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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.

What GAO Recommends

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

Recommendations for Executive Action

Recommendations for Executive Action

We are making the following three recommendations to the Department of Veterans Affairs:

NumberAgencyRecommendation
1Department of Veterans Affairs: 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)

2Department of Veterans Affairs: Office of the Under Secretary for Health

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)

3Department of Veterans Affairs: 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)

View recommendation(s) status

Introduction 


June 19, 2019

The Veterans Health Administration (VHA), within the Department of Veterans Affairs (VA), operates one of the nation’s largest health care systems, with 18 Veterans Integrated Service Networks (VISN) that manage and oversee 172 medical centers and other medical facilities. VHA anticipates that it will provide care to more than 7 million veterans in fiscal year 2019 and that demand for its services will grow in the coming years.

We and others have identified challenges VHA faces in managing and overseeing its health care system, including VHA’s ability to ensure that its medical centers provide timely access to quality health care for veterans. These challenges contributed to VA health care’s addition to GAO’s High-Risk List in 2015, and its continued inclusion in the 2017 and 2019 high-risk reports.[1]

Additionally, in February 2015, VHA’s Task Force on Improving Effectiveness of VHA Governance produced a report with 21 recommendations for improving operational effectiveness and efficiency, including recommendations to improve operations at the VISN level.[2] The task force noted that the VISNs largely operated independently and that there was little collaboration across medical centers. Based in part on the task force's recommendations, VHA realigned the VISNs, which included decreasing the number of VISNs from 21 to 18 and reassigning some medical centers to different VISNs. In addition, the task force identified a need for VHA to focus on the composition of VISN offices in order to improve their efficiency, organizational alignment, and business outcomes. In response to one of the task force's recommendations, VHA established the VISN Staffing Task Force to consider and recommend the appropriate staffing levels and positions needed to operate the VISNs.

You asked us 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.

To examine the extent to which VHA oversees VISNs’ management and oversight of medical centers, we reviewed documentation from VHA, including policies and related documents that describe VISN-level responsibilities. We also reviewed information VHA officials use to assess, monitor, compare, and manage performance across VISNs, such as VISN director performance plans. We interviewed officials from VHA’s Office of the Deputy Under Secretary for Health for Operations and Management, which is responsible for VISN oversight and monitoring. We also interviewed officials from a non-generalizable sample of five VHA program offices, which develop and manage policies and programs related to: (1) homelessness, (2) mental health and suicide prevention, (3) sterile processing services, (4) community engagement, and (5) internal audits and risk assessment. We selected program offices to include those both with and without corresponding subject-matter positions at each of the 18 VISNs, to determine what, if any, oversight responsibilties these offices have over VISNs. For example, we included the VHA program office that specializes in homelessness, as each VISN must have a full-time equivalent (FTE) employee assigned to homelessness, according to VHA’s standardized VISN organizational chart.[3] We interviewed officials from all 18 VISNs to obtain their perspectives on VHA’s oversight. We also interviewed officials from four medical centers to obtain their perspectives on VISNs’ management and oversight of their medical centers. We selected a non-generalizable sample of medical centers for variation in geographic location, VHA's categorization of medical center complexity level, urban or rural location, and VHA’s 2017 star ratings.[4] We evaluated VHA’s process for overseeing VISNs' management and oversight of medical centers against relevant federal standards for internal control.[5]

To examine how VHA oversees VISN staffing, we reviewed: (1) VHA policies and guidance, related to staffing, (2) related internal and external assessments of VISN staffing, and (3) organizational charts from all 18 VISNs. We also reviewed VISN staffing data from VA’s core human resources processing system—HR Smart—for fiscal years 2013 through 2017. We interviewed VHA officials about how these data were collected and documented, as well as the steps taken to ensure that the data were complete. Based on this information, we determined that these data were sufficiently reliable for the purposes of our reporting objective. We also interviewed officials from VHA and the 18 VISNs about VHA’s process to oversee VISN staffing. We evaluated VHA’s process for overseeing VISN staffing against relevant federal standards for internal control.[6]

We conducted this performance audit from March 2018 to June 2019 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Background 


VHA’s health care delivery system is organized regionally, around VISNs. The VISNs were established in 1995 as a part of a strategy to decentralize VA health care decisions and bring decision-making closer to the point of care. VISNs were initially designed to be the basic budgetary and planning unit of VHA. VISN directors--who each report to VHA's Deputy Under Secretary for Operations and Management--were given the autonomy and authority to develop and implement local management, administrative, and staffing arrangements when necessary to meet health care needs. Since then, the number of VISNs has decreased from the original 22 to 18, VISN boundaries have been realigned, and the staffing structure has changed to help support emerging VHA-wide health care needs. Collectively, staffing across all VISNs averaged about 1,000 FTEs each year, from fiscal years 2013 to 2018.

VISNs manage regional markets that deliver health care, social services, and support services to veterans. Each VISN is responsible for overseeing medical centers within a defined geographic area. VISNs manage the day-to-day functions of medical centers within their networks through efforts such as periodic strategic, business, and financial planning meetings. VISNs' oversight of medical centers includes the following examples:

Site visits. VHA requires VISN officials to conduct site visits to medical centers at least twice a year. During these visits, VISN officials may review medical center operations or specific program areas and may make recommendations for improvement. According to VISN officials, some VISNs have tracking mechanisms to ensure medical centers take corrective actions, and others leave the responsibility for resolving site visit recommendations to medical centers.

Conference calls. VISN directors and senior leadership officials told us they hold regular conference calls with medical center staff. These calls can be used to discuss current issues of interest, including process-improvement initiatives, and challenges medical centers are experiencing, among other issues.

Performance reviews. VISN officials review a dashboard of measures to assess medical center performance.[7] The measures may include those from VHA’s Strategic Analytics for Improvement and Learning (SAIL) system, which as of fiscal year 2018 included 29 performance measures (27 quality measures and 2 measures of overall efficiency and capacity) in areas such as acute care mortality, access to care, and employee satisfaction.[8] SAIL is a diagnostic tool that allows VHA to assess medical centers’ performance relative to their peers, and determine year-to-year improvement based on relevant clinical data. For example, SAIL includes an online performance management tool called Symphony that tracks performance measures related to medical center access, outcomes, and productivity, and includes an early warning system to notify VISN and medical center officials of results that require action.

Best practices and regional consortiums. According to VHA, each VISN is part of a regional consortium—comprised of several VISNs in a particular geographic area—that are to share resources and best practices, conduct program reviews, and discuss common needs. Regional consortiums were formed to foster collaboration among medical centers and to enhance operations and the delivery of health care to veterans. To accomplish these goals, the consortiums use means such as regional contracts, sharing FTEs, and joint networks for referring patients and conducting telehealth, according to VISN officials. For each regional consortium, the corresponding VISN directors serve as a board of directors to approve and guide the consortium's actions.

Major Findings 

VHA’s Oversight of VISNs Is Limited

VHA’s Oversight of VISNs Relies Primarily on Individual Director Assessments

VHA officials told us they rely primarily on annual assessments of individual VISN directors’ performance to assess VISN operations. Officials said they supplement these assessments with meetings with VISN leadership, including quarterly reviews of VISN performance on specific topics. These oversight activities do not provide comprehensive information on VISN-wide operations or overall performance of VISNs.

According to federal standards for internal control, management should design control activities through its policies and procedures that help it achieve its objectives, such as effective management and performance. The establishment of policies aimed at validating the propriety and integrity of both the organization and individual performance measures helps management monitor performance.[9] Additionally, the Office of Personnel Management’s A Handbook for Measuring Employee Performance notes that by measuring only individual actions an organization might find that the organization as a whole has failed to meet its objectives, even if most of its employees are appraised highly.[10]

VHA officials told us that individual VISN director performance reviews, conducted annually, are VHA’s primary assessment of VISN performance. We found that these individual assessments rely heavily on medical center information.[11] Specifically, VHA’s Senior Executive Service Part V. Performance Appraisal System handbook states that VISN directors are assessed using a performance appraisal template that identifies expectations across five elements established by the Office of Personnel Management: (1) Leading Change, (2) Leading People, (3) Business Acumen, (4) Building Coalitions, and (5) Results Driven.[12] None of the five elements include performance measures or an evaluation specific to the VISN level, including its oversight of medical centers.

VHA's handbook designates a relative weight for each element used to calculate a director’s rating. Sixty percent of the VISN director’s performance review—assessed by the first four elements—is based on the director’s individual performance. The remaining 40 percent—assessed through the Results Driven element—is based entirely on medical center performance information. SAIL results for medical centers within the VISN contribute to the Results Driven element. As noted earlier, SAIL assesses performance across a broad range of evidence-based indicators, including measures such as patient mortality, length of stay, and readmissions. Other medical center performance information, including data on access to care, comprised the remainder of the Results Driven element. VHA officials acknowledged an individual VISN directors' personal performance is not always indicative of that VISN's performance as a whole, but said the medical center performance data that inform these individual assessments is how they can best determine how well a VISN is doing leading and providing oversight to medical centers. As previously stated, it is important for an organization to have both individual and organizational-level performance measures to help monitor performance.

VHA officials told us they also assess VISN performance through meetings with VISN officials. For example, VHA officials told us they conduct quarterly VISN reviews that are generally about an hour in length, and involve the VISN director and the Deputy Under Secretary for Health for Operations and Management, among others. During these quarterly reviews, the VISN director uses a VHA-designated template to provide an update on the VISN’s performance on specified topics. From our review of the template, we found that the quarterly reviews focus primarily on VISN-reported activities, successes and challenges.[13] They do not typically include performance measures specific to the VISN level, such as how VISNs are performing their intended roles to carry out oversight and management of medical centers. Instead, performance measures included in the quarterly review template measure medical centers’ performance within a VISN, similar to some of the measures used to assess the individual performance assessment for VISN directors. For example, the quarterly template includes medical centers' SAIL metrics. In our prior work, we reported that best practices for formal assessments are to be objective and measure the results, impact, or effects of a program or policy.[14] These formal assessments can also help in determining the appropriateness of goals or the effectiveness of strategies.

VHA officials told us that they also hold periodic meetings with VISN leadership and weekly meetings with VISN directors. For example, officials from the Office of the Deputy Under Secretary for Health for Operations and Management told us they regularly meet with all VISN chief medical officers and quality management officers, as well as meet with all deputy VISN network directors. VHA officials also told us they facilitate weekly calls with all VISN directors and hold monthly meetings with VISN directors, as part of the National Leadership Council.[15] These calls and meetings do not include a comprehensive assessment of VISN performance, but rather serve as check-in meetings and include program office presentations. They also include discussion of any new topics of interest, or emerging or ongoing issues for VISNs or medical centers, according to VISN officials.

Although individual assessments and periodic meetings provide some useful information on how the VISN is doing in specific areas, it is also important to have a process to assess overall VISN performance in managing and overseeing medical centers. In our prior work, we reported that routine organizational assessments can provide feedback to an agency on how well day-to-day activities and programs developed to operationalize goals and objectives contribute to the achievement of those goals and objectives, such as VHA's goal to ensure effective oversight of medical centers.[16] 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 Lacks a Comprehensive Policy That Defines VISN Roles and Responsibilities

VHA does not have a comprehensive policy that defines VISNs’ roles and responsibilities to manage and oversee medical centers. This is contrary to federal standards for internal control,which call for management to assign responsibilities and hold individuals accountable, and for management to consider how components interact within the whole organization in order to fulfill responsibilities and meet operating objectives.[17] VHA requires the use of policy to assign responsibilities for executing a course of action to individuals or groups.[18] VHA and VISN officials told us that although they do not have a comprehensive policy that clearly documents VISN roles and responsibilties, they have several documents they believe help VISNs understand their roles and responsibilities. These documents include program office policies, VISN directors’ job descriptions, and a newly developed Network Director Playbook. However, our review of these documents found that they lack broader VISN-level responsibilities, as described below.

Program office policies. In our review of program office policies, we found high-level outlines of VISN director responsibilities for implementing specific policies or programs, but these outlines did not detail broader VISN-level responsibilities, such as what the VISN is expected to do to manage and oversee medical centers. For example, a VHA directive on homelessness states that the VISN director is responsible for ensuring veterans have timely access to VHA homeless programs and services at medical centers, as well as ensuring quality care for veterans. However, this directive does not discuss other VISN responsibilities outside of the director or for areas outside of the specific program area. Additionally, although VISN director responsibilities are outlined in policies, VHA officials told us that program offices do not have direct oversight responsibilities of VISNs. As previously noted, VISN directors report to the Deputy Under Secretary for Health for Operations and Management.

VISN director job descriptions. Job descriptions state that VISN directors are expected to provide leadership and management skills in various areas, such as strategic planning, quality assessments, and human resources, as well as establish operational, financial and strategic plans for the VISN. The VISN director job descriptions are tied to an individual position and do not clearly describe what the VISN as a whole is responsible for accomplishing.

Network Director Playbook. VISN officials told us that they developed a Network Director Playbook to reduce variation in VISNs. The playbook describes the responsibilities of VISN directors as (1) managing regional markets that deliver health care, social services, and support services to veterans, and (2) providing administrative and clinical oversight of medical centers. The playbook also highlights seven high-level topic areas pertaining to VISN-level roles, but it does not include additional detail on what is expected of the VISN, nor does it provide goals for what is to be achieved in these areas.[19] The remainder of the playbook provides a resource guide and primer for VISN directors on various topics. For example, the playbook includes resource chapters on administrative investigations, the communication process, governance, and other topics related to VISNs’ management and oversight of medical centers. VHA officials noted that the playbook is guidance rather than policy. Officials we interviewed from four VISNs agreed, stating that the playbook was meant to serve as a guide when needed, but is not required to be followed. One VISN director told us that he does not use the playbook because he views it as a guide only for new VISN directors.

The lack of a comprehensive policy defining VISN-level roles and responsibilities for managing and overseeing medical centers makes it difficult for VHA to develop an effective oversight process that ensures adequate monitoring of VISN activities and a way to address poorly performing VISNs. The Task Force on Improving Effectiveness of VHA Governance 2015 report included a recommendation for VHA to articulate the work and roles and responsibilities of the VISNs, and provided a framework and suggested roles.[20] In response to this recommendation, VHA officials told us they have taken several steps, which include the standardization of the VISN governance process and expanding the VISNs’ role in key operational elements, such as contracting and information technology. Additionally, in 2018, VHA conducted a review of the VISN structure to inform a VISN redesign process.[21] The resulting December 2018 Veterans Integrated Services Networks (VISN) Redesign Report also noted the lack of clearly defined roles and responsibilities at the VISN level. Clearly defined roles and responsibilities would better position VHA to develop an oversight process to effectively assess overall VISN performance in managing and overseeing medical centers.

VHA Has Standardized VISN Staffing Levels and Positions, but Does Not Ensure VISNs Adhere to Them

VHA has standardized staffing levels and positions for VISN staffing, but we found that VHA does not fully monitor VISNs' adherence to them. VHA uses a standardized VISN organizational chart to document these staffing levels and positions.(See appendix I for VHA’s standardized VISN organizational chart.) The standardized chart was developed by the VISN Staffing Task Force, which VHA established in 2015 to recommend the appropriate staffing levels and mix of positions to effectively operate VISNs and to standardize key functions.[22] The Deputy Under Secretary for Health for Operations and Management approved the standardized organizational chart in July 2016. VHA officials told us they expect VISNs to adhere to it.

According to VHA's standardized VISN staffing levels, each VISN is allowed between 63 and 66 FTE staff based on the VISN’s complexity, veteran demographics, and the health of the veteran population served by its medical centers. These VISN staff are responsible for carrying out the functions of the VISN for overseeing and managing medical centers, including implementing national policies and programs, managing internal and external relationships, and sharing best practices. The standardized VISN organizational chart also contains 28 key positions (each representing one FTE unless otherwise noted) that should be in place at every VISN, including a chief medical officer, mental health lead, and patient safety officer. Additionally, the organizational chart contains a specific staffing composition for each VISN: 44 base positions, six administrative positions, 12 clinical or administrative analytical positions, and up to four adjustment positions based on the size of the VISN. [23]

VHA officials told us that to oversee staffing, they compared VISNs’ organizational charts to VHA’s standardized organizational chart. Specifically, on June 14, 2018, the Office of the Deputy Under Secretary for Health emailed all VISN directors to request that they align their individual staffing levels and positions to the standardized chart, document any changes as a result of the alignment on their individual VISN organizational charts, and submit them by June 22, 2018, to the Deputy Under Secretary for Health for Operations and Management for review and approval. Apart from this one-time review and approval process, VHA officials told us they do not have an oversight process to review VISN organizational charts on a regular basis.[24]

VHA officials told us the process VHA used to review VISNs’ organizational charts involved checking that VISNs’ reported total FTEs were within the allotted allowance and adhered to the staffing composition. As of February 2019, VHA had approved the organizational charts for 15 of 18 VISNs based on the standardized VISN organizational chart. According to officials, the remaining three VISNs had either not submitted a chart for review or not had their chart approved.

VHA's review and approval process did not ensure that VISN organizational charts always included the 28 key positions. In our analysis comparing the 15 approved VISN organizational charts to the standardized chart, we found one to five key positions were not listed on the organizational charts of six of the 15 VISNs with approved organizational charts[25] For example, one VISN was missing both the primary care and geriatrics and extended care positions on its organizational chart. VISN officials provided various reasons for the positions not being listed on the organizational charts. For example, VISN officials said that in several instances the position did not appear on the chart because these responsibilities were being performed as a collateral duty--taken on in addition to normal duties--for a staff person at the VISN or at one of the medical centers in the VISN.[26]

VHA officials told us there is some limited flexibility in the standardized VISN organizational chart. However, they also said that they have not documented the criteria for approving VISNs’ organizational charts that do not adhere to the standardized chart, nor have they documented approvals that have allowed for flexibility.

VHA officials told us they also did not confirm that VISNs staffed the key positions listed in their organizational charts. In our analysis of VISNs’ organizational charts, we compared positions listed on each chart with VISN data about staff employed at each of the VISNs as documented in VA’s HR Smart system.[27] We found that most position titles in HR Smart did not match position titles in the organizational charts, and VHA officials told us that no position-title crosswalk exists. The lack of a crosswalk limits VHA’s ability to monitor VISN staffing on an ongoing basis and ensure that the VISNs are staffed consistently with the standardized organizational chart. VHA officials told us that they expect VISNs to accurately report their staffing compositions via their organizational charts, and acknowledge they do not assess the extent to which this occurs.

VHA’s current monitoring of VISN staffing is inconsistent with federal standards for internal control, which state that management should establish and operate monitoring activities and evaluate the results.[28] Establishing a process to routinely oversee staffing would help VHA ensure VISNs staff the positions it has determined necessary for effective operations and would provide VHA leadership with greater assurance that key positions--as determined by the standardized VISN organizational chart--are filled at the VISNs.

Conclusions 


Given VISNs’ responsibilities for managing and overseeing VA medical centers, it is important that VHA have a robust process for ensuring that VISNs function as intended. Although VHA gathers information on VISN director performance, and on specific aspects of VISN operations, establishing a process for assessing the overall performance of VISNs would enable VHA to better determine how VISNs are performing. Furthermore, a comprehensive policy clearly defining VISN roles and responsibilities would better enable VHA to develop an effective oversight process to ensure adequate monitoring of VISN activities and a way to address poorly performing VISNs.

Additionally, creating a process to oversee VISN staffing would help VHA ensure VISNs adhere to established staffing levels and positions. The lack of clearly defined roles and responsibilities leaves VHA challenged to determine whether its expectations of VISN staffing levels- and positions are appropriate. By establishing a process for routine oversight of staffing, VHA would have greater assurances that VISNs have the staff in place that VHA has determined are needed to effectively operate VISNs. A lack of appropriate staffing could hinder VISNs' ability to oversee the care that VA medical centers provide to veterans.

Agency Comments and Our Evaluation 


We provided VA with a draft of this report for review and comment. VA provided written comments, which are reprinted in appendix II. In its comments, VA noted that VHA’s plan to modernize its governance structure, clinical services, human resources, and organizational structure, in addition to other efforts, will address all three of our recommendations.

VA concurred with two of our recommendations—for VHA to develop a process to assess the overall performance of VISNs and to establish a process to routinely oversee VISN staffing—and provided information on how implementation of its modernization efforts will address them, with targeted completion dates of November 2019 and March 2020, respectively. VA concurred in principle with our recommendation for VHA to establish a comprehensive policy clearly defining VISN roles and responsibilities for managing and overseeing medical centers. In its comments, VA noted that providing written guidance outlining oversight roles and responsibilities for all levels of the organization is part of its planned modernization efforts and that it expects this guidance will define VISN roles and responsibilities. VA provided a target completion date for the recommendation of November 2019. VA added that this guidance may take various forms, including governance principles, standard operating procedures, and decision authorities. Although these guidance documents may clarify VISN roles and responsibilities, they do not denote a comprehensive policy, and as we described in our report VHA requires the use of policy to assign responsibilities for executing a course of action to individuals or groups.Therefore, we maintain that VA should establish a comprehensive policy that clearly defines VISN roles and responsibilities for managing and overseeing medical centers.

We are sending copies of this report to the appropriate congressional committees, the Secretary of Veterans Affairs, and other interested parties. In addition, the report is available at no charge on the GAO Web site at http://www.gao.gov.

If you or your staff have any questions about this report, please contact me at (202) 512-7114 or at draperd@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix III.

Debra A. Draper

Director, Health Care

Congressional Addressees

The Honorable Julia Brownley
Chair
The Honorable Neal Dunn
Ranking Member
Subcommittee on Health
Committee on Veterans’ Affairs
House of Representatives

The Honorable Peter A. DeFazio
House of Representatives

The Honorable Ann McLane Kuster
House of Representatives

The Honorable Brad Wenstrup
House of Representatives

Appendixes 


Appendix I: Veterans Health Administration (VHA) Standardized Veterans Integrated Service Network Organizational Chart, as of July 2016

Appendix II: Comments from the Department of Veterans Affairs

Appendix III: GAO Contact and Staff Acknowledgments

GAO Contact

Debra A. Draper, (202) 512-7114 or draperd@gao.gov.

Staff Acknowledgments

In addition to the contact named above, Janina Austin, Assistant Director; Ashley Dixon, Analyst-in-Charge; Jennie F. Apter; and Helen Sauer made key contributions to this report. Also contributing were Muriel Brown and Jacquelyn Hamilton.

References

Abbreviations

AbbreviationDescription
FTEfull-time equivalent
SAILStrategic Analytics for Improvement and Learning
VADepartment of Veterans Affairs
VHAVeterans Health Administration
VISNVeterans Integrated Service Network

End Notes

Contacts

Debra A. Draper

Director, Health Care, draperd@gao.gov, (202) 512-7114

Congressional Relations

Orice Williams Brown, Managing Director, williamso@gao.gov, (202)-512-4400
U.S. Government Accountability Office
441 G Street NW, Room 7125, Washington, DC 20548

Public Affairs

Chuck Young, Managing Director, youngc1@gao.gov, (202)-512-4800
U.S. Government Accountability Office
441 G Street NW, Room 7149, Washington, DC 20548

Strategic Planning and External Liaison

James-Christian Blockwood, Managing Director, spel@gao.gov, (202)-512-4707
U.S. Government Accountability Office
441 G Street NW, Room 7814, Washington, DC 20548

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