changes in their service-connected conditions. It further stated that regional office management ensures compliance with the procedures through the quality assurance program, and makes the decisions about which claims processors are best suited to perform the work. Accordingly, as of March 2020, VBA plans to assess the quality of routine future examinations requested by non-raters. Based on the results of this new quality review, VBA will determine if any additional actions are needed. VBA plans to complete this effort by October 2020. We are encouraged by VA's interest in conducting this analysis, and we will consider closing the recommendation when that effort is complete.

Recommendation: The Under Secretary for Benefits should align training requirements with the knowledge, skills, and abilities needed for reviewing claims to decide whether to conduct a reevaluation. (Recommendation 5)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with this recommendation in principle. As noted in recommendation 4, as of March 2020, VBA plans to assess the quality of routine future examinations requested by non-raters, and determine if any additional actions are needed. VA also stated that if any refresher training is warranted for raters, local quality review team members can provide focused training locally. VBA plans to complete this effort by October 2020. We will consider closing the recommendation when that effort is complete.

Recommendation: The Under Secretary for Health should ensure that any action plan for achieving health equity includes key elements for successful implementation by consistently applying criteria identified in GAO's past work on effectively managing performance, including developing performance measures to assess progress and creating clear lines of accountability by designating specific offices or officials with responsibility for coordinating efforts to implement actions and committing resources necessary for achieving its goals and objectives. (Recommendation 1)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: To ensure the availability of information on health care outcomes by race and ethnicity throughout the VA health care system, the Secretary of Veterans Affairs should conduct an assessment to determine the completeness and accuracy of race and ethnicity data captured in VA's electronic health record, and implement corrective actions as necessary to resolve any identified deficiencies. (Recommendation 2)

Agency: Department of Veterans Affairs: Office of the Secretary
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The VA Under Secretary of Health should use workload data from the most recently completed fiscal year as part of the models that inform VISNs' and medical centers' general purpose funding needs, when doing so would not significantly delay the allocation of funds. (Recommendation 1)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: April 2020: GAO will update the status of this recommendation when VA provides additional information.

Recommendation: The VA Under Secretary of Health should establish a formal process to document VHA's review of VISNs' adjustments to medical center allocation levels. (Recommendation 2)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: April 2020: GAO will update the status of this recommendation when VA provides additional information.

Recommendation: The VA Under Secretary of Health should revise VHA's existing guidance to require VISNs to provide information on how they determined how much and for what reasons they made adjustments to medical center allocation levels. (Recommendation 3)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: April 2020: GAO will update the status of this recommendation when VA provides additional information.

Recommendation: The VA Under Secretary of Health should revise its existing guidance to require VISNs—in conjunction with medical centers—to develop and submit approaches to improve efficiency at medical centers with declining workload that received adjusted funding levels. These approaches could include adjusting the level of services offered. (Recommendation 4)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open
Priority recommendation

Comments: April 2020: GAO will update the status of this recommendation when VA provides additional information.

Recommendation: The VA Under Secretary of Health should require VISNs to provide explanations on the amount of funds redistributed between VISNs and medical centers and VHA to document its review of these redistributions. (Recommendation 5)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: April 2020: GAO will update the status of this recommendation when VA provides additional information.

Recommendation: The Secretary of the VA should direct the Under Secretary for Health to collect complete staffing data for the Family Caregiver Program that includes Caregiver Support Program Office funded staff, VAMC funded staff, and staff that assist the program as a collateral duty at each VAMC. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation. The Veterans Health Administration (VHA) has reported that the Caregiver Support Program Office had identified a solution for identifying VHA Family Caregiver Program staff in the Human Resource (HR) Smart system. VHA reported that current full- and part-time employees funded by the Caregiver Support Program Office will be identified with a specific specialty code in HR Smart. However, as of April 2020, this capability was not yet available in HR Smart and staffing for the program continued to be manually updated and tracked. Further, the proposed use of HR Smart will still not result in complete information that the Caregiver Support Program Office can use to track all staff who support the program because according to VHA, staff that assist the program as a collateral duty and VAMC-funded staff who support the program will not be tracked through HR Smart. As of July 2020, this recommendation remains open pending further updates from VHA.

Recommendation: The Secretary of the VA should direct the Under Secretary for Health to establish a process to ensure that the Family Caregiver Program staffing data that are collected and reported to the Caregiver Support Program Office are accurate. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: VHA concurred with this recommendation. In February 2020, the Veterans Health Administration (VHA) reported that the Caregiver Support Program Office had identified a solution for identifying full-time VHA Family Caregiver Program staff in the Human Resource (HR) Smart system through the use of a specific specialty code. VHA reported that once implemented, the use of the HR SMART specialty code would provide more accurate information regarding staffing. In April 2020, VHA stated that were would also be a static field called "position skill type" that would track positions with a skill type category of caregiver and that Veterans Integrated Service Network (VISN) leads for the Family Caregiver Program would use this field to cross check the new specialty code and identify and correct any reporting inconsistencies. As of July 2020, this recommendation remains open pending further updates from VHA.

Recommendation: The Under Secretary for Health should document same-day services objectives and develop performance goals and related performance measures to facilitate the periodic assessment of the impact of same-day services on veterans' access to care. (Recommendation 1)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: The Under Secretary for Health should develop a process to assess the overall performance of VISNs in managing and overseeing medical centers. (Recommendation 1)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open

Comments: 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, with a target completion date of September 2020. 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.

Recommendation: 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)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open
Priority recommendation

Comments: 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. VHA plans to crosswalk existing policies to the new structure and organizations, with a target completion date of September 2020. 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.

Recommendation: 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)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open

Comments: VHA concurred with our recommendation. In December 2019, VHA reported its office for Manpower Management began reviewing changes to VISN organizational structure and positions. In February 2020, VHA provided GAO with the guidance for VISN staffing and a draft Manpower Management directive, with target completion date of May 2020 for approval. For closure, VHA should provide the approved VA Directive 5010 documentation outlining the process developed to routinely oversee VISN staffing, including efforts by the DUSHOM in partnership with Workforce Management and Consulting and Manpower and Management, such as policy directives, organizational charts, amongst others.

Recommendation: To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations develop and implement a process to assess veterans' changing expectations and disseminate this information to VAMCs. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation, but noted that it had already developed and implemented effective systems for obtaining Veterans' input in facility planning. However, we found that the information VA collects through these efforts may be limited based on our review of VA's surveys, including VSignals and the Survey of Enrollees, as well as our discussions with several Veterans Service Organizations. For example, we found that VA's efforts were limited because they either focused on overall veteran expectations without a means of assessing how they differed by demographics, or they focused on veteran satisfaction with their past experiences. Moreover, satisfaction with past experiences, as operationalized by VA for the surveys we reviewed, measured how someone is with what they received--while "expectations," as defined by VA, would measure or gain insight into what it is that someone would want, and which may or may not be what they are receiving. Thus, while satisfaction, as operationalized by VA, can be an indicator of an expectation, as defined by VA, the two are not synonymous. Although VA considers this recommendation closed, we are working with them to identify ways that expectations, as VA has defined the term, can be measured.

Recommendation: To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations instruct VAMCs on how to meet VA's strategic goal of incorporating veterans' changing needs and expectations into facility planning, such as by identifying certain resources or tools and directing VAMCs to use them. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: VA agreed with the recommendation and indicated that it would instruct users on what data to use in planning and updates, which would help ensure veterans' input is incorporated where appropriate. As of its fiscal year 2021 budget justification, VA still had not provided this guidance to the VAMCs, but noted that it would provide it in scheduled facility planning calls that were expected to start in the second quarter of fiscal year 2020.

Recommendation: To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations provide additional instruction to VAMCs on how to incorporate the concept of foundational health services into facility planning. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation and noted that it would clarify prior guidance on the foundational health services for VAMCs, which it expected to complete in June 2019. In November 2019, VA told us that it had reviewed this prior guidance from August 2017 that had defined foundational services, and has rescinded it. However, we are working with VA to determine if this decision to rescind the prior guidance was distributed to VAMCs.

Recommendation: To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations systematically gather feedback from facility planners and address (as necessary) their concerns with the reliability of the SCIP process, including providing additional information on how SCIP's space estimates are derived. (Recommendation 4)

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: VA agreed with this recommendation and indicated that it would update its training instructions to facility planners by adding an explanation of how SCIP space estimates are derived. In addition, VA noted that it would survey facility planners about their concerns with the SCIP space estimates, and use these results to either address the concerns or make improvements to SCIP. As of November 2019, VA had not completed the training or the survey, but noted that they are in the process of updating training materials for the FY22 SCIP planning process--which was targeted to start 2019. We will work with VA to obtain relevant documentation of these efforts.

Recommendation: The Under Secretary for Benefits should develop and implement a new regional office performance measure that allows it to better measure the accuracy of each regional office's work. (Recommendation 3)

Agency: Department of Veterans Affairs: Veterans Benefits Administration
Status: Open

Comments: VBA is working to develop and implement a new measure to assess the accuracy of each regional office. We will close this recommendation once VA has finalized and implemented the new measure.

Recommendation: The Under Secretary for Health should establish an achievable wait-time goal for the consolidated community care program that VA plans to implement that will permit VHA to monitor whether veterans are receiving VA community care within time frames that are comparable to the amount of time they would otherwise wait to receive care at VHA medical facilities. (Recommendation 1)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open
Priority recommendation

Comments: The Veterans Health Administration (VHA) agreed with our recommendation and stated in March 2020 that it is taking steps to establish a wait-time goal for the new consolidated community care program-the Veterans Community Care Program. Actions include updating VHA's current directives and the implementation of the HealthShare Referral Manager, a software system that will provide VHA the capability to monitor wait times.

Recommendation: The Under Secretary for Health should design an appointment scheduling process for the consolidated community care program that VA plans to implement that sets forth time frames within which (1) veterans' referrals must be processed, (2) veterans' appointments must be scheduled, and (3) veterans' appointments must occur, which are consistent with the wait-time goal VHA has established for the program. (Recommendation 2)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open
Priority recommendation

Comments: The Veterans Health Administration (VHA) agreed with our recommendation and stated in March 2020 that it is taking steps to design an appointment scheduling process for the new consolidated community care program-the Veterans Community Care Program. This includes actions to develop a wait-time goal, and the development and review of VHA's new community care directive.

Recommendation: The Under Secretary for Health should establish a mechanism that will allow VHA to systematically monitor the average number of days it takes for VAMCs to prepare referrals, for VAMCs or TPAs to schedule veterans' appointments, and for veterans' appointments to occur, under the consolidated community care program that VA plans to implement. (Recommendation 3)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open

Comments: The Veterans Health Administration (VHA) agreed with our recommendation and stated in March 2020 that it is taking steps to establish a mechanism to monitor appointment timeliness for the new consolidated community care program-the Veterans Community Care Program. This includes the implementation of the HealthShare Referral Manager, a software system that will allow VHA to measure timeliness of appointment scheduling actions, development of a wait-time goal, review of current VHA directives, and the development of reports that can be used by VA medical centers to monitor appointment scheduling timeliness.

Recommendation: The Under Secretary for Health should implement a mechanism to prevent veterans' clinically indicated dates from being modified by individuals other than VHA clinicians when veterans are referred to the consolidated community care program that VA plans to implement. (Recommendation 4)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open

Comments: The Veterans Health Administration (VHA) agreed with our recommendation and stated that it is taking steps to implement a mechanism to prevent veterans' clinically indicated dates (CID) from being modified by VHA staff other than VHA providers for the new consolidated community care program-the Veterans Community Care Program. Specifically, VHA developed the HealthShare Referral Manager (HSRM), a software system for VA medical center (VAMC) staff to use to manage VCCP referrals, including creating authorizations and scheduling veteran appointments with community providers. VHA deployed the HSRM at all VAMCs as of June 24, 2019, and according to VHA officials, the system was fully implemented as of December 31, 2019. In March 2020, VHA provided documentation that shows (1) the VHA clinician populates the CID field when they create the referral in VA's electronic medical record system, (2) when the referral is forwarded to HSRM for referral management and appointment scheduling by VAMC staff, the CID field in HSRM is auto-populated based on the CID in VA's electronic medical record system, and (3) the auto-populated CID field in HSRM cannot be edited. However, under VA's current scheduling process, some VHA staff can still edit the referral after the VHA provider enters the CID and before it is sent to the HSRM for scheduling. VHA will need to take action to ensure this part of the process has protections to ensure veterans' CIDs aren't modified after being entered by the VHA provider.

Recommendation: The Under Secretary for Health should implement a mechanism to separate clinically urgent referrals and authorizations from those for which the VAMC or the TPA has decided to expedite appointment scheduling for administrative reasons. (Recommendation 5)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open

Comments: The Veterans Health Administration (VHA) did not concur with this recommendation, and states a mechanism is no longer needed as VA medical center staff are responsible for appointment scheduling under the new consolidated community care program, the Veterans Community Care Program (VCCP), not staff from third-party administrators. However, we believe this recommendation is still relevant, and in July 2020 we asked VHA for evidence to show that VA medical center staff, when scheduling VCCP appointments, are not changing routine referrals to an urgent status to expedite appointment scheduling in cases of delays.

Recommendation: The Under Secretary for Health should (1) establish oversight mechanisms to ensure that VHA is collecting reliable data on the reasons that VAMC or TPA staff are unsuccessful in scheduling veterans' appointments through the consolidated community care program VA plans to implement, and (2) demonstrate that it has corrected any identified deficiencies. (Recommendation 6)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open

Comments: The Veterans Health Administration (VHA) agreed with our recommendation and stated in March 2020 that it is taking steps to establish an oversight mechanism to ensure VHA is collecting reliable data in cases where staff are unsuccessful in scheduling veterans' appointments for the new consolidated community care program-the Veterans Community Care Program. This includes actions to implement the HealthShare Referral Manager, a software system that will allow VHA to produce reports on reasons for unsuccessful scheduling attempts, development of a community care directive, and an analysis of the reasons behind unsuccessful scheduling.

Recommendation: The Secretary of Veterans Affairs should ensure that the contracts for the consolidated community care program VA plans to implement include performance metrics that will allow VHA to monitor average driving times between veterans' homes and the practice locations of community providers that participate in the TPAs' networks. (Recommendation 7)

Agency: Department of Veterans Affairs
Status: Open

Comments: The Veterans Health Administration agreed with this recommendation, and as of March 2020, reported that it included performance metrics related to drive times in its contracts for the new third-party administrators in Regions 1-4 of the new Community Care Network under the Veterans Community Care Program. The contracts for Regions 5 and 6 have not been awarded yet.

Recommendation: The Under Secretary for Health should issue a comprehensive policy directive and operations manual for the consolidated community care program VA plans to implement and ensure that these documents are reviewed and updated in a timely manner after any significant changes to the program occur. (Recommendation 10)

Agency: Department of Veterans Affairs: Office of the Under Secretary for Health
Status: Open

Comments: The Veterans Health Administration agreed in principle with this recommendation, and stated that it has taken action to develop a new community care directive, which was under technical review as of March 2020.

Recommendation: The VHA Undersecretary for Health should provide updated guidance to VAMCs on the governance of the patient advocacy program, including clear definitions of reporting lines. (Recommendation 1)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VHA concurred with this recommendation and has provided regular updates on its progress in implementing it. As of April 2019, VHA's Office of Patient Advocacy (OPA) partnered with VA's Center for Healthcare Organization and Implementation Research (CHOIR) to better understand the current state of patient advocacy services in VHA, focusing on position descriptions, grade levels, and reporting structures. VA medical center staff completed questionnaires about the patient advocacy program in January 2019 and VHA analyzed the results. CHOIR officials are conducting site visits to interview key staff directly to identify the benefits and opportunities for improvements with patient advocacy services, including reporting structure. Upon completion of site visits to validate questionnaire findings, CHOIR will present their final recommendations to OPA. OPA will develop reporting structure guidance and work with workforce management and VHA senior leaders to communicate and implement the guidance. VHA's target completion for these efforts is December 2019.

Recommendation: The VHA Undersecretary for Health should assess and provide guidance to VAMCs on appropriately staffing the patient advocacy program, including guidance on how to determine the appropriate number and type of staff. (Recommendation 2)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VHA concurred with this recommendation and has provided regular updates on its progress in implementing it. As of April 2019, VHA's Office of Patient Advocacy (OPA) partnered with VA's Center for Healthcare Organization and Implementation Research (CHOIR) and VHA's Workforce Management to develop an evidence-based patient advocacy staffing model that accounts for facility size, complexity and geographic region. A set of questions was distributed to all VAMCs in December 2018. Responses to these questions have been analyzed by CHOIR, and on-site interviews at select facilities are in progress to validate the report findings. VHA's Workforce Management is working with CHOIR and OPA to use the results to develop a recommended and validated staffing model. This guidance will also be incorporated in the future revision of the VHA directive. The target completion of these efforts is December 2019.

Recommendation: The VHA Undersecretary for Health should monitor PATS data-entry practices to ensure all complaints are entered into PATS and that veterans' feedback is coded consistently. (Recommendation 5)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VHA concurred with this recommendation and has provided regular updates on its progress in implementing it. As of April 2019, VHA's Office of Patient Advocacy (OPA) receives a weekly report from both the Patient Advocate Tracking System (PATS) and PATS-Replacement (PATS-R) Systems reporting on the number of new cases entered at every VA medical center (VAMC). With development of the PATS-R web-based tool, OPA, the Veterans Experience Office and the PATS-R developers have conducted a review of existing codes and are currently working with various VHA program offices to standardize codes across various data systems. VA plans to develop an auditing toolkit to ensure standardized, timely documentation of complaints, including accurate coding within PATS. The target completion date for these efforts is December 2019.

Recommendation: The Under Secretary for Health should specify in VHA policy that reviews of providers' clinical care after concerns have been raised should be documented, including retrospective and comprehensive reviews. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with the recommendation and indicated plans to revise policy to codify requirements to document reviews. As of April 2020, VA estimates completing these and other revisions to the policy in August 2020.

Recommendation: The Under Secretary for Health should specify in VHA policy a timeliness requirement for initiating reviews of providers' clinical care after a concern has been raised. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

Comments: VA agreed with the recommendation and indicated plans to revise policy to incorporate timeline expectations for initiating reviews after clinical care concerns have been raised. As of April 2020, VA estimates completing these and other revisions to the policy in August 2020.

Recommendation: The Undersecretary for Health should develop and implement a process to accurately count all physicians providing care at each medical center, including physicians who are not employed by VHA. (Recommendation 1)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open
Priority recommendation

Comments: As of January 2020, VHA continues to disagree with the recommendation and has not taken any action. Although VA responded to our report by stating that the ability to count physicians does not affect its ability to assess workload, we maintain that an accurate count of all physicians providing care at each medical center is necessary for accurate workforce planning. To implement the first recommendation, VHA needs to develop a system-wide process to collect information on all physicians providing care at VAMCs, including physicians that are not employed by VHA. This information should be available at the local level for workforce planning purposes.

Recommendation: The Undersecretary for Health should develop and issue guidance to the VAMCs on determining appropriate staffing levels for all mission-critical physician occupations. (Recommendation 2)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VHA concurred with this recommendation. In November 2017, VHA's Executive in Charge chartered the Specialty Care Provider Staffing and Network Model Workgroup to develop a methodology for determining the scope and complexity of specialty care services. The Workgroup also developed an analytical tool to support local decision-making around specialty staffing levels. According to VHA, the Specialty Care Services Staffing model has been validated across some VHA regions. The Workgroup was directed to develop an Executive Decision Memorandum for an official determination as to implementation of the model. As of January 2020, VHA was awaiting the results of the Governing Board's decision on the Executive Decision Memorandum, the guidance documents, and analytical template. VHA reported the target date for completion is March 2020.

Recommendation: The Undersecretary for Health should establish a system-wide method to share information about physician trainees to help fill vacancies across VAMCs. (Recommendation 4)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VHA concurred with this recommendation. VHA is working to develop the necessary capacity to enable a system-wide method for sharing information about physician trainees to help fill vacancies. In April 2019, VHA anticipated having this system in place by the end of fiscal year 2019. However, VHA has not submitted any additional information since April 2019. VHA has also created a VHA-Trainee Recruitment and Hiring Workgroup (the Workgroup). The Workgroup serves as the advisory group on trainee recruitment and hiring, for the purpose of developing a permanent Trainee Recruitment and Hiring Function. The Workgroup is holding Virtual Trainee Recruitment Events for critical occupations. Until GAO sees evidence of a system-wide method for sharing information about physician trainees, this recommendation will remain open.

Recommendation: The Undersecretary for Health should take additional steps to ensure that VA's website reports health care quality measures that cover a broad range of health care services, highlights key differences in the clinical quality of care, and presents this information in an easily accessible and understandable way (Recommendation 1).

Agency: Department of Veterans Affairs
Status: Open

Comments: As of January 2020, VA provided information that they had updated information on its website to include more quality measures, particularly as they relate to outpatient care. While VA has made progress in reporting on additional measures, we reviewed VA's website-specifically, their Access and Quality webpage which is the primary webpage for veterans to access information on quality-as of February 2020 and found that VA has still yet to report on a broad range of quality measures that would assist veterans in making health care decisions for inpatient care. For example, VA does not report any quality measures related to readmissions and mortality; length-of-stay; or efficiency. VA also continues to report only one timely and effective care measure for inpatient care. With regards to presentation of its quality measures, VA no longer links its Access and Quality webpage to the homepage of VA's website, making it more difficult to find. Additionally, for the new outpatient measures that VA has added to its website, VA has not presented these measures in an easily understandable way as there is little explanation of what they are measuring and how veterans can use these measures to make healthcare decisions. We will keep this recommendation open until VA has made further updates to its website.

Recommendation: The Undersecretary for Health should direct VA Central Office to conduct a systematic assessment of the completeness and accuracy of patient clinical information across VAMCs that is used to calculate the health care quality measures VA reports and address any deficiencies that affect the accuracy of these measures (Recommendation 2).

Agency: Department of Veterans Affairs
Status: Open

Comments: As of January 2020, VA has said they have focused on three main efforts as it relates to documenting information on VA quality of care, including: timeliness of access information (e.g., wait times) to health care within VA facilities; timeliness and accuracy of payments to community care providers; and accuracy of coding and documentation within VA and from community providers. In particular, VA has conducted several efforts to improve education and training on clinical documentation and coding, particularly for providers. VA has also said it has made efforts in requiring programs across regional networks aimed at improving clinical documentation and coding. While these efforts can help with improving documentation of care to veterans, it is unclear how VA Central Office has assessed whether these efforts have actually achieved its goals and improved the accuracy of its quality measures. As we stated in our report, VA Central Office has not conducted a systematic assessment of the completeness and accuracy of the clinical data recorded in VA patient medical records across all VAMCs. The results of such a systematic analysis could help identify the deficiencies, if any, in the recording of patient clinical information and what steps, if any, VA Central Office may need to take to address them. We will keep this recommendation open until VA provides information on a systematic assessment of clinical documentation.

Recommendation: 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)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open
Priority recommendation

Comments: VA agreed with our recommendation. In October 2019, VHA issued an interim policy on program office memos (also known as "operational memos") that described how these guidance documents should be vetted and recertified. For example, operational memos issued after VHA's new interim policy will expire 2 years after publication if no further action is taken. In November 2019, VHA further clarified in another interim policy the purpose of all national policy and guidance documents, including the purpose and audience for each document type. Because VHA interim policy, by definition, is automatically rescinded after 1 year unless incorporated into a national policy directive, VHA needs to provide us with the finalized version of its recertified national policy directive in order to fully implement this recommendation. The recertified national policy directive should include the framework outlined in its interim policy documents.

Recommendation: The Under Secretary for Health should develop standard processes for consistently maintaining and disseminating guidance documents to each level of the organization. (Recommendation 2)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: 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 October 2019, VHA issued an interim policy requiring all operational memos to be maintained on its publications website. Because interim policy is automatically rescinded after 1 year, VHA needs to provide us with the finalized version of its recertified national policy directive that includes the process it established to maintain these documents. In addition, VHA has not provided documentation of how it will disseminate operational memos so that VHA program offices, VISNs, and VAMCs are aware of new or rescinded guidance.

Recommendation: 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)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VA agreed with our recommendation. In June 2018, VHA reported that it had formed a Field Advisory Workgroup to provide continuing advice on national policy. VHA reported its findings and recommendations from the first workgroup meeting in December 2017 to senior leadership, and held another series of interviews in Summer 2018 to gain additional feedback about how national policy changes affect local facilities. In November 2019, VHA noted that it is developing a standardized process for collecting feedback from the field on published policies. To fully implement this recommendation, VHA should provide documentation of the mechanism by which program offices systematically obtain feedback from VISNs and VAMCs on national policy after implementation and how it will take the appropriate actions.

Recommendation: The Under Secretary for Health should establish a standard policy exemption waiver process and centrally track and monitor approved waivers. (Recommendation 5)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: VA agreed with our recommendation. In October 2018, VHA reported that it had collected information on the waiver procedures and areas of improvement that exist at both the national and local levels. Based on this information, VHA's Waiver Workgroup was finalizing its recommendations for implementing a formal waiver process. As of November 2019, VHA had not yet reached a decision on how to proceed. To fully implement this recommendation, VHA should provide us with documentation of a process that standardizes policy exemptions waivers, including tracking and monitoring those that are approved.

Recommendation: 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)

Agency: Department of Veterans Affairs: Veterans Health Administration
Status: Open

Comments: 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. VHA also established resources for the new interim policy, such as a list of local policies as required by national policy. Because VHA interim policy, by definition, is automatically rescinded after 1 year unless incorporated into a national policy directive, VHA needs to provide us with the finalized version of its recertified national policy directive in order to fully implement this recommendation.

Recommendation: To improve care for women veterans, the Secretary of Veterans Affairs should direct the Under Secretary for Health to strengthen the environment of care inspections process and VHA's oversight of this process by expanding the list of requirements that facility staff inspect for compliance to align with VHA's women's health handbook, ensuring that all patient care areas of the medical facility are inspected as required, clarifying the roles and responsibilities of VA medical facility staff responsible for identifying and addressing compliance, and establishing a process to verify that noncompliance information reported by facilities to VHA Central Office is accurate and complete.

Agency: Department of Veterans Affairs
Status: Open

Comments: As of October 2018, VA has taken some actions to address this recommendation, but additional actions are needed to fully implement it. We will update the status of this recommendation when we receive additional information from VA.

Recommendation: To improve care for women veterans, the Secretary of Veterans Affairs should direct the Under Secretary for Health to monitor women veterans' access to key sex-specific care services--mammography, maternity care, and gynecology--under current and future community care contracts. For those key services, monitoring should include an examination of appointment scheduling and completion times, driving times to appointments, and reasons appointments could not be scheduled with community providers.

Agency: Department of Veterans Affairs
Status: Open
Priority recommendation

Comments: As of June 2017, VHA still lacks data and performance measures for the availability under Choice of sex-specific care, such as mammograms, maternity care, or gynecology. In contrast, for another VA care in the community program, PC3 (a program that the Choice third party administrators also administer) VHA collects data and has performance measures to evaluate women veterans' access to mammography and maternity care. To fully implement this recommendation, VHA needs to extend the collection of data to include care delivered through the Choice Program and other community care programs and establish related performance measures. VA is in the process of letting contracts for its new community care program and is expected to have contracts in place for all regions of the country in fiscal year 2019