GAO: VHA Fails to Evaluate, Respond to Many Report Recommendations

by U.S. Medicine

December 5, 2016

VISN Realignment Lacks Oversight

By Sandra Basu

WASHINGTON—A major realignment of VISN boundaries has been occurring with “little monitoring” from VHA’s central office, according to a recent Government Accountability Office (GAO) report.

“Without adequate monitoring, including a plan for evaluation, VHA cannot be certain it is effectively implementing the ongoing VISN realignment,” the report found.

Under VHA’s realignment,  the number of VISNs will decrease from 21 to 18. VHA anticipates this process will be completed by the end of fiscal year 2018, according to GAO.

“VHA officials on the task force implementing the realignment told GAO they thought VISNs could implement the realignment independently without the need for close monitoring,” according to the report. “VHA also did not provide guidance to address VISN and VAMC challenges that could have been anticipated, including challenges with services and budgets, double-encumbered positions (two officials in the same position in merging VISNs), and information technology.”

 In addition, GAO said that ,at the time of its review, VHA did not have plans to evaluate the realignment and said that, if it did conduct a review, the optimal time would be after the realignment is mostly complete.

GAO called this “inconsistent with federal internal control standards for monitoring.”

“Without adequate monitoring, including a plan for evaluation, VHA cannot be certain it is effectively implementing the ongoing VISN realignment,” the agency explained.

GAO stated that “an evaluation may be useful to correct any identified implementation deficiencies.”

 “It can also help inform future organizational structure changes by offering VHA the opportunity to anticipate challenges and proactively provide guidance to address them,” it said.

 Department of Veterans' Affairs (VA) Veterans Health Administration (VHA) Regional Map, Post-Realignment

Department of Veterans’ Affairs (VA) Veterans Health Administration (VHA) Regional Map, Post-Realignment

Reports on Healthcare

The finding was part of a report that GAO created in response to questions about VHA’s ability to oversee its healthcare system and provide timely care. In addition to examining the extent to which VHA monitored VISN realignment, the GAO also examined whether VHA has a process for evaluating recommended organizational structure changes in order to determine appropriate actions and then to implement them

For example, GAO reviewed a response to a report produced by an internal task force that evaluated VHA’s governance. Additionally, it looked at VA’s response to two high-profile external reports, the Independent Assessment of the Health Care Delivery Systems and Management Processes of the Department of Veterans Affairs and the Final Report of the Commission on Care. Both of those documents made sweeping recommendations to improve VHA and were discussed at congressional hearings.

GAO concluded that “VHA devoted significant time and effort to these different task forces, but then either did not act or acted slowly to implement recommendations.”

Instances where the responses to report recommendations were incomplete, not documented or not timely were documented by the GAO.

It cited as an example the Integrated Project Team, which was chartered by VHA to implement selected recommendations from the Independent Assessment, which cost $68 million in taxpayer dollars. The group of 18 senior VA and VHA officials worked about six months “but did not produce a documented implementation plan or initiate implementation of recommendations,” according to the review.

“VHA officials later told us that, although the Integrated Project Team developed eight topic areas that applied to the Independent Assessment’s recommendations and presented them at the strategic planning summit, they would not be moving forward with further work to develop and approve an implementation plan,” GAO wrote.

Rather, VHA officials said that, “since the strategic planning summit, they have been focused on addressing other priorities such as the Commission on Care report, proposed legislation that could affect VHA operations, and the under secretary for health’s five priorities for VHA.”

The report also explained that VHA’s internal Governance Task Force made 21 recommendations, of which 13 were not approved by the VA under secretary for health. Yet, no documentation exists of that decision because they were communicated verbally, not in writing.

Among the unimplemented recommendations was one by both the VHA’s Internal Governance task force and the Independent Assessment to downsize and restructure VHA’s central office.

The under secretary for health told GAO that “his immediate priorities were to focus on improving access to care and hiring officials for vacant senior-level positions, and as a result he did not want to make significant changes to VHA’s organizational structure.”

GAO’s Recommendations

When it comes to the reviews and task forces that recommended improvements in its organizational structure, The GAO concluded  “VHA lacks the processes needed to ensure that officials can evaluate those recommendations, document decisions, monitor and evaluate implementation, and hold staff accountable.”

In addition, the report explained that “without adequate monitoring, including a plan for evaluation, VHA cannot be certain it is effectively implementing the ongoing VISN realignment.”

            Among the GAO’s recommendations was that VA needs to develop a process to ensure that organizational structure recommendations resulting from internal and external reviews of VHA are evaluated for implementation.

“This process should include the documentation of decisions and assigning officials or offices responsibility for ensuring that approved recommendations are implemented,” the recommendation stated.

It also recommended conducting an evaluation of the implementation of the VISN realignment.

In response, VA said it agreed with GAO’s conclusions and recommendations.

“The VHA will develop a consistent process to ensure that organizational structure changes are evaluated and implemented appropriately,” the VA said in comments attached the report.

It explained that “VHA’s Office of Workforce Management and Consulting will develop a structured, methodical process to assess the implementation progress and outcomes of organizational structural recommendations.”

When it comes to the VISN realignment, VA said that by evaluating the implementation of the VISN realignment that it will “ensure proper oversight and make corrections where necessary.”

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