[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
IMPROVING THE DEPARTMENT OF VETERANS AFFAIRS EFFECTIVENESS: RESPONDING
TO RECOMMENDATIONS FROM OVERSIGHT AGENCIES
=======================================================================
HEARING
before the
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
WEDNESDAY, MAY 22, 2019
__________
Serial No. 116-13
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
39-917 WASHINGTON : 2021
COMMITTEE ON VETERANS' AFFAIRS
MARK TAKANO, California, Chairman
JULIA BROWNLEY, California DAVID P. ROE, Tenessee, Ranking
KATHLEEN M. RICE, New York Member
CONOR LAMB, Pennsylvania, Vice- GUS M. BILIRAKIS, Florida
Chairman AUMUA AMATA COLEMAN RADEWAGEN,
MIKE LEVIN, California American Samoa
MAX ROSE, New York MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia JACK BERGMAN, Michigan
SUSIE LEE, Nevada JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR., DANIEL MEUSER, Pennsylvania
California STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN, W. GREGORY STEUBE, Florida
Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
Ray Kelley, Democratic Staff Director
Jon Towers, Republican Staff Director
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
CHRIS PAPPAS, New Hampshire, Chairman
KATHLEEN M. RICE, New York JACK BERGMAN, Michigan, Ranking
MAX ROSE, New York Member
GILBERT RAY CISNEROS, JR., AUMUA AMATA COLEMAN RADEWAGEN,
California American Samoa
COLLIN C. PETERSON, Minnesota MIKE BOST, Illinois
CHIP ROY, Texas
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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Wednesday, May 22, 2019
Page
Improving The Department Of Veterans Affairs Effectiveness:
Responding To Recommendations From Oversight Agencies.......... 1
OPENING STATEMENTS
Honorable Chris Pappas, Chairman................................. 1
Honorable Jack Bergman, Ranking Member........................... 3
Honorable Mark Takano, Chairman, Full Committee on Veterans'
Affairs........................................................ 8
WITNESSES
The Honorable Gene Dodaro, Comptroller General of the United
States, U.S. Government Accountability Office (GAO)............ 5
Prepared Statement........................................... 25
The Honorable Michael Missal, Inspector General, U.S. Department
of Veterans Affairs............................................ 6
Prepared Statement........................................... 45
STATEMENTS FOR THE RECORD
The Honorable Robert Wilkie, Secretary, U.S. Department of
Veterans Affairs............................................... 54
Department of Veterans Affairs (VA) and the Department of Defense
(DOD) Graduate Medical Education (GME) Programs................ 55
QUESTION FOR THE RECORD
U.S. Government Accountability Office (GAO)...................... 60
IMPROVING THE DEPARTMENT OF VETERANS AFFAIRS EFFECTIVENESS: RESPONDING
TO RECOMMENDATIONS FROM OVERSIGHT AGENCIES
----------
Wednesday, May 22, 2019
Committee on Veterans' Affairs,
U. S. House of Representatives,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 2:00 p.m., in
Room 210, House Visitors Center, Hon. Chris Pappas, [Chairman
of the Subcommittee] presiding.
Present: Representatives Rose, Cisneros, Takano, Bergman,
Radewagen, Bost, Roy.
OPENING STATEMENT OF CHRIS PAPPAS, CHAIRMAN
Mr. Pappas. Today's hearing will come to order. Today's
hearing of the Oversight and Investigation Subcommittee is
entitled, ``Improving the Department of Veterans Affairs
Effectiveness: Responding to Recommendations from Oversight
Agencies.''
Both, the Government Accountability Office, the oversight
arm of Congress, and the Department of Veterans Affairs Office
of Inspector General, have made many recommendations for
improving the Department.
Today, we will examine whether the VA is responding to
these recommendations with effective and meaningful actions
that better address the needs of our Nation's veterans. Today's
hearing is the first during this congressional session for the
Oversight and Investigation Subcommittee.
I, Ranking Member General Bergman, and all 7 of the other
Members of this Subcommittee, are charged with conducting
oversight across the programs and operations of the Department
of Veterans Affairs, as well as those of other Federal agencies
that serve our veterans. In carrying out its responsibilities,
this Subcommittee will conduct hearings, site visits, and
investigations nationwide. Oversight is a critical
responsibility of Congress, as described by Article I of our
Nation's constitution and the Subcommittee will not take our
duties lightly.
During the coming months and through the remainder of the
session, we will examine important topics that span the entire
range of the Federal programs meant to serve our Nation's
veterans. The Subcommittee will, at times, delve into some
arcane topics and at other times, we may stir some controversy,
even, but the Subcommittee will likely reveal failings of the
Department of Veterans Affairs and also show whether the VA is
heading in the right direction.
We will also find examples where Congress must take action,
whether to update and correct current laws, or require better
accountability from Federal agencies and officials; however,
all the Subcommittee's work will have a central goal: ensuring
the Nation provides the support we need to give it to our
veterans who earned it, the men and women who served our Nation
at home and abroad.
Today's hearings will reveal the work of two independent
and non-partisan government agencies that have a long history
in oversight of the Department of Veterans Affairs. Both, the
Government Accountability Office and the Department's Office of
Inspector General, regularly identify key concerns about VA
operations and each year, hundreds of reports are issued that
recommend improvements. Their work is critical for the
Department, for Congress, and for the public to understand the
workings, the needs, and at times, the shortcomings of the VA.
Of course, it is ultimately up to the VA to implement the
recommendations GAO and the IG make, but it does not always do
so in a timely manner. For example, some of the GAO priority
recommendations have remained unimplemented since 2012. The VA
health care system has been on the GAO's high-risk list since
2015 and the Department still has not developed a viable action
plan for getting off that list.
GAO has added a second VA operational area, acquisition
management, to its high-risk list this year. The inspector
general has more than 500 recommendations that VA still needs
to implement and about a quarter of those have been awaiting
implementation for more than a year.
Through their oversight work, GAO and the VA Inspector
General repeatedly find systemic weaknesses at the VA, such as
poor governance structures, a lack of leadership continuity,
and failure to communicate effectively. These problems
translate into real risks for veterans. For example, just last
fall, GAO found that a lack of consistent program leadership
resulted in VA spending only about 23 percent of $6.5 million
allocated for suicide prevention outreach during fiscal year
2018.
As part of their testimony, the witnesses will describe the
importance of strong and consistent leadership to ensure
recommendations are implemented and major management challenges
are addressed. Unfortunately, a key witness is missing and that
is represented by the chair that is empty. Secretary Wilkie of
the Department of Veterans Affairs declined our invitation, and
he elected not to arrange for a representative of the
Department to come in his place.
The secretary did not offer any scheduling conflicts or
other credible reasons for why he decided not to participate;
rather, he seemed to feel it would not be in his or the
Department's best interests to share a panel with our two
oversight witnesses who are here with us today.
Frankly, I find the VA's absence unacceptable. Contrary to
what the secretary claimed in his communications with Chairman
Takano and Ranking Member Roe when declining to participate in
the hearing, House Veterans Affairs Committee has had a long
history of seating the VA witnesses on panels with witness from
the GAO and the IG. This is also quite common across other
Congressional committees.
One question I had planned to ask the secretary today was
whether he considers addressing the audits, the examinations,
and the recommendations of the GAO and the IG to be a high
priority and whether these findings have helped shape his
leadership of the Department. The Department's refusal to
participate in today's hearing speaks volumes about the degree
to which it values the insights and recommendations that Mr.
Dodaro and Mr. Missal have to offer.
It is my sincere hope that the secretary will soon come to
the conclusion that the VA cannot go it alone. And to be clear,
this Subcommittee invited the secretary to appear today in
order to allow for greater dialogue and discussion on this
critical path forward. Congress is at its best when it invites
those of different views to share their analysis and opinions,
even when they strongly disagree, so we can endeavor to find
the best solutions to the problems faced by our Nation and our
veterans.
With that, I would like to recognize Ranking Member Bergman
for 5 minutes for any opening remarks he may wish to make here
today.
General Bergman?
OPENING STATEMENT OF JACK BERGMAN, RANKING MEMBER
Mr. Bergman. Thank you, Mr. Chairman, and congratulations
on holding your first hearing as Chairman of the O & I
Subcommittee. Historically, and especially last term, it was a
very bipartisan Subcommittee focused on asking tough questions
and getting good results and dialogue, not only from the likes
of, you know, GAO and the IG, but the VA, as well.
We are here today to understand how the Department of
Veterans Affairs responds to recommendations of the VA
Inspector General and the Government Accountability Office. In
an organization as large and complex as VA, there will be
challenges and there will be problems, and sometimes the people
who are responsible need to be held accountable for the good of
the organization. Other times, challenges and problems are more
systemic.
In either case, a good measure of leadership and
organizational health is an agency's response to these
challenges. Unfortunately, VA is not participating in today's
hearing. It has not been the recent past practice of the
Committee to invite the secretary to testify at a Subcommittee
hearing. Additionally, we generally place the secretary on a
panel of his own out of deference. I understand that attempts
were made to accommodate the Agency, but in the end, compromise
could not be reached. I hope that in the future, we can
overcome these issues because we need to hear from the VA to
fully understand the issues.
We are fortunate, however, to have the comptroller general
and the VA Inspector General here today representing their
organizations, which are working day-in and day-out, to improve
VA's effectiveness and efficiency. Comptroller General Dodaro,
Inspector General Missal, thank you for being here. Your
organizations provide a valuable service to VA and the men and
women who rely on VA for benefits and health care.
My interest today is on what happens after the GAO or the
IG issue recommendations in their reports. What procedures are
in place at VA to ensure timely and proper implementation of
recommendations and how does GAO and the IG help VA close
recommendations.
I am also interested in understanding who at VA is
accountable for monitoring implementation of GAO and IG
recommendations across the department and what happens when the
process foreclosing those recommendations stalls. As you know,
the Department of Veterans Affairs Office Accountability and
Whistleblower Protection Act of 2017 created the Office of
Accountability and Whistleblower Protection and tasked it with
the responsibility for recording, tracking, reviewing, and
confirming implementation of recommendations. It is clear from
VA's statement that the OAWP is not performing those functions
as of yet, so I would appreciate our witnesses' ideas on how
OAWP can improve the state of affairs.
I am also interested in hearing from the comptroller
general what he sees as best practices and how other agencies
developed and executed successful work plans to work their way
off the high-risk list.
Again, it is unfortunate that VA is not here today, because
it appears that there are good facts for VA to highlight.
According to the data on the inspector general's website, VA
has closed approximately 94 percent of the over 8,600
recommendations issued by the IG since October of 2012.
Additionally, of the 510 open recommendations, only 123, or
less than 1.5 percent of all recommendations are over one- year
old.
Similarly, according to the GAO's priority open
recommendation letter, dated March 28th, 2019, VA has
implemented 90 percent of GAO's recommendations issued within
the last 4 years, which is higher than the government-wide
average of 77 percent and 10 percent above GAO's target of 80
percent. This is not to say that the VA is perfect, but it
suggests that in recent years, VA is trending in the right
direction. The question now is whether VA is properly
addressing the highest priority recommendations and what
barriers, if any, exist to closing them out. I look forward to
a constructive hearing as we look for opportunities to improve
how VA responds to GAO and IG recommendations.
With that, Mr. Chairman, I yield back.
Mr. Pappas. Thank you very much, General Bergman. I look
forward, as well, to working with you over this term.
I will now recognize our first witness, Mr. Gene Dodaro,
Comptroller General of the United States, and Head of the
Government Accountability Office. Mr. Dodaro was confirmed by
the Senate in his role in 2010 and is serving a 15-year term,
but his career at the GAO goes back 45 years. His agency
produces hundreds of reports each year leading to billions of
dollars of savings by Federal agencies and important
improvement agencies and programs.
The Subcommittee thanks you for appearing today, and Mr.
Dodaro, you have 5 minutes.
STATEMENT OF GENE L. DODARO
Mr. Dodaro. Thank you very much, Mr. Chairman. Good
afternoon to you, Ranking Member Bergman, Congressmen Bost,
Cisneros, and Rose. It is very nice to see you all here this
afternoon.
I want to highlight the fact that our work at the VA has
shown that there are many dedicated and talented people there
working very diligently to try to serve our veterans; however,
the agency is seriously hobbled by underlying fundamental
management weaknesses that make it very difficult for them to
implement management reforms.
In order to highlight the attention of the administration
and the Congress to these areas, I have placed a number of VA
management issues on our high-risk list. In 2015, we added
managing risk and improving health care to the list due to
ambiguous policies and procedures, inadequate oversight and
accountability, information technology challenges and
inadequate training, and unclear resource needs and allocation
priorities.
This past March, when we updated the high-risk list, which
we do across government at the beginning of each new Congress,
we added the acquisition management area at VA to the list, as
well. Here, again, they had outdated policies and procedures.
They hadn't been updated in over 10 years. There was not an
effective strategy for medical and surgical procurements in
place. Contract managers, management, and staff were overworked
and in a lot of cases, there wasn't adequate training, and so
these areas were problematic.
In 2003, we also added across the Federal Government,
managing disability programs. One of the most significant
disability programs, in addition to the Social Security
Administration, is at VA. There were concerns with processing
of initial claims, as well as appeals and backlogs and
timeliness, as well as updating the eligibility criteria, which
hasn't been updated in decades, despite efforts on the part of
the Veterans Administration.
These are very serious management problems and I would make
the point, though, that while implementation of our
recommendations is an appropriate benchmark to use. It really
is not going to be sufficient alone to solve VA's underlying
management weaknesses and get off the high-risk list. The
criteria for getting off the list is leadership commitment that
is sustained, the fact that they have the capacity, the
resources, and the people, and importantly, there needs to be a
corrective-action plan that deals with the underlying root
causes of the problems. And there needs to be a monitoring
effort with milestones and metrics to be able to gauge
progress, and there needs to be actually some demonstrated
progress in fixing the problems.
The high-risk list includes the highest management risks
across the Federal Government--there are 35 areas on the list--
the reason I put VA on there is because while we can make
recommendations, VA can address them, but then we make new
recommendations that are still dealing with the same underlying
problems. And that is the pattern we are in with the Veterans
Administration.
Therefore, just addressing our recommendations isn't going
to deal with the underlying management weaknesses there. I
think the Department recognizes this and is embarking at the
VHA on a modernization program that has 10 lines of effort and
is trying to put things in place. VA has come to the Congress
requesting legislation to modernize its disability claims
process and is implementing those reforms right now.
But in order for these reforms to be successful, VA leaders
are going to have to energize an entrenched bureaucracy that is
challenged in successfully implementing management reforms. GAO
is dedicated to working with the Department in order to help it
achieve success, and I am happy to share our experiences with
other agencies in the Q&A portion. Twenty-six areas have come
off the high-risk list over time. There is a prescription for
success here. I have discussed this prescription with the
Veterans Administration, and we are trying to work with them to
implement it there, as well, but we are not there yet.
And so, I look forward to taking questions from you at the
appropriate time.
[The prepared statement of Gene L. Dodaro appears in the
Appendix]
Mr. Pappas. Thank you, Mr. Dodaro.
I would now like to recognize Mr. Michael Missal, Inspector
General of the Department of Veterans Affairs. Mr. Missal was
confirmed by the Senate in his role in 2016. He had had
previous experience in both, the private sector and in other
government agencies, including the Securities and Exchange
Commission.
The Office of Inspector General conducts investigations,
audits, evaluations, and inspections of VA programs to
eliminate waste and fraud, as well as to detect and prevent
criminal activity.
The Subcommittee thanks you for appearing today Mr. Missal.
You have 5 minutes.
STATEMENT OF MICHAEL J. MISSAL
Mr. Missal. Thank you. Chairman Pappas, Ranking Member
Bergman, Chairman Takano, and Members of the Subcommittee, as
we approach Memorial Day, the Office of Inspector General
honors the men and women who have laid down their lives in
defense of our country.
At the outset, I want to express our appreciation for the
work of this Subcommittee on behalf of veterans. I thank you
for the opportunity to discuss recommendations issued by the
OIG that assist VA in improving services and benefits to
veterans and their families and caregivers.
I also appreciate testifying with Mr. Dodaro, as we work
closely together to ensure coordination and avoid duplication
on our respective oversight responsibilities.
OIG recommendations are directed at every level of VA
operations. They affect the quality and access to health care
for veterans, and benefits for veterans with disabilities,
their caregivers, and family members, and the effective
stewardship of VA's approximately two-hundred-billion-dollar
budget.
OIG reports focus not only on solutions to a defined
problem, but also identify the underlying root causes of issues
that negatively impact current programs and future initiatives.
As a result, these recommendations may also be a roadmap that
other facilities, offices, or programs can follow to apply any
lessons learned across VA and to take corrective actions
applicable to other relevant VA operations.
Our critical work could not be accomplished without
congressional support of OIG efforts through its appropriations
and the attention given to OIG reports and recommendations. The
OIG looks forward to working with our many stakeholders to
advance recommendations for improvement in all VA programs,
services, and systems. This includes recommendations proposed
in the 100 reports issued during the first half of fiscal year
2019.
When developing recommendations, we focus on several key
principles, including the following: first, recommendations are
directed to the specific VA office or program official that has
the responsibility and authority required to implement them.
While our recommendations may be narrowly addressed to a
particular VA facility or operation, VA should be disseminating
information about identified problems and remediation plans to
officials in all VA offices that could potentially have the
same issues and are positioned to take positive action. We meet
often with senior leaders and other VA staff to discuss
specific issues and trends we identify in our work.
Second, recommendations are current with ongoing issues and
except in rare circumstances, should not require more than 1
year to implement from the report's publication. This helps
minimize the risk that OIG recommendations languish, become
outdated, or lag behind VA policy and program changes.
Third, OIG recommendations are objective and driven by all
documentation and other information collected and analyzed in
accordance with audit, inspection, review, and investigative
standards.
Finally, while we make recommendations, we do not direct
how they are executed. It is important to note that OIG staff
cannot mandate that VA accept OIG recommendations or pursuant
to Federal law, direct specific action to carry them out.
Consistent with this limitation, OIG reports may contain
recommendations for VA to take appropriate administrative
action against a specific VA employee for misconduct, but VA
leaders and managers are then responsible for determining any
appropriate administrative action.
As of the last reporting period, there were 84 OIG reports
and 403 recommendations that had been open less than 1 year.
The total monetary benefit associated with these
recommendations is more than $2.7 billion. There were also 40
reports and 133 recommendations that remained open for more
than 1 year. The total monetary benefit related to these
reports is more than $329 million.
The OIG is deeply committed to serving veterans and the
public by conducting effective oversight of VA programs and
operations through independent audits, inspections, review, and
investigations. That commitment can only be realized by making
practical, meaningful recommendations that enhance VA's
programs and operations, as well as prevent and address fraud,
waste, and abuse.
Mr. Chairman, this concludes my statement. I am happy to
answer any questions that you or other Members of the
Subcommittee may have.
[The prepared statement of Michael J. Missal appears in the
Appendix]
Mr. Pappas. Well, thank you very much, Mr. Missal for your
testimony.
I would now like to recognize the Chairman of the Full
Committee, Chairman Takano, who has joined us for this first
hearing of our Subcommittee. If there are no objections, I
recognize Chairman Takano for 5 minutes.
OPENING STATEMENT OF MARK TAKANO, CHAIRMAN, FULL COMMITTEE ON
VETERANS' AFFAIRS
Mr. Takano. Thank you, Chairman Pappas and Ranking Member
Bergman.
I came to today's hearing for two important reasons. First,
I wanted to note that this is the first hearing of the session
for the Subcommittee on Oversight and Investigations. The
Subcommittee has a long and successful history of reviewing
issues of great importance to our Nation's veterans. Past
hearings have examined concerns with veteran's health care,
delved into major problems with agency contracts, and reviewed
whether the Department's money is well spent. I know that
Chairman Pappas, Ranking Member Bergman, and the rest of the
Subcommittee will move forward with sharp eyes and an even-
handed approach, as it examines the gamut of issues and
challenges facing the Department.
The best oversight is conducted with nonpartisan approach
based on evidence and facts. The comptroller general and VA
Inspector General are here today to help us understand the
evidence and facts and I want to welcome them, too. Welcome,
gentlemen.
However, I also must note that we have an empty chair at
the witness table. The Department of Veterans Affairs decided
not to show up for the hearing today. This is unacceptable. By
not appearing today, the VA secretary is ignoring an
opportunity to show that the Department cares about addressing
the serious concerns GAO and the IG have identified.
The Veterans Health Administration and VA contracting are
both at high risk, according to the Government Accountability
Office. The comptroller general is here to testify about needed
action by the Department. We need to hear from VA leadership
about their plan to be removed from the Department's--from the
high-risk list.
The VA Inspector General is here to testify about the 510
recommendations totaling approximately $3 billion that have not
been yet implemented by the Department. These include
recommendations to address medical-supply chain failures that
have, at times, led to delayed procedures at the DC VA Medical
Center. Other recommendations focus on inappropriate denial of
claims for veterans who experienced military sexual trauma. The
IG is also here to discuss its work on how VA is can and should
improve its suicide prevention programs and the Veterans Crisis
Line.
It is Congress' constitutional duty, and I say that again,
it is Congress' constitutional duty to oversee the Federal
Government. This Committee will not abandon its duty to protect
the interests of veterans, their families, and taxpayers.
Now, the secretary wrote to me and Ranking Member Phil Roe,
stating that participating on a panel with the Department's
watchdogs was somehow a break with tradition or practice.
Frankly, this is a terrible excuse. VA doesn't get to pick and
choose which hearings they will attend. His refusal to show up
sends Congress the wrong message.
Instead, we need to hear that VA will address the concerns
identified by independent, credible investigators and auditors.
The Department and the Committee have a history of working
cooperatively with each other. I expect VA to show up and be
accountable for the next hearings of the Committee.
I look forward to the hearings and other work that the
Committee will undertake in this session of Congress, and with
the remaining time, I do want to ask a question for Mr. Missal
of the VA OIG.
Mr. Missal, your testimony discussed some important work by
your office regarding the prevention of suicides. As you know,
it is the number one priority for this Committee. It is a
continuing tragedy that on average, 20 veterans commit suicide
each day. I understand that the Office of Inspector General
released a report on March 2017 that examined the VA's Veterans
Crisis Line. The report revealed many serious problems with the
crisis line, substantially impacting the quality of responses
to veterans' needs. Sixty recommendations followed on a range
of issues, such as improved crisis line staff training, more
modern technology, and better cooperation with the VA Office of
Suicide Prevention.
Mr. Missal, did VA implement all of those recommendations
and how timely was VA's response?
Mr. Missal. Chairman Takano, I believe all of those
recommendations are now closed out. We share the seriousness of
suicide. We have a number of different active projects on it
right now and with respect to the Veterans Crisis Line, we put
out a report in 2016 and followed that up with one in 2017. We
recently went back just to ensure that it is operating as
effectively as possible, given how many veterans it touches.
Mr. Takano. Well, thank you very much.
And I yield back, Mr. Chairman.
Mr. Pappas. Thank you very much, Chair Takano.
And since we are on to the question portion of the
Subcommittee hearing, I would like to recognize myself for 5
minutes.
It is noteworthy that both of our witnesses here today
understand the importance of strong and consistent leadership
for ensuring that major problems are addressed and that the
recommendations are ultimately implemented. Unfortunately, the
VA faces a major challenge. Currently, too many top positions
remain unfilled at hospitals and within VA headquarters,
itself; further, many of the leadership positions are filled
with people serving in an acting capacity.
The Subcommittee staff has analyzed some data regarding
leadership instability within the Veterans Health
Administration, which is charged with taking care of the health
care needs of more than 9 million veterans across this country.
I have a few charts here today. Chart number 1 here behind
me shows that during the past 5 years, the Veterans Health
Administration has gone for a total of 824 days without a
confirmed leader. Dr. Richard Stone is currently leading the
VHA in an acting capacity.
Also behind me, we found that 48 percent of senior
leadership positions within the Veterans Health Administration
are currently held by individuals serving in an acting or
interim role. In addition to that, the Veterans Health
Administration has been affected by turnover in the position of
the VA's chief information officer. Since January 2017 alone, 4
different individuals have led the VA's Office of Information
Technology. With a significant number of major IT projects in
the works for the VHA, this level of top-leadership turnover
has presented numerous risks to the successful completion of
those very projects.
I know that Dr. Stone and the vast majority of the VA and
VHA leaders, even those serving in an acting capacity, are
working really hard and are very dedicated to serving our
veterans; however, a lack of permanence when leaders are, at
times, wearing multiple hats within the agency, dividing their
attention between key management responsibilities, is hardly
the best situation for ensuring quality care.
So, for both witnesses, Inspector General Missal and
Comptroller Dodaro, do these charts point to a major problem
for the VA? And do these leadership problems challenge the
ability for the Department to address your recommendations?
Mr. Missal. I agree that they present major challenges for
VA. Continuity of leadership is a key issue. Leadership sets
the tone at the top. VA is a very large, complex organization.
It takes anyone a significant amount of time to really
understand the programs, operations, and culture. In addition,
when you have somebody in an acting position, they don't have
the authority or the support of many of the staff that they are
going to be able to move a program or initiative forward. We
have found in many situations; leadership has been a key issue
that has caused or resulted in some of the problems.
Mr. Dodaro. I agree with Mr. Missal. And, actually, I was
about ready to downgrade the Veterans Health Administration in
the health care area in our rating on leadership commitment to
not met, But I kept it at partially met, based upon a
conversation I had with Secretary Wilkie--I am giving him the
benefit of the doubt--and I have had a lot of follow-up with
Dr. Stone, as well.
But this is a serious problem and there needs to be
sustained leadership at the VA. I have met with each of the
last 4 secretaries. They have all had different priorities and
initiatives that have taken the Department in somewhat
different directions and kept it from having sustained
leadership.
One of the reasons I put things on the high-risk list is
that most of the problems need to be addressed across multiple
administrations. These are the hardest management problems in
the government, and in order to have them succeed, there have
to be plans in place that sustain it across a period of time,
and it is difficult to do it with a lot of turnover and lack of
sustained leadership.
Mr. Pappas. Well, thank you for that response.
Mr. Comptroller, looking at a parallel example in a
different agency, the Department of Homeland Security was
unable to pass a major financial audit. Among other things,
this led it to be included on the Department's high-risk list.
And I am wondering if you could talk a little bit about what
happened in that case and what DHS has done to address its
high-risk designation and what it might hold for the VA.
Mr. Dodaro. Yes. We designated the Department of Homeland
Security high risk the day it was stood up and created back in
2003. They have made a lot of progress over a period of time.
We have met with a lot of secretaries, deputy secretaries, and
other key officials there.
In the early days, it was difficult to see a lot of
progress, but eventually they became more engaged with us. And
several years ago we agreed on the 30 outcomes that we use to
gauge whether or not they were going to be successful or not.
So, we both agreed on what outcomes we were trying to achieve
in this area.
I just reported in March, 17 of the 30 areas they have met
now and are on their way. One of them is for 4 years running
now. They received a clean opinion on their financial audit,
which they hadn't for more years previously, and most of the
other areas, they are on their way to make some progress.
They still have significant issues, particularly in getting
more modern financial management systems and improving their
acquisition procedures. They still have issues, which is why
they are still on the list, but they have a plan. Now, that
plan has remained the same with changes in administration over
time, because we have agreed on it. We meet on a quarterly
basis. The Department of Homeland Security rates themselves
against the criteria we have for coming off the list, we review
it, and then we respond to them and their efforts. So, we have
a very constructive working relationship there.
Of course, they have some vacancies themselves, but I am
hoping to continue to work with them. I just testified a few
weeks ago, and Congressman Rose is on that Committee, on the
management challenges at the Department of Homeland Security.
But I have mentioned to VA that DHS is a good model and
that is what we are trying to work toward both, with VHA and
VBA. And so, I am hopeful that we can take those success
factors.
Now, the other important thing that I want to emphasize, is
that hardly any area on the high-risk list gets off the list
without sustained congressional oversight, as well, and action
by the Congress. Engagement by the Congress is absolutely
critical to the success of agencies coming off the high-risk
list.
I would encourage this Committee to remain focused on that
and continue to work to ensure VA is addressing these
fundamental management weaknesses, because otherwise, the
efforts will keep repeating themselves and there will be
serious problems with any reform that needs to be implemented.
Mr. Pappas. Thank you, sir.
I would now like to turn it over to General Bergman, the
Ranking Member, for 5 minutes.
Mr. Bergman. Thank you, Mr. Chairman.
And both, Mr. Dodaro and Mr. Missal, you used the terms
symptoms versus root causes. I am glad to hear you say that,
because we can waste a lot of time dealing with symptoms, and
unless we deal with the root causes and we are not going to get
the results that we know we need.
And Mr. Dodaro, you said VA is hobbled by fundamental
management weaknesses. Is one of those weaknesses the ability
to identify root causes versus symptoms?
Mr. Dodaro. That is part of it. We had a difficult time
getting VA to do root-cause analysis a few years ago. For
example, when we put the health care area on the list. But,
eventually, they came to a list of root causes and I outlined
what those were that they identified themselves and they
comport with a lot of what we identified.
Mr. Bergman. Okay. So, actually, they were able to--
Mr. Dodaro. They were able to come up with the root cause.
What they haven't been able to do, though, is translate that
into an action plan to deal with the root causes that have
metrics and milestones and clear accountability and a lot of
other fundamental--
Mr. Bergman. I have to--because I know we are on the same
wavelength here, and Mr. Missal, you mentioned that GAO can
recommend, but not require; is that correct?
Mr. Missal. Our office can recommend, but not require.
Mr. Bergman. Yeah, so the point is, as we then go back and
forth in between what you both are articulating, this is pretty
much the same question for both of you: Would you please
explain how your office and the VA collaborate to close
recommendations and who within VA is responsible for
facilitating that collaboration.
Mr. Missal. We have a very active program on outstanding
recommendations. Once a recommendation has been published in a
report, we review them quarterly with VA to see what progress
they are making. We expect to get in writing the progress that
they have made, and we continue that throughout, until the
recommendation is closed.
The responsible person would be the person to whom the
recommendation is addressed. All of our recommendations are
addressed to an individual, whether it is the secretary, deputy
secretary, or on down from there.
Mr. Bergman. Okay. Mr. Dodaro?
Mr. Dodaro. Yes, we coordinate through their Office of
Congressional Liaison and that individual, then, has us work
with the individual officials that are responsible for the
area. For example, at the Veterans Health Administration, our
people meet with them on a monthly basis. We go over their
recommendations every 4 to 6 weeks and then we meet with the
VBA separately.
So, we have regular meetings with them to help them
understand what they need to do to implement the recommendation
and very specifically answer any questions they have, and then
make it clear that when we will recommend that something will
be fixed. VA will come up with a plan to fix it and will want
us to close the recommendation. We will say, No, no, no, no. It
takes more than a plan. You actually have to implement the plan
and you have to deal with this issue.
Those are the kinds of conversations that we have with
them. I think we have an effective process working with them to
close these recommendations.
Mr. Bergman. I see my time is running out here, but, Mr.
Dodaro, I have one more here for you. Roughly 26 areas have
been removed from the high-risk list. Some areas were removed
in as little as 3 years, while one took 29 years. What are the
top three, best practices that GAO has found effective in
helping agencies address high-risk concerns?
Mr. Dodaro. Number one is an effective action plan that
deals with root causes, as well as the metrics, milestones. You
need a roadmap and you need to evaluate how well you are
getting there in achieving those objectives and dealing with
the underlying root causes. That has not been done at VA in any
of the areas that we have designated on the high- risk list
yet.
Number two is sustained congressional leadership. There
also needs to be buy-in from the agency leadership at the top
and at all levels. And that leadership has to engage with GAO,
but importantly, send the proper messages to their agencies.
Number three is congressional engagement in this process.
Congress is a key stakeholder in the process, not only from an
oversight standpoint, but also to make sure that whatever VA
needs to implement these actions, that Congress is willing to
provide.
Those are the top three.
Mr. Bergman. Okay. I yield back.
Mr. Pappas. Thank you, General Bergman.
I now recognize Mr. Cisneros for 5 minutes.
Mr. Cisneros. Good afternoon, gentlemen. Thank you for
being here.
Mr. Dodaro, in adding VA's acquisition management to the
high-risk list last year, the GAO cited evidence from its
September 2018 report on the Veterans First program, which
requires VA to give preference to veteran-owned small
businesses when awarding contracts.
Among other things, the GAO found that VA training lacked
clarity on how contracting officers should balance the
preference for veteran-owned small businesses with fair and
reasonable price determination when lower prices might be found
on the open market. In addition, the GAO found that the VA's
online training sessions on the Veterans First policy were not
mandatory, so only about 52 percent of VA contracting officers
had completed the training.
You recommended that the VA design more targeted training,
considered making it mandatory. Can you tell me about the
extent to which the VA has implemented this recommendation?
Mr. Dodaro. First, VA has clarified the guidance to
contracting officers to have them document the determinations
that they make. They are actually doing some compliance checks
now to make sure that the new policy is being implemented
effectively. They are moving toward making the training
mandatory and then providing it to all people. That hasn't
fully happened yet, but they are on their way to having that
accomplished.
Mr. Cisneros. So, this is, I guess, some of the problems
that we are seeing, right, when you talk about the management
weakness. I mean, how difficult is it to make a mandatory
training? It seems like it should be something that could be
done with a simple letter.
Mr. Dodaro. At GAO, I make that decision and I make it
right away.
Mr. Cisneros. Uh-huh.
Mr. Dodaro. It is important. They should be able to do
this, but they also have to work with their union and all the
union bargaining agreements and how the training would be
provided, and so that may take some time.
Mr. Cisneros. You know, Mr. Missal, you said you could not
implement--and this is just to kind of really follow up on some
of General Bergman's questions--but you said you can make
recommendations, but you can't make the VA implement these
recommendations.
Mr. Missal. That is correct.
Mr. Cisneros. Like you said, you will designate an
individual as to who is responsible for this needs to handle
it. I mean, some of these recommendations have been on the list
for a long time. Are they being worked? Are they being ignored
sometimes? Why aren't these recommendations being implemented
if they are really trying to make change?
Mr. Missal. It really varies. About 85 to 90 percent of the
recommendations we make are closed within a year. And just with
respect to the recommendations, while we can't require them to
implement them, what we do when we make the recommendation is
ask VA if they are going to concur in it. VA concurs with
almost all of our recommendations. We then ask them for an
action plan: How are you going to implement it?
So, VA commits to the action plan, including the date when
they think they will be finished with it. That gives us a
structure to follow through. It is still VA's decision to do
it. We can't require them, but by having an action plan, we can
watch closely what they are doing.
Mr. Cisneros. As you are going along, and like if a plan--
let me ask you this: How often is a recommendation that you
make, where they say, you know, we are not going to do this.
Mr. Missal. It is very rare. I think we have had a handful
in the last few years.
Mr. Cisneros. All right. So, they are working on all of
these recommendations that you are saying, but when something
is taking 29 years, what is the root cause of that? Is it
really coming back down to management again?
Mr. Missal. It is a few that are open more than 5 years. It
is typically a staffing issue, or we get the sense that it is
not their priority.
But if we see recommendations that are open for a long time
that we think really need to be closed out, I don't hesitate to
escalate it. For instance, if it is at a mid- level person, I
will escalate it at VA, and I typically get a very positive
reaction when I bring it up. They explain that VA is committed
to doing it, we think it is important, and it needs to have the
right attention.
Mr. Cisneros. And one last question for Mr. Dodaro, and you
can probably give us this one for the record because I am
running out of time, but there is always going to be turnover.
We know that there is always, with each new administration,
there is going to be new secretaries, there is going to be new
assistant secretaries, but you talked about the weakness in
management there at the VA.
Is it at the bureaucratic level or do we not have sustained
professional managers there at the VA that can manage the day-
to-day operations there? And I am out of time, so if you could
just submit that for the record, I would appreciate that.
Mr. Dodaro. I will do that.
Mr. Cisneros. Thank you. I yield back my time.
Mr. Pappas. Thank you, Mr. Cisneros.
I now recognize Mr. Bost for 5 minutes.
Mr. Bost. Thank you, Mr. Chairman.
Mr. Dodaro, I kind of want to go down that same path, and
that is because a couple of years ago our office discovered,
because we thought it was just the VA just adjacent to my
district that was having this problem, but that was the fact
that the management there at the individual VAs were--they had
had, I think, 6 or 7 temporary managers over a 6-year period,
because there was a rule that you could not be assigned a
temporary management position for more than 280 days. If you
continue down that path, what you have is--I was in small
business. I couldn't memorize the names of the people I was
even working within 280 days, let alone, figure out what the
problems were and get them fixed.
So, we actually moved forward with a bill at that time to
try to have them show us a plan where they would correct this
problem. And what we also discovered was it wasn't just that
VA; there were a total of about 20 we discovered that were in
that same type situation.
Have you noticed any change at all and is that the type of
management problem you are talking about?
Mr. Dodaro. That is one of many, yes. That is definitely
one of them. You know, for example, you can have somebody
operate in an acting position longer than 210 days under the
Federal Vacancies Act, but they can't carry out non-delegable
functions, but most of the functions are delegable and should
be in place.
But part of the problem here is that there are weaknesses
at every level in lines of accountability. Sometimes at the
medical center level, there are issues. The VISNs, do not have
clear accountability. There are headquarters offices, and it is
really not clear exactly what the line of accountability is.
What we find in health care, for example, there were 800
national policies. There were 55,000 local policies. And there
was no alignment between the national policies and the local
policies. If you don't have that, how are you going to train
people to implement things? Nobody is really in charge.
What we have recommended in the past--and it may be
something that this Committee should consider--is there needs
to be a chief management officer in certain positions, and I
have recommended in the past that this person be given a term
appointment. So, they would be confirmed by the Congress. They
wouldn't set policy, but they would make sure that the
management infrastructure is there to work properly to
implement whatever policy, that whatever administration it is,
would want going forward.
We have successfully had that position installed at the
Department of Defense. There is a position like that at the
Department of Homeland Security. There is not, really, a
management integration function at the VA right now, which I
think is something that needs to be remedied.
We have not been able to succeed, though, in getting term
positions. But some positions in the government, like the
commissioner of the Internal Revenue Service, the Social
Security Administration, FAA, they have 5-year terms that can
be renewed for 5 years, and that has helped provide more
management stability at those 3 entities.
So, I think this is something that the Committee should
consider. I would be happy to work with the Committee on these
types of structural changes.
Mr. Bost. One more question I have, and either one of you
could possibly answer this, but another thing we discovered,
also, is that there is not a set standard for certain jobs and
I'm going to give one example. At one of our VA's, it was a
personnel officer. There was no requirement of an education
level. There was no requirement of anything of past experience
in the field.
But then when we asked the VA about this, I mean, obviously
if you are hiring a doctor, you are going to get a doctor, but
in the position of management, there are no set standards or
criteria that are met, and I think that is one of the problems
why when we use the term ``when you visit one VA, you visited
one VA.'' Because we had in this case, a very inexperienced
person in charge of personnel, and because of that, you got a
lot of unique hires, to say.
Mr. Dodaro. I would say--and I know Mr. Missal will say it,
so I will be very brief on this--I would say VA is a large,
decentralized organization, but it only works because of
individual actions at levels. There is not a system in place
that ensures these things are dealt with in a uniform matter on
almost any issue.
Mr. Bost. Thank you. My time is up.
I yield back.
Mr. Pappas. Thank you. Mr. Rose is now recognized for 5
minutes.
Mr. Rose. Mr. Missal--I am always very respectful of--I
have a name that no one ever messes up--I want to talk very
briefly about staff vacancies. You know, we have noted in the
past the top-five shortages being psychiatrists, human
resources professionals, primary care providers, psychologists,
and med techs.
Do you find right now that there is enough of a sense of
urgency, that there is enough resourcing around this? What is
your perception of the ongoing work in this area?
Mr. Missal. I think it is due to a variety of reasons. We
do a staffing report on a yearly basis pursuant to
congressional mandate. And what we do is we actually survey the
medical centers and say, ``Tell us what your priorities are,
where your important vacancies are.''
As you correctly point out, psychiatrist was mentioned, I
believe it was by 83 out of the 141 medical centers.
Mr. Rose. Sure.
Mr. Missal. And when you think of suicide as being the
number one clinical priority, psychiatrists play such an
important role.
Number two is HR. How can they hire people if their HR
function isn't fully staffed? We found a significant problem in
our report on the Washington, D.C. Medical Center where there
were vacancies in many of the support areas that ensure quality
health care, like sterilization, like housekeeping to clean
rooms--
Mr. Rose. Right.
Mr. Missal [continued]. --and they had a deficient HR--
Mr. Rose. Well, what is interesting to me is that when you
are sitting down with a four-star general, they never complain
about the absence of colonels, right, because they grow them
themselves. Do you think that it is time for the VA to start to
consider ways in which we could actually--God forbid in this
town, we think long term--and build a pipeline of medical
professionals? Is it time to start thinking about that?
Mr. Missal. One of our recommendations on the staffing plan
is for them to build staffing models to do precisely what you
are talking about.
Mr. Rose. What about a training model, though? What about
starting to pay for people's education with a guaranteed time
of service required on the back end?
Mr. Missal. VA has some of those programs. They do have it
for physicians and other positions, as well.
Mr. Rose. I am talking about dramatically expanding it. Is
there something that we can do to guarantee a pipeline? Again,
I have never heard a four-star or a two-star or whatever
complain, Man, I don't have enough majors.
Mr. Missal. Well, we made a number of recommendations on
how they can improve staffing. It is frustrating that they
haven't implemented all of those, because to me, staffing one
of the core functions of an organization.
Mr. Rose. I agree.
Mr. Missal. If you can't get that right, it is hard to get
the other things.
Mr. Rose. I agree. I know that, Chairman Pappas, that is
something that, you know, we would love to think about.
Mr. Dodaro, you mentioned that Congress needs to continue
to assert its role in this. How, in the absence of--the fact
that the VA is not even showing up right now, the secretary or
a designee, leads me to believe that they don't care that much.
Is it possible to have progression reports? Are there things--
what is your recommendation for how, beyond oversight hearings,
what can we do as a Committee to highlight the absence of any
progress or some suitable progress on this matter and to push
or shame or compel the VA leadership to do something?
Mr. Dodaro. Yes. In the past, what I have recommended
Congress has done is on several issues, they will ask for
quarterly reports from the agencies on--
Mr. Rose. And so your recommendation is to legislatively
mandate quarterly reports?
Mr. Dodaro. Well, if they are not coming to the hearings, I
mean, you need to get the information.
Mr. Rose. How do you do that?
Mr. Dodaro. You have the power to--both, in the
appropriation process, as well as authorization. You can compel
them to provide regular reports.
Mr. Rose. What are examples where there has been mandated
quarterly reports in other departments?
Mr. Dodaro. IRS is one example. I think you are going to
really need it in the electronic health care record area.
Mr. Rose. I agree.
Mr. Dodaro. The IRS tried the big bang and the long- term
effort on tax-system modernization and that didn't work well.
You need incremental reports. You are talking about
anywhere from a $10-16 illion-dollar program being implemented
over a ten-year period of time. You need incremental reports.
You could have them report on how well they are responding to
GAO and IG recommendations, how well they are dealing with the
high-risk areas. You can have them do that.
They will complain it is onerous and whatever, but you need
to get the information, and, particularly, if they are not
appearing at hearings, that is a way to get it.
Mr. Rose. That is very helpful.
Mr. Dodaro. Yes. Also, through the appropriation process,
we have worked with the Congress in the past to fence some of
the money. In other words, like on some of these IT systems,
you can only spend so much, and actually, there are quarterly
reports required in some agencies before they can spend the
money to go into the next tranche on IT.
Mr. Rose. Cash and shame.
Mr. Dodaro. Yes.
Mr. Rose. Cash and shame.
Mr. Dodaro. Yes, I would also say, if I might, on the
graduate medical-education area, the Government spends about
$16 billion a year right now on these--to pay for graduate
medical education for doctors both, at VA and DoD, as well. And
the part of the issue that we have identified, though, is that
they have never evaluated the success of those programs. And if
they could evaluate those programs, I think there would be a
basis for supporting what you are suggesting.
Mr. Rose. And just to close out, I mean, it seems that
there is a crisis with staffing in the VA, but not a crisis in
staffing at the DoD health care facilities and I am curious as
to why that is when everyone is just trying to take care of
soldiers and vets. So, we should look at that.
Mr. Dodaro. Yes, one thing we could do is look at the two
programs and compare. [GAO provided additional information for
the record. See insert A.]
Mr. Rose. That is great. Thank you.
Mr. Pappas. Thank you, Mr. Rose.
I now recognize Ms. Radewagen for 5 minutes.
Ms. Radewagen. Thank you, Mr. Chairman, and Ranking Member.
I want to welcome the panel.
So, my question is, the latest addition to the high-risk
list, VA Acquisition Management, could you please describe how
this area was identified for the high-risk list.
Mr. Dodaro. Yes, we had been asked by the Congress to look
at the functions that have been put in place; particularly, the
surgical and medical procurement strategy they had in place. VA
was hoping to achieve about $150 million of savings. We went in
and found that they didn't really involve the clinicians in the
development of that process. It was expected that 40 percent of
all the procurements would be made off of their master list on
that area, but it was only about 20 percent. So, they weren't
achieving the savings.
We found that they were still using a lot of emergency
purchases, rather than going through a competitive process and
having a better system. The regulations hadn't been updated
since 2008. They have been working on an update since 2011. We
talked to the contracting officers and they felt their workload
was excessive and that they weren't getting necessary training.
There was a range of issues. We did a number of audits and
that led us to the conclusion that there was a systemic problem
here that needed to be addressed.
Ms. Radewagen. Okay. So, also, it stands to reason that VA
would close the easiest recommendations first. So, if we are
talking about moving the needle in terms of closing
recommendations with the greatest impact to solving the
overarching problem, where would you--and it is a bit
subjective--where would you say VA stands today?
Mr. MissalMissal. VA closes anywhere between--or we close--
so, we don't close a recommendation unless we get confidence
that the solution that VA has agreed to is going to be
sustainable. We close 85 to 90 percent of the recommendations
we make within a year. And so, we watch it very carefully. We
monitor what they are doing. We test it. We require everything
in writing before we close out a recommendation.
And to make sure they are effective; it is really our
responsibility to come up with recommendations that get to the
root cause of the issue. Because when we do a report, we not
only identify what went wrong, but why it went wrong, and our
recommendations really have to focus on the fact that we want
to address the issue, make sure it doesn't happen again, and
that other VA facilities or programs that may have similar
issues, can learn from that, as well.
Mr. Dodaro. Yes, I would say that--
Ms. Radewagen. Thank you, Mr. Chairman.
Oh, go ahead.
Mr. Dodaro. Yes, I would say from my standpoint, they are
doing a pretty good job of implementing our recommendations,
working hard to do that. They are not doing such a good job in
addressing the underlying root causes for the problems. And
unless they do that, they will fix a set of recommendations and
we will make a whole new set of recommendations and we will get
into that kind of pattern.
I think addressing the underlying management weaknesses has
to be done in order for all of us to say that our Government
has the very best management operation at the VA to serve
veterans.
Ms. Radewagen. Thank you both.
Thank you, Mr. Chairman. I yield back.
Mr. Pappas. Thank you, Ms. Radewagen.
If the witnesses will oblige, General Bergman and I just
want to take a few more minutes to get in a couple more
questions. And I wanted to just follow up on a question that
Chairman Takano referenced. He asked about the VA Office of
Suicide Prevention.
And, Mr. Missal and Mr. Dodaro, is your office currently
conducting any audits or examinations of any of the VA's
suicide prevention programs?
Mr. Missal. Yes, we have a number of active projects going
on right now. We have approximately 4 to 5 on individual
suicides, including the one in the West Palm Beach medical
facility where a veteran was in in-patient mental health and
while there, committed suicide. And, we are also exploring
other areas, as well.
Because of the critical importance of this issue and the
tragedy of the issue, we are expanding out to look at broader
programs, with respect to suicide. And as I previously said,
with respect to the VCL, we went out recently, again, to review
that. That touches about 750,000 contacts a year.
Mr. Pappas. Thank you.
Mr. Dodaro. Yes, we are, at the request of Chairman Takano,
looking at the pattern that has emerged recently of veterans
committing suicide on VA campuses and what is, perhaps, behind
that issue.
Mr. Pappas. Well, thank you. I know the entire Committee
looks forward to working with you on these matters.
I just wanted to call up one thing that Secretary Wilkie
provided in his testimony. He said, ``The Department is
currently working on establishing a process to create
functionality within the Office of Accountability and
Whistleblower Protection, which would both, track and confirm,
implementation of recommendations of both, the GAO and the
IG.''
Congress established this statutory requirement 2 years
ago, however, the secretary did not provide a target deadline
for following that particular law, and so I just wanted to make
it clear that we will be following up with the Department on
the timeline for ensuring that there is a clear and effective
process to ensure implementation of that.
One final thing--and Congressman Rose had asked a bit about
what can Congress do to ensure action on these
recommendations--and one thing I wanted to ask you both if
there is anything the Committee should be looking into to
consider how we can empower you both and both of your agencies
to do your job even better?
Mr. Missal. I think having hearings like this and shining a
spotlight on the issue is one great way to do that. We publish
semiannually, the number of recommendations that have been
outstanding for more than a year with details. So, we provided
that information. We try to put as much transparency on our
work as possible. And given the importance of recommendations,
we feel that we can't do enough with respect to that.
Mr. Dodaro. One of the things I was pleased to see last
year is that Congress passed the GAO/IG legislation that will,
in future years, require certain agencies, as part of their
annual budget submission to the Congress, to identify actions
that they are taking to implement open GAO recommendations. So,
there'll be a systematic process to do that.
In the interim, every year I send a letter to each
department agency head outlining the highest-priority
recommendations from our standpoint, and you could ask what
they are doing to implement those recommendations, to have them
report to you on that, and we can help critique that submission
and other reports.
But I agree with Mr. Missal that the most effective tool to
Congress is to have hearings and to have people come up. The
action that occurs, just because Congress holds a hearing is,
has a cathartic effect on the agencies and prompts them to take
action. And I have seen this not just at VA; it is across the
government.
Mr. Pappas. Thank you. General Bergman, you are recognized
for 5 minutes.
Mr. Bergman. Thank you, Mr. Chairman.
And on the subject of oversight of the electronic health
record modernization, I was the proud cosponsor of the Veterans
EHR Modernization Oversight Act, which was enacted last
December, and is one of the toughest pieces of reporting
legislation to ever come out of this Committee. So, we know we
have our work cut out for us on that, but we are going to be
like a dog on a bone on that one.
Now, this question is for both of you. The Accountability
and Whistleblower Protection Act, which I referenced earlier,
of 2017, established the Office of Accountability and
Whistleblower Protection and tasked it with recording,
tracking, reviewing, and confirming implementation of
recommendations from GAO and the IG.
From each of your organization's perspective, what are
practices that OAWP could build into their policies and
procedures that could help VA address recommendations and
improve services?
Mr. Missal. We meet regularly with OAWP to talk about how
they are going to be implementing a number of their policies,
that they have not done so yet. I have a regular meeting with
Dr. Bonzanto to do so. I know this is one area where they are
working hard to try to implement it, to get it off the ground.
From our perspective, we coordinate from the OIG, all of
the recommendations from VA. VA doesn't do the same thing. If
it is a VHA recommendation, it goes to VHA. If it is VBA, VBA
deals with it. If it is Office of Information and Technology,
they take it.
So, I think having a practice where VA has the reservoir of
all of the recommendations, will get greater attention,
certainly, from the most senior leaders of VA. They really need
to put that together to have a better indication of the number,
types, and extent of recommendations that they have.
Mr. Dodaro. I agree with Mr. Missal on that. That is a very
good suggestion and a good potential outcome.
The head of that office came to visit with me, and I
pledged to work with them, to coordinate with them on their
responsibilities. I still think the Department is working out
exactly how this is going to operate, because we are basically
still operating as we have in the past, as I mentioned earlier,
dealing with the Office of the Congressional Liaison and other
things. And so, until we hear further from them on how they are
going to work their internal coordination on the GAO
recommendations, it is pretty much status quo.
But whatever they work out internally, I can pledge that we
will work with them. It is to our benefit and everybody's
benefit that our recommendations be implemented.
Mr. Bergman. Okay. And one final question. You know, in the
military, we routinely change commanders, because you don't
command a unit forever; you are there for a while and then you
move on. But one of the things that we have is we have
turnovers. Whether it be in the form of a brief, face-to-face,
whether it be in the form of a folder or a binder or some
record of what that unit is doing, where they have made their
gains, where they have their challenges, et cetera, et cetera.
We talked about sustained leadership within the different
levels of the VA. Do you sense, is there any corporate
knowledge, if you will, that is passed along when someone is
leaving a position of leadership and someone new coming in, is
there a pass-down?
Mr. Missal. Again, it is going to depend on the situation,
but if I could just generalize, I don't think they do as good
of a job as they can. There has been an extraordinary number of
senior leaders who have turned over--and I don't just mean at
the very top, but at program offices, et cetera--and they don't
frequently have a good sense of the history, what the
priorities have been, and it takes them a long time to get up
to speed.
And given all the critical issues facing VA now, that
really does hamper implementing it, and that is why when we
look at continuity of leadership, we think that is a really
critical and important issue that VA just needs to get better
at.
Mr. Dodaro. Yes, I really don't know whether they do that
or not, but I do know that if they do, it is not evident.
Mr. Bergman. Okay. Well, thank you very much.
Mr. Chairman, I yield back.
Mr. Pappas. Thank you. I recognize Ms. Radewagen for 5
minutes.
Ms. Radewagen. Thank you, Mr. Chairman.
One last question here. DoD's supply chain management was
removed from the high-risk list this year. Could you please
share how that came around, what type of engagement GAO had
with DoD to get off the list, and lessons learned from that
engagement. And as a follow-up, would you please also explain
what, if any, best practices from that successful removal are
now being applied to VA offices on the high-risk list.
Mr. Dodaro. Yes. The DoD supply chain management was one of
the charter members of the high-risk list when we created the
list in 1990. That was the one that has been on there for 29
years. And for many years, DoD ignored our recommendations and
didn't make any movement until Congress required them to
develop plans, on inventory management, and to report to the
Congress. Then, they saw the benefit of those plans, which
turned into the plans on asset visibility and material
distribution. As a result, they have saved millions of dollars
and they have a better system now to get the materials to the
military at the right place and the right time and the right
amounts.
That was a very good example of how Congress was the
catalyst in that case, and then once DoD started implementing
our recommendations and seeing the value of it, then it took
over from there and we had a very constructive working
relationship with them.
But it took too long. That could have been handled a long
time ago and I am hoping at VA, we can take the lessons learned
from DoD and help it to be a faster process. But so far, we
don't have the plans. We are still lacking the plans that were
lacking at DoD when we first put the area on the high-risk
list. Until they have those plans and their reports against
those plans, you aren't going to see any material change in our
ratings.
Ms. Radewagen. Thank you, Mr. Chairman.
I yield back.
Mr. Pappas. Well, thank you very much.
Before closing today's hearing, I just want to make a
couple final points. I know that General Bergman and I share
the same outlook, that we are really committed to ensuring that
the work of this Subcommittee remains bipartisan, that there
may be points in times where members disagree with one another,
but we certainly have to move past the point where we are
disagreeable and focus on the job that we are here to do, and I
know that all the Members of this Subcommittee share that
outlook.
I really want to thank our two witnesses, as well, for
being here with us today. I want to express, you know, a real
great appreciation to both, Comptroller Dodaro and General
Missal, for their ongoing oversight work at the Department of
Veterans Affairs. The audits, the inspections, the
examinations, and reviews provide critical facts, analysis and
recommendations for the Department, for Congress, certainly,
and ultimately, for the general public.
And also please relay to your staff, you know, our thanks
for the incredible work that they do. As was shown today, the
impact on both, the GAO and the Office of the Inspector
General, results in very real improvements to the Department of
Veterans Affairs and our veterans are ultimately better served
because of the work that they do and that you do.
General Bergman, I am happy to recognize you, if you would
like to close.
Mr. Bergman. Well said, Mr. Chairman. My time is finite.
Mr. Pappas. Thank you. Members will have 5 legislative days
to revise and extend their remarks and include extraneous
material, and, without objection, the Subcommittee stands
adjourned.
[Whereupon, at 3:13 p.m., the Subcommittee was adjourned.]
A P P E N D I X
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Prepared Statement of Gene L. Dodaro
Why GAO Did This Study
VA is responsible for providing benefits and services to veterans,
including health care, disability compensation, and various types of
financial assistance. In fiscal year 2019, VA received a total budget
of $201.1 billion and a discretionary budget of $86.6 billion-the
largest in VA's history-to carry out its mission. GAO, along with the
VA Inspector General and other entities, continues to identify
significant deficiencies in VA's governance structures and operations-
all of which can affect the care provided to our nation's veterans.
This testimony focuses on the status of VA's efforts to address
GAO's high-risk designations and open GAO recommendations in the
following areas: VA health care, acquisition management, and disability
claims workloads and benefit eligibility criteria, among other areas.
It is primarily based on GAO's March 2019 high-risk update and a body
of work that spans more than a decade.
What GAO Recommends
Since 2000, GAO has made more than 1,200 recommendations to reduce
VA's high-risk challenges, and VA has implemented approximately 70
percent. GAO will continue to monitor VA's progress in implementing the
remaining open recommendations.
Sustained Leadership Needed to Address High-Risk Issues
What GAO Found
The Department of Veterans Affairs (VA) has longstanding management
challenges. As a result, GAO added several VA programs to its High-Risk
List. This list focuses attention on government operations that are
most vulnerable to fraud, waste, abuse, or mismanagement, or in need of
transformation. These include managing risks and improving VA health
care, VA acquisition management, and improving and modernizing VA
disability programs, including managing claims and updating eligibility
criteria.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Note: VA acquisition management was a newly designated high-risk
area in 2019. As such, it was not rated on the five criteria in March
2019.
VA health care was designated high risk in 2015 due to concerns
about VA's ability to ensure the cost-effective and efficient use of
resources to improve the timeliness, quality, and safety of health care
for veterans. GAO 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. VA's efforts to address each of these areas have been
impeded by leadership instability. However, since his July 2018
confirmation, Secretary Wilkie has demonstrated his commitment to
address the department's high-risk designations. His actions to date
have allowed the department to maintain its leadership commitment
rating of partially met in GAO's 2019 High- Risk update. VA also
partially met the action plan criteria. As of March 2019, it did not
meet the other three criteria for removal from the High-Risk List
(agency capacity, monitoring, and demonstrated progress). This is, in
part, because GAO continues to have audit findings that illustrate that
the five areas of concern have not been fully addressed. For example:
In a series of reports from 2012 through 2018, GAO found
VA's wait time data unreliable for primary and specialty care as well
as for care in the community. GAO also found that VA did not measure
the full wait times that veterans experience in obtaining care across
these settings.
In November 2017, GAO reported that VA medical center
officials did not always conduct or document timely required reviews of
providers when allegations of wrongdoing were made against them.
In April 2019, GAO found that VA's governance plan for
modernizing its electronic health record system was not fully defined,
potentially jeopardizing its fourth attempt at modernization.
In April 2019, GAO reported that VA's appraisal process
for assessing medical center director performance relies heavily on a
system with long- identified deficiencies that remain unaddressed, thus
diminishing VA's ability to hold officials accountable.
In its 2019 High-Risk Report, GAO added VA acquisition management
as a high- risk area in light of the department's numerous contracting
challenges and the significant Federal investment in serving veterans.
To date, GAO has identified challenges in the following areas: (1)
outdated acquisition regulations and policies; (2) lack of an effective
medical supplies procurement strategy; (3) inadequate acquisition
training; (4) contracting officer workload challenges; (5) lack of
reliable data systems; (6) limited contract oversight and incomplete
contract documentation; and (7) leadership instability. For example, as
of May 2019, VA does not have updated acquisition regulations and
officials expect to have a full update by 2021; a process which has
been in place since 2011.
GAO designated improving and modernizing Federal disability
programs, including VA's program, as high risk in 2003. GAO identified
two areas of concern related to VA: (1) managing disability claims
workload and (2) updating disability benefit eligibility criteria. As a
result of these concerns, veterans may not have their disability claims
and appeals processed in a timely manner. GAO reported in March 2018
that VA is making a major effort to reform its appeals process by
onboarding new staff and implementing new technology. However, its
appeals planning process does not provide reasonable assurance that it
will have the capacity to successfully implement the new process and
manage risks. VA agreed with GAO's recommendation to better assess
risks associated with appeals reform.
VA leadership has committed to addressing GAO's high-risk concerns
and has launched several transformational efforts. For example, VA is
currently implementing the Veterans Health Administration Plan for
Modernization, a framework that aims to modernize the department, as
well as the VA MISSION Act of 2018. This Act requires VA to consolidate
programs that allow veterans to receive care outside VA. If successful,
these efforts could be transformative for VA. However, such success
will only be achieved through sustained leadership attention and
detailed action plans that include metrics and milestones to monitor
and demonstrate VA's progress. Sustained congressional oversight will
also be essential.
Chairman Pappas, Ranking Member Bergman, and Members of the
Subcommittee:
I am pleased to be here today to discuss the Department of Veterans
Affairs' (VA) efforts to address longstanding management challenges. As
a result of these challenges, we added several VA programs to our High-
Risk List. \1\ This list focuses attention on government operations
that are most vulnerable to fraud, waste, abuse, or mismanagement, or
in need of transformation.
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\1\ GAO, High-Risk Series: Substantial Efforts Needed to Achieve
Greater Progress on High- Risk Areas, GAO-19-157SP (Washington, D.C.:
Mar. 6, 2019).
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VA is in need of transformation. We, along with VA's Inspector
General and other entities, continue to identify significant
deficiencies in VA's governance structures and operations-all of which
can affect the care provided to our nation's veterans. \2\ To address
these deficiencies, we have made over 1,200 recommendations to VA since
2000; VA has implemented approximately 70 percent of them. However,
important recommendations remain unimplemented (open), and we continue
to identify similar deficiencies in recent and ongoing work. In March
2019, we sent a letter to the Secretary of VA that detailed 30 open
recommendations that we deem the highest priority for implementation
(priority recommendations). \3\ Fully addressing these open
recommendations could significantly improve VA operations; however, the
recommendations highlight issues that are symptomatic of broader,
systemic management and oversight challenges that will only be
addressed through transformative action. Our High-Risk Report provides
VA a roadmap for this needed transformation.
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\2\ See VA Management Challenges: Actions Needed to Improve
Management and Oversight of VA Operations, GAO-19-422R (Washington,
D.C.: Apr. 10, 2019); Commission on Care, Final Report of the
Commission on Care (Washington, D.C.: Jun. 30, 2016); The MITRE
Corporation, Independent Assessment of the Health Care Delivery Systems
and Management Processes of the Department of Veterans Affairs,
(Washington, D.C: Sep. 1, 2015); and Department of Veterans Affairs,
Inspector General's Management and Performance Challenges, (Washington,
D.C.: 2018).
\3\ GAO, Priority Open Recommendations: Department of Veterans
Affairs, GAO-19-358SP (Washington, D.C.: Mar. 28, 2019), GAO-19-157SP.
Priority recommendations are those that GAO believes warrant priority
attention from heads of key departments or agencies. They are
highlighted because, upon implementation, they may significantly
improve government operation, for example, by realizing large dollar
savings; eliminating mismanagement, fraud, and abuse; or making
progress toward addressing a high-risk or duplication issue.
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Secretary Wilkie has said that VA is committed to addressing our
high- risk concerns and has launched several transformational efforts.
For example, VA is currently implementing its modernization plan, a
framework through which the department intends to systemically overhaul
its structure, culture, governance, and systems through organizational
improvements. Congress has also acted to drive overarching change by,
for example, passing the VA MISSION Act of 2018 (VA MISSION Act). \4\
Among other things, this Act requires VA to consolidate several
community care programs into a permanent program. \5\ VA is currently
implementing aspects of this Act.
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\4\ Pub. L. No. 115-182, 132 Stat. 1393 (2018).
\5\ The Veterans Access, Choice, and Accountability Act of 2014
created the Veterans Choice Program as a temporary program to address
problems with veterans' timely access to care at VA medical facilities.
Under the Veterans Choice Program, when eligible veterans face long
wait times, lengthy travel distances, or other challenges accessing
care at VA medical facilities, they may obtain health care services
from community providers- that is, providers who are not directly
employed by VA. Pub. L. No. 113-146, 128 Stat. 1754 (2014). The
Veterans Choice Program's authority sunsets on June 6, 2019.
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My statement today focuses on the status of VA's efforts to address
its high-risk designations and open GAO recommendations in the
following areas: (1) managing risks and improving VA health care; (2)
VA acquisition management; (3) improving and modernizing Federal
disability programs; and (4) other government-wide high-risk areas that
have direct implications for VA and its operations. This statement also
describes VA's ongoing efforts to transform and modernize the
department.
This statement is based on our 2019 high-risk update and our body
of work that spans more than a decade. \6\ For these products we
analyzed VA's documents related to the department's efforts to address
its high- risk areas and interviewed VA officials, among other things.
More detailed information on the scope and methodology of our prior
work can be found within each specific report. We conducted the work on
which this statement is based 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.
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\6\ GAO-19-157SP. For more information on the GAO High-Risk List,
see https://www.gao.gov/highrisk/overview, which we accessed May 16,
2019. For more information on our body of work on VA, see https://
www.gao.gov/key--issues/managing--risks--improving--va--health--care/
issue--summ ary?from, which we accessed May 16, 2019.
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Background
VA is responsible for providing benefits to veterans, including
health care, disability compensation, and various types of financial
assistance. In fiscal year 2019, VA received a total budget of $201.1
billion, and the largest discretionary budget in its history-$86.6
billion, about $20 billion higher than in 2015. The department operates
one of the largest health care delivery systems in the nation through
its Veterans Health Administration (VHA), with 172 medical centers and
more than 1,000 outpatient facilities organized into regional networks.
VA has faced growing demand by veterans for its health care services,
with the total number of veterans enrolled in VA's health care system
rising from 7.9 million to more than 9 million from fiscal year 2006
through fiscal year 2017. In fiscal year 2019, VHA received $73.1
billion of VA's $86.6 billion discretionary budget.
In addition to providing health care services, VA provides cash
benefits to veterans for disabling conditions incurred in or aggravated
by military service. To carry out its mission, VA spends tens of
billions of dollars to procure a wide range of goods and services,
including medical supplies; to construct hospitals, clinics, and other
facilities; and to provide the information technology (IT) to support
its operations.
We have made hundreds of recommendations to improve VA's management
and oversight of the services it provides to veterans. Specifically,
since 2000, we have made 1,225 recommendations to VA. While VA has
implemented most of the recommendations, a number remain open, as of
April 2019. Specifically,
more than 125 recommendations related to VA health care
remain open, including 17 recommendations that have remained open for 3
years or more;
15 recommendations related to improving VA acquisition
management remain open, including 1 recommendation that has remained
open for 3 years or more; and
12 recommendations related to management of disability
claims workloads.
In 2017, we began sending letters to VA and appropriate
congressional committees identifying priority recommendations for VA to
implement in order to significantly improve its operations. We
categorized these recommendations into nine areas: (1) veterans' access
to timely health care; (2) veterans' community care program; (3) human
capital management; (4) information technology; (5) appeals reform for
disability benefits; (6) quality of care and patient safety; (7)
national policy documents; (8) contracting policies and practices; and
(9) veterans' access to burial options. \7\
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\7\ GAO-19-358SP.
Overall Rating for the Managing Risks and Improving VA Health Care
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High-Risk Area Remained Unchanged in 2019
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
related to managing risks and improving VA health care: (1) ambiguous
policies and inconsistent processes; (2) inadequate oversight and
accountability; (3) IT challenges; (4) inadequate training for VA
staff; and (5) unclear resource needs and allocation \8\priorities \9\.
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\8\ GAO, High-Risk Series: An Update, GAO-15-290 (Washington, D.C.:
Feb. 11, 2015).
\9\ The five criteria for removal are the agency must have (1) a
demonstrated strong commitment and top leadership support to address
the risks; (2) the capacity-the people and other resources-to resolve
the risks; (3) a corrective action plan that identifies the root
causes, identifies effective solutions, and provides for substantially
completing corrective measures in the near term, including but not
limited to steps necessary to implement solutions we recommended; (4) a
program instituted to monitor and independently validate the
effectiveness and sustainability of corrective measures; and (5) the
ability to demonstrate progress in implementing corrective measures.
Each criterion is rated as met, partially met, or not met.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Since our 2017 High-Risk Report, ratings for all five criteria
remain unchanged as of March 2019. 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
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 and working
with GAO. The Secretary's actions, to date, have allowed the department
to maintain its leadership commitment rating as of March 2019.
The action plan criterion also remains partially met as of March
2019. 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 told us that instead of
revising the March 2018 action plan, it will incorporate its plans to
address the high-risk designation into the department's current
initiatives. Specifically, VA is currently implementing the VHA Plan
for Modernization, through which the department intends to modernize
VA's structure, culture, governance, and systems through organizational
improvements. VA officials have indicated that the VHA Plan for
Modernization is intended, among other things, to address the high-risk
areas for VA health care. VA officials also told us they are currently
developing operational plans for the VHA Plan for Modernization, and
these plans will include goals, time frames, and metrics, among other
things. VA estimates that the operational plans will be complete by
September 2019.
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.
For each of the five identified areas of concern related to
managing risks and improving VA health care, ratings reflect the level
of progress VA has made to address them.
Ambiguous policies and inconsistent processes. Since our 2017 High-
Risk Report, ratings for all five criteria remain unchanged for this
area of concern as of March 2019.
Leadership commitment: partially met. In September 2017,
we reported that VHA had approximately 800 national policies, the
majority of which were outdated. \10\ VHA reported reducing the number
of national policies by 26 percent, and work continues in this area. In
addition, VHA established an inventory of approximately 55,000 local
policies as of October 2017. In October 2018, VHA noted its plans to
determine who is responsible for monitoring implementation of national
and local policy, as well as the alignment between these levels of
policy. At that time, VHA also discussed its future plans to monitor
the implementation and alignment of national and local policy and
update its national policy directive by the end of June 2019.
Additionally, VA has implemented a structure for leadership input into
the policy process, such as at the VHA Chief of Staff level. However,
senior leadership has lacked the stability needed to ensure issued
policy meets agency goals.
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\10\ GAO, Veterans Health Care: Additional Actions Could Further
Improve Policy Management, GAO-17-748. (Washington, D.C.: Sept. 22,
2017).
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 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. In June 2017,
VA also identified the following as enterprise-wide root causes of its
high-risk designation:
disjointed strategic planning;
poorly defined roles, responsibilities, and decision
authorities;
poor horizontal and vertical integration;
lack of reliable data and analysis;
ineffective human capital management; and
inadequate change management.
VA relied on these root cause analyses as the foundational drivers
for the VHA Plan for Modernization. However, VA has not used these
analyses to develop and prioritize appropriate milestones and metrics
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 show progress in this area. Since its
2015 high-risk designation, we have made 50 new recommendations in this
area of concern, 32 of which were made since our 2017 report was
issued. For example,
In November 2017, we reported that, due in part to
misinterpretation or lack of awareness of VHA policy, VA medical center
officials did not always conduct or document timely required reviews of
providers when allegations were made against them. We also found that
VHA was unable to reasonably ensure appropriate reporting of providers
to oversight entities such as state licensing authorities. As a result,
VHA's ability to provide safe, high quality care to veterans is
hindered because other VA medical centers, as well as non-VA health
care entities, may be unaware of serious concerns raised about a
provider's care.
We recommended that VHA direct medical centers to document and
oversee reviews of providers' clinical care after concerns are raised,
among other recommendations. All of our recommendations remain open. As
of January 2019, VA estimated completing the recommended revisions to
its policy and audit processes in August 2019 and August 2020,
respectively. \11\
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\11\ GAO, VA Health Care: Improved Policies and Oversight Needed
for Reviewing and Reporting Providers for Quality and Safety Concerns,
GAO-18-63 (Washington, D.C.: Nov. 15, 2017).
In July 2018, we reported that VA collected data related
to employee misconduct and disciplinary actions, but data
fragmentation, reliability issues, and inadequate guidance impeded
department-wide analysis of those data. Thus, VA management is hindered
in making knowledgeable decisions regarding the extent of misconduct
---------------------------------------------------------------------------
and how it was addressed.
We recommended that VA develop and implement guidance to collect
complete and reliable misconduct and associated disciplinary-action
data department-wide, whether through a single information system, or
multiple interoperable systems. VA concurred with this priority
recommendation, which remains open. VA reported that it expects to
implement one or more information systems that will collect misconduct
and associated disciplinary action data in January 2020. \12\
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\12\ GAO, Department of Veterans Affairs: Actions Needed to Address
Employee Misconduct Process and Ensure Accountability, GAO-18-137
(Washington, D.C.: July 19, 2018).
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Inadequate oversight and accountability. Since our 2017 High-Risk
Report, ratings for one criterion improved and four remain unchanged
for this area of concern as of March 2019.
Leadership commitment: partially met. 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 March 2019, the rating for
this criterion improved to 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 a lack of progress in this area. Since its 2015 designation,
we made 89 new recommendations in this area of concern, 54 of which
were made since our 2017 report was issued. For example:
In October 2017, we reported that VHA is unable to
accurately count the total number of physicians who provide care in its
VA medical centers. VHA has data on the number of mission-critical
physicians, which includes primary care and mental health physicians,
it employs (more than 11,000) and who provide services on a fee-basis
(about 2,800). \13\ However, VHA lacks data on the number of contract
physicians and physician trainees, and thus has no information on the
extent to which medical centers nationwide use these arrangements and
whether contract physicians are working in mission-critical
occupations. As such, VHA cannot ensure that its workforce planning
process sufficiently addresses gaps in physician staffing, including
those for mental health providers, which may affect veterans' access to
care, among other issues.
\13\ VHA obtains data from its Veterans Integrated Service Networks
and VA medical centers on which occupations are the highest priority
for recruitment and retention based on known recruitment and retention
concerns, among other factors. VHA then consolidates this data to
identify the nationwide top 10 mission-critical occupations and top 5
mission-critical physician occupations. In fiscal year 2016, the ten
mission-critical clinical occupations were physician, registered nurse,
human resource manager, physical therapist, physician assistant,
psychologist, medical technologist, occupational therapist, diagnostic
radiologic technologist, and pharmacist. See U.S. Department of
Veterans Affairs, Veterans Health Administration, Mission Critical
Occupation Report (2016).
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We recommended that VHA 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. VHA did not concur
with this recommendation, which we reiterated in our priority
recommendation letter. \14\
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\14\ GAO, Veterans Health Administration: Better Data and
Evaluation Could Help Improve Physician Staffing, Recruitment, and
Retention Strategies, GAO-18-124 (Washington, D.C.: Oct 19, 2017).
In a series of reports from 2012 through 2018, GAO found
VA's wait time data unreliable for primary and specialty care, as well
as for care in the community. GAO also found that VA did not measure
the full wait times that veterans experience in obtaining care across
these settings. Specifically, in December 2012, we made two
recommendations to VA to improve the reliability and oversight of wait
time measures, both of which are designated as priority, and remain
open. \15\
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\15\ GAO, VA Health Care: Reliability of Reported Outpatient
Medical Appointment Wait Times and Scheduling Oversight Need
Improvement, GAO-13-130. (Washington, D.C.: Dec 21, 2012).
Similarly, 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.
Specifically, we found (1) a lack of data on the timeliness of
accepting referrals and opting veterans in to the program, (2)
inaccuracy of clinically indicated dates, which are used to measure the
timeliness of care, and (3) unreliable data on the timeliness of urgent
care. \16\
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\16\ The Veterans Choice Program allows eligible veterans to obtain
health care services from providers not directly employed by VA.
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We recommended that VA take steps to improve the timeliness and
accuracy of data on veterans' wait times for care and its oversight of
the future community care program that will consolidate other community
care programs with the Veterans Choice Program, whose authority sunsets
on June 6, 2019. VA concurred with eight of the 10 recommendations
related to these findings, all of which remain open. \17\ VA reported
that, in order to improve wait times data accuracy under the Veterans
Community Care Program, it intends to implement several initiatives
through September 2019. \18\
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\17\ In June 2018, we recommended that the Under Secretary for
Health should implement a mechanism to separate clinically urgent
referrals and authorizations from those for which the VA medical
facility or the third-party administrator has decided to expedite
appointment scheduling for administrative reasons. VA did not agree
with this recommendation and stated there will no longer be a need to
separate clinically urgent referrals for care from those that need
expediting under the Veterans Community Care Program. However, we
maintain that our recommendation is warranted. In particular, we found
that VA's data did not always accurately reflect the timeliness of
urgent care because both VA medical center and third-party
administrator staff inappropriately re- categorized some routine care
referrals and authorizations as urgent ones for reasons unrelated to
the veterans' health conditions.
\18\ GAO, Veterans Choice Program: Improvements Needed to Address
Access-Related Challenges as VA Plans Consolidation of its Community
Care Programs, GAO-18-281 (Washington, D.C.: June 4, 2018).
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In September 2018, we reported on the timeliness of third-party
administrators' payments to community providers under VA's largest
community care program, the Veterans Choice Program. Although VA has
taken steps to improve the timeliness of claim payments to these
providers, VA is not collecting data or monitoring compliance with
third-party administrators' customer service requirements for provider
calls. This could adversely affect the timeliness with which community
providers are paid, possibly making them less willing to participate
and affecting veterans' access to care.
We recommended that VA collect data on and monitor compliance with
its requirements pertaining to customer service for community
providers. VA agreed with the recommendations, but has not yet
implemented them. \19\
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\19\ See GAO, Veterans Choice Program: Further Improvements Needed
to Help Ensure Timely Payments to Community Providers, GAO-18-671
(Washington, D.C.: Sep. 28, 2018).
In November 2018, we reported that VHA's suicide
prevention media outreach activities declined in recent years due to
leadership turnover and reorganization. Additionally, we found that VHA
did not assign key leadership responsibilities or establish clear lines
of reporting for its suicide prevention media outreach campaign, which
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hindered its ability to oversee the campaign.
In April 2019, VA implemented one of the recommendations by
providing a new oversight plan for its suicide prevention media
outreach campaign. It plans to implement the remaining recommendation
by working with communications experts to develop metrics, targets, and
an evaluation strategy to improve its outreach efforts. \20\
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\20\ GAO, VA Health Care: Improvements Needed in Suicide Prevention
Media Outreach Campaign Oversight and Evaluation, GAO-19-66
(Washington, D.C.: Nov. 15, 2018).
In April 2019, we reported that VHA's appraisal process
for assessing medical center director performance relies heavily on
medical center performance information. VHA designed the Strategic
Analytics for Improvement and Learning (SAIL) system to provide
internal benchmarking of medical center performance and to promote high
quality health care delivery across its system of regional networks and
medical centers. SAIL was evaluated in 2014 and 2015 by VHA and an
external contractor, respectively, but VHA has not assessed the
recommendations from those evaluations, or taken action on them. The
evaluations, which found issues related to the validity and reliability
of SAIL and its ratings for measuring performance and fostering
accountability, together included more than 40 recommendations for
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improvement.
Without ensuring that the recommendations resulting from these
previous evaluations are assessed and implemented as appropriate, the
identified deficiencies may not be adequately resolved, and VHA's
ability to hold officials accountable for taking the necessary actions
may be diminished. VA concurred with the two recommendations we made to
address these findings, both of which remain open. \21\
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\21\ GAO, Veterans Health Administration: Past Performance System
Recommendations Have Not Been Implemented GAO-19-350 (Washington, D.C.:
Apr. 30, 2019).
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Information technology challenges. Since our 2017 High-Risk Report,
ratings for one criterion regressed, one improved, and three remain
unchanged this area of concern as of March 2019.
Leadership commitment: not met. In March 2019, the rating
for this criterion declined to not met. In January 2019, the Senate
confirmed a new VA Chief Information Officer (CIO). 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 March 2019, the rating for
this criterion improved to 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 show 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 six actions to
provide clinicians and pharmacists with improved tools to support
pharmacy services to veterans and reduce risks to patient safety. This
included 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. \22\
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\22\ GAO, VA Information Technology: Pharmacy System Needs
Additional Capabilities for Viewing, Exchanging, and Using Data to
Better Serve Veterans, GAO-17-179 (Washington, D.C.: June 14, 2017).
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In April 2019, we testified that from 2001 through 2018,
VA pursued three efforts to modernize its health information system-
the Veterans Health Information Systems and Technology Architecture
(VistA). (See Fig. 2.) However, these efforts resulted in high costs,
created challenges ensuring the interoperability of health data, and
ultimately did not result in a modernized VistA. Specifically, in
December 2017, we reported that VA obligated over $1.1 billion for
contracts with 138 contractors during fiscal years 2011 through 2016
for two modernization initiatives, an Integrated Electronic Health
Record program with the DoD and VistA Evolution. We have ongoing work
that examines the cost to VA of VistA and the department's actions to
transition from VistA to a new electronic health record system. \23\
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\23\ GAO, Veterans Affairs: Addressing IT Managements Challenges Is
Essential to Effectively Supporting the Department's Mission, GAO-19-
476T (Washington, D.C.: Apr. 2, 2019).
Regarding the department's most recent effort, the Electronic
Health Record Modernization, we testified in April 2019 that the
governance plan for this program was not fully defined, which could
jeopardize its fourth attempt to modernize its electronic health record
system. VA plans to implement the same electronic health record system
the DoD is currently deploying. The new system is intended to be the
authoritative source of clinical data to support improved health,
patient safety, and quality of care provided by VA.
VA has not fully implemented our priority recommendation calling
for the department to define the role of the Interagency Program Office
in the governance plans for acquisition of the department's new
electronic health record system. VA concurred with this recommendation
and reported that the Joint Executive Committee, a joint governance
body, approved a role for the Interagency Program Office, but as of
April 2019 VA has yet to provide us with documentation of this
development. \24\
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\24\ GAO, Electronic Health Records: Clear Definition of the
Interagency Program Office's Role in VA's New Modernization Effort
Would Strengthen Accountability, GAO-18-696T (Washington, D.C.: Sept.
13, 2018).
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
(a) The HealtheVet initiative was VA's first VistA modernization
project, which had the goals of standardizing the department's health
care system and eliminating the approximately 130 different systems
used by its field locations at that time.
(b) The integrated Electronic Health Record program was VA's second
VistA modernization initiative, which it launched in conjunction with
the Department of Defense (DoD). The program was intended to replace
the two separate electronic health record systems used by the two
departments with a single, shared system.
(c) The VistA Evolution program was a joint effort of the Veterans
Health Administration and VA's Office of Information and Technology.
The program was to be comprised of a collection of projects and efforts
focused on improving the efficiency and quality of veterans' health
care, modernizing the department's health information systems,
increasing the department's data exchange and interoperability with DoD
and private sector health care partners, and reducing the time it takes
to deploy new health information management capabilities.
We also testified in April 2019 that VA has not yet fully
addressed the recommendation we made in September 2014 to expedite the
process for identifying and implementing an IT system for the Family
Caregiver Program. We reported in September 2014 that the Family
Caregiver Program, which was established to support family caregivers
of seriously injured post-9/11 veterans, has not been supported by an
effective IT system. Specifically, we reported that, due to limitations
with the system, the program office did not have ready access to the
types of workload data that would allow it to routinely monitor
workload problems created by the program. Without such information, the
program's workload issues could persist and impact the quality and
scope of caregiver services, and ultimately the services that veterans
receive.
VA concurred with our recommendation and subsequently began taking
steps to implement a replacement system. However, the department has
encountered delays and reported recently initiating an effort to
implement a new IT system to support the program based on existing
commercially available software. We have ongoing work to evaluate VA's
effort to acquire a new IT system to support the Family Caregiver
Program. \25\
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\25\ GAO, VA Health Care: Actions Needed to Address Higher-Than-
Expected Demand for the Family Caregiver Program, GAO-14-675
(Washington, D.C.: Sept. 18, 2014) and GAO, Veterans Affairs:
Addressing IT Management Challenges Is Essential to Effectively
Supporting the Department's Mission GAO-19-476T (Washington, D.C.: Apr
2, 2019).
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Inadequate training for VA staff. Since our 2017 High-Risk Report,
ratings for one criterion improved and four remain unchanged for this
area of concern as of March 2019.
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.
Action plan: partially met. In March 2019, the rating for
this criterion improved to partially met. VA completed a root cause
analysis for training deficiencies, which informed the goals underlying
its action plan. 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 show progress in this area. Since
its 2015 designation, we have made 11 new recommendations in this area
of concern, 3 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.
\26\
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\26\ GAO, VA Health Care: Improved Guidance and Oversight Needed
for the Patient Advocacy Program, GAO-18-356 (Washington, D.C.: Apr 12,
2018).
Unclear resource needs and allocation priorities. Since our 2017
High-Risk Report, ratings for one criterion improved and four remain
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unchanged for this area of concern as of March 2019.
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. In March 2019, the rating for
this criterion improved to 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 show 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; this limits VA's ability to assess
whether resources are being used effectively to serve veterans.
Specifically, we found that productivity metrics may not account for
all providers or clinical services, reflect the intensity of clinical
workload, and reflect providers' clinical staffing levels.
Additionally, we found that efficiency models may also be adversely
affected by inaccurate workload and staffing data. As a result, VA
cannot systematically identify best practices to address low
productivity and inefficiency as well as determine the factors VA
medical centers commonly identify as contributing to low productivity
and inefficiency.
We made four recommendations to address these findings; three of
which VA implemented in the spring of 2018 by improving productivity
metrics and staffing and workload data. To implement the remaining
recommendation, VA should establish a process to oversee medical
centers' plans for addressing low clinical productivity and
inefficiency. \27\
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\27\ GAO, VA Health Care: Improvements Needed in Data and
Monitoring of Clinical Productivity and Efficiency, GAO-17-480
(Washington, D.C.: May 24, 2017).
In August 2018 we reported that VA medical centers face
challenges operating their Sterile Processing Services programs-
notably, addressing workforce needs, such as lengthy hiring time frames
and limited pay and professional growth potential. VHA's Sterile
Processing Services workforce challenges pose a potential risk to VA
medical centers' ability to ensure access to sterilized medical
equipment. Until VHA examines these workforce needs, VHA won't know
whether or to what extent the reported challenges adversely affect VA
medical centers' ability to effectively operate their Sterile
Processing Services programs and ensure access to safe care for
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veterans.
We recommended that VA examine workforce needs and take action
based on this assessment, as appropriate. VA concurred with this
recommendation, which remains open. \28\
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\28\ GAO, VA Health Care: Improved Oversight Needed for Reusable
Medical Equipment, GAO-18-474 (Washington, D.C.: Aug. 3, 2018).
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VA Acquisition Management Was Added to GAO's High-Risk List in 2019
In light of numerous contracting challenges that we have
identified, and given the significant investment in resources to
fulfill its critical mission of serving veterans, we added VA
acquisition management as a new high- risk area in 2019. \29\ VA has
one of the most significant acquisition functions in the Federal
government, both in dollar amount of obligations and number of contract
actions. Specifically, about a third of VA's discretionary budget in
fiscal year 2018, or about $27 billion, has been used to contract for
goods and services.
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\29\ GAO-19-157SP.
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We have identified challenges in the following areas of concern
related to VA's acquisition management: (1) outdated acquisition
regulations and policies; (2) lack of an effective medical supplies
procurement strategy;
(3)inadequate acquisition training; (4) contracting officer
workload challenges; (5) lack of reliable data systems; (6) limited
contract oversight and incomplete contract file documentation; and (7)
leadership instability.
Outdated acquisition regulations and policies. VA's procurement
policies have historically been outdated, disjointed, and difficult for
contracting officers to use. In September 2016, we reported that (1)
the acquisition regulations contracting officers currently follow have
not been fully updated since 2008 and (2) VA had been working on
completing a comprehensive revision of its acquisition regulations
since 2011. \30\
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\30\ GAO, Veterans Affairs Contracting: Improvements in Policies
and Processes Could Yield Cost Savings and Efficiency, GAO-16-810
(Washington, D.C.: Sep. 16, 2016).
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VA's delay in updating this fundamental source of policy has
impeded the ability of contracting officers to effectively carry out
their duties. We recommended in September 2016 that VA identify
measures to expedite the revision of its acquisition regulations and
clarify what policies are currently in effect. VA concurred with this
priority recommendation and, as of January 2019, had rescinded or re-
issued updated policy memoranda for all information letters, which VA
previously used to provide guidance that was temporary in nature.
VA has also made some progress in updating its acquisition
regulations, but more work remains to be done over the next several
years. As of April 2019, VA reports that 15 of the 41 parts in its
acquisition regulations update were published as final rules, 10 were
issued as proposed rules for public comment, and the remainder are at
an earlier stage of the rulemaking process. All parts are scheduled to
be out for public comment by March 2020, but the final rules are not
expected to be published until April 2021.
Lack of an effective medical supplies procurement strategy. VA's
program for purchasing medical supplies has not been effectively
executed, nor is it in line with practices at leading hospitals. To
support more efficient purchasing of medical supplies for its 172
medical centers that serve the needs of about 9 million veterans, VA
launched the Medical Surgical Prime Vendor-Next Generation (MSPV-NG)
program in December 2016. MSPV-NG was part of VA's overall effort to
transform its supply chain and achieve $150 million in cost avoidance.
In November 2017, we reported that VA's approach to developing its
catalog of supplies was rushed and lacked key stakeholder involvement
and buy-in. It also relied on establishing non-competitive blanket
purchase agreements for the overwhelming majority of products,
resulting in low utilization by medical centers. VA had set a target
that medical centers would order 40 percent of their supplies from the
MSPV-NG catalog, but utilization rates were below this target with a
nationwide average utilization rate across medical centers of about 24
percent as of May 2017. This low utilization adversely affected VA's
ability to achieve its cost avoidance goal.
We recommended in November 2017 that VA develop, document, and
communicate to stakeholders an overarching strategy for the program. VA
concurred with this priority recommendation and is developing
strategies to address it. First, in February 2019, VA developed and
documented a new, overarching acquisition strategy for its Medical
Surgical Prime Vendor (MSPV) program, and has begun the process of
communicating it to key stakeholders, including clinical and logistics
staff. Further, VA is developing a separate strategy to involve
clinicians in developing requirements with plans to complete a pre-
pilot of this strategy by September 2019. In response to a
congressional request to assess these and other program changes, we
recently began a review of VA's MSPV program. \31\
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\31\ GAO, Veterans Affairs Contracting: Improvements in Buying
Medical and Surgical Supplies Could Yield Cost Savings and Efficiency,
GAO-18-34 (Washington, D.C.: Nov 9, 2017).
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Inadequate acquisition training. VA acquisition training, at times,
has not been comprehensive nor provided to staff that could benefit
from it. A 2006 statute required, and a 2016 Supreme Court decision
(Kingdomware Technologies, Inc. v. United States) reaffirmed, that VA
is to give preference to veteran-owned small businesses when
competitively awarding contracts-a program known as Veterans First. In
September 2018, we reported that training on VA's Veterans First policy
did not address some of its more challenging aspects. For example, many
of the contracting officers we interviewed were uncertain about how to
balance the preference for veteran-owned small businesses with fair and
reasonable price determinations when lower prices might be found on the
open market. \32\
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\32\ GAO, Veterans First Program: VA Needs to Address
Implementation Challenges and Strengthen Oversight of Subcontracting
Limitations, GAO-18-648 (Washington, D.C.: Sep. 24, 2018).
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In addition, VA provided several installments of online training
sessions on the Veterans First policy to contracting officers but did
not make them mandatory. As a result, only 52 percent of VA contacting
officers completed the follow-up training by the spring of 2018. We
recommended in September 2018 that VA provide more targeted training to
contracting officers on how to implement the Veterans First policy,
particularly in the area of making fair and reasonable price
determinations, and assess whether this training should be designated
as mandatory. VA concurred, and in April 2019, VA's Chief Acquisition
Officer (CAO) stated that VA is taking steps to make this training
mandatory. VA also reported that its Acquisition Academy will provide
Veterans First training to all contracting staff on May 30, 2019.
Contracting officer workload challenges. The majority of our
reviews since 2015 have highlighted workload as a contributing factor
to the challenges that contracting officers face. Most recently, in
September 2018, we reported that about 54 percent of surveyed VA
contracting officers said their workload was not reasonable and found
that workload stresses have exacerbated the struggles that they face
implementing the department's Veterans First policy. \33\
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\33\ GAO-18-648.
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In addition, in September 2016, we reported that VHA contracting
officers processed a large number of small dollar-value actions to
support medical center operations, many of which involve emergency
procurements of routine items to support immediate patient care.
Contracting officers and the department's Acting CAO told us that these
frequent and urgent small-dollar transactions reduce contracting
officers' efficiency and ability to take a strategic view of VHA's
overarching procurement needs. We reported in November 2017 that
emergency procurements accounted for approximately 20 percent-$1.9
billion-of VHA's overall contract actions in fiscal year 2016. Figure 3
shows the percent of VHA contract actions designated as emergencies in
fiscal year 2016 by each network contracting office. \34\
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\34\ GAO-16-810.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
(a) Veterans Integrated Service Networks, organizations that manage
medical centers and associated clinics across a given geographic area,
are served by a corresponding network contracting office. Some Veterans
Integrated Service Networks have been consolidated over time, and in
fiscal year 2016, there were 19 Veterans Integrated Service Networks
despite being numbered up to 23. As of fiscal year 2017, there were
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only 18 in total.
We recommended in November 2017 that VHA network contracting
offices work with medical centers to identify opportunities to more
strategically purchase goods and services frequently purchased on an
emergency basis. VA concurred with this recommendation and recently
offered to provide us with a demonstration of the supply chain
dashboard that VA uses to track items purchased on an emergency basis,
which we plan to attend by the end of May 2019. VA also agreed to
conduct an analysis of its purchase card spending to identify items
that should be purchased through its MSPV program. VA expects to
complete this analysis by July 2019. If implemented, this would allow
for both greater contracting officer efficiency and cost savings. For
example, based on a similar recommendation we made in 2012, VA began
more systematically employing strategic sourcing in FY 2013, and in
subsequent fiscal years reported about $10 billion in savings over a 5-
year period.
Lack of reliable data systems. The lack of accurate data has been a
long-standing problem at VA. In September 2016, we reported that VA had
not integrated its contract management and accounting systems,
resulting in duplicative efforts on the part of contracting officers
and increased risk of errors. \35\ We and VA's Inspector General each
recommended that VA perform data checks between the two systems. VA
concurred with this recommendation and some VA contracting
organizations have made efforts to address this risk. Further, VA
reported in March 2019, that it plans to adopt a new integrated
financial and contract management system, which it plans to install VA-
wide over a 9- year period, with the final site receiving the system in
2027.
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\35\ GAO-16-810.
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Limited contract oversight and incomplete contract file
documentation. VA has had difficulty ensuring that its contracts are
properly monitored and documented. In September 2018, we reported that,
although VA obligated $3.9 billion to veteran-owned small businesses in
fiscal year 2017, its contracting officers were not effectively
monitoring compliance with key aspects of the department's Veterans
First policy, such as limits on subcontracting (which ensure that the
goal of the program-to promote opportunities for veteran-owned
businesses-is not undermined). In many cases, we found that clauses
requiring compliance were not included in the VA's contracts and orders
with veteran businesses because the contracting officers either forgot
to include them or were unaware of the requirement. \36\
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\36\ GAO-18-648.
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The contracting officers we spoke with also said that they do not
have sufficient time or knowledge to conduct oversight. Through limited
reviews, VA has identified a number of violations that would warrant a
broader assessment of the fraud risks to the program. We recommended in
September 2018 that VA establish a mechanism to ensure that mandatory
subcontracting-related clauses be consistently incorporated into set-
aside contracts with veteran-owned businesses and that VA conduct a
fraud risk assessment for the Veterans First program. VA concurred with
these recommendations and is taking steps to implement them. For
example, VA reported in April 2019 that it had made modifications to
its electronic contract management system to ensure the clauses would
be included in set-aside contracts and anticipated completing testing
of the modifications in May 2019.
We also reported in September 2016 that a number of VA contract
files we reviewed were missing key documents, increasing the risk that
key processes and regulations were not followed. \37\ We recommended
that VA focus its internal compliance reviews to ensure that required
contract documents are properly prepared and documented. VA concurred
with this recommendation. Since then, VA has made policy changes that
revised its processes for compliance reviews of contract documentation.
We are currently following up with VA to obtain the results of its
compliance reviews to determine if VA has fully implemented this
recommendation.
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\37\ GAO-16-810.
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Leadership instability. We have previously reported, most recently
in September 2018, that procurement leadership instability has made it
difficult for the VA to execute and monitor the implementation of key
acquisition programs and policies. For example, changes in senior
procurement leadership, including the CAO and VHA's Chief Procurement
and Logistics Officer, occurred during the implementation of MSPV-NG
and similar instability in leadership affected the MSPV-NG program
office itself. Overall, the MSPV-NG program office has had four
directors, two of whom served in an acting capacity, since its
inception in 2014. \38\
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\38\ GAO-18-648.
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To address this instability, we recommended in November 2017 that
VA appoint a non-career employee as the CAO and prioritize the hiring
of the MSPV-NG program office's director position on a permanent basis.
VA concurred with these recommendations and implemented them in 2018.
Stable leadership should help bring consistent and much needed
direction to the MSPV-NG program, but we recently identified other
areas within the VA where sustained leadership is also needed. For
instance, in September 2018, we reported there have been six Acting
Directors within the past 2 and a half years within an oversight office
that helps assess whether VA is in compliance with aspects of its
Veterans First policy.
Ratings for the VA Disability High-Risk Areas Either Remained Unchanged
or Regressed in 2019
We designated improving and modernizing Federal disability programs
as high risk in 2003. An estimated one in six working-age Americans
reported a disability in 2010. Many of these Americans need help
finding or retaining employment, or rely on cash benefits if they
cannot work.
Three of the largest Federal disability programs-one run by VA-
disbursed about $270 billion in cash benefits to 21 million people with
disabilities in fiscal year 2017. However, Federal disability programs,
including VA's, struggle to meet their needs. In particular, VA
struggles to manage its disability claims workloads, and, when
determining whether individuals qualify for disability benefits, VA
relies on outdated eligibility criteria.
Managing disability claims workloads. Since our 2017 High-Risk
Report, our assessment of ratings for all five criteria remains
unchanged for this area of concern for VA as of March 2019.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Leadership commitment: met. VA has maintained leadership
focus on managing initial disability claims and appeals workloads
through various initiatives to improve benefits processing and reduce
backlogs. Enhancing and modernizing VA's disability claims and appeals
processes are goals in its 2018-2024 strategic plan.
Capacity: partially met. VA has continued building the
capacity to process initial disability claims, such as using an
electronic system to distribute claims ready for decisions to available
staff. On appeals, VA is reforming its process, onboarding hundreds of
new staff, and implementing new technology. However, as we reported in
March 2018, VA's appeals plan does not provide reasonable assurance
that it will have the capacity to implement the new process and manage
risks. VA agreed with our recommendation to better assess risks
associated with appeals reform and took some steps to address risks,
such as limited testing of the new process. However, as of April 2019
VA has not fully addressed this recommendation. For example, VA has not
developed plans to fully address risks, such as veterans choosing more
resource-intensive options at higher rates than expected. \39\
---------------------------------------------------------------------------
\39\ GAO, VA Disability Benefits: Improved Planning Practices Would
Better Ensure Successful Appeals Reform. GAO-18-352. (Washington, D.C.:
Mar. 22, 2018).
---------------------------------------------------------------------------
Action plan: partially met. VA continues to implement
plans to reduce the initial disability claims backlog. For appeals
reform, VA submitted its appeals plan in November 2017 and provided
several progress reports throughout 2018. In March 2018, we reported
that VA's plan for implementing a new disability appeals process did
not explain how VA would assess the new process compared to the legacy
process, and did not fully address risks associated with implementing a
new process.
We made two recommendations to improve VA's disability benefit
appeals process, including that VA (1) clearly articulate in its
appeals plan how it will monitor and assess the new appeals process
compared to the legacy process, and (2) ensure that its appeals plan
more fully addresses related risks, given the uncertainties associated
with implementing a new process. As of April 2019, VA has taken actions
to address our recommendations, although key steps remain. For example,
VA has not fully articulated detailed steps and time frames for
assessing the relative performance of the new and legacy appeals
processes. Without this assessment, VA cannot determine the extent to
which the new process will achieve final resolution of veterans'
appeals sooner than the legacy process. \40\
---------------------------------------------------------------------------
\40\ GAO-18-352.
Monitoring: partially met. VA monitors the timeliness of
initial disability claims and legacy appeals, and has set timeliness
goals for some, but not all, of the appeal options under the new
process. VA's plans also signal how it intends to monitor the
allocation of staff for concurrent workloads in its legacy and new
appeals processes. However, as of April 2019, VA has yet to specify a
complete set of balanced goals for monitoring the new and legacy
appeals processes (including timely and accurate processing of appeals
while ensuring veteran satisfaction).
Demonstrated progress: partially met. VA reported it
reduced the backlog of initial disability claims from 611,000 in March
2013 to about 81,000 at the end of fiscal year 2018. However, VA's
Inspector General reported in September 2018 that VA overstated its
performance by only reporting about 79 percent of the backlog. For
appeals, VA addressed some gaps in its plan for implementing appeals
reform, in accordance with our 2017 and 2018 recommendations, and has
prioritized processing of legacy appeals. However, as of September
2018, VA still had a backlog of about 396,000 legacy appeals.
Updating disability benefit eligibility criteria. Since our 2017
High-Risk Report, VA's ratings for the action plan and monitoring
criteria regressed while the other three remain unchanged as of March
2019.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Leadership commitment: met. VA has sustained leadership
focus on updating its Veterans Affairs Schedule for Rating Disabilities
(VASRD)-used to assign degree of disability and compensation levels for
veterans with military service-connected injuries or conditions-to
reflect advances in medicine and labor market changes.
Capacity: partially met. In August 2017, VA officials
told us that it had taken actions to hire more staff for the
regulations updates and leverage outside researchers to evaluate
veterans' loss of earnings in the current economy. However, as of
September 2018, the agency was still working to hire these staff.
Moreover, VA's current earnings loss study covers only 8 of over 900
diagnostic codes and 2 of 15 body systems. VA needs to continue its
current hiring and earnings loss planning efforts to ensure it has the
capacity to comprehensively update the VASRD.
Action plan: partially met. In March 2019, the rating for
this criterion declined to partially met. As of April 2019, VA's
efforts to update the VASRD included new plans to conduct earnings loss
studies. Veterans Benefits Administration officials stated they
completed a study for eight diagnostic codes under two body systems,
and the agency is determining whether its current approach for
evaluating earnings loss is applicable to updating other diagnostic
codes. However, we lowered VA's prior rating of met to partially met
because its latest August 2018 updated plan, issued since our 2017
High-Risk Report, provided limited detail on key planned activities,
potentially jeopardizing its third attempt at modernization over the
past decade. For example, VA's plans do not indicate how and when VA
will assess the applicability of its current approach, and does not
include plans for updating earnings loss information for the remaining
diagnostic codes and body systems.
Monitoring: partially met. In March 2019, the rating for
this criterion declined to partially met. According to VA officials, VA
continues to track its progress toward finishing the medical updates by
fiscal year 2020 and has updated its project plan to reflect delayed
time frames. However, we lowered VA's prior rating for this criterion
from met to partially met because VA's plans have changed since our
last update, and although it is conducting a study to update earnings
loss information for some diagnostic codes and body systems, its plan
does not include timetables for monitoring these or future updates to
earnings loss information.
Demonstrated progress: partially met. VA reported that as
of December 2018, it promulgated final regulations for 6 of 15 body
systems, proposed regulations for 2, and is reviewing draft regulations
for the remaining 7. However, VA has fallen about 4 years behind in its
efforts to fully update the VASRD and has not completed earnings loss
updates.
Other Government- Wide High-Risk Areas Have Implications for VA
Operations
Several other government-wide high-risk areas include VA and its
operations. These areas include (1) improving the management of IT
acquisitions and operations, (2) strategic human capital management,
(3) managing Federal real property, and (3) ensuring the cybersecurity
of the nation.
Improving the management of IT acquisitions and
operations. The executive branch has undertaken numerous initiatives to
better manage the more than $90 billion that is annually invested in IT
across the government. However, our work shows that Federal IT
investments, including those made by VA, too frequently fail or incur
cost overruns and schedule slippages while contributing little to
mission-related outcomes. Thus, in 2015, we added improving the
management of IT acquisitions and operations to the High-Risk List.
\41\ To address the portion of the high-risk area for which it is
responsible, VA should, among other things, implement our past
recommendations on improving IT workforce planning practices and
establishing action plans to modernize or replace obsolete IT
investments. \42\
---------------------------------------------------------------------------
\41\ GAO-15-290.
\42\ GAO-19-157SP.
---------------------------------------------------------------------------
In August 2018, for example, we found that VA's policies did not
fully address the role of its CIO consistent with Federal laws and
guidance in the areas of IT workforce, IT strategic plan, IT budgeting,
and IT investment management. Until VA fully addresses the role of the
CIO in all of its policies, it will be limited in addressing
longstanding IT management challenges. We recommended that VA's IT
management policies address the role of the CIO for key
responsibilities in the four areas we identified. VA concurred with
this recommendation, which remains open. \43\
---------------------------------------------------------------------------
\43\ GAO, Federal Chief Information Officers: Critical Actions
Needed to Address Shortcomings and Challenges in Implementing
Responsibilities, GAO-18-93 (Washington, D.C.: Aug. 2, 2018).
Strategic human capital management. This area was added
to our High-Risk List in 2001 and continues to be at risk today because
mission-critical skills gaps both within Federal agencies and across
the Federal workforce are impeding the government from cost-effectively
serving the public and achieving results. \44\ As of December 2018, VA
reported an overall vacancy rate of 11 percent at VHA medical
facilities, including vacancies of over 24,000 medical and dental
positions and around 900 human resource positions. Also, with 32
percent of the VA workforce eligible to retire in the next 5 fiscal
years, VA must address these mission-critical skill gaps and vacancies
that we continue to identify in our work. \45\
---------------------------------------------------------------------------
\44\ GAO, High-Risk Series: An Update, GAO-01-263 (Washington,
D.C.: Jan. 1, 2001).
\45\ Percentage based on VA employees on board at the start of
fiscal year 2017.
---------------------------------------------------------------------------
In December 2016, for example, we found that VHA's limited human
resources capacity combined with weak internal control practices has
undermined VHA's human resources operations and its ability to improve
delivery of health care services to veterans. Further, VHA is
challenged by inefficiencies in its performance management processes,
including the lack of a performance appraisal IT system, which prevents
it from identifying trends and opportunities for improvement. VHA can
better support medical centers by establishing clear lines of
accountability for engagement efforts, collecting and leveraging
leading practices, and addressing barriers to improving engagement. We
made three recommendations to VA to improve its performance management
system. VA partially concurred with these recommendations, which remain
open. \46\
---------------------------------------------------------------------------
\46\ GAO, Veterans Health Administration: Management Attention Is
Needed to Address Systemic, Long-standing Human Capital Challenges,
GAO-17-30 (Washington, D.C.: Dec. 23, 2016).
Managing Federal real property. Since Federal real
property management was placed on the High-Risk List in 2003, the
Federal government has given high-level attention to this issue.
However, Federal agencies, including VA, continue to face long-standing
challenges, including (1) effectively disposing of excess and
underutilized property, (2) relying too heavily on leasing, (3)
collecting reliable real property data for decision making, and (4)
protecting Federal facilities.
In January 2019, for example, we reported that VA has enhanced its
data collection on vacant properties, but the agency does not collect
information needed to track and monitor disposal projects at the
headquarters level. Without information on the status of disposal
projects, VA cannot readily track and monitor its progress and identify
areas where facilities' managers may need additional assistance. As a
result, we recommended that VA improve its procedures related to
disposal of excess and underutilized property to help local facility
managers plan, implement, and execute projects to dispose of those
properties. In addition, VA should collect key information on the
status of these disposal projects to help manage the process and
identify areas where management attention is needed. VA concurred with
the three recommendations we made related to these findings, all of
which remain open. \47\
---------------------------------------------------------------------------
\47\ GAO, VA Real Property: Clear Procedures and Improved Data
Collection Could Facilitate Property Disposals, GAO-19-148 (Washington,
D.C.: Jan. 9, 2019).
Ensuring the cybersecurity of the nation. We have
designated information security as a government-wide high-risk area
since 1997. We expanded this high-risk area in 2003 to include
protection of critical cyber infrastructure and, in 2015, to include
protecting the privacy of personally identifiable information. Federal
agencies and our nation's critical infrastructures are dependent on IT
systems and electronic data to carry out operations and to process,
maintain, and report essential information. The security of these
systems and data is vital to public confidence and national security,
prosperity, and well- being. Because many of these systems contain vast
amounts of personally identifiable information, agencies must protect
the confidentiality, integrity, and availability of this information.
In addition, they must effectively respond to data breaches and
security incidents when they occur.
In May 2016, for example, we found that VA had developed a risk
assessment for their selected high-risk systems, but had not always
effectively implemented access controls. These control weaknesses
included those protecting system boundaries, identifying and
authenticating users, authorizing access needed to perform job duties,
and auditing and monitoring system activities. Weaknesses also existed
in patching known software vulnerabilities and planning for
contingencies. An underlying reason for these weaknesses is that the
key elements of information security programs had not been fully
implemented. VA concurred with all of our five recommendations related
to improving its cybersecurity controls. However, two recommendations-
which specifically call for the department to conduct security control
assessments and develop a continuous monitoring strategy-remain open.
\48\
---------------------------------------------------------------------------
\48\ GAO, Information Security: Agencies Need to Improve Controls
over Selected High- Impact Systems, GAO-16-501. (Washington, D.C.: May
18, 2016).
---------------------------------------------------------------------------
In November 2018, the department's inspector general reported that
VA had made progress in developing, documenting, and distributing
policies and procedures to support its security program, but identified
IT security as a major management challenge due to the persistence of
deficiencies. \49\ For example, the inspector general identified
significant deficiencies related to access, configuration management,
change management, and service continuity. In addition, VA's financial
statement auditor reported deficiencies in the department's IT security
controls as a material weakness for financial reporting purposes. \50\
The auditor has reported IT security controls as a material weakness
for more than 10 years.
---------------------------------------------------------------------------
\49\ Department of Veterans Affairs, Agency Financial Report Fiscal
Year 2018. (Washington, D.C.: November 26, 2018).
\50\ A material weakness is a deficiency, or combination of
deficiencies, in internal control, such that there is a reasonable
possibility that a material misstatement of the entity's financial
statements will not be prevented, or detected and corrected in a timely
basis.
---------------------------------------------------------------------------
VA's Transformational Efforts Are Ongoing
Since his confirmation in July 2018, Secretary Wilkie has
demonstrated his commitment to addressing the department's high-risk
designations by, among other things, creating an office to direct an
integrated approach for high-risk concerns and communicating to VA
leaders the importance of addressing our recommendations. Additionally,
VA leadership has also encouraged senior leaders to meet with GAO
subject matter experts from acquisition, performance, human capital,
and financial management, among other areas, to discuss leading
practices and VA's modernization efforts. In addition, senior leaders
from GAO and VA meet regularly to identify and address the root causes
of high-risk issues, and discuss the status of our recommendations and
VA's efforts to address them.
Fully addressing these issues will require sustained leadership
attention on these issues as well as leadership stability-something
that VA has not had in recent years. In particular, in the 2 years
prior to Secretary Wilkie's confirmation, VA experienced leadership
instability with senior- level vacancies in key positions, including
the Under Secretary for Health, CIO, and Deputy Under Secretary for
Health for Community Care.
In addition to sustained leadership, VA must develop action plans
for addressing the high-risk issues. \51\ As noted earlier, VA
officials have stated that they are currently working to address our
high-risk concerns through the implementation of the VHA Plan for
Modernization. The plan, which identifies high-level implementation
targets through 2020, provides a framework to address the Secretary's
four priorities: (1) improving training and customer service; (2)
implementing the VA MISSION Act and improving veterans' access to care;
(3) connecting the VA's electronic health records system to the DoD's
to ensure a continuum of care for transitioning service members; and
(4) transforming VA's business systems. As part of this effort, VA is
focused on ``10 lanes of effort,'' including transitioning to the same
electronic health record system the DoD is currently deploying, and
transforming its business systems- including its human resource
management, finance and acquisition management, and supply chain
functions-to improve the quality and availability of services at VA
medical centers. \52\
---------------------------------------------------------------------------
\51\ GAO-19-157SP.
\52\ The 10 lanes of effort for the VHA Plan for Modernization are
(1) Commit to Zero Harm; (2) Streamline VHA Central Office; (3) Develop
Responsive Shared Services; (4) Reduce Unwarranted Variation Across
Integrated Clinical and Operational Service lines; (5) Engage Veterans
in Lifelong Health, Well-Being and Resilience; (6) Revise Governance
Processes and Align Decision Rights; (7) VA MISSION Act: Improving
Access to Care; (8) Modernize Electronic Health Records; (9) Transform
Financial Management System; and (10) Transform Supply Chain.
---------------------------------------------------------------------------
In closing, VA has launched several significant efforts to address
many of the underlying management challenges it faces, including
transforming its electronic health record and financial management
systems, updating its medical surgical prime vendor program, and
implementing the VA MISSION Act. Any one of these efforts would be a
significant undertaking for an agency given their scope, time frames,
and costs, and VA is attempting to concurrently implement them. If
successful, these efforts could be transformative for VA. Sustained
congressional oversight of VA's efforts will also be needed. We stand
ready to support this oversight through continued monitoring of VA's
efforts as it ensures that the modernization efforts integrate and
address many of the concerns that led to the designation of various VA
areas as high risk.
Chairman Pappas, Ranking Member Bergman, and Members of the
Subcommittee, this concludes my statement. I would be pleased to
respond to any questions you may have.
GAO Contacts and Staff Acknowledgments
For further information about this statement, please contact Debra
A. Draper at (202) 512-7114 or [email protected] or Sharon M. M. Silas at
(202) 512-7114 or [email protected] for VHA health care issues; Shelby S.
Oakley at (202) 512-4841 or [email protected] for VA acquisition
management issues; or Elizabeth H. Curda at (202) 512-7215 or
[email protected] for VA disability claims issues. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this statement. Key contributors to this statement
were Ann Tynan, Mark Bird, David Bruno, Keith Cunningham, Cathleen
Hamann, Lisa Gardner, Steven Lozano, William Reinsberg, Maria Storts,
Jamie Whitcomb, Amanda Cherrin (Analyst-in-Charge), Kate Tussey, Jeff
Hartnett, and Teague Lyons. Vikki Porter and Jacquelyn Hamilton also
contributed to this statement.
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Prepared Statement of Michael J. Missal
Chairman Pappas, Ranking Member Bergman, and members of the
Subcommittee, thank you for the opportunity to discuss the Office of
Inspector General's (OIG's) oversight of the operations of the
Department of Veterans Affairs (VA). The mission of the OIG is to
conduct effective oversight of VA's programs and operations through
independent audits, inspections, reviews, and investigations.
This statement focuses on the processes the OIG uses to develop
recommendations that will assist VA in improving services and benefits
to veterans and their caregivers and families. Examples of critical
recommendations are highlighted, as well as OIG-identified Major
Management Challenges facing VA. OIG recommendations generally address
specific allegations or concerns in particular VA facilities, offices,
or programs. OIG reports focus not only on solutions to a defined
problem, but also identify the underlying root causes of issues that
negatively impact current programs and future initiatives whenever
possible. As a result, these recommendations may also be a road map
that other facilities, offices, or programs can follow to apply any
lessons learned across VA and to take corrective actions applicable to
other relevant VA operations.
In addition to using data to drive OIG oversight work, stakeholders
within VA and the larger veteran community-as well as Congress and
other oversight bodies-play an invaluable role in identifying problems
and pushing for implementation of recommendations for positive change.
This critical work would not be accomplished without congressional
support of OIG efforts through its appropriations and the attention
given to OIG reports and recommendations. The OIG looks forward to
working with its many stakeholders to advance recommendations for
improvement in all VA programs, services, and systems, including those
proposed in the 100 reports issued during the first half of fiscal year
(FY) 2019.
AUTHORITY AND PRINCIPLES GUIDING OIG RECOMMENDATIONS
The OIG was created by the Inspector General (IG) Act of 1978 and
strengthened through amendments to the IG Act in 1988, the IG Reform
Act of 2008, and the IG Empowerment Act of 2016. Pursuant to Section 4
of the United States Code Title 5 Appendix, the Inspector General is
responsible for
(1) conducting and supervising audits and investigations;
(2) recommending policies designed to promote economy and
efficiency in the administration of, and to prevent and detect criminal
activity, waste, abuse, and mismanagement in VA programs and
operations; and
(3) keeping the Secretary and Congress fully and currently informed
about significant problems and deficiencies in VA programs and
operations and the need for corrective action.
When developing recommendations, OIG staff focus on several key
principles, including the following:
First, carefully articulated recommendations are directed to the
specific VA office or program official that has the responsibility and
authority required to satisfactorily implement them. Recommendations
could be directed to anyone from the Secretary to a service line chief
at a medical facility. Recommendations must be clear, be capable of
execution, and specify who is accountable within VA for implementation.
While the OIG's recommendations may be narrowly addressed to a
particular VA facility or operation, VA should be disseminating
information about identified problems and remediation plans to
officials in all VA offices that could potentially have the same issues
and are positioned to take positive action.
Second, recommendations are contemporaneous with ongoing issues
and, except in rare circumstances, should not require more than one
year to implement from the report's publication. As explained later,
this helps align implementation with reporting requirements to
Congress, while also minimizing the risk that OIG recommendations
languish, become outdated, or lag behind VA policy and program changes.
In the instance that a recommendation would require implementation over
a longer period, VA and OIG staff work to develop implementation plans
that have quarterly milestones to support tracking progress towards
implementation.
Third, OIG recommendations are objective and nonpartisan-driven by
data, evidence, and all documentation that are collected and analyzed
in accordance with audit, inspection, and investigative standards. The
OIG's statutory independence allows it to determine which VA programs,
services, operations, and systems to examine that will have the
greatest impact on veterans' lives and taxpayers' investments, and to
then communicate those findings with Congress, VA's stakeholders, and
the public.
Finally, the OIG makes recommendations, but does not direct how
they are executed. It is important to note that OIG staff cannot
mandate that VA accept OIG recommendations or direct specific action to
carry them out. Consistent with this limitation, OIG reports may
contain recommendations for VA to ``take appropriate administrative
action'' against a specific VA employee for misconduct, but under
Federal law, VA leaders and managers are then responsible for
determining any appropriate administrative action. VA determines the
level of disciplinary or adverse actions to be taken, if any. The OIG
closes out these recommendations upon VA providing acceptable
documentation that no action was deemed necessary, that specific
administrative action was taken, or the individual left Federal
employment. VA leaders are solely responsible for managing VA and
setting its policy, including determining how best to implement OIG
recommendations. VA and the OIG may disagree about a specific
recommendation, but those situations are rare and are noted in the
published report.
OIG RECOMMENDATIONS DEVELOPMENT
When OIG staff perform an audit, review, inspection, or
administrative investigation, they conduct months of work that can
involve on-site inspections, interviews, document and record reviews,
data collection, and more. Using all information collected, staff
prepare a draft report with findings that are based on thorough,
objective, and balanced analyses. These reports usually include
recommendations for VA corrective action or improvement. The draft
report is typically sent to appropriate VA managers for review prior to
publication to ensure accuracy. This process provides VA an opportunity
to comment on the report's factual content and findings. The comments
also outline VA management's position on implementing OIG
recommendations and are included in the final OIG report. If management
concurs with the recommendation, their response must include an
implementation plan and a self-determined estimated date of completion.
OIG staff will then review the implementation plan to determine if it
satisfies the intent of the recommendation. In the event VA concurs
with an OIG finding but not the recommendation, VA will need to provide
an alternative action they believe will satisfy the intent of the
recommendation. The VA workplan to carry out the recommendation and
address the underlying finding is key to OIG staff's follow-up process,
as detailed later in this statement.
In some occasions, consistent with the OIG's statutory independence
from VA, a final report may be issued without VA's response or
concurrence of the findings and recommendations, or an acceptable
implementation plan. However, it is rare for VA to not concur with OIG
findings or recommendations, averaging just one percent of all
responses over FYs 2017, 2018, and 2019 to date. OIG staff and leaders
have open lines of communication with VA counterparts to resolve these
situations. If VA does not concur with a finding or recommendation, and
OIG staff cannot reach agreement with the VA office, OIG leaders will
escalate the matter with VA managers up to the Deputy Secretary, who is
the final VA deciding official, prior to publishing a report with
nonconcurrence on recommendations.
In addition, VA may ``concur in principle'' or ``partially concur''
with a recommendation, but OIG requires VA to clearly explain the
concern with the finding or recommendation (including a perceived
inability to implement) that is cause for the qualified response.
Overall, it is important for comments to make clear whether VA concurs
or nonconcurs with each finding, as well as with specific
recommendations.
TRACKING OIG RECOMMENDATIONS
OIG recommendations can be accessed in several ways. The most up-
to-date information can be found on the OIG website, www.va.gov/oig.
The recommendations webpage provides live tracking on the status of OIG
published reports and recommendations open for less than a year, open
for more than a year, and closed as implemented. \1\ This online
dashboard also provides the realized and potential monetary impact of
VA's implementation of OIG recommendations. The webpage search
functionality allows users to isolate reports with open
recommendations.
---------------------------------------------------------------------------
\1\ https://www.va.gov/oig/recommendation-dashboard.asp.
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Pursuant to the IG Act of 1978, the Semiannual Report (SAR) to
Congress presents the OIG's accomplishments during the prior six-month
reporting period. \2\ Within the SAR, the OIG lists all open
recommendations, including recommendations that have been open more
than one year.
---------------------------------------------------------------------------
\2\ An archive of SARs is available at https://www.va.gov/oig/
publications/semiannual-reports.asp.
---------------------------------------------------------------------------
On January 3, 2019, the Good Accounting Obligation in Government
Act (P. L. 115-414) was enacted, mandating each agency include in its
annual budget justification submitted to Congress an explanation for
the reasons why no final action has been taken regarding a Government
Accountability Office or OIG recommendation open more than 12 months,
as well as a timeline to implement the recommendation if the agency
concurred. It is expected that the agency budget justification will
include this information in the FY 2021 budget submission.
Current State of OIG Recommendations
As of March 31, 2019, there were 84 OIG reports and 403
recommendations that had been open less than one year. The total
monetary benefit associated with these recommendations is more than
$2.7 billion. Also, as of March 31, 2019, there were 40 reports and 133
recommendations that remained open for more than one year. The total
monetary benefit related to these reports is more than $329 million.
FOLLOW-UP PROCESSES
While there have been instances in which VA has resolved an issue
at the time of a report's publication, the vast majority of
recommendations take time to implement fully. To ensure completion, the
OIG engages its centralized follow-up staff to track the implementation
of all report recommendations with the responsible VA office. This
consolidated function helps ensure specially trained staff provide
consistent management of OIG follow-up activities, frees report authors
to work on other projects, and helps the OIG prepare timely and
accurate status reporting for the website, SAR, and other products.
Timelines
In addition to VA's comments on a draft report, the responsible VA
office provides a workplan describing the process and timeline for each
recommendation to be implemented. After the report is issued, the OIG
follow-up group is responsible for entering all this information into a
tracking system, analyzing the report's recommendations and VA
comments, and then preparing the appropriate documentation request to
the responsible VA office.
At quarterly intervals starting 90 days after report issuance, the
follow-up group requests the VA office provide an accounting of actions
taken to implement open recommendations, as well as whether the VA
office believes a recommendation may be closed. Each VA administration
and staff office maintains a point of contact for this process, which
helps with consistency in addressing implementation issues, tracking
progress, and coordinating the response of the VA office assigned the
recommendation. After receiving the VA office's report, the follow-up
staff draft a preliminary assessment to the responsible OIG office,
which wrote the report, as to whether any recommendations appear ready
to close. The responsible OIG office then reviews the materials and
provides a final determination whether any recommendations have been
satisfactorily implemented and can be closed. If the VA office does not
provide any response, follow-up staff can escalate the issue for
resolution by connecting OIG leaders to the appropriate VA leaders.
Recommendation Closure or Suspension
The responsible OIG office has the subject-matter expertise related
to the recommendation at issue, and no recommendation may be closed
without that office's approval. The decision to close a recommendation
is based on a review of VA's supporting documentation or independent
information obtained by OIG that indicates the corrective action has
occurred or progressed enough to show recommendation implementation.
For example, a recommendation to train employees on a particular issue
is not closed if the VA office says it will conduct the training, but
rather if the VA provides syllabus and scheduling documentation showing
adequately developed training is underway and will continue in a
systematic fashion.
In a very few cases, there may be a need for OIG leadership to
temporarily suspend follow-up activities or close recommendations as
``not able to be implemented.'' For example, suspension may be
warranted when a planned corrective action has gone stagnant due to
circumstances beyond the control of the VA office (such as the need for
a technology solution) and no viable alternatives exist, or if the
program materially changes or is terminated and so the recommendation
no longer applies. As mentioned earlier, if VA does not concur with a
recommendation following OIG outreach at report publication or during
follow-up, that nonconcurrence is noted and reported publicly and to
Congress. If a new report is issued that repeats not-yet-implemented
recommendations from a prior report, follow-up staff would close out
the initial recommendations and consolidate all recommendations related
to unresolved concerns into the new report.
Aligned with the schedule for preparing the SAR, follow-up staff
work with responsible OIG staff every six months to review open
recommendations to determine whether any problems exist in
implementation or whether circumstances would allow closure of any
recommendations. As needed, OIG staff can confer with VA offices to
examine the issues preventing implementation and work to revise related
implementation plans.
IMPACTFUL RECOMMENDATIONS AFFECT A RANGE OF VA PROGRAMS
OIG recommendations are directed at every level of VA operations,
affecting the quality and access to health care for more than 7 million
veterans; benefits for veterans with disabilities, their caregivers,
and family members; and the effective stewardship of appropriated
funds. They can be directed at individual facilities, regional
networks, or national program or administrative offices. The following
reports are highlighted to demonstrate how OIG staff perform sustained
follow-up on identified areas of weakness to ensure meaningful
improvement within VA.
Veterans Health Administration Examples
Critical Deficiencies at the Washington DC VA Medical Center. In
March 2017, the OIG received a confidential complaint and additional
subsequent allegations that the Washington DC VA Medical Center had
equipment and supply issues that could be putting patients at risk for
harm. The OIG conducted an inspection, issuing an interim report in
April 2017, and a final report in March 2018. \3\ The final report
provided findings in four areas: (1) risk of harm to patients, (2)
hospital service deficiencies affecting patient care, (3) lack of
financial controls, and (4) failures in leadership. These deficiencies
spanned many years, impacting the core medical center functions that
health care providers need to effectively provide quality care. In
particular, the report detailed the failure to ensure supplies and
equipment reached patient care areas when needed, in part due to the
facility's failure to use its inventory management IT system. The OIG
made 40 recommendations, and VA concurred with each one. While VA
provided detailed action plans on how the recommendations would be
implemented and identified progress made, of the 40 recommendations, 13
are still open as of May 14, 2019.
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\3\ Interim Summary Report, April 17, 2017; Critical Deficiencies
at the Washington DC VA Medical Center, March 7, 2018.
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This report was meant to not only improve conditions at the DC VA
Medical Center, but also to serve as a guide for other VA medical
facilities' logistical services and to improve integrated reviews and
oversight by Veterans Integrated Service Networks (VISNs) and VA
central offices.
Expendable Inventory Management System: Oversight of Migration from
Catamaran to the Generic Inventory Package. As a result of the
inventory management issues identified at the DC VA Medical Center, the
OIG conducted a national audit in which the audit team surveyed 21
medical centers and conducted unannounced on-site visits to 11 of those
21. They found other medical centers also encountered challenges as
part of the migration to a new inventory management system and that
significant discrepancies existed between actual inventory and the data
for tracking expendable medical supplies. \4\ Also, they found proper
inventory monitoring and management practices were lacking. Some of the
issues stemmed from the failure to provide adequate oversight of the
migration at the Veterans Health Administration (VHA) level, while
others stemmed from a lack of oversight from the VISN. The OIG's May 1,
2019, report included six recommendations to the Executive in Charge
for the Office of the Under Secretary for Health regarding inventory
distribution and controls, which VA is now implementing.
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\4\ Expendable Inventory Management System: Oversight of Migration
from Catamaran to the Generic Inventory Package, May 1, 2019.
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Veterans Crisis Line. The OIG is monitoring VA's delivery of mental
health care and the operations of its suicide prevention programs. The
OIG conducted a review of the Veterans Crisis Line (VCL) in 2016 and
again in 2017 because of VHA's inability to implement OIG
recommendations for this critical program in a timely manner, as well
as the receipt of additional allegations.
On March 20, 2017, the OIG issued Evaluation of the Veterans Health
Administration Veterans Crisis Line, reporting deficiencies in multiple
areas of the VCL's administration. \5\ Although the OIG was impressed
with the dedication of VCL staff assisting veterans and loved ones, the
OIG staff found VCL's management team faced significant obstacles
providing suicide prevention and crisis intervention services to
veterans, service members, and their families. The VCL's biggest
challenges included meeting the operational and business demands of
responding to over 500,000 calls per year, and training staff to assess
and respond to the needs of individual contacts with veterans and
family members under stressful, time-sensitive conditions.
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\5\ Evaluation of the Veterans Health Administration Veterans
Crisis Line, March 20, 2017.
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The OIG staff found deficiencies in the governance and oversight of
VCL operations following its realignment under VHA's Office of Member
Services, a business operations group with expertise in call center
operations. While VA leaders stated that Member Services and the Office
of Mental Health Operations would work closely together to manage VCL
services, the review found decisions were made with insufficient
clinical input. The OIG also identified internal quality assurance
deficiencies, including that there was an inadequate process to
collect, analyze, and effectively review relevant quality management
data to improve outcomes for callers. OIG staff made 16 recommendations
to VA to improve crisis intervention services for veterans in distress.
Among other weaknesses, the OIG identified in response to a complaint
that there was a failure to properly respond to a veteran during
multiple calls, resulting in missed opportunities to provide crisis
intervention services. The OIG closed out the report recommendations on
March 28, 2018, after accepting VA's implementation plan for the final
open recommendation.
It is important to note that the March 2017 report resulted, in
part, from VA's failure to implement prior OIG recommendations made in
a February 2016 report, Healthcare Inspection-Veterans Crisis Line
Caller Response and Quality Assurance Concerns, Canandaigua, New York.
\6\ The OIG's seven recommendations from the 2016 report remained open
for more than a year. OIG staff conducted the subsequent review because
the failure to implement previous recommendations was impairing the
VCL's ability to increase the quality of crisis intervention services
to callers. The OIG's February 2016 report recommendations were
eventually closed out on July 31, 2017.
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\6\ Healthcare Inspection-Veterans Crisis Line Caller Response and
Quality Assurance Concerns, Canandaigua, New York, February 11, 2016.
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Suicide Prevention. Many OIG reports also provide recommendations
for facilities after reviewing the care provided to individual
patients. The recommendations often can be used as guidance for other
facilities within the VA system as well. For example, a September 2018
Review of Mental Health Care Provided Prior to a Veteran's Death by
Suicide Minneapolis VA Health Care System, Minnesota examined the care
of a patient who died from a self-inflicted gunshot wound less than 24
hours after being discharged from an inpatient mental health unit. \7\
Even though the action plans had target implementation dates no later
than January 31, 2019, six of the seven recommendations remain open.
The recommendations for corrective action relate to care provider
coordination, accuracy of documentation, inclusion of family members in
a veteran's health care and discharge, and completion of analyses after
a tragic event.
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\7\ Review of Mental Health Care Provided Prior to a Veteran's
Death by Suicide Minneapolis VA Health Care System, Minnesota,
September 25, 2018.
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The OIG previously reported on the performance of multiple VHA
facilities by conducting a trends analysis of suicide prevention
programs. In an Evaluation of Suicide Prevention Programs in Veterans
Health Administration Facilities, the OIG examined suicide prevention
efforts in VHA facilities to assess facility compliance with relevant
VHA guidelines. \8\ OIG conducted this review at 28 VHA medical
facilities during its comprehensive assessment program reviews from
October 1, 2015, through March 31, 2016. The OIG found that most
facilities had a process for responding to referrals from the VCL and a
process to follow up on high-risk patients who missed appointments.
However, the OIG identified system weaknesses in areas such as outreach
activities; suicide prevention safety plan completion, content, and
distribution; flagging records of high-risk inpatients and notifying
the Suicide Coordinator of the admission; and evaluating high-risk
inpatients during the 30 days following discharge. The OIG's six
recommendations to the then-Acting Under Secretary for Health are now
closed.
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\8\ Evaluation of Suicide Prevention Programs in Veterans Health
Administration Facilities, May 18, 2017.
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Routine Inspections. The OIG continues to conduct unannounced
cyclical assessments of operations and quality control programs at VHA
medical facilities, now known as Comprehensive Healthcare Inspection
Program (CHIP) reports. These reports focus on leadership within a
facility and key factors that affect patient care, such as quality,
safety, and value; the credentialing and privileging process;
environment of care; and medication management. Additionally, the OIG
annually rotates high-interest topics in these fields, such as
posttraumatic stress disorder care, mammography results and follow-up,
and controlled substances inspection programs. \9\ OIG staff may also
conduct more frequent follow-ups to assess VA's progress in
implementing recommendations when a facility appears unable to address
OIG findings. These additional inspections help ensure issues do not
remain unresolved over long periods of time.
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\9\ Semiannual Report to Congress, Issue 80.
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For example, in May 2015, an OIG assessment of the VA St. Louis
Health Care System in Missouri identified 45 recommendations to address
concerns across the facility's operations. \10\ Due to the wide-ranging
issues, in November of the same year, OIG staff conducted another
review of the facility to assess progress on the action plans, with a
particular focus on quality and environment of care. \11\ While some
progress was noted, OIG staff made additional recommendations in those
areas of focus. OIG staff returned to the facility yet again in June
2016. In that report, the OIG made one recommendation related to the
environment of care. \12\ Finally, OIG staff conducted an inspection of
the facility in 2018 that resulted in seven recommendations, which have
all been closed. \13\
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\10\ Combined Assessment Program Review of the VA St. Louis Health
Care System, St. Louis, Missouri, May 18, 2015.
\11\ Combined Assessment Program Follow-Up Review of the VA St.
Louis Health Care System, St. Louis, Missouri, January 20, 2016.
\12\ Combined Assessment Program Follow-Up Review of Environment of
Care at the VA St. Louis Health Care System, St. Louis, Missouri,
January 18, 2017.
\13\ Comprehensive Healthcare Inspection Program Review of the VA
St. Louis Health Care System, Missouri, August 23, 2018.
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VISN Reviews. To augment oversight of VHA-related recommendations,
the OIG is launching routine reviews of VISNs. There is limited utility
to having medical facilities implement recommendations if those
corrective actions are not supported by the VISN. This expanded focus
on VISNs is meant to address the oversight and services that VISNs
provide all medical centers within their network that affect efficient
operations and quality patient care. After completing several
successful pilot visits, the OIG will be conducting unannounced reviews
for four VISNs during the remainder of FY 2019. OIG staff conducting
facility- and VISN-level inspections are engaging in coordination
efforts to ensure reports regarding medical facilities make relevant
connections to their VISN responsible for leadership, support, and
oversight. The reports will include recommendations to improve
accountability for the provision of high-quality health care.
Veterans Benefits Administration Examples
In October 2017, the OIG implemented a new national inspection
model for oversight of the Veterans Benefits Administration (VBA).
Previously, the OIG largely conducted oversight through inspections of
VBA's 56 regional offices. Under the new model, the OIG conducts
nationwide audits and reviews of high-impact programs and operations
within VBA to accomplish the following objectives:
Identify systemic issues that affect veterans' benefits
and services
Determine the root causes of identified problems
Make useful recommendations to drive positive change
across VBA
Since October 1, 2017, the OIG has published 19 VBA-related
oversight reports. VBA has generally concurred with the recommendations
and provided acceptable action plans, with the closure of most
recommendations that have been open for over one year.
Two recent OIG reports regarding VBA claims processing for complex
claims related amyotrophic lateral sclerosis (ALS or Lou Gehrig's
disease) and to military sexual trauma (MST) demonstrate the value of
OIG recommendations. In 2016, VBA moved to a National Work Queue (NWQ)
for the processing of disability compensation claims. Previously, VBA
used Segmented Lanes to process claims. Under that approach,
specialized claims, like those for MST and ALS, were routed to staff
experienced with those claims. Under the NWQ, VBA no longer directed
complex claims to specialized teams, but rather distributed daily to
each VA regional office (VARO) new claims, which the VARO then assigned
to processors by workload. These OIG reports detail how national policy
changes have had negative impacts on claims processing. While well-
intentioned efforts to expedite overall benefits processes were carried
out, there was an unintended impact on VBA's ability to review and
process certain claims accurately.
Accuracy of Claims Involving Service-Connected Amyotrophic Lateral
Sclerosis. In November 2018, the OIG examined whether VBA accurately
decided veterans' claims involving service-connected ALS. \14\ VA
describes ALS as a rapidly progressive neurological disease that
attacks the nerve cells responsible for directly controlling voluntary
muscles. Because a statistical correlation was found between military
service activities and the development of ALS, VA established a
presumption of service connection for this disease in 2008. Thus,
veterans who develop the disease during service, or any time after
separation from military service, generally receive benefits if they
had active and continuous service of 90 days or more. Although VBA
prioritizes these claims, staff must also accurately decide these
claims because it is a serious condition that often causes death within
three to five years from the onset of symptoms.
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\14\ Accuracy of Claims Involving Service-Connected Amyotrophic
Lateral Sclerosis, November 20, 2018.
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OIG staff reviewed a statistical sample of 100 veterans' cases
involving service-connected ALS from April through September 2017. The
team found that VBA staff made 71 errors involving 45 veterans' ALS
claims, projecting that 430 of 960 total ALS veterans' cases had
erroneous decisions. For example, rating personnel incorrectly decided
ALS claims related to one or more of the following categories:
Special monthly compensation benefits
Evaluations of medical complications of ALS
Effective dates
Additional benefits related to adapted housing or
automobiles
Inaccurate or conflicting information in decisions
Proposals to discontinue service connection
These errors resulted in estimated underpayments of about $750,000
and overpayments of about $649,000 over a six-month period, for a
potential $7.5 million in underpayments and $6.5 million in
overpayments over a five year period. Also, VBA staff generally did not
tell veterans about available special monthly compensation benefits.
Most rating personnel indicated that they do not often receive claims
involving ALS or higher levels of special monthly compensation, which
makes these claims more difficult to evaluate. The Under Secretary for
Benefits concurred with the OIG's two recommendations to implement a
plan to improve and monitor decisions involving service-connected ALS
and to provide notice regarding additional special monthly compensation
benefits that may be available. These recommendations are still open.
Denied Posttraumatic Stress Disorder Claims Related to Military
Sexual Trauma. In August 2018, the OIG reviewed VBA's denied PTSD
claims related to veterans' MST to determine whether staff correctly
processed the claims. \15\ Some service members are understandably
reluctant to submit a report of MST, particularly when the perpetrator
is a superior officer. Service members may also have concerns about the
potential for negative performance reports or punishment for collateral
misconduct. There is also sometimes the perception of an unresponsive
military chain of command. If the MST leads to PTSD, it is often
difficult for victims to produce evidence to support the assault's
occurrence. VBA policy correctly requires staff to follow additional
steps for processing MST-related claims so veterans have further
opportunities to provide adequate evidence.
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\15\ Denied Posttraumatic Stress Disorder Claims Related to
Military Sexual Trauma, August 21, 2018.
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VBA reported that it processed approximately 12,000 claims per year
over the last three years for PTSD related to MST. In FY 2017, VBA
denied about 5,500 of those claims (46 percent). The OIG review team
assessed a sample of 169 MST-related claims that VBA staff denied from
April through September 2017. The review team found that VBA staff did
not properly process veterans' denied MST-related claims in 82 of 169
cases. As a result, the OIG estimated that VBA staff incorrectly
processed approximately 1,300 of the 2,700 MST-related claims denied
during that time (49 percent). The OIG found that multiple factors led
to the improper processing and denial of MST-related claims. Included
among these factors were the lack of reviewer specialization, lack of
an additional level of review, discontinued special focused reviews,
and inadequate training.
The OIG made six recommendations to the Under Secretary for
Benefits including that VBA review all approximately 5,500 MST-related
claims denied from October 2016 through September 2017, take corrective
action on those claims in which VBA staff did not follow all required
steps, assign MST-related claims to a specialized group of claims
processors, and improve oversight and training on addressing MST-
related claims. The Under Secretary concurred with the recommendations
and has already taken steps to address them, particularly in the area
of training, with four recommendations currently still open. The Under
Secretary also stated that, in FY 2019, VBA will review every denied
MST-related claim decided since the beginning of FY 2017.
STEWARDSHIP OF APPROPRIATED FUNDS EXAMPLES
While some OIG recommendations focus primarily on improving quality
of care for veterans, or program effectiveness, others emphasize
deficiencies in the efficient use of taxpayer dollars or misusing
appropriated funds. Several examples follow demonstrating the need for
more effective controls, stronger oversight practices, and greater
accountability so that VA funding is put to the most efficient and
effective use to the benefit of veterans, their caregivers, and
families.
VA's Oversight of State Approving Agency Program Monitoring for
Post-9/11 GI Bill Students. A December 2018 OIG report examined the
effectiveness of VA and State Approving Agencies' (SAAs') monitoring of
participating educational programs, which identified serious concerns,
including gaps in approval practices that led to ineligible and
potentially ineligible schools participating in the program. \16\ The
OIG conducted this audit to determine if VA and SAAs were effectively
reviewing and monitoring education and training programs that enrolled
Post-9/11 GI Bill students to ensure only eligible programs
participated. Prior OIG reports noted financial risks for these
programs. \17\ Based on its review, the OIG estimated that 86 percent
of SAAs did not adequately oversee the education and training programs
to make certain only eligible programs participated. In total, the
audit team projected that VBA annually issues an estimated $585 million
in related improper Post-9/11 GI Bill tuition and fee payments to
ineligible or potentially ineligible schools and that $473.8 million of
this amount will be paid to for-profit schools. \18\ Oversight
deficiencies occurred, in part, because VBA maintained it has a limited
role for oversight of SAAs. The OIG recommended clarifying requirements
for approvals, requiring periodic re-approval of programs, reporting
schools with misleading advertising, strengthening compliance surveys
for program eligibility, revising program assessment standards, and
confirming that SAA funding can support the recommended steps. Of
those, one recommendation has been closed as implemented, and OIG staff
are monitoring VBA's progress on the remaining five.
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\16\ VA's Oversight of State Approving Agency Program Monitoring
for Post-9/11 GI Bill Students, December 3, 2018.
\17\ Id. at 49-50.
\18\ ``Under OMB Circular A-123, App. C, Pt. I-A, Risk Assessing,
Estimating, and Reporting Improper Payments, (October 20, 2014),
improper payments are payments that should not have been made or were
made in an incorrect amount under statutory, contractual,
administrative, or other legally applicable requirements; payments made
to ineligible recipients; and payments where an agency's review is
unable to discern it is proper due to insufficient documentation.'' Id.
at 3.
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Audit of Compensation and Pension Benefit Payments to Incarcerated
Veterans. On occasion, OIG staff audit programs and monitor
recommendation implementation, but continue to receive allegations of
specific acts of wrongdoing through the OIG Hotline. In June 2016, the
OIG audited whether VBA was adjusting compensation and pension (C&P)
benefit payments for veterans incarcerated in federal, state, and local
correctional institutions in a timely manner and as required by Federal
law. \19\ The OIG identified program weaknesses and determined that VBA
did not consistently take action to adjust C&P benefits for
incarcerated veterans as legally required. VBA's ineffective actions in
processing incarceration adjustments resulted in significant improper
benefit payments totaling more than $100 million. If conditions
remained the same and improvements were not made, VBA could have made
additional inaccurate payments (improper payments) of more than $200
million over a 5-year period from FY 2016 through FY 2020. The report's
six recommendations are now closed.
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\19\ Audit of Compensation and Pension Benefit Payments to
Incarcerated Veterans, June 28, 2016.
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However, this was not the first time OIG reported on problems with
C&P benefit payments adjustments. In 1986 and 1999, OIG identified
similar issues with C&P benefit payments to incarcerated veterans, and
VA provided remediation plans. \20\ Because problems in this area have
tended to reoccur or new problems emerge, the OIG continues to identify
and follow up on similar improper payments reported through the OIG
Hotline. One recent example involves a veteran improperly receiving
$46,200. \21\
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\20\ Evaluation of Benefit Payments to Incarcerated Veterans,
February 5, 1999.
\21\ Semiannual Report to Congress, Issue 80.
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MAJOR MANAGEMENT CHALLENGES
Each year, pursuant to Section 3516 of United States Code Title 31,
the OIG provides Congress with an update summarizing the most serious
management and performance challenges identified by OIG work as well as
an assessment of VA's progress in addressing them. \22\ These
challenges are aligned with the OIG's six areas of focus outlined in
its strategic plan: (1) leadership and workforce investment, (2) health
care delivery, (3) benefits delivery, (4) financial management, (5)
procurement practices, and (6) information management.
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\22\ U.S. Department of Veterans Affairs Office of Inspector
General Management and Performance Challenges, November 2018.
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The OIG has made VA leadership and governance a top priority in
recognition that deficiencies in these areas ultimately affect the care
and services provided to veterans and allow significant problems to
persist unresolved for years. And, as in prior years, access to health
care remains a significant challenge for VA. This is a particular
concern as prodigious changes are underway for expanding community care
and enhancing access to care in VA facilities and as VA implements
changes to its benefit appeals process. The OIG has noted specific
progress in quality improvement and patient care processes during CHIP
inspections and other work in individual facilities, yet deficiencies
remain in other areas affected by inadequate staffing and IT systems.
The OIG has also focused on problems identified VA-wide regarding
information management, financial management, and procurement practices
that, while critical to VA carrying out its missions, have been at the
heart of failures in providing medical care and a range of benefits and
services to veterans and their families. OIG audits and reviews, such
as the audit of VA's consolidated financial statements, as required
under the Chief Financial Officer's Act and the review of VA's
compliance with the Improper Payments Elimination and Recovery Act,
establish that eliminating continued shortfalls in VA's financial
management systems would improve VA's effectiveness at using
appropriated funds to benefit veterans. \23\
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\23\ Audit of VA's Financial Statements for Fiscal Years 2018 and
2017, November 26, 2018; VA's Compliance with the Improper Payments
Elimination and Recovery Act for FY 2017, May 15, 2018.
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CONCLUSION
A strength of the OIG's oversight work is the commitment to
identifying underlying causes, which is the foundation for developing
meaningful and comprehensive recommendations. By addressing these
causes, VA can more effectively address not only the symptoms but
prevent future occurrences. The OIG has commonly found the following
through its oversight work:
Poor governance structures
Lack of continuity of leadership
Failure to communicate effectively
Failure to ensure accountability
Poor financial management
IT failures and not using IT effectively
Poor planning and forecasting
Failure to anticipate the consequences of policy changes
HR and staffing issues
Poor training
Poor quality assurance
Inadequate, outdated, conflicting, or absent policies
Culture of complacency
Bureaucracy ahead of veterans
The OIG is committed to serving veterans and the public by
conducting effective oversight of VA programs and operations through
independent audits, inspections, reviews, and investigations. That
commitment can only be realized by making practical, meaningful
recommendations that enhance VA's programs and operations as well as
prevent and address fraud, waste, and abuse.
Mr. Chairman, this concludes my statement. I would be happy to
answer any questions you or other members of the Subcommittee may have.
STATEMENTS FOR THE RECORD
ROBERT WILKIE
The Department of Veterans Affairs (VA) appreciates the work of the
U.S Government Accountability Office (GAO) and the VA Office of
Inspector General (OIG) to help the Department make improvements to
programs throughout our enterprise that facilitate more effective and
efficient services and benefits to our Nation's Veterans. VA has a
strong collaborative relationship with both GAO and OIG. VA treats all
recommendations seriously and strives to implement the concurred upon
recommendations in a timely manner.
The Department would have liked to participate in this hearing;
unfortunately, to do so would have been contrary to the longstanding
practice of prior Administrations and this Administration by allowing
Executive Branch officials to testify at a Congressional hearing on a
panel that includes non-Executive Branch witnesses.
According to GAO, VA leads the Federal government with a 90 percent
recommendation implementation rate. In March 2019, GAO issued its
biennial high-risk report in which GAO added VA Acquisition Management
as a high-risk area. This is the third high-risk area for VA-Managing
Risks and Improving VA Health Care was added in 2015, and Improving and
Modernizing Federal Disability Programs was added in 2003. The
Department is committed to implementing all concurred upon GAO
recommendations and moving off of GAO's high-risk list. In November,
Secretary Wilkie met with the Comptroller General to discuss the high-
risk report areas and high priority recommendations. During that
meeting, Secretary Wilkie assured the Comptroller General that the
Department appreciates GAO's work and that VA is working on taking
corrective action on all open GAO recommendations.
With regard to the GAO high priority recommendations, in 2018, GAO
identified 26 priority recommendations. Since that time, VA implemented
5 of the 26 open priority recommendations and GAO closed 1 priority
recommendation on a program that recently underwent significant
statutory changes. When GAO issued its March 2019 priority open
recommendations report, VA had 20 open priority recommendations and GAO
added 10 new priority recommendations bringing the total to 30 priority
recommendations. VA provides GAO with updates on all open priority
recommendations. Within the Department, several initiatives are
underway to more directly focus administrations and staff offices on
the development of milestones and metrics and demonstrated progress on
implementing GAO recommendations. VA leaders and staff meet
periodically with GAO to discuss VA's efforts to implement action plans
related to open recommendations and receive feedback from GAO on the
progress being made.
The VA OIG is the independent oversight entity within VA that
conducts reviews and recommends improvements that are designed to
promote economy, efficiency, and effectiveness throughout VA programs
and operations. The VA OIG issues hundreds of reports and
recommendations each year involving programs throughout the VA
enterprise. During the last 12 months, OIG issued 128 reports with 715
recommendations on VA programs and operations. The administrations and
staff offices work with OIG inspectors and investigators to come to
agreed upon corrective action plans to resolve audit recommendations.
The Department strives to complete OIG recommendations with the same
urgency as all oversight recommendations.
In June 2017, the Department of Veterans Affairs Accountability and
Whistleblower Protection Act was enacted. The Act, among other things,
statutorily established the Office of Accountability and Whistleblower
Protection (OAWP) and codified its establishment under section 323 of
title 38 of the United States Code (U.S.C.). As prescribed by Congress
under 38 U.S.C. Sec. 323(c)(1)(F), one of OAWP's core functions is to
record, track, review, and confirm ``implementation of recommendations
from audits and investigations carried out by [VA OIG], the Medical
Inspector of the Department, the Special Counsel, and the Comptroller
General of the United States, including the imposition of disciplinary
actions and other corrective actions contained in such
recommendations.'' The Department is currently working on establishing
processes to create this functionality within OAWP which would enhance
oversight on the implementation of recommendations issued by, among
other entities, GAO and VA OIG. The Department looks forward to
updating the Committee on its implementation.
Conclusion
Our mission is to serve our Veterans. We are committed to taking
corrective action on all oversight recommendations to ensure that VA is
the most efficient and effective organization possible for our
Veterans. Your continued support is essential to providing the best
services and benefits for Veterans and their families.
Overview and Comparison of the Department of Veterans Affairs (VA) and
the Department of Defense (DOD) Graduate Medical Education (GME)
Programs
Key Points of Comparison between VA and DOD GME Programs
In contrast with DOD, which administers its own residency
programs, VA generally does not sponsor or administer residency
programs. Instead, the VA physician training program is administered
through affiliations with academic institutions and teaching hospitals.
VA does not directly pay salaries to the medical
residents that rotate through its facilities. Instead, VA uses
disbursement agreements to reimburse affiliated institutions for the
health care services provided at VA medicals centers (VAMC) by medical
residents. The affiliate institutions are ultimately responsible for
administering salaries to their GME participants that are completing
rotations at VAMCs.
Medical residents who participate in VA's GME program
have no service obligation to VA after the completion of their
residency programs.
VA GME Program Overview
The Veterans Health Administration (VHA) GME program is carried out
through coordinated programs and activities in partnership with
affiliated U.S. academic institutions (affiliates), such as medical
schools and teaching hospitals.
While VHA's GME program is administered by its Office of
Academic Affiliation (OAA), VAMCs enter into separate affiliation
agreements with each affiliate-under which the VA medical center and
the affiliate agree to share responsibility for the academic program.
In the vast majority of cases, VAMCs do not serve as the
primary sponsor and training site for medical residents. VA reports
that 99 percent of its GME programs are sponsored by an affiliate.
Residents complete service rotations at VAMCs that are
affiliated with their academic institution.
VAMCs enter into disbursement agreements with the
affiliates in order to reimburse them for services provided by
residents rotating through the VA medical centers. VA reports that its
GME program is affiliated with 144 of the 152 accredited allopathic
medical schools and all 34 of the accredited osteopathic medical
schools in the United States.
Number of residents in the pipeline. VA is the largest provider of
medical training in the United States.
VHA statistics for the 2017-18 academic year show that
45,296 medical residents trained at VAMCs.
Physician residents represent approximately 50 percent of
the total number of physicians working in VA facilities.
The Veterans Access, Choice, & Accountability Act of 2014
authorized the addition of up to 1,500 additional physician residency
positions over a ten year period, with a focus on medical specialties
and geographic locations of high priority for VA. Through the first
five years of this effort, VHA had approved 1,055 additional physician
resident positions.
Recruitment of VA Physicians through GME
Lack of a service requirement. Medical residents who participate in
VA's GME program have no service obligation to VA after the completion
of their residency programs. However, VA sees its GME program as having
a major impact on developing the VA health care workforce.
In our 2017 report on VHA physician staffing and
recruitment, agency officials noted that access to the GME pool of
potential hires serves as an important recruitment resource. \1\
---------------------------------------------------------------------------
\1\ See GAO, Veterans Health Administration: Better Data and
Evaluation Could Help Improve Physician Staffing, Recruitment, and
Retention Strategies, GAO-18-124 (Washington, D.C.: Oct 19, 2017).
Additionally, officials reported that physician training
programs provide current physicians with teaching opportunities that
also bolster recruitment and retention.
VA reports that about 60 percent of its physicians
participated in VA training programs prior to employment.
According to the VA Trainee Satisfaction Survey completed
by more than 23,000 trainees during the 2016-17 academic year, 73
percent of respondents indicated a willingness to work at VA after
their VA clinical training experience.
Recruitment challenges. Despite VHA's large and expanding graduate
medical training program, VAMCs experience difficulties hiring
physicians who receive training through its residency programs. We have
reported on some of these difficulties in physician recruitment,
including barriers to recruiting VA GME participants for permanent
employment after the completion of their residency programs.
In October 2017, we reported that VHA did not track the
number of physician trainees who were hired following graduation, but
VA officials stated that the number was small in comparison to the
almost 44,000 physician trainees educated at VAMCs each year. \2\
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\2\ See GAO-18-124.
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We found that VAMCs faced challenges hiring physician
trainees, in part, because VHA did not share information on graduating
physician trainees for recruitment purposes with VAMCs across the
system.
Our October 2017 report also described delays in VAMCs'
hiring offers to graduates. Agency officials noted that VAMCs could not
make employment offers to medical resident trainees until they had
completed their training programs. Competitors often make hiring offers
as early as trainees' second year of residency, according to VAMC
officials.
VHA officials said some VAMCs use existing policy
flexibilities to recruit trainees more proactively by making early
hiring offers that are contingent on the trainee meeting certain
conditions, such as completing training, and that these actions improve
the likelihood of successful recruitment.
Other Recruitment and Retention Efforts-National Recruitment Service
and Financial Incentives
VHA has a National Recruitment Service within VHA's Workforce
Management and Consulting Office.
In fiscal year 2016, the National Recruitment Service,
comprised of 19 VHA physicians, referred 2,200 candidates to VAMCs,
which resulted in 325 physicians hired, according to VHA officials.
VHA uses a variety of financial incentives to recruit new
physicians.
Financial incentives include market-based salaries, an
education debt reduction program, bonus pay for recruitment, retention,
and relocation, and continuing medical education funding.
The VA MISSION Act of 2018 created two new scholarship
opportunities and a loan repayment program to recruit medical students
and residents.
The Veterans Healing Veterans Medical Access and
Scholarship Program provides four years of tuition, fees, and stipend
support for two veterans at nine medical schools in exchange for four
years of clinical practice at a VA facility after completion of a
residency and/or fellowship.
The VA Health Professions Scholarship Program provides
annual medical or dental school scholarships (tuition, fees, and
stipend) in exchange for 18 months of service at a VA facility for each
year of support.
The Specialty Education Loan Repayment Program is a loan
repayment program targeted towards physician residents. Its purpose is
to provide VA with needed medical specialists in geographic areas and
VA facilities where VA needs those specialists. Applicants can apply
right after the residency match or up to two years before completion of
the residency. The program can repay up to $160,000 of education loans
total; each year of service at a VA facility qualifies for $40,000 in
loan repayment, with a minimum of two years of service required.
In our October 2017 report, we recommended that VHA
conduct a comprehensive, system-wide evaluation of the physician
recruitment and retention strategies used by VAMCs to determine their
overall effectiveness, identify and implement improvements, ensure
coordination across VHA offices, and establish an ongoing monitoring
process.
VHA concurred with our recommendation, and in May 2019,
VHA submitted an evaluation of its physician recruitment and retention
programs. The report covered the use of the Education Debt Reduction
Program, physician pay tables, and recruitment, retention, and
relocation incentives. One result of the evaluation is that VHA
provided Veterans Integrated Service Networks with recommendations on
how to efficiently allocate their recruitment, retention, and
relocation incentives.
Other health professions: VAMCs serves as training sites for other
health professions, including dentistry, nursing, and social work,
among others. VA statistics from the 2017-18 academic year indicate
that 49,958 individuals participated in dental, nursing, or associated
health profession training at VAMCs.
For more information about VHA's GME program contact Sharon M.
Silas at (202) 512-7114 or [email protected], and for more information
about VHA physician staffing and recruitment, contact Debra A. Draper
at (202) 512-7114 or [email protected].
DOD GME Programs
Military Residency Programs
The military services' GME programs provide specialty training to
medical school graduates who agree to an active duty service
obligation. Through GME programs, military medical officers acclimate
to the military while developing core competencies and critical wartime
medical readiness skills, such as combat casualty care and treatment of
injuries from explosive or biological incidents. According to military
service officials, specialty training through GME programs is an
important recruitment and retention tool because it may encourage
continued service beyond the fulfillment of the initial active duty
service obligation. Programs are accredited by and follow the standards
of the Accreditation Council for Graduate Medical Education, a civilian
organization, and managed by each respective military services. The
military services generally partner with civilian teaching hospitals,
where residents rotate for training in areas or populations not seen at
a DOD hospital.
Service requirement: While in a military residency
program, participants incur an additional 6 months of active duty
service obligation for each 6 months in training, with a minimum of 2
years active duty service obligation.
Number of residents: In fiscal year 2018, there were
3,189 residents and fellows enrolled in DOD GME programs, training in
70 specialties, at military treatment facilities. \3\
---------------------------------------------------------------------------
\3\ An additional 23 specialties did not have any residents in
fiscal year 2018. The count of students only includes residents and
fellows at military treatment facilities, although residents and
fellows may be trained in civilian GME programs as well. See GAO,
Defense Health Care: DOD's Proposed Plan for Oversight of Graduate
Medical Education Programs, GAO-19-338 (Washington, D.C.: Mar. 28,
2019).
The National Defense Authorization Act for Fiscal Year 2017 (NDAA
2017) directed the Secretary of Defense to establish and implement a
process to oversee GME programs, and transferred administrative and
management responsibility for military treatment facilities from the
military services to the Defense Health Agency and requires the agency
to assume responsibility for the policy, procedures, and direction of
GME programs. However, each military service's medical command remains
responsible for recruiting, organizing, training, and equipping their
medical personnel.
While we have done recent work on DOD's proposed plan for oversight
of GME programs, we have not done work on DOD's GME/residency programs.
The following is related work specific to medical students.
DOD Programs for Medical Students
In addition to recruiting medical school graduates, DOD's two
primary programs for creating a pipeline of future military physicians
are its scholarship program, managed by the services-the Armed Forces
Health Professions Scholarship Program (AFHPSP)-and DOD's sponsored
medical school-the Uniformed Services University of the Health Sciences
(USUHS). \4\
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\4\ For more information about these programs and the data that
follow, see GAO, Military Personnel: Additional Actions Needed to
Address Gaps in Military Physician Specialties, GAO-18-77 (Washington,
D.C.: Feb 28, 2018).
Benefits and service requirement: AFHPSP medical students
receive a monthly stipend and incur an obligation to serve 6 months of
active duty service for each 6 months of benefits received, with a 2-
year minimum obligation. \5\ In addition, DOD pays for all qualified
educational expenses, including tuition, books, and fees. USUHS medical
students receive the pay and benefits of an officer at the O-1 level
and incur a minimum 7-year service obligation. Most AFHPSP and USUHS
participants go on active duty and perform their GME training at
military hospitals, although some AFHPSP participants are granted
deferments while they pursue civilian GME.
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\5\ There are some exceptions to active duty service obligation
incurred. For example, Department of Defense Instruction 6000.13 states
that an AFHPSP participant may serve his or her service obligation in a
component of the Selected Reserve for a period twice as long as the
participant's remaining active duty obligation.
---------------------------------------------------------------------------
Number of medical students: The services reported that
they generally met their recruitment goals for AFHPSP, and that the
program enabled DOD to successfully recruit approximately 800 to 850
medical students per year from fiscal years 2011 to 2016. Further,
USUHS successfully recruits an additional 170 medical students per
year.
Recruitment challenges: However, although the services
report that they are generally meeting their AFHPSP recruitment goals,
we found that they are not recruiting the maximum number of
participants (that is, 2,100) they are allowed. Instead, for fiscal
years 2011 through 2015, the Army enrolled in its program approximately
71 percent to 85 percent of the maximum allowed; the Navy about 59
percent to 63 percent; and the Air Force approximately 70 percent to 79
percent.
Officials from these services cited various factors that
limit their ability to recruit the maximum number of participants they
are allowed-such as restrictions on the number of physicians they are
authorized to bring into the military in any given year; concern that
increasing AFHPSP goals could reduce the overall quality of medical
student recruits; and the limited number of slots available in military
GME programs-making it difficult to place an increased number of AFHPSP
participants in these residency programs.
Medical students who do not meet their service
requirement: In 2008, we examined the number of participants in two DOD
programs who do not enter active duty following completion of the
program of studies for which they were enrolled, including the extent
to which the military services have sought and received reimbursement
for stipends or annual grants paid. \6\
---------------------------------------------------------------------------
\6\ See GAO, Military Personnel: Better Debt Management Procedures
and Resolution of Stipend Recoupment Issues Are Needed for Improved
Collection of Medical Education Debts, GAO-08-612R (Washington, D.C.:
Apr. 1, 2008).
---------------------------------------------------------------------------
Our analyses of service and Defense Finance and
Accounting Service data showed that, for fiscal years 2003 through
2007, fewer than 1 percent (171) of the total number of participants
(19,921) withdrew from the programs or, alternatively, graduated but
did not go on to active duty service.
Upon withdrawal or release from the program, participants
are obligated to reimburse the government for all or some portion of
their medical education expenses unless relieved of that obligation by
their respective service secretary. We found that DOD has procedures in
place to recoup medical education expenditures from participants who
fail to complete their education or serve their active duty obligation,
and many cases we reviewed were processed in a timely manner. However,
in some cases, it took more than 5 years from the time recoupment
actions on individuals' debts were initiated until the time the Defense
Finance and Accounting Service established an official debt account and
began collection efforts.
At that time, we made five recommendations to strengthen
DOD's debt collection efforts, all of which DOD has since implemented.
Retention challenges: Nonetheless, we also found that
retaining fully qualified physicians is challenging for the military
services, and that the added stresses of deployments and the general
perceptions of war, along with the potential for health care providers
to earn significantly more money in the private sector, have caused
some physicians to separate from military service once they have
fulfilled their service obligations. \7\
---------------------------------------------------------------------------
\7\ See GAO-08-612R, and GAO, Military Personnel: Status of
Accession, Retention, and End Strength for Military Medical Officers
and Preliminary Observations Regarding Accession and Retention
Challenges, GAO-09-469R (Washington, D.C.: Apr. 16, 2009).
---------------------------------------------------------------------------
Examples of Other Military Physician Recruitment Programs
Financial Assistance Program (FAP). Provides annual
grants of up to $45,000 and monthly stipends of more than $2,000 for
physicians accepted or enrolled in a residency program. Participants
incur a minimum 2-year active duty obligation or 6-month active duty
obligation for every 6 months or portion thereof of FAP sponsorship,
whichever is greater. FAP participants will serve on active duty in a
grade commensurate with their educational experience. Participants
receive full pay and allowances for their respective grades for a
period of 14 days active duty for annual training performed for each
year of participation.
Health Professions Loan Repayment Program. Provides
repayment of educational loans for fully qualified health
professionals. Participants incur a 2-year active duty obligation or 1
year of active duty obligation for each year of repayment, whichever is
greater.
Specialized Training Assistance Program. Provides a
monthly stipend of more than $2,000 for physicians in designated
specialties currently accepted or enrolled in a residency program.
Participants incur a 1-year obligation in the Army Selected Reserve for
every 6 months or portion thereof of financial assistance.
For more information about DOD's GME programs or physician
recruitment, contact Brenda S. Farrell, (202) 512-3604 or
[email protected].
Succession Planning
The most recent work we have on succession planning is Human
Capital: Selected Agencies Have Opportunities to Enhance Existing
Succession Planning and Management Efforts, GAO-05-585. This work
included a review of how four agencies including the Census Bureau,
Department of Labor (DOL), Environmental Protection Agency (EPA) and
Veterans Health Administration (VHA) are implementing succession
planning and management efforts. Key findings include:
All four agencies had implemented succession planning and
management efforts that collectively are intended to strengthen
organizational capacity. However, in light of governmentwide fiscal
challenges, we found that the agencies had opportunities to enhance
some of their succession efforts.
While all of the agencies assigned responsibility for
their succession planning and management efforts to councils or boards,
VHA had established a Subcommittee and high-level positions that are
directly responsible for its succession efforts.
The four agencies had begun to link succession efforts to
strategic planning. DOL, EPA, and VHA had identified gaps in
occupations or competencies, undertaken strategies to address these
gaps, and were planning or taking steps to monitor their progress in
closing these gaps.
All of the agencies' succession efforts included training
and development programs at all organizational levels. However, there
were opportunities to coordinate and share these programs and create
synergies through benchmarking with others, achieving economies of
scale, limiting duplication of efforts, and enhancing the effectiveness
of programs, among other things.
In the report we made eight recommendations, including two
recommendations to VA. All eight recommendations have been closed and
implemented. For more information on this work and the recommendations:
https://www.gao.gov/products/GAO-05-585.
In addition to this work, GAO is currently looking at whether VA's
succession planning policies and procedures are consistent with OPM's
guidance for succession planning. For additional information on this
work contact Robert Goldenkoff, [email protected].
Examples of Quarterly Reporting Requirements for GAO
------------------------------------------------------------------------
GAO Section(s)/
Authority Title Summary
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P.L 115-141 Explanatory Requires VA to submit quarterly
ConStatement. Div. reports on implementation of VA's
Appropriations J. Military electronic health records. Report to
Act, 2018 Constructioinclude detailed obligations,
VA and Related expenditures, and deployment strategy
Agencies by VA facility. Directs GAO to perform
Appropriations quarterly performance reviews of the
Act, 2018. VA electronic health record
Veterans deployment. GAO reporting date not
Electronic specified.
Health Records
------------------------------------------------------------------------
P.L 115-55 Sec. 3 Requires VA to submit to Congress and
Veterans CompreheGAO, no later than 90 days after
Appeals Plan for enactment, a comprehensive plan for
Improvement Processing of processing legacy appeals and for
and Legacy Appeals implementing a modernized appeals
Modernization and system. VA to report quarterly until
Act of 2017. Implementing the modernized appeals system is
New Appeals implemented and semiannually for 7
System. (a) years following implementation.
Plan Required. Requires GAO to (1) assess VA's
(b) Elements. initial plan, including whether the
(c) Review by plan comports with sound planning
Comptpractices, (2) identify any gaps in
General of the the plan, and (3) provide
United States. recommendations for improvement as
(1) In General. appropriate. Report no later than 90
(A). (B). (2) days after VA submits the initial
Elements. (A). plan.
(B). (C).
------------------------------------------------------------------------
QUESTION FOR THE RECORD
U.S. GOVERNMENT ACCOUNTABILITY OFFICE (GAO)
July 1, 2019
The Honorable Chris Pappas
Chairman
Subcommittee on Oversight and Investigations
Committee on Veterans' Affairs
House of Representatives
Dear Mr. Chairman
This letter responds to your request that we address questions
submitted for the record related to the May 22, 2019, hearing entitled
Improving the Department of Veterans Affairs Effectiveness: Responding
to Recommendations from Oversight Agencies. GAO's responses to these
questions are enclosed.
If you have any questions about this response or need additional
information, please contact please contact Debra A. Draper at (202)
512-7114 or [email protected] or Sharon M. M. Silas at (202) 512-7114 or
[email protected] for VHA health care issues; Shelby S. Oakley at (202)
512-4841 or [email protected] for VA acquisition management issues; or
Elizabeth H. Curda at (202) 512-7215 or [email protected] for VA
disability claims issues.
Sincerely yours,
Debra Draper
Director, Health Care
Sharon Silas
Acting Director, Health Care
Shelby Oakley
Director, Contracting and National Security Acquisitions
Elizabeth Curda
Director, Education, Workforce, and Income Security
Enclosure
Attachment - Additional Questions for the Record
The Honorable Gil Cisneros
1. At the hearing, Rep. Cisneros asked GAO to provide a response
for the record on VA turnover and management weaknesses. Specifically,
Rep. Cisneros asked GAO's thoughts about whether the issue is primarily
among career employees or political appointees or both.
In recent years, VA's workforce has experienced instability among
both career employees and political appointees.
First, VA has experienced mission-critical skill gaps and vacancies
throughout the department, which includes career employees. As of
December 2018, VA reported an overall vacancy rate of 11 percent at
Veterans Health Administration (VHA) medical facilities, including
vacancies of over 24,000 medical and dental positions and around 900
human resource positions. With 32 percent of the VA workforce eligible
to retire in the next 5 fiscal years, VA must address these mission-
critical skill gaps and vacancies that we continue to identify in our
work. \1\ For example:
---------------------------------------------------------------------------
\1\ Percentage based on VA employees on board at the start of
fiscal year 2017.
In December 2016, we found that VHA's limited human
resources capacity combined with weak internal control practices has
undermined VHA's human resources operations and its ability to improve
delivery of health care services to veterans. \2\ Further, VHA is
challenged by inefficiencies in its performance management processes,
including the lack of a performance appraisal IT system, which prevents
it from identifying trends and opportunities for improvement. VHA can
better support medical centers by establishing clear lines of
accountability for engagement efforts, collecting and leveraging
leading practices, and addressing barriers to improving engagement. We
made three recommendations to VA to improve its performance management
system. VA partially concurred with these recommendations, which remain
open.
---------------------------------------------------------------------------
\2\ GAO, Veterans Health Administration: Management Attention Is
Needed to Address Systemic, Long-standing Human Capital Challenges,
GAO-17-30 (Washington, D.C.: Dec. 23, 2016).
---------------------------------------------------------------------------
In October 2017, we reported that VHA is unable to
accurately count the total number of physicians who provide care in its
VA medical centers. \3\ VHA has data on the number of mission-critical
physicians, which includes primary care and mental health physicians,
it employs (more than 11,000) and who provide services on a fee-basis
(about 2,800). \4\ However, VHA lacks data on the number of contract
physicians and physician trainees, and thus has no information on the
extent to which medical centers nationwide use these arrangements and
whether contract physicians are working in mission-critical
occupations. As such, VHA cannot ensure that its workforce planning
process sufficiently addresses gaps in physician staffing, including
those for mental health providers, which may affect veterans' access to
care, among other issues. Additionally, we found that VHA has not
evaluated the effectiveness of its physician recruitment and retention
strategies. One such strategy-hiring physician trainees-is weakened by
ineffectual hiring practices, such as delaying employment offers until
graduation. VHA could strengthen its strategies by comprehensively
evaluating the causes of recruitment and retention difficulties and
identifying effective solutions.
---------------------------------------------------------------------------
\3\ GAO, Veterans Health Administration: Better Data and Evaluation
Could Help Improve Physician Staffing, Recruitment, and Retention
Strategies, GAO-18-124 (Washington, D.C.: Oct. 19, 2017).
\4\ VHA obtains data from its Veterans Integrated Service Networks
and VA medical centers on which occupations are the highest priority
for recruitment and retention based on known recruitment and retention
concerns, among other factors. VHA then consolidates this data to
identify the nationwide top 10 mission-critical occupations and top 5
mission-critical physician occupations. In fiscal year 2016, the ten
mission-critical clinical occupations were physician, registered nurse,
human resource manager, physical therapist, physician assistant,
psychologist, medical technologist, occupational therapist, diagnostic
radiologic technologist, and pharmacist. See U.S. Department of
Veterans Affairs, Veterans Health Administration, Mission Critical
Occupation Report (2016).
---------------------------------------------------------------------------
As a result of these findings, we made five recommendations,
including that VA develop a process to count all physicians, provide
guidance on productivity measurement, and evaluate its physician
recruitment and retention strategies. VA concurred with four of the
five recommendations, but did not concur with the one to accurately
count all physicians, stating that its workforce assessment tools are
sufficient. However, GAO maintains that this is essential for effective
workforce planning.
VA has implemented two of the five recommendations. For example, in
May 2019, VA submitted an evaluation of its physician recruitment and
retention programs. The report covered use of the Education Debt
Reduction Program, physician pay tables, and recruitment, retention,
and relocation incentives. One result of the evaluation is that VHA
provided Veterans Integrated Service Networks (VISNs) with
recommendations on how to efficiently allocate their recruitment,
retention, and relocation incentives. Evaluating physician recruitment
and retention programs will allow VHA to ensure that funds for these
activities are effective and efficient.
Also since the 2017 High-Risk Report was issued in February 2017,
VA experienced leadership instability in several senior positions, some
of which are political appointments. For example, there was notable
turnover in critical politically appointed positions including the VA
Secretary, Chief Information Officer, and Chief Financial Officer.
Secretary Robert Wilkie was confirmed in July 2018. As a result, in our
2019 High-Risk Report, GAO determined that VA partially met the
leadership commitment criterion for managing risks and improving VA
health care high-risk area, as it did in 2017. As of June 2019, key
leadership vacancies remain, including the political appointments for
VA Deputy Secretary and Under Secretary for Health positions; according
to the Partnership for Public Service, VA is second among Federal
departments in terms of Senate confirmations with 83 percent of key
positions filled. \5\
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\5\ See https://ourpublicservice.org/political-appointee-tracker/,
which we accessed on June 17, 2019.
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Fully addressing GAO's open recommendations could significantly
improve VA operations; however, the recommendations highlight issues
that are symptomatic of broader, systemic management and oversight
challenges that will only be addressed through transformative action.
As the Comptroller General testified during the hearing, the reason
that VA was added to the High-Risk List in 2015 was due, in part, to
underlying management weaknesses. As a result, VHA is embarking on an
administration-wide modernization program, and VBA is implementing
reforms to modernize its disability claims process. Per the statements
of the Comptroller General during the hearing, in order for these
efforts to be successful, VA leaders are going to have to energize an
entrenched bureaucracy that is challenged in implementing management
reforms. Successfully implementing these reforms and fully addressing
the issues that led to VA's high-risk designations will require
sustained leadership attention on high-risk related issues as well as
leadership stability.