Key Issues > High Risk > Managing Risks and Improving VA Health Care
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Managing Risks and Improving VA Health Care

The Department of Veterans Affairs (VA) has taken steps to maintain its leadership commitment and develop its action plan, but still needs to demonstrate capacity and establish metrics to monitor and demonstrate progress addressing VA health care concerns.

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The VA operates one of the largest health care delivery systems in the nation, providing health care to more than 9 million veterans. Since we designated VA health care as a high-risk area in 2015, VA has begun to address each of the identified five areas of concern: (1) ambiguous policies and inconsistent processes; (2) inadequate oversight and accountability; (3) information technology challenges; (4) inadequate training for VA staff; and (5) unclear resource needs and allocation priorities.

Since we issued our 2017 High-Risk Report, VA has undergone significant transition. Prior to Secretary Wilkie’s confirmation in July 2018, VA’s leadership was in a state of flux with numerous senior-level vacancies, including the Secretary, Under Secretary for Health, Chief Financial Officer, Chief Information Officer, and the Deputy Under Secretary for Health for Community Care positions. During this period of leadership instability, VA began implementing several major modernization initiatives. It is transitioning to the same electronic health record system the Department of Defense is currently deploying, and VA’s community care program has undergone major structural change and received significant funding increases.

Managing Risks and Improving VA Health Care

Since our 2017 High-Risk Report, ratings for all five criteria remain unchanged.

Specifically, the leadership commitment and action plan criteria remain partially met. Although VA has experienced leadership instability over the past 2 years in several senior positions, a new Secretary was confirmed in July 2018. Secretary Robert Wilkie has demonstrated his commitment to addressing the department’s high-risk designation by, among other things, creating an office to direct an integrated, focused high-risk approach and communicating to VA leaders the importance of addressing our recommendations. The Secretary’s actions, to date, have allowed the department to maintain its leadership commitment rating. The action plan criterion also remains partially met. In March 2018, VA submitted an action plan to address the underlying causes of its high-risk designation, but the plan did not clearly link actions to stated outcomes and goals or establish a framework to assess VA’s progress. VA officials have indicated that they are currently working to revise their action plan, and that the January 2019 draft VHA Plan for Modernization is intended, among other things, to address our long-standing concerns.

The monitoring, demonstrated progress, and capacity criteria remain unmet since our 2017 High-Risk Report. In order to address the monitoring and demonstrated progress criteria, VA’s ongoing revisions to its action plan need to include the addition of certain essential components, including metrics, milestones, and mechanisms for monitoring and demonstrating progress in addressing the high-risk areas of concern. VA’s capacity rating also remains not met. Though the department took steps to establish offices, workgroups, and initiatives to address its high-risk designation, many of these efforts are either in the initial stages of development or resources have not been allocated.

We have made 353 recommendations related to VA health care since 2010, 175 of which were made after VA health care was put on the High-Risk List in 2015. As of December 2018, the department has implemented nearly 60 percent of the recommendations related to VA health care made since January 2010.


Ambiguous Policies and Inconsistent Processes

Enforcement of Tax LawsSince our 2017 High-Risk Report, ratings for all five criteria remain unchanged.

Leadership commitment: partially met. VA has implemented a structure for leadership input into the policy process, such as at the Veterans Health Administration (VHA) Chief of Staff level. However, senior leadership has lacked the stability needed to ensure issued policy meets agency goals.

Capacity: not met. Since 2017, VA has issued an updated directive on policy management, and put in place procedures to train staff and obtain input from all levels on policy development. However, VA continues to face challenges in this area because it is reliant on contracts and information technology (IT) resources, which if delayed, can impede progress toward meeting goals.

Action plan: partially met. Since 2017, VA has further refined its root cause analysis for this area of concern. VA relied on these root causes as the foundational drivers for a January 2019 draft of the VHA Plan for Modernization. However, VA has not used the root cause analysis to develop and prioritize appropriate milestones and metrics in the action plan. Additionally, VA’s action plan did not include all goals and substantive actions taken. For example, in its March 2018 action plan, VA described its future plans to determine the roles of national and local policy in agency operations. However, VA’s action plan did not reflect the October 2017 establishment of an inventory of approximately 55,000 local policies, which set a baseline for understanding policy burden, or explain how it will use that inventory to inform the pilot process for national policy development that is mentioned in the action plan.

Monitoring: not met. Since the March 2018 action plan lacked specific metrics and mechanisms for assessing and reporting progress, it is not clear how VA is monitoring its progress.

Demonstrated progress: not met. Our work continues to indicate VA is not yet able to demonstrate progress in this area. Since its 2015 high-risk designation, we have made 48 new recommendations in this area of concern, 30 of which were made since our 2017 report was issued. For example, in September 2017, we found that VHA does not have a process to systematically ensure that local policies align with national policies. Without such a process, VHA may be unable to ensure that its facilities consistently implement national policies as intended to ensure timely, high-quality care for the nation’s veterans. As a result, we recommended that VHA establish a standard process to periodically monitor that local policies align with national policies. VA concurred with this recommendation, which remains open.


Inadequate Oversight and Accountability

Enforcement of Tax LawsSince our 2017 High-Risk Report, ratings for one criterion improved and four remain unchanged.

Leadership commitment: partially met. Since this area of concern’s 2015 designation, VA has made organizational changes, including establishing the Office of Integrity, to standardize and streamline the agency’s oversight of its programs and personnel. However, since 2017, the lack of stability in the Under Secretary for Health position has hindered its ability to demonstrate sustained commitment to improving this area of concern.

Capacity: not met. VA has begun to implement capacity-building initiatives directed at improving oversight and accountability. For example, VHA’s Office of Internal Audit and Risk Assessment, a key component of the department’s oversight and accountability model, began conducting audits in 2018. However, according to VA’s action plan, the department has yet to allocate resources for this office, such as sufficient staff to carry out its activities.

Action plan: partially met. In 2018, VA conducted an analysis of the root causes contributing to findings of inadequate oversight and accountability, an important step in identifying the underlying factors contributing to this area of concern. However, the resulting action plan lacked key elements, including clear metrics to monitor and assess progress.

Monitoring: not met. The March 2018 action plan lacked specific metrics and mechanisms for assessing and reporting progress in this area.

Demonstrated progress: not met. Our work continues to indicate VA is not demonstrating progress in this area. Since its 2015 designation, we made 85 new recommendations in this area of concern, 50 of which were made since our 2017 report was issued. For example, in June 2018, we reported that VHA could not systematically monitor the timeliness of veterans’ access to Veterans Choice Program care because it lacked complete, reliable data to do so. As a result, we recommended that VA take steps to improve its oversight of the future consolidated community care program that will replace the Veterans Choice Program when authority sunsets on June 6, 2019. VA concurred with this recommendation, which remains open.


Information Technology Challenges

Enforcement of Tax LawsSince our 2017 High-Risk Report, ratings for one criterion regressed, one improved, and three remain unchanged.

Leadership commitment: not met. In January 2019, the Senate confirmed a new VA Chief Information Officer. This is the fourth official to lead VA’s IT organization since our 2017 High-Risk Report, and the frequent turnover in this position raises concerns about VA’s ability to address the department’s IT challenges.

Capacity: not met. In May 2018, VA awarded a contract to acquire the same commercial electronic health record system as the Department of Defense (DOD). However, VA is early in the transition and its actions are ongoing. Additionally, VA has developed a strategy for decommissioning its legacy IT systems, which are tying up funds that could be reallocated for new technology to enable improved veteran care, but has made limited progress in implementing this effort.

Action plan: partially met. In 2018, VA conducted an analysis to identify the root causes of IT challenges, which informed the goals in its action plan. However, VA’s action plan contained significant information gaps, including missing interim milestone dates. These information gaps raise questions about VA’s commitment to addressing IT-related root causes and need to be addressed before we can consider this criterion met.

Monitoring: not met. The March 2018 action plan lacked specific metrics and mechanisms for assessing and reporting progress.

Demonstrating progress: not met. Our work continues to indicate VA is not yet able to demonstrate progress in this area. Since its 2015 high-risk designation, we have made 14 new recommendations in this area, 12 of which were made since our 2017 report was issued. For example, in June 2017, to address deficiencies we found related to VA’s pharmacy system, we recommended that VA take 6 actions to provide clinicians and pharmacists with improved tools to support pharmacy services to veterans and reduce risks to patient safety, including assessing the extent to which the interoperability of VA and DOD’s pharmacy systems impacts transitioning service members. VA generally concurred with these recommendations, all of which remain open.


Inadequate Training for VA Staff

Enforcement of Tax LawsSince our 2017 High-Risk Report, ratings for one criterion improved and four remain unchanged.

Leadership commitment: not met. VA officials have reported progress in establishing a process to develop an enterprise-wide annual training plan to better ensure that VA staff are adequately trained to provide high-quality care to veterans. However, the actions necessary to complete and implement this training plan are not reflected in VA’s March 2018 action plan for the training area of concern, raising questions about the process through which it will be developed. The lack of progress in setting clear goals for improving training demonstrates that VA lacks leadership commitment to address our concerns in this area.

Capacity: not met. VA has created working groups and task forces—such as the Learning Organization Transformation Subcommittee in the National Leadership Council—with specific responsibilities. However, VA’s ability to demonstrate capacity is limited because, according to VA’s March 2018 action plan, the department relies on external contractor support services to meet training goals, and that funding has not been allocated.

Action plan: partially met. VA completed a root cause analysis for training deficiencies, which informed the goals underlying its action plan, resulting in an increased rating. However, the action plan continues to have deficiencies identified in 2017. For example, not all goal descriptions correspond to planned actions and the action plan lacks detail about how and which data will be collected to assess progress.

Monitoring: not met. The March 2018 action plan lacked specific metrics and mechanisms for assessing and reporting progress.

Demonstrated progress: not met. Our work continues to indicate that VA is not yet able to demonstrate progress in this area. Since its 2015 designation, we have made 10 new recommendations in this area of concern, 2 of which were made since our 2017 report was issued. For example, in April 2018 we reported that, while the department has recommended training for patient advocates—staff members who receive and document feedback from veterans or their representatives—it has not developed an approach to routinely assess their training needs or monitored training completion. The failure to conduct these activities increases VA’s risk that staff may not be adequately trained to advocate on behalf of veterans. As a result, we recommended VHA develop an approach to routinely assess training needs and monitor training completion. VA concurred with our recommendations, which remain open.


Unclear Resource Needs and Allocation Priorities

Enforcement of Tax LawsSince our 2017 High-Risk Report, ratings for one criterion improved and four remain unchanged.

Leadership commitment: partially met. In December 2017, a VA Chief Financial Officer (CFO) was confirmed after the department spent over 2.5 years under an interim CFO. In addition, VA is in the process of establishing a new office to estimate workforce resource requirements.

Capacity: not met. VA has established functions intended to inform cost analyses of major VA initiatives, including a new financial management process to replace its outdated financial systems. However, it is unclear in its action plan the extent to which VA has identified the resources needed to establish and maintain these functions.

Action plan: partially met. Since our 2017 High-Risk Report, VA conducted a root cause analysis of this area of concern. However, VA’s action plan lacks metrics for monitoring progress and does not include all of VA’s ongoing actions, such as efforts to assess current and future regional demand for veterans’ health care services.

Monitoring: not met. Since VA’s action plan lacks specific metrics and mechanisms for assessing and reporting progress, it is not clear how VA is monitoring its progress.

Demonstrating progress: not met. Our work continues to indicate VA is not yet able to demonstrate progress in this area. Since its 2015 designation, we have made 16 new recommendations in this area of concern, 10 of which were made since our 2017 report. For example, in May 2017, we reported identifying several limitations with VA’s clinical productivity metrics and statistical models for tracking clinical efficiency that limit VA’s ability to assess whether resources are being used effectively to serve veterans. We recommended VA establish an ongoing process to systematically review its medical centers’ plans for addressing low clinical productivity and inefficiency, and ensure that the plans are being successfully implemented. VA concurred with this recommendation, which remains open.

Ambiguous Policies and Inconsistent Processes

We have made 90 recommendations related to this area of concern since 2010. As of December 2018, 35 recommendations remain open. In addition to implementing those recommendations, VA should improve its policies and processes by building capacity and finalizing its action plan.

Inadequate Oversight and Accountability

We have made 148 recommendations related to this area of concern since 2010. As of December 2018, 59 recommendations remain open. In addition to implementing those recommendations, VA should demonstrate commitment to oversight and accountability by building capacity and finalizing its action plan.

Congressional Actions Needed

Congress should consider continuing to hold hearings and receive periodic updates from VA, through which it can examine and address VA health care challenges and bring increased visibility to VA’s progress in addressing its high-risk designation.

Information Technology Challenges

We have made 25 recommendations related to this area of concern since 2010. As of December 2018, 15 recommendations remain open. In addition to implementing those recommendations, VA should demonstrate commitment to addressing its IT challenges by stabilizing senior leadership, building capacity, and finalizing its action plan.

Inadequate Training for VA Staff

We have made 16 recommendations related to this area of concern since 2010. As of December 2018, 3 recommendations remain open. In addition to implementing those recommendations, VA should improve training by stabilizing senior leadership, finalizing its action plan, and allocating necessary resources.

Unclear Resource Needs and Allocation Priorities

We have made 64 recommendations related to this area of concern since 2010. As of December 2018, 13 recommendations remain open. In addition to implementing those recommendations, VA should improve resource allocation by building capacity, identifying and allocating needed staff and funds, and finalizing its action plan.

Looking for our recommendations? Click on any report to find each associated recommendation and its current implementation status.