[Senate Hearing 115-323]
[From the U.S. Government Publishing Office]
S. Hrg. 115-323
GAO'S HIGH-RISK LIST AND THE VETERANS HEALTH ADMINISTRATION
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
MARCH 15, 2017
__________
Printed for the use of the Committee on Veterans' Affairs
__________
U.S. GOVERNMENT PUBLISHING OFFICE
31-207 PDF WASHINGTON : 2018
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COMMITTEE ON VETERANS' AFFAIRS
Johnny Isakson, Georgia, Chairman
Jerry Moran, Kansas Jon Tester, Montana, Ranking
John Boozman, Arkansas Member
Dean Heller, Nevada Patty Murray, Washington
Bill Cassidy, Louisiana Bernard Sanders, (I) Vermont
Mike Rounds, South Dakota Sherrod Brown, Ohio
Thom Tillis, North Carolina Richard Blumenthal, Connecticut
Dan Sullivan, Alaska Mazie K. Hirono, Hawaii
Joe Manchin III, West Virginia
Thomas G. Bowman, Staff Director \1\
Robert J. Henke, Staff Director \2\
Tony McClain, Democratic Staff Director
Majority Professional Staff
Amanda Meredith
Gretchan Blum
Leslie Campbell
Maureen O'Neill
Adam Reece
David Shearman
Jillian Workman
Minority Professional Staff
Dahlia Melendrez
Cassandra Byerly
Jon Coen
Steve Colley
Simon Coon
Michelle Dominguez
Eric Gardener
Carla Lott
Jorge Rueda
\1\ Thomas G. Bowman served as Committee majority Staff Director
through September 5, 2017, after being confirmed as Deputy Secretary of
Veterans Affairs on August 3, 2017.
\2\ Robert J. Henke became the Committee majority Staff Director on
September 6, 2017.
C O N T E N T S
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March 15, 2017
SENATORS
Page
Tillis, Hon. Thom, U.S. Senator from North Carolina.............. 1
Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana...... 1
Rounds, Hon. Mike, U.S. Senator from South Dakota................ 29
Murray, Hon. Patty, U.S. Senator from Washington................. 31
Boozman, Hon. John, U.S. Senator from Arkansas................... 33
WITNESSES
Draper, Debra A., Ph.D., Director, Health Care Team, Government
Accountability Office.......................................... 2
Prepared statement........................................... 5
Response to posthearing questions submitted by:
Hon. Jon Tester............................................ 37
Hon. Mazie K. Hirono....................................... 39
Hon. Sherrod Brown......................................... 40
Missal, Michael J., Inspector General, U.S. Department of
Veterans Affairs; accompanied by John D. Daigh, Jr., M.D., CPA,
Assistant Inspector General for Healthcare Inspections, Office
of Inspector General........................................... 14
Prepared statement........................................... 15
Response to posthearing questions submitted by:
Hon. Jon Tester............................................ 43
Hon. Mazie K. Hirono....................................... 44
Hon. Joe Manchin III....................................... 44
Hon. Sherrod Brown......................................... 45
Clancy, Carolyn M., M.D., Deputy Under Secretary for Health for
Organizational Excellence, Veterans Health Administration, U.S.
Department of Veterans Affairs; accompanied by Jennifer Lee,
M.D., Deputy Under Secretary for Health for Policy and
Services; and Amy Parker, Executive Director of Operations,
Office of Management........................................... 21
Prepared statement........................................... 22
Response to request arising during the hearing by:
Hon. Thom Tillis........................................... 27
Hon. Jon Tester............................................ 28
Hon. Patty Murray.......................................... 32
Response to posthearing questions submitted by:
Hon. Jon Tester............................................ 46
Hon. Richard Blumenthal.................................... 49
Hon. Mazie K. Hirono....................................... 50
Hon. Joe Manchin III....................................... 51
Hon. Sherrod Brown......................................... 53
GAO'S HIGH-RISK LIST AND THE VETERANS HEALTH ADMINISTRATION
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WEDNESDAY, MARCH 15, 2017
U.S. Senate,
Committees on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 2:30 p.m. in room
418, Russell Senate Office Building, Hon. Thom Tillis,
presiding.
Present: Senators Boozman, Rounds, Tillis, Tester, Murray,
and Brown.
OPENING STATEMENT OF HON. THOM TILLIS,
U.S. SENATOR FROM NORTH CAROLINA
Senator Tillis. I call the hearing to order. Thank you all
for being here. Senator Isakson is out today and I will be
standing in. Senator Boozman is at a meeting where he should be
joining us and taking the gavel shortly.
We all continue to wish the very best for Senator Isakson
who is recovering from back surgery. He submitted a statement
in a prior meeting. Although the reality is I am wearing this
bow tie, which is a University of Georgia bow tie, because I am
repaying a bet that I lost, but since I am sitting in his chair
for a little bit today I am going to say I am doing it in honor
of Senator Isakson.
I would like to welcome the witnesses. Then, we are going
to defer to Senator Tester to allow him to make his opening
statement. He has a meeting outside, in the anteroom, which we
will let him move to. I want to thank the witnesses on the
panel today.
Senator Tester, I will wait until after your opening
statement, in the interest of time, to introduce the witnesses.
OPENING STATEMENT OF HON. JON TESTER,
RANKING MEMBER, U.S. SENATOR FROM MONTANA
Senator Tester. Thank you, Chairman Tillis. I very much
appreciate the hospitality, and thank you all for being here
today.
As many of you know, we had a hearing on GAO's High-Risk
List a few weeks ago at the Homeland Security and Government
Affairs Committee. During the questioning of the Comptroller,
Gene Dodaro, who is a guy that I like a lot, who works really
tirelessly to help agencies work more effectively and save
taxpayer dollars, he told me that he was very concerned about
the VA's reaction to its inclusion on the list.
Chief among his concerns is that the VA did not seem to
move--did not seem overly interested in doing what it takes to
be removed from that High-Risk List. Now that is something that
should concern the panelists and something that should concern
everybody. Dr. Clancy, I would love to hear from you whether
the VA is being productive in addressing those GAO concerns and
whether there is an appropriate sense of urgency, because, I
want to tell you, the fact that the VA has not fully met the
action plan for getting off the list is worrisome in and of
itself.
Meanwhile, recent reports from the VA Inspector General,
including one about VA in Montana that was released late last
week, indicate that the problems that caused GAO to add it to
this list are still occurring. According to that report--and
the IG is here--according to that report, the IG found that
steps have been taken to improve consult time, in addition, and
address factors that contribute to future delays at Fort
Harrison in Montana, but that is little solace to the four
veterans who are identified in that report as being potentially
harmed by the consult backlog.
On behalf of them and the veterans seeking care at
facilities across this country, we need to do better, the VA
has to do better. I think you guys realize that, but I want you
to know.
I will hold everybody at the VA accountable for this.
Secretary Shulkin knows this, and he also knows we will hold
everybody in the leadership team accountable too, including the
team at Fort Harrison.
If done right, VA's action and response to the GAO concerns
can leave that agency and, more importantly, the veterans of
this country in a better place, which is what we want. We want
the best services and care for our veterans.
I want to thank you again for calling this hearing. It is
always good to work with the good Senator from North Carolina.
This is an important topic and I think it has bipartisan
support.
Senator Tillis. Thank you, Senator Tester.
We are welcoming to the panel today Debra Draper, Ph.D.,
Director, Health Care Team, Government Accountability Office;
Michael Missal, Inspector General, Department of Veterans
Affairs. I think that he is accompanied by Dr. John Daigh--did
I pronounce that correctly?--Assistant Inspector General for
Healthcare Inspections, Office of the Inspector General;
Carolyn M. Clancy, M.D., Deputy Under Secretary for Health for
Organizational Excellence, Department of Veterans Affairs;
Jennifer Lee, M.D., Deputy Under Secretary for Health for
Policy and Services, Department of Veterans Affairs; and Amy
Parker, Executive Director of Operations, Office of Management,
Department of Veterans Affairs.
If you all would like to begin with your opening
statements; we will just go from left to right. If we can keep
those tight so we can get to questions I would appreciate it.
STATEMENT OF DEBRA A. DRAPER, Ph.D., DIRECTOR, HEALTH CARE
TEAM, U.S. GOVERNMENT ACCOUNTABILITY OFFICE
Ms. Draper. Chairman Tillis, Ranking Member Tester, and
Members of the Committee. I appreciate the opportunity to be
here today to discuss the status of veterans' health care as a
high-risk area. In my testimony today, I will focus on the
concerns that led to this designation, what actions VA has
taken in response, and what additional actions are needed to
ensure progress and eventual removal from the list.
Veterans' health care was added to GAO's High-Risk List for
the first time in 2015, because of concerns about VA's ability
to ensure the timeliness, cost-effectiveness, quality, and
safety of the care provided to veterans. In designating
veterans' health care as high risk, we categorize our specific
concerns into five categories: (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.
At the time, we were also concerned that VA had not
implemented more than 100 GAO recommendations related to
veterans' health care, and many had been open for three or more
years.
Last month, as we do every 2 years, at the start of each
new Congress, we updated our High-Risk List and reported on
progress made by each area on our list, including veterans'
health care. We assess progress and potential for removal from
the list based on five criteria: leadership commitment;
capacity, in terms of people and resources; an action plan;
monitoring; and demonstrated progress.
Our assessment is that VA has taken some, albeit
exceedingly limited actions, to address the concerns that led
to its high-risk designation. For example, some leadership
actions have been taken, including the establishment of a task
force, working groups, and a governance structure to address
the concerns. Additionally, VA leadership provided us with an
action plan in August, in which they acknowledged the deep-
rooted nature of the concerns and stated that addressing these
would require substantial time and work.
Based on these actions, we concluded that VA had partially
met the high-risk removal criteria of leadership commitment and
an action plan, and had made no progress with regard to the
other three criteria: capacity; monitoring; and demonstrated
progress.
I want to be very clear that even in the areas where VA has
made some progress, there is a long path toward fully meeting
the criteria. For example, the action plan submitted to us
lacked many critical elements, including an analysis of the
root causes for each of the categories of concern, a critical
step to better understanding why the problem exists, and what
specifically needs to be addressed; reasonable timelines, given
the significant scope of the efforts needed; clear metrics
necessary for measuring and monitoring progress; and finally,
the plan lacked an assessment of the resources needed for
implementation.
We also continue to be concerned about the large number of
open recommendations, and while VA has taken actions to address
some of these, considerable work remains. As I noted at the
time of its high-risk designation in 2015, VA had more than 100
open GAO recommendations related to veterans' health care.
Seventy-four new recommendations have been added since then.
Currently, there are still more than 100 open recommendations
and about a quarter of these have been open for three or more
years.
It is critical that VA resolve our recommendations in a
timely manner, not only to remedy the specific weaknesses
identified but because they may be symptomatic of larger
underlying problems that also need to be addressed.
There are a number of actions that VA needs to immediately
take to move forward. The most important of these are ensuring
strong, department-level leadership support; developing a
robust action plan that provides a clear roadmap for what needs
to be done, when it will be done, how progress will be
measured, and what resources are needed to ensure successful
implementation; integrating VA's response to its high-risk
designation with other initiatives such as the Secretary's 10-
point plan; and resolving open recommendations in a timely
manner.
We are very concerned about VA's exceedingly slow pace of
progress. Unfortunately, as of today, VA is not much further
ahead at addressing the concerns that led to its high risk
designation than it was 2 years ago. The lack of progress
raises several important questions, including how seriously VA
is taking this, whether the right people with the right skills
are being tasked to address the high risk concerns, and whether
the overall responsibility for achieving removal from the High-
Risk List is at the right organizational level within VA.
Mr. Chairman, this concludes my opening remarks. I would be
happy to answer any questions.
[The prepared statement of Ms. Draper follows:]
Prepared Statement of Debra A. Draper, Director, Health Care,
U.S. Government Accountability Office
Chairman Isakson, Ranking Member Tester, and Members of the
Committee: I am pleased to be here today to discuss the status of the
Department of Veterans Affairs' (VA) actions to address the concerns
that led to the high-risk designation we made related to VA health
care. We added managing risks and improving VA health care to our High
Risk List in 2015 due to our concern 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.\1\ We
expressed continued concerns about VA health care in our 2017 high-risk
report.\2\
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\1\ GAO, High Risk Series: An Update, GAO 15 290 (Washington, DC:
Feb. 11, 2015).
\2\ GAO, High Risk Series: Progress on Many High-Risk Areas, While
Substantial Efforts Needed on Others, GAO 17 317 (Washington, DC: Feb.
15, 2017).
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VA's Veterans Health Administration (VHA) operates one of the
largest health care delivery systems in the Nation, with 168 medical
centers and more than 1,000 outpatient facilities organized into
regional networks. VA has faced a growing demand by veterans for its
health care services--due, in part, to servicemembers returning from
military operations in Afghanistan and Iraq and the needs of an aging
veteran population--and that trend is expected to continue. The total
number of veteran enrollees in VA's health care system rose from 7.9
million to almost 9 million from fiscal year 2006 through fiscal year
2016. Over that same period, VHA's total budgetary resources have
increased substantially, from $37.8 billion in fiscal year 2006 to
$91.2 billion in fiscal year 2016.
Although VA's budget and enrollees have substantially increased for
at least a decade, there have been numerous reports during this same
period--by us, VA's Office of the Inspector General, and others--of VA
facilities failing to provide timely health care.\3\ In some cases, the
delays in care or VA's failure to provide care at all reportedly have
resulted in harm to veterans. In response to these serious and
longstanding problems with access to VA health care, the Veterans
Access, Choice, and Accountability Act of 2014 was enacted, which
provided temporary authority and $10 billion in funding through
August 7, 2017 (or sooner, if those funds are exhausted) for veterans
to obtain health care services from community (non-VA) providers to
address long wait times, lengthy travel distances, or other challenges
they may face accessing VA health care.\4\ Under this authority, VA
introduced the Veterans Choice Program in November 2014, which offers
veterans the option to receive hospital care and medical services from
a non-VA provider when a VA facility cannot provide an appointment
within 30 days, or when veterans reside more than 40 miles from the
nearest VA facility.\5\
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\3\ See, for example, GAO, VA Health Care: Actions Needed to
Improve Newly Enrolled Veterans' Access to Primary Care, GAO 16 328
(Washington, DC: Mar. 18, 2016) and GAO, VA Mental Health: Clearer
Guidance on Access Policies and Wait-Time Data Needed, GAO 16 24
(Washington, DC: Oct. 28, 2015). See also, for example, Department of
Veterans Affairs, Office of Inspector General, Veterans Health
Administration, Review of Alleged Patient Deaths, Patient Wait Times,
and Scheduling Practices at the Phoenix VA Health Care System, Report
No. 14-02603-267 (Washington, DC: Aug. 26, 2014) and VA, Department of
Veterans Affairs Access Audit, System-Wide Review of Access, Results of
Access Audit Conducted May 12, 2014, through June 3, 2014.
\4\ Pub. L. No. 113-146, 128 Stat. 1754. The $10 billion is meant
to supplement VA's medical services budget and is funded through a
separate appropriations account, the Veterans Choice Fund. The 2014 law
also appropriated $5 billion to expand VA's capacity to deliver care to
veterans by hiring additional clinicians and improving the physical
infrastructure of VA's medical facilities.
\5\ VA has purchased care from non-VA community providers through
its care in the community programs since as early as 1945. VHA has
numerous programs, including the Veterans Choice Program, through which
it purchases VA care in the community services.
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In addition to concerns about timely access to care, VA faces
challenges regarding the reliability, transparency, and consistency of
its budget estimates for medical services, as well as weaknesses in
tracking obligations for medical services and estimating budgetary
needs for future years. These challenges were evident in June 2015,
when VA requested additional funds from Congress because agency
officials projected a fiscal year 2015 funding gap of about $3 billion
in its medical services appropriation account.\6\ The projected funding
gap was largely due to administrative weaknesses that slowed the
utilization of the Veterans Choice Program in fiscal year 2015 and
resulted in higher-than-expected demand for VA's previously established
VA community care programs.\7\ To address the projected funding gap in
fiscal year 2015, the VA Budget and Choice Improvement Act provided VA
temporary authority to use up to $3.3 billion from the Veterans Choice
Program appropriation for obligations incurred for other specified
medical services.\8\ In our June 2016 report on VA's health care
budget, we reported that VA officials anticipated requesting another
increase in funding for health care services in the budget request for
fiscal year 2018.\9\ Over the course of fiscal year 2016, utilization
of the Veterans Choice Program increased considerably, and the Veterans
Choice Fund had a $4.5 billion remaining balance at the start of fiscal
year 2017 to cover community care services.\10\ However, in
February 2017, a VA official told us that VA would need an estimated $2
billion in addition to its fiscal year 2018 advance appropriation of
about $70 billion to continue providing services.\11\
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\6\ See GAO, VA's Health Care Budget: In Response to a Projected
Funding Gap in Fiscal Year 2015, VA Has Made Efforts to Better Manage
Future Budgets, GAO 16 584 (Washington, DC: Jun. 3, 2016). In our 2016
report, the projected funding gap refers to the period in fiscal year
2015 when VA's obligations for medical services were projected to
exceed its available budget authority for that purpose for that year.
The Antideficiency Act prohibits agencies from incurring obligations in
excess of available budget authority. 31 U.S.C. Sec. 1341(a). An
evaluation of whether an Antideficiency Act violation occurred in
fiscal year 2015 was outside the scope of our work.
\7\ In particular, VA officials expected that the Veterans Choice
Program would absorb much of the increased demand from veterans for
health care services delivered by non-VA providers, but instead the
slow utilization resulted in veterans continuing to receive care
through previously established VA community care programs that drew
funds from VA's medical services appropriation account.
\8\ Pub. L. No. 114-41, Tit. IV, Sec. 4004, 129 Stat. 443, 463-464
(2015). Specifically, VA was authorized to use the Veterans Choice
Program appropriation to cover obligations incurred for the other
specified medical services starting May 1, 2015, until October 1, 2015.
\9\ See GAO 16 584.
\10\ At the start of fiscal year 2016, VA issued a policy
memorandum to its VAMCs requiring them to offer eligible veterans
referrals to the Veterans Choice Program before they authorize care
through VA's previously established community care programs.
\11\ Each year, Congress provides funding for VA health care
through the appropriations process. Specifically, Congress provides
appropriations for the coming fiscal year (which begins October 1 of
that year), as well as an advance appropriation for the following
fiscal year. VA's advance appropriation for fiscal year 2018 was
enacted on September 29, 2016. Pub. L. No. 114-223, 130 Stat. 857, 869
(2016).
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My statement today, which is based on our February 2017 High-Risk
Series: Progress on Many High-Risk Areas, While Substantial Efforts
Needed on Others, will address (1) actions VA has taken over the past 2
years to address the areas of concern that led us to place VA health
care on our High-Risk List in 2015, (2) the number of open GAO
recommendations related to VA health care, and (3) additional actions
VA needs to take to address the concerns that led to the high-risk
designation. 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.
background
Since 1990, we have regularly reported on government operations
that we have identified as high risk due to their vulnerability to
fraud, waste, abuse, and mismanagement, or the need for transformation
to address economy, efficiency, or effectiveness challenges. Our high-
risk program--which is intended to help inform the congressional
oversight agenda and to guide efforts of the administration and
agencies to improve government performance--has brought much-needed
focus to problems impeding effective government and costing billions of
dollars. In 1990, we designated 14 high-risk areas. Since then,
generally coinciding with the start of each new Congress, we have
reported on the status of progress to address previously designated
high-risk areas, determined whether any areas could be removed or
consolidated, and identified new high-risk areas.
Since 1990, a total of 60 different areas have appeared on the
High-Risk List, 24 areas have been removed, and 2 areas have been
consolidated. On average, high-risk areas that have been removed from
the list remained on it for 9 years after they were initially added.
Our experience has shown that the key elements needed to make progress
in high-risk areas are top-level attention by the administration and
agency leaders grounded in the five criteria for removal from the High-
Risk List, as well as any needed congressional action. The five
criteria for removal that we issued in November 2000 are as
follows:\12\
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\12\ GAO, Determining Performance and Accountability Challenges and
High Risks, GAO 01 159SP (Washington, DC: November 2000).
Leadership Commitment. The agency demonstrates strong
commitment and top leadership support.
Capacity. The agency has the capacity (i.e., people and
resources) to resolve the risk(s).
Action Plan. A corrective action plan exists that defines
the root cause and solutions, and provides for substantially completing
corrective measures, including steps necessary to implement solutions
we recommended.
Monitoring. A program has been instituted to monitor and
independently validate the effectiveness and sustainability of
corrective measures.
Demonstrated Progress. The agency is able to demonstrate
progress in implementing corrective measures and in resolving the high-
risk area.
These five criteria form a road map for efforts to improve and
ultimately address high-risk issues. Addressing some of the criteria
leads to progress, while satisfying all of the criteria is central to
removal from the list. In our April 2016 report, we provided additional
information on how agencies had made progress addressing high-risk
issues.\13\ Figure 1 shows the five criteria for removal for a
designated high-risk area and examples of actions taken by agencies as
cited in that report.
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\13\ GAO, High-Risk Series: Key Actions to Make Progress Addressing
High-Risk Issues, GAO 16 480R (Washington, DC: Apr. 25, 2016).
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Importantly, the actions listed are not ``stand alone'' efforts
taken in isolation from other actions to address high-risk issues. That
is, actions taken under one criterion may also be important in meeting
other criteria. For example, top leadership can demonstrate its
commitment by establishing a corrective action plan including long-term
priorities and goals to address the high-risk issue and using data to
gauge progress--actions which are also vital to monitoring criteria.
va has made limited progress in addressing the concerns that led to the
2015 va health care high-risk designation
VA officials have expressed their commitment to addressing the
concerns that led to the high-risk designation for VA health care. As
part of our work for the 2017 high-risk report, we identified actions
VA had taken, such as establishing a task force, working groups, and a
governance structure for addressing the five areas of concern
contributing to the designation: (1) ambiguous policies and
inconsistent processes; (2) inadequate oversight and accountability;
(3) information technology (IT) challenges; (4) inadequate training for
VA staff; and (5) unclear resource needs and allocation priorities. For
example, in July 2016, VA chartered the GAO High Risk List Area Task
Force for Managing Risk and Improving VA Health Care to develop and
oversee implementation of VA's plan to address the root causes of the
five areas of concern we identified in 2015.
VA's task force and associated working groups are responsible for
developing and executing the department's high-risk mitigation plan for
each of the five areas of concern we identified. VA also executed two
contracts with a total value of $7.8 million to support its actions to
address the concerns behind the high-risk designation. These
contracts--with the MITRE Corporation and Atlas Research, LLC--are
intended to provide additional support for actions such as developing
and executing an action plan, creating a plan to enhance VA's capacity
to manage the five areas, and assisting with establishing the
management functions necessary to oversee the five high-risk-area
working groups.
On August 18, 2016, VA provided us with an action plan that
acknowledged the deep-rooted nature of the areas of concern, and stated
that these concerns would require substantial time and work to address.
Although the action plan outlined some steps VA plans to take over the
next several years to address the concerns that led to its high-risk
designation, several sections were missing critical actions that would
support our criteria for removal from the High-Risk List, such as
analyzing the root causes of the issues and measuring progress with
clear metrics. In our feedback to VHA on drafts of its action plan, we
highlighted these missing actions and also stressed the need for
specific timelines and an assessment of needed resources for
implementation. For example, VA plans to use staff from various
sources, including contractors and temporarily detailed employees, to
support its high-risk-area working groups, so it is important for VA to
ensure that these efforts are sufficiently resourced.
Overall Rating for Managing Risks and Improving VA Health Care
As we reported in the February 2017 high-risk report, when we
applied the five criteria for High-Risk List removal to each of the
areas of concern, we determined that VA has partially met two of the
five criteria: leadership commitment and an action plan. VA has not met
the other three criteria for removal: capacity to address the areas of
concern, monitoring implementation of corrective actions, and
demonstrating progress. It is worth noting that although both criteria
were rated as partially met, the department made significantly less
progress in developing a viable action plan than it has in
demonstrating leadership commitment. Specifically, VA partially met the
action plan criterion for only one of the five areas of concern--
ambiguous policies and inconsistent processes--whereas VA partially met
the leadership commitment criterion for four out of five areas of
concern.
The following is a summary of the progress VA has made in
addressing the five criteria for removal from the High-Risk List for
each of the five areas of concern we identified.\14\
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\14\ For more detailed analysis of VA's actions in each of the five
areas of concern, see GAO 17 317.
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Ambiguous Policies and Inconsistent Processes
Summary of concern. When we designated VA health care as a high-
risk area in 2015, we reported that ambiguous VA policies led to
inconsistent processes at local VA medical facilities, which may have
posed risks for veterans' access to VA health care. Since then, we
highlighted the inconsistent application of policies in two recent
reports examining mental health and primary care access at VA medical
facilities in 2015 and 2016, respectively.\15\ In both reports, we
found wide variation in the time that veterans waited for primary and
mental health care, which was in part caused by a lack of clear,
updated policies for appointment scheduling; therefore, we recommended
that VA update these policies. These ambiguous policies contributed to
errors made by appointment schedulers, which led to inconsistent and
unreliable wait-time data. For mental health, we also found that two
policies conflicted, leading to confusion among VA medical center staff
as to which wait-time policy to follow. In 2015, VA resolved this
policy conflict by revising its mental health handbook, but other
inconsistent applications of mental health policy have not yet been
addressed, such as our recommendation to issue guidance about the
definitions used to calculate veteran appointment wait times, and
communicate any changes to those definitions within and outside VHA.
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\15\ See GAO, VA Health Care: Actions Needed to Improve Newly
Enrolled Veterans' Access to Primary Care, GAO 16 328 (Washington, DC:
Mar. 18, 2016); and GAO, VA Mental Health: Clearer Guidance on Access
Policies and Wait-Time Data Needed, GAO 16 24 (Washington, DC: Oct. 28,
2015).
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2017 assessment of VA's progress. Based on actions taken since
2015, VA has partially met our criteria for removal from the High-Risk
List for this area of concern for leadership commitment and action
plan. VA has partially met the leadership commitment criterion because
it established a framework for developing and reviewing policies--with
the goal of ensuring greater consistency and clarity--and set goals for
making the policy-development process more efficient. VA has partially
met the action plan criterion for this high-risk area of concern
because its action plan described an analysis of the root causes of
problems related to ambiguous policies and inconsistent processes, an
important aspect of an action plan. However, VA has not met our
criteria for removal from the High-Risk List for capacity, monitoring,
and demonstrated progress for this area of concern because it has not
addressed gaps that exist between its stated goals and available
resources, addressed inconsistent application of policies at the local
level, or demonstrated that its actions are linked to identified root
causes.
Inadequate Oversight and Accountability
Summary of concern. In our 2015 high-risk report, we found that VA
had problems holding its facilities accountable for their performance
because it relied on self-reported data from facilities, its oversight
activities were not sufficiently focused on compliance, and it did not
routinely assess policy implementation. We continued to find a lack of
oversight in our October 2015 review of the efficiency and timeliness
of VA's primary care. For example, we found inaccuracies in VA's data
on primary care panel sizes, which are used to help medical centers
manage their workload and ensure that veterans receive timely and
efficient care.\16\ We found that while VA's primary care panel
management policy required facilities to ensure the reliability of
their panel size data, it did not assign responsibility for verifying
data reliability to regional- or national-level officials or require
them to use the data for monitoring purposes. As a result, VA could not
be assured that local panel size data were reliable, or know whether
its medical centers had met VA's goals for efficient, timely, and
quality care. We recommended that VA incorporate an oversight process
in its primary care panel management policy that assigns
responsibility, as appropriate, to regional networks and to VA's
central office for verifying and monitoring panel sizes.
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\16\ GAO, VA Primary Care: Improved Oversight Needed to Better
Ensure Timely Access and Efficient Delivery of Care, GAO 16 83
(Washington, DC: Oct. 8, 2015).
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2017 assessment of VA's progress. VA has partially met the
leadership commitment criterion for this area of concern because it
established a high-level governance structure and adopted a new model
to guide the department's oversight and accountability activities.
However, VA has not met our criteria for removal from the High-Risk
List for capacity, action plan, monitoring, or demonstrated progress
for this area of concern because the department continues to rely on
existing processes that contribute to inadequate oversight and
accountability.
Information Technology Challenges
Summary of concern. In our 2015 high-risk report, we identified
limitations in the capacity of VA's existing IT systems, including the
outdated, inefficient nature of certain systems and a lack of system
interoperability as contributors to VA's IT challenges related to VA
health care. We have continued to report on the importance of VA
working with the Department of Defense to achieve electronic health
record interoperability. In August 2015, we reported on the status of
these interoperability efforts and noted that the departments had
engaged in several near-term efforts focused on expanding
interoperability between their existing electronic health record
systems. However, we were concerned by the lack of outcome-oriented
goals and metrics that would more clearly define what VA and the
Department of Defense aim to achieve from their interoperability
efforts. Accordingly, we recommended that the departments establish a
timeframe for identifying outcome-oriented metrics and define related
goals for achieving interoperability. In February 2017, we reported
that VA has begun to define an approach for identifying outcome-
oriented metrics focused on health outcomes in selected clinical areas,
and it also has begun to establish baseline measurements.\17\ We intend
to continue monitoring the departments' efforts to determine how these
metrics define and measure the results achieved by interoperability
between the departments.
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\17\ GAO, Veterans Affairs Information Technology: Management
Attention Needed to Improve Critical System Modernizations, Consolidate
Data Centers, and Retire Legacy Systems, GAO 17 408T (Washington, DC:
Feb. 7, 2017).
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2017 assessment of VA's progress. VA has partially met our
leadership commitment criterion by involving top leadership from VA's
Office of Information & Technology in this area of concern, but it has
not met our four remaining criteria for removing IT challenges from the
High-Risk List. For example, VA has not demonstrated improvement in
several capacity actions, such as establishing specific
responsibilities for its new functions, improving collaboration between
internal and external stakeholders, and addressing skill gaps. VA also
needs to conduct a root cause analysis that would help identify and
prioritize critical actions and outcomes to address IT challenges.
Inadequate Training for VA Staff
Summary of concern. When identifying this area of concern in our
2015 high-risk report, we described several gaps in VA's training, as
well as burdensome training requirements. We have continued to find
these issues in our subsequent work. For example, in our December 2016
report on VHA's human resources (HR) capacity, we found that VA's
competency assessment tool did not address two of the three personnel
systems under which VHA staff may be hired.\18\ We recommended that VHA
(1) develop a comprehensive competency assessment tool for H.R. staff
that evaluates knowledge of all three of VHA's personnel systems and
(2) ensure that all VHA H.R. staff complete it so that VHA may use the
data to identify and address competency gaps among H.R. staff. Without
such a tool, VHA will have limited insights into the abilities of its
H.R. staff and will be ill-positioned to provide necessary support and
training.
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\18\ GAO, Veterans Health Administration: Management Attention Is
Needed to Address Systemic, Long-standing Human Capital Challenges, GAO
17 30 (Washington, DC: Dec. 23, 2016).
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2017 assessment of VA's progress. VA has not met any of our
criteria for removing this area of concern from the High-Risk List. VA
intends to establish a comprehensive health care training management
policy and a mandatory annual training process; however, as of
December 2016, VA officials said they had not begun drafting a new
policy to replace an outdated document from 2002 that contains training
requirements that are no longer relevant. The high-level nature of the
descriptions in the action plan and lack of action to update outdated
policies and set goals for improving training shows that VA lacks
leadership commitment to address the concerns that led to our inclusion
of this area in the 2015 high-risk report.
Unclear Resource Needs and Allocation Priorities
Summary of concern. In our 2015 high-risk report, we described gaps
in the availability of data needed for VA to identify the resources it
needs and ensure they are effectively allocated across VA's health care
system as contributors to our concern about unclear resource needs and
allocation priorities. We have continued to report on this concern. For
example, in our September 2016 report on VHA's organizational
structure, we found that VA devoted significant time, effort, and funds
to generate recommendations for organizational structure changes
intended to improve the efficiency of VHA operations.\19\ However, the
department then either did not act or acted slowly to implement the
recommendations. Without robust processes for evaluating and
implementing recommendations, there was little assurance that VHA's
delivery of health care to the Nation's veterans would improve. We
recommended that VA develop a process to ensure that it evaluates
organizational structure recommendations resulting from internal and
external reviews of VHA. This process should include documenting
decisions and assigning officials or offices responsibility for
ensuring that approved recommendations are implemented. We concluded
that such a process would help VA ensure that it is using resources
efficiently, monitoring and evaluating implementation, and holding
officials accountable.
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\19\ GAO, VA Health Care: Processes to Evaluate, Implement, and
Monitor Organizational Structure Changes Needed, GAO 16 803
(Washington, DC: Sept. 27, 2016).
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2017 assessment of VA's progress. VA's actions have partially met
our criterion for leadership commitment but not met the other four
criteria for removing this area of concern from the High Risk List.
VA's planned actions do not make clear how VHA, as the agency managing
VA health care, is or will be incorporated into VA's new framework for
the strategic planning and budgeting process.\20\ It is also not clear
how the framework will be communicated and reflected at the regional
network and medical center levels. VA also has not identified what
resources may be necessary to establish and maintain new functions at
the national and local levels, or established performance measures
based on a root cause analysis of its unclear resource needs and
allocation priorities.
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\20\ In its action plan, VA reported adopting a framework in 2016
called ``Managing for Results'' to better connect VA's requirements
setting process (that forecasts veterans' needs) with its process for
developing the department's budget. VA stated that full implementation
of the framework will take place over several budget cycles.
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more than 100 gao recommendations for improving
va health care remain open
Since we added VA health care to our High-Risk List in 2015, VA's
leadership has increased its focus on implementing our prior
recommendations, but additional work is still needed. Between
January 2010 and February 2015 (when we first designated VA health care
as a high-risk area), we made 178 recommendations to VA related to VA
health care. When we made our designation in 2015, the department only
had implemented about 22 percent of them.\21\ Since February 2015, we
have made 74 new recommendations to VA related to VA health care, for a
total of 252 recommendations from January 1, 2010 through February 15,
2017 (when we issued the 2017 high-risk report).\22\ VA has implemented
about 50 percent of these recommendations. However, there continue to
be more than 100 open recommendations related to VA health care, almost
a quarter of which have remained open for 3 or more years.\23\ We
believe that it is critical that VA implement our recommendations not
only to remedy the specific weaknesses we previously identified, but
because they may be symptomatic of larger underlying problems that also
need to be addressed. Since the 2015 high-risk report, we have made new
recommendations to VA relating to each of the five areas of concern.
(See table 1.)
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\21\ Of the 178 recommendations, 134 were open because VA had not
yet implemented them. Additionally, 39 had been closed because VA
implemented them, and 5 had been closed without VA implementing them.
We close recommendations without agencies having implemented them
primarily if the recommendation is no longer valid because
circumstances have changed.
\22\ See GAO 17 317.
\23\ Specifically, 112 recommendations are open because VA has not
yet implemented them, 25 of which have been open for 3 or more years.
In addition, 127 recommendations were closed because VA implemented
them, and 13 were closed without VA implementing them.
Table 1: GAO Recommendations to the Department of Veterans Affairs (VA) Related to VA Health Care from January
1, 2010 through February 15, 2017, by Area of Concern
----------------------------------------------------------------------------------------------------------------
Cumulative
Number of Number of percentage of
recommendations recommendations Cumulative GAO
prior to GAO added since GAO number of GAO recommendations
VA health care area of concern high-risk high-risk recommendations VA has
designation designation Jan. 1, 2010 implemented,
(Jan. 1, 2010 (Feb. 11, 2015 through Feb. Jan. 1, 2010
through Feb. through Feb. 15, 2017* through Feb.
11, 2015)* 15, 2017)* 15, 2017
----------------------------------------------------------------------------------------------------------------
Ambiguous policies and inconsistent 42 21 63 52%
processes..................................
Inadequate oversight and accountability..... 63 36 99 51
Information technology challenges........... 11 2 13 44
Inadequate training for VA staff............ 6 8 14 43
Unclear resource needs and allocation 48 6 54 66
priorities.................................
Not assigned to an area of concern.......... 8 1 9 44
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Total..................................... 178 74 252 50%
----------------------------------------------------------------------------------------------------------------
Source: GAO. GAO 17 473T.
* Recommendation counts listed include both implemented and not implemented recommendations as of the dates
indicated.
sustained leadership support and strategic focus needed to
meet high-risk removal criteria
VA has taken an important step toward addressing our criteria for
removal from the High-Risk List by establishing the leadership
structure necessary to ensure that actions related to the High-Risk
List are prioritized within the department. It is imperative, however,
that VA demonstrate strong leadership support as it continues its
transition under a new administration, address weaknesses in its action
plan, and continue to implement our open recommendations.
As a new administration sets its priorities, VA will need to
integrate those priorities with its high-risk-related actions, and
facilitate their implementation at the local level through strategies
that link strategic goals to actions and guidance. In its action plan,
VA separated its discussion of department-wide initiatives, like MyVA,
from its description of High-Risk List mitigation strategies.\24\ We do
not view high-risk mitigation strategies as separate from other
department initiatives; actions to address the High-Risk List can, and
should be, integrated in VA's existing activities.
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\24\ According to VA, MyVA intends to make changes to VA's systems
and structures to (1) improve the veteran experience, (2) improve the
employee experience, (3) achieve support services excellence, (4)
establish a culture of continuous performance improvement, and (5)
enhance strategic partnerships.
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VA's action plan did not adequately address the concerns that led
to the high-risk designation because it lacked root cause analyses for
most areas of concern, as well as clear metrics and identified
resources needed for achieving VA's stated outcomes. This is especially
evident in VA's plans to address the IT and training areas of concern.
In addition, with the increased use of community care programs, it is
imperative that VA's action plan include a discussion of the role of
community care in decisions related to policies, oversight, IT,
training, and resource needs. VA will also need to demonstrate that it
has the capacity to sustain efforts by devoting appropriate resources--
including people, training, and funds--to address the high-risk
challenges we identified. Until VA addresses these serious underlying
weaknesses, it will be difficult for the department to effectively and
efficiently implement improvements addressing the five areas of concern
that led to the high-risk designation.
We will continue to monitor VA's institutional capacity to fully
implement an action plan and sustain needed changes in all five of our
areas of concern. To the extent we can, we will continue to provide
feedback to VA officials on VA's action plan and areas where they need
to focus their attention. Additionally, we have ongoing work focusing
on VA health care that will provide important insights on progress,
including the policy development and dissemination process,
implementation and monitoring of VA's opioid safety, Veterans Choice
Program implementation, physician recruitment and retention, and
processes for enrolling veterans in VA health care.
Finally, we plan to also continue to monitor VA's efforts to
implement our recommendations and recommendations from other reviews
such as the Commission on Care.\25\ To this end, we believe that the
following GAO recommendations require VA's immediate attention:
\25\ The Veterans Access, Choice, and Accountability Act of 2014
established the Commission on Care to examine, assess, and report on
veterans' access to VA health care and to strategically examine how
best to organize VHA, locate health resources, and deliver health care
to veterans during the next 20 years. The Commission's June 2016 report
to the President included 18 recommendations to improve veterans'
access to care and, more broadly, to improve the quality and
comprehensiveness of that care. On September 1, 2016, the President
concurred with 15 of the 18 recommendations and directed VA to
implement them.
improving oversight of access to timely medical
appointments, including the development of wait-time measures that are
more reliable and not prone to user error or manipulation, as well as
ensuring that medical centers consistently and accurately implement
VHA's scheduling policy.
improving oversight of VA community care to ensure--among
other things--timely payment to community providers.
improving planning, deployment, and oversight of VA/VHA IT
systems, including identifying outcome-oriented metrics and defining
goals for interoperability with DOD.
ensuring that recommendations resulting from internal and
external reviews of VHA's organizational structure are evaluated for
implementation. This process should include the documentation of
decisions and assigning officials or offices responsibility for
ensuring that approved recommendations are implemented.
Moreover, it is critical that Congress maintain its focus on
oversight of VA health care to help address this high-risk area.
Congressional committees responsible for authorizing and overseeing VA
health care programs held more than 70 hearings in 2015 and 2016 to
examine and address VA health care challenges. As VA continues to
change its health care service delivery in the coming years, some
changes may require congressional action--such as VA's planned
consolidation of community care programs after the Veterans Choice
Program expires. Sustained congressional attention to these issues will
help ensure that VA continues to improve its management and delivery of
health care services to veterans.
Chairman Isakson, Ranking Member Tester, and Members of the
Committee, this concludes my statement. I would be pleased to respond
to any questions you may have.
Senator Tillis. Thank you.
Mr. Missal.
STATEMENT OF MICHAEL J. MISSAL, INSPECTOR GENERAL, U.S.
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY JOHN D. DAIGH,
JR., M.D., CPA, ASSISTANT INSPECTOR GENERAL FOR HEALTHCARE
INSPECTIONS, OFFICE OF INSPECTOR GENERAL
Mr. Missal. Senator Tillis and Members of the Committee,
thank you for the opportunity to discuss the work of the VA
Office of Inspector General and how we provide effective
oversight of VA programs and operations through independent
audits, inspections, and investigations. I am accompanied by
Dr. David Daigh, the Assistant Inspector General for Healthcare
Inspections.
The OIG seeks to prevent and detect fraud, waste, and abuse
and make meaningful recommendations to drive economy,
efficiency, and effectiveness throughout VA's programs and
operations. Our goal is to undertake impactful work that will
assist VA in providing the appropriate and timely services and
benefits that veterans so deservedly earned and ensuring the
proper expenditure of taxpayer funds.
I have had the great privilege of serving as the Inspector
General since May 2, 2016. Since that time, I have fully
immersed myself in the work, priorities, and policies of the
OIG. We have made a number of enhancements since I started, in
an effort to do more impactful work in a timelier manner.
The OIG shares a similar mission with GAO. It is important
that we have a strong relationship with GAO, to ensure we avoid
duplication of effort as much as possible. To that end, one of
the first things I did when I started was to meet with
Comptroller General Dodaro, Dr. Draper, and his other senior
staff. Our offices have had a number of communications since
that time to promote coordination and more effective oversight
of VA.
GAO added VA health care to its biannual High-Risk List in
2015, and it remains on the High-Risk List that was just issued
in 2017. GAO focused its concern in five broad areas. While our
work is determined by what we believe is the most effective
oversight of VA, a number of our reports addressed concerns in
these same five areas. My written statement includes examples
of OIG work in each of the areas that resulted in GAO placing
VA health care on its High-Risk List. It should be noted that
many of the OIG's reports could fit into more than one area. I
will highlight a few of those reports now.
We have issued a number of reports in the past few years
that include VA's ambiguous policies and inconsistent
processes. For example, our review of the Health Eligibility
Center determined that VA had not effectively managed its
business processes to ensure the consistent creation and
maintenance of essential health care eligibility data.
Proper oversight by management would ensure that programs
and operations would work effectively and efficiently. Our
September 2016 report on the Denver replacement medical center
is an extremely costly example of the result of inadequate
oversight. Through all phases of the project, we identified
various factors that significantly contributed to delays and
rising costs. This occurred due to a series of questionable
business decisions and mismanagement by VA senior officials,
resulting in a project years behind schedule and costing more
than twice the initial budget of $800 million.
We have frequently identified VA struggles to design,
procure, and/or implement functional IT systems. IT security is
continually reported as a material weakness in VA's
consolidated financial statements. Moreover, VA has a high
number of legacy IT systems needing replacement. Furthermore,
after years of effort focused on replacement of VA's legacy
scheduling software, a new scheduling system is still not in
place. VA's issues with scheduling software are related to the
inability to define its requirements and determine if a
commercial solution is available or if it must design the
system.
One prevailing theme of the OIG's work related to wait
times and scheduling issues was the inadequate, lack of, or
incorrect training provided to VA staff responsible for
scheduling appointments. As we have stated in reports that have
been issued since the allegations at the Phoenix VA health care
system surfaced in April 2014, the lack of training for
schedulers, the lack of understanding of the process by their
managers, and, in some cases, the disregard of VA scheduling
policies created a system where services have not been provided
timely, and in some situations, wait times were not accurately
portrayed. VA needs to accurately forecast the demand for
health care services in both the near term and the long term.
In conclusion, the OIG is committed to providing effective
oversight of the programs and operations of VA. We will
continue to produce reports that provide VA, Congress, and the
public with recommendations that we believe will help VA
operate its programs and services in a manner that will
effectively and timely deliver services and benefits to
veterans and spend taxpayer money appropriately.
Senator Tillis, this concludes my statement. Dr. Daigh and
I would be happy to answer questions that you or other Members
of the Committee may have.
[The prepared statement of Mr. Missal follows:]
Prepared Statement of Michael J. Missal, Inspector General,
U.S. Department of Veterans Affairs
Mr. Chairman, Ranking Member Tester, and Members of the Committee,
Thank you for the opportunity to discuss the work of the VA Office of
Inspector General (OIG) and how the OIG provides effective oversight of
VA programs and operations through independent audits, inspections, and
investigations. The OIG seeks to prevent and detect fraud, waste, and
abuse, and make meaningful recommendations to drive economy,
efficiency, and effectiveness throughout VA programs and operations.
Our goal is to undertake impactful work that will assist VA in
providing the appropriate and timely services and benefits that
veterans so deservedly earned, and ensuring the proper expenditure of
taxpayer funds. I am accompanied by John D. Daigh, Jr., M.D., CPA,
Assistant Inspector General for Healthcare Inspections.
I have had the great privilege of serving as the Inspector General
since May 2, 2016. Since that time, I have fully immersed myself in the
work, priorities, and policies of the OIG. We have made a number of
enhancements since I started, including issuing a Mission, Vision, and
Values statement; increasing transparency; creating a Rapid Response
team in our Healthcare Inspections directorate; expanding our data
analytics capabilities; and being more proactive in our review areas. I
believe that these changes, as well as other enhancements we will make,
will enable us to do additional impactful work in a more timely manner.
The OIG shares an analogous mission with the Government
Accountability Office (GAO). It is important that the VA OIG has a
strong relationship with GAO to ensure that we avoid duplication of
effort as much as possible. To that end, one of the first things I did
when I started was to meet with Comptroller General Dodaro and some of
his senior staff. Our offices have communicated regularly since that
time to promote coordination and more effective oversight of VA.
In February 2015, GAO added Managing Risks and Improving VA Health
Care to its biannual High Risk list. It focused its concerns in five
broad areas:
Ambiguous policies and inconsistent processes,
Inadequate oversight and accountability,
Information technology challenges,
Inadequate training for VA staff, and
Unclear resource needs and allocation priorities.
While our work is determined by what we believe is the most
effective oversight of VA, a number of our reports address concerns in
these same five areas. I will highlight a sampling of OIG work in each
of the areas that resulted in GAO placing VA Health Care on its High
Risk list. However, it should be noted that many of the OIG's reports
could fit in more than one area.
ambiguous policies and inconsistent processes
We have issued a number of reports in the past few years that
include VA's ambiguous policies and inconsistent processes. Our recent
report \1\ on wait time in one specific Veteran Integrated Service
Network (VISN), we assessed the reliability of wait time data and
timely access within VISN 6 which includes VHA facilities in North
Carolina and Virginia. The objective of the audit was to determine
whether VISN 6 facilities provided new patients timely access to health
care within its medical facilities and through Choice, as well as to
determine whether VISN 6 facilities appropriately managed consults. We
reported that veterans who were authorized Choice care in VISN 6 did
not consistently receive the authorized health care within 30 days as
required by Health Net's contract with VA.
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\1\ Audit of Veteran Wait Time Data, Choice Access, and Consult
Management in VISN 6, March 2, 2017
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We reviewed a statistical sample of 389 Choice authorizations
provided to Health Net by VISN 6 medical facility staff during the
first quarter of Fiscal Year (FY) 2016. Based on our sample results, we
estimated that for the approximately 34,200 veterans who were
authorized Choice care in VISN 6, approximately 22,500 veterans who
received Choice care waited an average of 84 days to get their care
through Health Net providers. We estimated it took VA medical facility
staff an average of 42 days to provide the authorization to Health Net
to begin the Choice process and an additional 42 days for veterans to
receive the medical service through Health Net providers. We identified
delays related to authorizations for primary care, mental health care,
and specialty care. VHA's Chief Business Officer addressed a potential
cause for delay in creating appointments by executing a contract
modification effective November 1, 2015. This change allowed Health Net
to initiate phone contact with a veteran to arrange a Choice
appointment, rather than require the veteran to contact Health Net as
previous required. Our analysis showed that, while still untimely, this
change lowered the percentage of veterans who waited more than 5 days
for Health Net to create an appointment from 86 percent to 69 percent.
The Under Secretary for Health concurred with our 10
recommendations and provided a responsive action plan and milestones to
address the recommendations regarding monitoring controls over
scheduling requirements, wait time data, and access to health care and
consult management. Our recommendations will help ensure staff use
clinically indicated and preferred appointment dates consistently,
medical facilities conduct required scheduler audits, and staffing
resources are adequate to ensure timely access to health care. The
report's recommendations remain open.
Another example, in September 2015, we reported in Review of
Alleged Mismanagement at the Health Eligibility Center that VA's Chief
Business Office (CBO) had not effectively managed its business
processes to ensure the consistent creation and maintenance of
essential health care eligibility data. Due to the amount and age of
the Enrollment System (ES) data, as well as lead times required to
develop and implement software solutions, a multiyear project
management plan was needed to address the accuracy of pending ES
records and improve the usefulness of ES data. We offered 13
recommendations in the report including one focused on controls to
ensure that future enrollment data are accurate and reliable before
being entered into the Enrollment System. VA concurred with the
recommendations and provided sufficient information to close all
recommendations in October 2016. We have an ongoing review of the
Health Eligibility Center focusing on the alleged lack of effective
governance over the Veterans Health Administration's (VHA) execution of
the health care enrollment program at its medical facilities. We expect
to issue our report in late spring 2017.
Another program that operates nationwide also had issues related to
inconsistent implementation of policies is the Homeless Grant Per Diem
Program. In a June 2015 report, Audit of Homeless Providers Grant and
Per Diem Case Management Oversight, we determined VA needed to clarify
eligibility requirements across the program to ensure that all homeless
veterans have equal access to case management services. Historically,
homeless veterans ineligible for VA health care have not been excluded
from the program. However, we questioned the application of the
program's eligibility criteria, and found the criteria were unclear and
inconsistently applied. This was confirmed in our interviews of VA's
Office of General Counsel, program directors, network homeless
coordinators, and liaisons, which revealed confusion occurred at all
program levels. We made five recommendations, three of which involved
establishing a definitive legal standard on program eligibility and
ensuring that policies and controls matched that standard and were
applied across the program. The recommendations dealing with policies
and controls remain open.
inadequate oversight and accountability
Proper oversight by management ensures that programs and operations
would work effectively and efficiently. Our September 2016 report,
Review of the Replacement of the Denver Medical Center, Eastern
Colorado Health Care System, on the management of the construction of a
new VA medical center in the Denver area, is an extremely costly
example of the result of inadequate oversight. We confirmed the project
to build a new medical center in the Denver area has experienced
significant and unnecessary cost overruns and schedule slippages.
Originally estimated for 2013 completion, it will not be ready before
mid-to-late 2018, about 20 years after its need was identified.
Through all phases of the project, we identified various factors
that significantly contributed to delays and rising costs, including:
Inadequate planning and design,
Initiation of the construction phase without adequate
design plans,
Changing the acquisition strategy mid-stream, and
Untimely change request processing.
This occurred due to a series of questionable business decisions
and mismanagement by VA senior officials. The report summarizes the
significant management decisions and factors that resulted in a project
years behind schedule and costing more than twice the initial budget of
$800 million. We made five recommendations and VA management concurred
with all recommendations. We recently requested information from VA on
the implementation status of the recommendations and will keep them
open until VA provides satisfactory evidence of implementation.
In June 2016, we issued a report on allegations related to
appointment cancellations at the Houston VA Medical Center, titled
Review of Alleged Manipulation of Appointment Cancellations at VA
Medical Center, Houston, Texas. We substantiated that two previous
scheduling supervisors and a current director of two outpatient clinics
instructed staff to input clinic cancellations incorrectly as canceled
by the patient. We also confirmed that a current director of two CBOCs
instructed staff, as recently as February 2016, to record an
appointment as canceled by the patient if clinic staff at one CBOC
offered to reschedule a veteran's appointment at a different CBOC
situated about 17 miles away and the veteran declined the appointment.
The CBOC Director noted this was appropriate since the CBOC was still
offering the patient an appointment. However, when interviewed
regarding these cancellations, the CBOC Director acknowledged she
instructed staff to cancel appointments by the patient if the veteran
declined an appointment in the alternate location. We made six
recommendations, including referring the matter to VA's Office of
Accountability Review (OAR), to determine what, if any, administrative
actions should be taken based on the factual circumstances developed in
our report.
In December 2014, we released an audit related to VA's National
Call Center for homeless veterans, titled Audit of The National Call
Center for Homeless Veterans. We reported that homeless and at-risk
veterans who contacted the Call Center often experienced problems
accessing a counselor and/or receiving a referral after completing the
Call Center's intake process. We reported:
Veterans could leave a message on an answering machine
only 27 percent of the time period reviewed,
Veteran messages were not referred to VA medical
facilities due to inaudible messages or no contact information in 16
percent of the time period reviewed,
Veterans were not referred to VA medical facilities
despite providing all the necessary information in 4 percent of the
time period we reviewed.
Moreover, the Call Center closed approximately 47 percent of
referrals even though the VA medical facilities had not provided the
Homeless veterans any support services. These missed opportunities
occurred due to lapses in the Call Center's management and oversight.
We made seven recommendations, including implementing effective
performance metrics to ensure homeless veterans receive needed
services. We closed our report in September 2015 based on information
received that all recommendations had been implemented.
information technology challenges
As we reported in our list of VA's Major Management Challenges
within VA's Annual Financial Report, we have frequently identified VA's
struggles to design, procure, and/or implement functional information
technology (IT) systems. IT security is continually reported as a
material weakness in the Consolidated Financial Statement audits that
are conducted annually by the OIG's independent auditing firm,
CliftonLarsonAllen (CLA).
VA has a high number of legacy systems needing replacement
including the Financial Management System; Integrated Funds
Distribution, Control Point Activity, Accounting and Procurement
system; Veterans Health Information Systems and Technology
Architecture, and the Benefits Delivery Network; After years of effort
focused on replacement of VA's legacy scheduling software, a new
scheduling system is still not in place. VA's issues with scheduling
appointments are related to the inability to define its requirements
and determine if a commercial solution is available or if it must
design a system. Replacing systems has been a major challenge across
the government and is not unique to VA. We have issued a number of
reports outlining access issues and our work in this area is
continuing.
While the difficulties between VA's electronic health record (EHR)
and the Department of Defense's EHR are well documented, the increased
utilization of care in the community will present further IT
challenges. To ensure that medical providers both inside and outside VA
have the most complete and up-to-date information, VA needs to find a
more effective method for sharing patients' EHRs. We reported on the
possibility of delays in care because of the difficulties in sharing
medical records in the Urology Clinic at the Phoenix VA Health Care
System in our October 2015 report, titled Healthcare Inspection, Access
to Urology Service, Phoenix VA Health Care System, Phoenix, Arizona.
Specifically, we identified approved authorizations for non-VA care
coordination (NVCC) urological care and a notation that an
authorization was sent to the non-VA provider. A scheduled date and
time of an appointment with the non-VA urologist was often documented.
However, we were unable to locate scanned documents from non-VA
providers in these patients' EHRs verifying that the patients had been
seen for evaluations, and if seen, what the evaluations might have
revealed. This finding suggested that the Phoenix VA Health Care System
(PVAHCS) did not have accurate data on the clinical status of the
patients who were referred for the specialty care.
Further, with respect to scanning and reviewing outside clinical
documents (for example, clinic notes, labs, or imaging results), when
the services were provided by TriWest Health Care Alliance (TriWest),
the treating providers' office submitted this data to the TriWest
Portal. To access that information, an NVCC staff member was required
to log into the TriWest Portal to print and scan these records into the
patients EHRs. This process was delayed because of the NVCC staffing
shortages, which could have resulted in important clinical information
not being reviewed for several months. We made three recommendations,
including one specifically related to ensuring that non-VA care
providers' clinical documentation is available in the EHRs in a timely
manner for PVAHCS providers to review. We closed our report in
June 2016 after VA provided information that addressed the
recommendations.
In the area of IT security, VA uses personally identifiable
information (PII), protected health information (PHI), and other
sensitive information to deliver benefits to veterans and their
dependents. Employees and contractors must safeguard this information.
As we reported in our September 2015 report, Review of Alleged Data
Sharing Violations at VA's Palo Alto Health Care System, the VA Palo
Alto Health Care System (VAPAHCS) did not ensure that contract staff
had the appropriate background investigations or proper security and
privacy awareness training before being granted access to VA patient
information. Additionally, facility Information Security Officers were
not involved prior to the contractor placing its software on a VA
server. We made three recommendations to VAPAHCS management and a
fourth recommendation that VA's Office of Information Technology
implement controls to ensure that unauthorized software is not procured
or installed on VA networks without a formal risk assessment and
approval to operate. We closed our report based on information provided
that the recommendations were implemented.
inadequate training for va staff
One prevailing theme of the OIG's work related to wait times and
scheduling issues was the inadequate, lack of, or incorrect training
provided to VA staff responsible for scheduling appointments. We
conducted extensive work related to allegations of wait time
manipulation through FY 2015 and FY 2016 after the allegations at the
PVAHCS surfaced in April 2014. As we have reported in more than 90
Administrative Summaries of Investigation and other reports that have
been issued, the lack of training for schedulers and the lack of
understanding of the process by their managers created a system in
which long wait times were not accurately portrayed to management.
In October 2016, we reported again that some confusion persists
regarding appointments. The focus for this report was on consult
management. In our report, Review of Alleged Consult Mismanagement at
the Phoenix VA Health Care System, we substantiated that in 2015,
PVAHCS staff inappropriately discontinued consults. We determined that
staff inappropriately discontinued 24 percent of specialty care
consults we reviewed. This occurred because staff were generally
unclear about specific consult management procedures, and services
varied in their procedures and consult management responsibilities. As
a result, patients did not receive the requested care or they
encountered delays in care. This report offered 14 recommendations
including ensuring that staff are hired and trained appropriately. We
are tracking VA's progress on implementing all the recommendations.
In January 2016, we determined that VHA did not provide medical
facilities with adequate tools to reasonably estimate non-VA care (NVC)
obligations in our report, Audit of Non-VA Medical Care Obligations.
The facilities we visited used a combination of methods that were
ineffective at ensuring NVC cost estimates were reasonable. The methods
used to calculate estimated costs included Medicare or contract rates,
historical costs, and the optional cost estimation tools provided by
CBO. The accuracy of estimates varied widely among these methodologies.
We made five recommendations including for VA to improve the cost
estimate tools so that NVC cost estimates are produced consistently.
The recommendations related to cost estimate tools remain open.
unclear resource needs and allocations priorities
In March 2017, we published Consult Delays and Management Concerns,
VA Montana Healthcare System, Fort Harrison, MT. We assessed the extent
that patients experienced delays in obtaining consults, and the impact
of any delays on patient outcomes. We reported that, for system
consults ordered through VA Montana Healthcare System in FY 2015, there
were apparent delays \2\ for:
\2\ We considered delayed consults to be those that were not
completed, canceled or discontinued within the expected timeframe.
---------------------------------------------------------------------------
11,073 of 26,293 patients (42 percent) with at least one
in-house consult;
11,863 of 21,221 patients (56 percent) with at least one
non-VA care consult; and
2,683 of 4,427 patients (61 percent) with at least one
Choice consult.
We found that delays among consults ordered in FY 2015 may have
harmed four patients. Beginning in July 2015, system leadership
initiated a focused effort to identify and resolve factors that
contributed to consult delays, including hiring additional support
staff to process consults. Despite this effort, we found evidence of
persistent issues with completing consults timely in FY 2016 (through
late August 2016). We also noted that system leadership initiated
ongoing reviews to determine if patient harm occurred due to delays in
care.
We made two recommendations to the VA Montana Director to ensure
that an external (non-system) source review the care of patients we
identified who were potentially harmed by consult delays and that VA
staff provide institutional disclosures, as appropriate. We also made a
recommendation regarding ongoing efforts to improve consult timeliness.
The VA Montana Director and the VISN 19 Director concurred with our
three recommendations and provided a responsive action plan and
milestones to address the recommendations.
The OIG has repeatedly reported on VA's legacy systems and how they
impair VA operations. A key element to accurate planning is a financial
system that provides timely information to VA leadership. As was
reported in Audit of VA's Financial Statements for Fiscal Years 2016
and 2015, VA's complex, disjointed, and legacy financial management
system architecture continues to deteriorate over time and no longer
meets the increasingly stringent and demanding financial management and
reporting requirements mandated by the Department of the Treasury and
the Office of Management Budget. VA continues to be challenged in its
efforts to apply consistent and proactive enforcement of established
policies and procedures throughout its geographically dispersed
portfolio of legacy applications and systems. VA announced in
October 2016 that it selected the Department of Agriculture as its
Federal shared service provider to deliver a modern financial
management solution to replace its existing core financial management
system. When completed, this will be a major and critical effort for VA
in modernizing its system architecture for financial management.
The audit of VA's FY 2016 Consolidated Financial Statements also
identified Community Care obligations, reconciliations, and accrued
expenses as a material weakness. Lack of tools to estimate non-VA Care
costs, lack of controls to ensure timely deobligations, and the
difficulty in reconciling non-VA Care authorizations to obligations in
VA's Financial Management System, make the accurate and timely
management of purchased care funds challenging. In addition, the Office
of Community Care (OCC) did not have adequate policies and procedures
for its own monitoring activities. OCC's activities were not integrated
with VA and VHA Chief Financial Officer (CFO) responsibilities under
Public Law (P.L.) 101-576, the Chief Financial Officers Act of 1990, to
develop and maintain integrated accounting and financial management
systems and provide policy guidance and oversight of all Community Care
financial management personnel, activities, and operations.
To address the difficulties in estimating costs, VA requested
legislation that would allow VA to record an obligation at the time of
payment rather than when care is authorized. In its consolidation plan,
VA said this would likely reduce the potential for large deobligation
amounts after the funds have expired. We recognize that the current
process and system infrastructure are complex and do not provide for
effective funds management. We caution that such a change alone--i.e.,
obligating funds at the time of payment--would not necessarily remove
all of VA's challenges in this area. VA would still need adequate
controls to monitor accounting, reconciliation, and management
information processes to ensure they effectively manage funds
appropriated by Congress.
VA needs to accurately forecast the demand for health care services
in both the near term and the long term. The OIG is required by Section
301 of Public Law 113-146, the Veterans Access, Choice, and
Accountability Act of 2014, to review VHA occupations with the largest
staffing shortages. We have issued three reports at this time and under
the statute we will report for another two years. In our most recent
report issued in September 2016,\3\ we identified (i) medical officer;
(ii) nurse; (iii) psychologist; (iv) physician assistant; and (v)
physical therapist/medical technician as five critical occupations with
the largest staffing shortages. In our initial review \4\ and our
subsequent reviews,\5\ we continue to recommend VHA create a staffing
model that considers demand and complexity, and matches that to budget
requests and allocations. While VHA has continually concurred with the
recommendation, their planned completion date is September 2017.
Further delay will potentially result in missed opportunities to
request appropriate funding when planning for the FY 2019 budget.
---------------------------------------------------------------------------
\3\ https://www.va.gov/oig/pubs/VAOIG-16-00351-453.pdf,
September 28, 2016
\4\ OIG Determination of Veterans Health Administration's
Occupational Staffing Shortages, January 30, 2015
\5\ OIG Determination of Veterans Health Administration's
Occupational Staffing Shortages, September 1, 2015
---------------------------------------------------------------------------
conclusion
The OIG is committed to providing effective oversight of the
programs and operations of VA. A number of our reports address the five
broad areas noted by GAO in placing VA Health Care on its High Risk
list. We will continue to produce reports that provide VA, Congress,
and the public with recommendations that we believe will help VA
operate its programs and services in a manner that will effectively and
timely deliver services and benefits to veterans and spend taxpayer
money appropriately.
Mr. Chairman, this concludes my statement and we would be happy to
answer any questions that you or other Members of the Committee may
have.
Senator Tillis. Thank you, Mr. Missal.
Dr. Clancy.
STATEMENT OF CAROLYN M. CLANCY, M.D., DEPUTY UNDER SECRETARY
FOR HEALTH AND ORGANIZATIONAL EXCELLENCE, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY JENNIFER LEE, M.D., DEPUTY UNDER SECRETARY FOR
HEALTH FOR POLICY AND SERVICES; AND AMY PARKER, EXECUTIVE
DIRECTOR OF OPERATIONS, OFFICE OF MANAGEMENT
Dr. Clancy. Good afternoon, Senator Tillis, Members of the
Committee. Thank you for the opportunity to discuss VA's
efforts to improve the issues identified by the GAO when they
placed VA health care on the High-Risk List in 2015. As you
noted, I am accompanied by Dr. Jennifer Lee and Amy Parker.
In its High-Risk List update, GAO identified managing risks
and improving VA health care as a high-risk area and noted five
associated issues, which we have detailed in our written
statement, and Debra Draper just reiterated.
On March 3, 2017, Secretary Shulkin met with Comptroller
General Dodaro to convey VA leadership's commitment to
accelerating the changes required to meet all of GAO's criteria
for removal from the High-Risk List. Secretary Shulkin
acknowledged the significant scope of the work that remains and
committed to better integrate its high risk-related actions
with the President's priorities and ongoing VA transformation
efforts.
We immediately began working with GAO to follow through on
Secretary Shulkin's commitments and to ensure continued VA
collaboration with our GAO colleagues. We take GAO's work and
the Inspector General's very seriously and appreciate the
advice and feedback we have received from them. We are pleased
to have the opportunity to report on our progress to date and
our plan to ultimately be removed from the list.
Addressing these risks will provide a sustainable
foundation for continued transformation of the Veterans Health
Administration. We have made progress since being placed on the
High-Risk List. Two years ago, VHA had over 800 policies and
over half of these had expired. On average, it took about 340
days to produce national policy, and VHA lacked a consistent
process for their development. Since that time, we have
established a workgroup of all outcome executives, meeting
every 2 weeks, tracking all policies and development, examining
every step of the process, addressing barriers, and piloted and
established a new lean process that would be completed within
120 days.
There are now approximately 650 active policies. New
policies are created and reviewed promptly, and essential
policies on access, scheduling, and consultations have been
completed, published, and widely disseminated. We have
committed to completing GAO's recommendations to ensure medical
facility controlled substance inspection programs meet our
requirements by October of this year.
VHA also instituted a significant organizational
transformation that aligned key offices, including offices of
compliance and business integrity, medical audit, a new
internal audit function, the management review service, and
ethics, under a single combined Office of Integrity, led by a
new leader, Assistant Deputy Under Secretary for Health, Dr.
Gerard Cox, who reports to me.
The newly established Office of Internal Audit and Risk
Assessment uses reports from VA's Office of Inspector General,
GAO, and the Office of Special Counsel to conduct further
assessments into potential weaknesses in VA health care
programs or care quality.
During the past 2 years, in partnership with GAO, we
conducted a comprehensive inventory of open recommendations and
instituted a regular process for adjudicating closure based on
documentation of completed actions, and linked them quite
specifically to the risk areas identified by the GAO. Now, more
than 45 percent of open recommendations were made, just in a
year or less, and we have requested closure on 18 percent of
the open recommendations.
We have learned that integrating with or updating our
veterans health information systems and technology
architecture, known as VistA, is difficult and costly. We must
be able to consistently access veteran information to succeed.
We certified our interoperability with the Department of
Defense on April 8, 2016. Today the Joint Legacy Viewer is
available to all clinicians in every one of our facilities
across the country, and we are also actively onboarding private
sector partners into our health information exchange, because
that is absolutely imperative for community care to work well.
Mr. Chairman, transformation is a marathon, not a sprint.
It takes several years to turn any organization around and we
are acutely aware that most of the candidates on GAO's High-
Risk List have taken multiple years to meet that requirement.
Secretary Shulkin is absolutely dedicated that we do this as
rapidly as possible.
While I am proud of the progress we have made in a short
time, I am also acutely aware that we have much more work to
do. I am grateful for the subject matter advice and
consultation provided by Dr. Draper and her colleagues, and
reiterate my commitment to working more closely with them.
We look forward to working with you and Members of this
Committee and to better serve our veterans, and to have
committed to quarterly briefings to your staff.
Thank you for the opportunity to testify and I look forward
to your questions.
[The prepared statement of Dr. Clancy follows:]
Prepared Statement of Carolyn M. Clancy, M.D., Deputy Under Secretary
for Health for Organizational Excellence, Veterans Health
Administration, U.S. Department of Veterans Affairs
Good afternoon, Chairman Isakson, Ranking Member Tester, and
Members of the Committee. Thank you for the opportunity to discuss the
Department of Veterans Affairs' (VA) efforts to improve the issues
identified by the Government Accountability Office (GAO) that placed VA
health care on the 2015 GAO High Risk List. I am accompanied today by
Dr. Jennifer Lee, Deputy Under Secretary for Health for Policy and
Services, and Amy Parker, Executive Director of Operations, Office of
Management.
introduction
In its 2015 High Risk List Update, GAO identified ``Managing Risks
and Improving VA Health Care'' as a high-risk area and noted five
associated high-risk issues:
Ambiguous policies and inconsistent processes;
Inadequate oversight and accountability;
Information technology (IT) challenges;
Inadequate training for VA staff; and,
Unclear resources needs and allocation priorities.
We take GAO's work seriously and appreciate the advice and feedback
we have received from our colleagues. We are pleased to have the
opportunity to report on our progress to date and our plan to be
removed from the list. Addressing these risks will provide a
sustainable foundation for continued transformation of the Veterans
Health Administration (VHA).
progress to date by risk area
Ambiguous Policies
Two years ago, VHA had over 800 policies, and more than
half had expired. On average, it took over 340 days to produce national
policy, and VHA lacked a consistent process for policy development.
Since that time, we have established a workgroup comprised of all
outcome executives that meets every two weeks and tracks all policies
in development. We examined every step of the process, addressed
barriers, and piloted and established a new, lean process with an
aspirational timeline of 120 days. Our new process incorporated review
and comments from medical centers and administrative offices--something
that had never been formally required in the past, and which addressed
many of the gaps identified by GAO. We funded seven full-time
contractors to support transformation. We identified and rescinded 112
expired policies and 20 additional policies that were no longer
relevant. We completed work updating many policies imperative to
addressing then-Under Secretary for Health Dr. David Shulkin's five
priorities, and are eliminating handbooks and manuals in an effort to
simplify and streamline national policy. There are now approximately
650 active policies, including essential policies on access,
scheduling, and consultations that were completed, published, and
widely disseminated. We are also beginning to experience the
unquantifiable benefits of culture change, as people in VA Central
Office and the field become aware of these new processes, and the
response has been overwhelmingly positive.
Inadequate Oversight and Accountability
VHA instituted a significant organizational transformation
that aligned several key offices including the Office of Compliance and
Business Integrity, the Office of the Medical Inspector, the Office of
Internal Audit and Risk Assessment, the Management Review Service, and
the National Center for Ethics in Health Care. These offices are led by
a newly established Assistant Deputy Under Secretary for Health for
Integrity, Dr. Gerard Cox, who reports to the Deputy Under Secretary
for Organizational Excellence. VHA also established a new Office of
Internal Audit and Risk Assessment that uses reports from VA's Office
of Inspector General (OIG), GAO, and the U.S. Office of Special Counsel
to conduct further assessments into potential weaknesses in VA health
care programs or care quality. The expected outcomes from VHA's
integration of oversight and accountability activities are that: 1) VHA
program offices, Veterans Integrated Service Networks (VISN), and
facilities will possess a common understanding of how their oversight
authorities, roles, and responsibilities align, 2) VHA will have a
workforce well trained in oversight standards, 3) program offices,
VISNs, and facilities will uniformly oversee policy implementation, and
4) VHA will have a culture that incorporates both values and process to
solve policy concerns.
During the past two years VA, in partnership with GAO,
conducted a comprehensive inventory of open recommendations and
instituted a regular process for adjudicating closure based on
documentation of completed actions. This adjudication process resulted
in closure of 91 recommendations, and we have requested closure on 18
percent of open recommendations. We have systematically cleared out the
backlog of old recommendations so that currently over 45 percent of our
open recommendations were made during the past 12 months. An additional
30 percent of open recommendations are between 1- and 3-years old.
information technology challenges
VA has learned that integrating with or updating the
Veterans Health Information Systems and Technology Architecture (VistA)
is difficult and costly. VistA Evolution is a joint VHA and Office of
Information and Technology project intended to improve the efficiency
and quality of Veterans' health care by modernizing VA's health
information systems, increase data interoperability with the Department
of Defense (DOD) and network care partners, and reduce the time it
takes to deploy new health information management capabilities. VistA
Evolution funds have enabled critical investments in systems and
infrastructure; supported interoperability, networking and
infrastructure sustainment; continuation of legacy systems; and other
efforts that are critical to maintenance and deployment. These
investments will deliver value for Veterans and VA providers regardless
of whether our path forward is to continue with VistA, shift to a
commercial Electronic Health Record (EHR) as DOD is doing, or some
combination of both.
Access to accurate Veteran information is one of our core
responsibilities, and today the Joint Legacy Viewer (JLV) is available
to all clinicians in every VA facility in the country. VA certified VA/
DOD interoperability on April 8, 2016, in accordance with section
713(b)(1) of the National Defense Authorization Act for Fiscal Year
2014 (Public Law 113-66). However, JLV is a read-only application.
Leveraging this JLV interoperability infrastructure, the Enterprise
Health Management Platform (eHMP) will ultimately replace JLV. eHMP is
a cornerstone of the VistA Evolution Program, building on the
capability for clinically actionable, patient-centric data pioneered by
JLV. eHMP will fill clinical gaps in VA's current tools, bridge the EHR
modernization effort, and simplify VHA's overall clinical user
experience. Upon completion, eHMP will offer robust support for
Veteran-centric health care, team-based health care, and quality driven
health care while improving access based on clinical need.
Inadequate Training for VA Staff
Training is vital to maintain a competent workforce and
ensure that Veterans consistently receive timely, safe, high quality
care. Training also requires a substantial investment of time and
resources. From March to June 2016, then-Under Secretary for Health Dr.
Shulkin directed a temporary moratorium on all Talent Management System
(TMS) assignments not assigned by law or Executive Order. A detailed
listing of previous training requirements was built to review all
assignments, and comprehensive recommendations from across the
organization were collected on existing training assignments. The VHA
training policy was revised based on the results of this training
review and is currently under evaluation.
As a result, all 32,326 VHA employee TMS assignments were
reviewed, and more than 700,000 hours of training were targeted for
potential removal along with possible savings of over $38.7 million in
hourly equivalent staff salary. To continue this improvement, VHA's new
Mandatory Training Policy will be implemented this year in a phased
rollout, with additional steps for review of content and comment from
field-based experts.
Unclear Resource Needs and Allocation Priorities
Key accomplishments for connecting strategy, requirements,
programming, budgeting, and execution (since June 2015) include:
Completion of the Quadrennial Strategic Planning Process
(QSPP)--Strategic Options and Alternative of Analysis Phases. Outputs
from the QSPP informed our planning guidance.
Selection of the U.S. Department of Agriculture as a
Federal Shared Service Provider to support the migration of a new
financial management system (FMS). VA established a Financial
Management Business Transformation program office and an Executive
Steering Committee to manage the multi-year effort to improve VA's
financial management accuracy and transparency.
Issuance of FY 2019-2023 Programming Guidance as the
disciplined framework to develop, assess, and prioritize multi-year
requirements. VA successfully implemented two Managing for Results
Programming cycles, which enhanced the connection of requirements and
resources to support more defensible budget justifications. This
included conducting Program Review Boards with senior leadership to
assess gaps, impacts, and mitigations in advance of budget formulation.
Publication of the FY 2018-2022 Programming Decision
Memorandum (PDM) to capture decisions from the Program Review Boards
and inform budget formulation guidance. The PDM included senior
leadership decisions for resource prioritization and enterprise-wide
mitigations to garner efficiencies and optimize strategic outcomes.
Publication of a VA Cost Estimating Guide as a new
financial policy outlining procedures for developing lifecycle
estimates for programs that meet requirement thresholds.
path forward
On March 3, 2017, Secretary Shulkin met with Comptroller General
Gene Dodaro to convey VA leadership's commitment to accelerating the
changes required to meet all of GAO's criteria for removal from the
High-Risk List. Secretary Shulkin acknowledged the significant scope of
the work that remains and committed to better integrate its high-risk
related actions with the President's priorities and ongoing performance
improvement initiatives.
VA immediately began working with GAO to follow through on
Secretary Shulkin's commitments to Comptroller General Dodaro and to
ensure continued VA collaboration with our GAO colleagues.
As we did in 2016, we will continue to place priority on
implementing GAO's and VA OIG's recommendations using our new
adjudication process. We have committed to completing GAO's
recommendations to ensure medical facility controlled substance
inspection programs meet VA requirements by October 2017. VHA's new
office of Internal Audit and Risk Assessment will lead this work and
will harmonize the policy, its implementation, training, and internal
controls for required corrective actions to ensure consistent
enterprise-wide management of controlled substances.
We will buildupon our accomplishments for same-day access for
Veterans with urgent problems in primary care or mental health, develop
and disseminate a policy that builds on current guidance to the field,
further improve our oversight of access to ensure all VA medical
facilities consistently prioritize the needs of Veterans with urgent
problems today, and transition to rely on Veterans' reports in how we
display information to the public on wait times.
VA will work with GAO and Congress to redesign the Veterans Choice
Program so it works for Veterans and community providers, improve
oversight of VA community care to ensure Veterans receive the care they
deserve, and ensure our community partners are paid in a timely
fashion.
VA needs Congressional action to extend the current Choice Program
beyond August 7, 2017. VA also needs new legislation to: (1) provide
standardized, clear eligibility criteria for Veterans to get care
closer to home; (2) facilitate building a high-performing network of
community care providers, which includes our DOD, other Federal, and
academic affiliate partners as the foundation and reimburses for care
using contemporary payment models; and (3) better coordinate benefits
for Veterans, allowing VA to work directly with third-party insurers.
We look to Congress and our stakeholders to help enact these changes
for Veterans within six months so that once all the Choice funds are
depleted, there will be a plan in place for Veterans to continue
receiving uninterrupted community care.
As described above, VA's patient scheduling and EHR system requires
significant improvement, and VA will take steps this year to address
these needs. In addition, VA will improve oversight of the systems, to
include establishing outcome-oriented metrics. VA's relationship with
DOD and our community providers is complex and evolving. We will work
closely with DOD to improve interoperability of VA and DOD record
systems, and with our community providers to ensure continuity of care
for Veterans. VA will implement a process to develop, document,
implement, and oversee organizational structure recommendations to
ensure approved recommendations are implemented, outcomes are measured,
and plans are adjusted as necessary.
VA is a complex ``system of systems,'' and this is reflected in the
root cause analysis work we have accomplished thus far. We will
complete this analysis in 2017, integrating the health care high-risk
area actions with the President's priorities, the Secretary's 10-Point
Plan, and with VA's ongoing performance improvement initiatives. We
will use the results of the analysis to fine tune and speed up VA's
progress in managing its health care high-risks.
VA efforts will buildupon each other across a period of years to
develop a sustainable solution to each high-risk issue, as well as to
put in place systems that dramatically reduce the chance that high-risk
issues will reemerge.
conclusion
Mr. Chairman, transformation is a marathon, not a sprint. It takes
several years to turn any organization around, and VA is no exception.
While I am proud of the transformation VA has undergone in response to
being placed on the High-Risk List, and the progress we have made, I am
also acutely aware we have much more work to do to meet all five of
GAO's criteria for removal. I am grateful for the subject matter expert
advice and consultation provided by Dr. Debra Draper and the GAO
medical team; it has proved invaluable in helping VA achieve the
progress we've made since 2015. We look forward to working with
Congress and GAO to better serve our Veterans. Thank you for the
opportunity to testify before the Committee. I look forward to your
questions.
Senator Tillis. Thank you, Dr. Clancy.
Are any of the other witnesses present intending to offer
an opening statement? Here to answer questions?
[No audible response.]
Senator Tillis. OK. Thank you.
Mr. Missal, I want to start with you. I want to get into
some of your specific observations, and, Dr. Draper, this may
relate to your lanes as well.
When we do these evaluations, do we do it purely from the
perspective of the regulatory, statutory construct as it exists
today? Is there ever a focus on the possible root cause of some
of the problems that need to be addressed being exacerbated by
current rules or regulations, or do you accept that as the
norm?
Mr. Missal. No, we do not accept that as the norm. When we
go into a project and we publish a report, I would like the
reports to answer at least four questions. One, why we are
doing this--and that may get to your question: is it a
regulatory issue; is there something to put it in perspective?
Two, what happened? Again, we should be accurate and fair as to
what happened. Third, why something happened, and that really
gets to the root cause of the problem. If a report is going to
be a learning experience, helping VA improve, we really have to
be pretty descriptive on why something happened. Then, fourth,
who was responsible, so that if somebody did not perform as
expected, that they could be held accountable.
Senator Tillis. Thank you for that.
Dr. Clancy, I think you know that the Ranking Member and I
worked together for the last couple of years, with Secretary
McDonald, to take a look at the transformation effort, the
breakthrough priorities, and getting updated on activities and
actions there. I think that there is some progress to be made.
One question that I have, with the transition now of Dr.
Shulkin to the role of Secretary, are any of those priorities
changing? Are there any efforts being made to try to
accelerate? Are we still on the same path, and can you give us
some update on where either those breakthrough policies or
specific remediation measures in reaction to the Inspector
General's report are actually--are we making progress? In other
words, where are we making traction?
Dr. Clancy. We have made a great deal of traction to the
transformation known as MyVA, in terms of the fact that all of
our facilities achieved same-day access. These are the major
medical centers for urgent problems and primary care and mental
health at the end of calendar year 2016.
Senator Tillis. How are we measuring that? I mean, how are
we measuring things so that I can go back and get a review of
the 100 or so recommendations, I think a quarter of which are 3
years old.
You referred in your opening comment to lean process. I
like that, because I have done lean process design in the
private sector. All those efforts are driven by metrics--
current State metrics, future metrics, any of the metrics you
are making positive progress along the way.
Are there specific things that you can speak to or submit
for the Committee's purposes to look at quantitative,
measurable changes that are in place, addressing the problems
that are in the report?
Dr. Clancy. We have a great deal of information on
quantifiable improvements in access, both in terms of wait
times and veterans' experience. There are reports of how often
can they get care when they needed it right away, and so forth,
and also plans in terms of future audits, because right at the
end of calendar year 2016 is when we achieved that addition of
same-day access.
Many of the priorities in the MyVA transformation are
continuing. I expect, as Dr. Shulkin's team comes together,
that some may just simply move to become organizational efforts
and not at that very high priority level, because they are
underway. You would expect that in any transformation. I would
imagine that has been part of your background prior to joining
the U.S. Senate as well, but certainly we would be happy to
take that for the record for a more complete picture.
[Responses were not received within the Committee's
timeframe for publication.]
Senator Tillis. Thank you. Mr. Missal, I also appreciate
the work that was done, looking specifically at VISN 6. That is
a little bit closer to home, since that covers my geography.
But, has there been any work done, in terms of even
rethinking--in my estimation, a lot of the problems that exist
with VA as a whole is how we are organized and the duplicative
technology processes that we see out there, inconsistent
experiences from VISN to VISN, and actually even within a VISN.
Are there other things that we can do to really put the
pressure on, and prioritizing in the right order? One of the
concerns that I have with the number of recommendations for
improvement, it is a target-rich environment for change. That
is the good news. The bad news is if you are shooting at every
target at the same time you are not going to hit any one of
them.
What is your view of the remedial measures that have gone
into place, and whether or not the department is organizing
properly to address the problems, and ultimately, over some
period of time, get off the High-Risk List?
Mr. Missal. We have looked at access to care in a number of
different ways. Before the VISN 6 report, we had been looking
at it facility by facility and it was hard to really get a
sense of whether there are any themes, or is there a wider-
spread problem other than at a particular facility. We
obviously found significant problems at VISN 6. We are looking
at another VISN, again, just to compare to see if it is a
leadership issue at the VISN. Is it higher? Is it lower than
that?
We try to make recommendations that are meaningful, that
hopefully you do not see the same mistake happen again. We are
going to continue to do that, and we are also going to be
looking at the whole governance structure as well, because I
agree, that could be an issue that could help a lot by
addressing it.
Senator Tillis. It just speaks to some of the impediments
that are a part of the root cause of the problem.
Ranking Member Tester.
Senator Tester. Thank you, Mr. Chairman. Mr. Missal, I
appreciate your work at Fort Harrison. Since you have been
confirmed I think you have done some very good work and I want
to thank you for that.
Dr. Clancy, I spoke with Secretary Shulkin about this
already and I need to make it clear. The findings in the
report, as I said in my opening statement, unacceptable. Debra,
as you may remember, the GAO issued a report in September 2014
on consult management. You made six recommendations that are
all still open, per your website. In one, the VHA promised to
complete the first round of VAMC consult audits by September
2016. Debra, was that completed?
Ms. Draper. They have started the audit process. They
provided us documentation in August, but we felt like the
information provided was not complete. They did not provide all
the documentation that we needed to assess the recommendations
for closure, so we sent it back to them. Just recently they
provided additional documentation; we are currently looking at
what they provided so that we can assess whether the
recommendation should be closed.
But, in the information they provided to us, 75 percent of
the VAMCs had done at least one audit--one consult. So, there
is work to be done.
Senator Tester. Was Fort Harrison included in any of those
results?
Ms. Draper. They did not provide us detail. It was 75
percent of the VA medical centers. I think this is being done,
spearheaded, through Dr. Clancy's office. She may be able to
tell you that.
Senator Tester. Go ahead, Dr. Clancy.
Dr. Clancy. Sure. I spoke with leadership from the facility
and the network yesterday, and they have made substantial
progress, about which I would be happy to provide specific
details. What I heard that was more important was: in addition
to the fact that they have already contacted three of the four
veterans--the fourth they are having some difficulty reaching
but will continue----
Senator Tester. Right.
Dr. Clancy [continuing]. And had disclosed to them and
their families what had happened, that they have not only made
progress but are looking upstream now at how did we get here.
Right? How might we use electronic consults to specialists,
noting a shortage of some specialists across the State, in
Montana, not just in VA.
Senator Tester. Yes, there are.
Dr. Clancy. And also looking at, are there ways that we
might be training primary care clinicians? Are they referring
to specialists too often, right, that they might be able to get
extra expertise----
Senator Tester. Got it.
Dr. Clancy [continuing]. If you have got a scarce resource.
I do not hear that very often. You are aware that the
entire leadership team has turned over there.
Senator Tester. I am.
Dr. Clancy. It was a very different tone then when I have
spoken to leadership at that facility before. We will certainly
keep you updated, as I know it is very high on Dr. Shulkin's
screen.
Senator Tester. That is good, and I do think we have
upgraded the leadership team in a big, big way--you guys have,
I should say, at Fort Harrison.
Another VHA started calls to share best practices with
respect to consults. Dr. Clancy, was Fort Harrison--did they
participate in those calls too?
Dr. Clancy. I would have to double-check to be concrete
about that, and I will take it for the record. Thanks.
[Responses were not received within the Committee's
timeframe for publication.]
Senator Tester. OK. All right.
Mike, your report on Fort Harrison indicated that steps had
been taken to improve consult timeliness. Are you confident
that these steps are sufficient?
Mr. Missal. You know, we have got recommendations. They
have an opportunity to prove to us that the steps that they
have agreed to take will be implemented. We look at all
recommendations very closely, and if we believe additional work
needs to be done we will do so.
Senator Tester. OK. All right. OK, that is fine.
The High-Risk Report describes deficiencies in the action
plan VHA submitted to address the high-risk status. Debra, can
you articulate the impact these deficiencies are having on
patient care within the VA?
Ms. Draper. Yes. Well, basically, our high-risk work is a
culmination of our work since 2010, so it reflects work in
areas like access, which includes wait time and scheduling, the
Choice Program, quality. So, in some of our work we have found
that delays in care have put patients at risk, or veterans at
risk for bad outcomes. I mean, I think there is sufficient
evidence to suggest that when care is delayed or care is not
received at all, for certain conditions, that the conditions
worsen and then it becomes much more complex and costly to then
treat that particular condition.
I can give you a couple of examples in our mental health
access report that we did in 2016. We found that for some
veterans, when their mental health care was delayed, they
decompensated and then their conditions became urgent and they
then required urgent care, which sometimes resulted in
hospitalization. We had other cases; for example, in the
reprocessing of reusable medical equipment, if not cleaned
properly or sterilized, it exposed many veterans to infectious
diseases such as hepatitis.
We have numerous examples, from the five areas that we have
identified as the areas of concern in our high risk report,
that are the underlying underpinnings that really, if not
addressed sufficiently, raise the risk of harm for veterans.
Senator Tester. Thank you, Mr. Chairman.
Senator Tillis. Senator Rounds.
HON. MIKE ROUNDS, U.S. SENATOR FROM SOUTH DAKOTA
Senator Rounds. Thank you, Mr. Chairman. Mr. Missal, I
would just like to start by asking a question about the
hospital in Aurora, CO. It originally was set up with $600 and
$700 million, as an estimate. Last time we checked, the
estimated overrun was $1 billion. That has been more than a
year ago. In your most recent review, is it still about $1
billion overrun or have we increased it since then?
Mr. Missal. We have not done any additional work. There is
going to be an additional cost once the facility is done to
essentially move into the facility, so that amount has to be on
top of the building costs as well.
Senator Rounds. So, how much, in addition to the $1 billion
overrun, are you estimating at this time, or are you
anticipating, and how will they come up with the resources to
pick up that cost?
Mr. Missal. I think it is going to be another--it was in
our report, and my recollection it was somewhere around another
$315 million, but these are not construction funds.
Senator Rounds. Did you look at--on another matter, have
you looked at the Choice Program and the operation of the
Choice Program?
Mr. Missal. Yes. We have done a number of reports on
Choice.
Senator Rounds. When you did the review of Choice, did you
look at the cost analysis of the administrative costs of Choice
versus non-Choice activity?
Mr. Missal. We did not examine it that closely. We looked
at, certainly, the administrative burdens of Choice and whether
or not it operated as a barrier for veterans, but we did not
actually look at the cost of each.
Senator Rounds. It seemed that--and the reason why I bring
it up, it seems as though there may be a duplication of
activity there, and I did not know whether or not you had found
that or had addressed it at all. My understanding is that there
is a third party which had been hired to actually do the
administration of the Choice to begin with, in terms of the
appointments, and then also for the billings on behalf of the
physicians, and that same third party is the same organization
that--like in our part of the country it is HealthNet, but
HealthNet handles not only VA Choice but they also do TRICARE
as well.
They seem to work very well within TRICARE but when it
comes to working with the VA, my understanding is that they
have a substantially higher cost, not because HealthNet charges
more but because they are required to work through additional
layers. In fact, every single time a veteran goes to a facility
or to a physician or to a provider, it is a review and a
reauthorization as opposed to a continuation of an existing
approval method. Is that correct?
Mr. Missal. I believe that is correct. When we looked at
Choice, we first looked at the implementation of Choice, which
took it from the beginning of the program until September 30,
2015. We found a lot of administrative burdens and that the
administration by VA caused significant delays.
We then looked at it again, as part of our VISN 6 report,
which went to the end of the calendar year, meaning December
31, 2015. Again, we saw some changes. It got a little better
but there are still burdens.
Senator Rounds. Just to continue along that same line, my
understanding, also, is that although they are perfectly
capable of making the review, delivering the requested payments
through providers and so forth--we have had delays of up to 9
months for providers--it seems as though HealthNet is not the
case where the problem is at. It actually goes into the VA and
the VA then farms it back out for a second review, to be put
back into their system, thus increasing the cost on a per claim
basis by perhaps a tenfold factor. Were you able to look at
that at all?
Mr. Missal. We understand that they have changed the
payments, where now they are doing bulk payments with the two
third-party administrators, HealthNet and TriWest. So, they are
constantly making changes to try to facilitate the payments.
Senator Rounds. Do you know if they are still duplicating
the efforts that those two third parties are expected to do?
Mr. Missal. I do not know precisely. I know they constantly
are looking at it. We have not--we are taking a hard look now
at it, but we----
Senator Rounds. Could I ask that in your next review you
look to see, because it appears to me that Choice, one way or
another, is going to continue on, and that we are going to
continue to use third parties somewhere along the line. If that
is the case, it seems inappropriate to have a duplication of
efforts within the VA, simply to get things paid. Number 1, it
seems to be a cost that we do not need, and second of all, it
most certainly delays the payment to providers, which there is
some reason why providers are not getting paid in a timely
fashion.
Mr. Missal. Right. We have an audit ongoing on the
payments. We can add that in.
Senator Rounds. OK. Thank you, sir. Thank you, Mr.
Chairman.
Senator Tillis. Senator Murray.
HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON
Senator Murray. Mr. Chairman, thank you very much. Thank
you to all of our panelists for being here today.
Let me just say, veterans have really benefited from
expanded access to affordable health insurance and the expanded
Medicaid, in particular, under ACA. That progress is really in
jeopardy as the American Health Care Act would effectively end
the Medicaid expansion and eliminate the coverage that is
helping so many of our veterans. This is more important now
than ever, as the VA continues to struggle with wait times, and
as we work to reform the way veterans receive care both in and
outside the VA.
Dr. Clancy, I wanted to ask you, what would happen to the
workload on VA and veterans' access to care if Congress repeals
the Affordable Care Act?
Dr. Clancy. We will be looking at that very closely,
Senator. What I can tell you is that we did a policy analysis
that compared States that had expanded Medicaid under the ACA,
compared with those that had not, and saw that that increased
demand for our services, somewhere between 6 and 18 percent--
the broad range just refers to type of services. I believe 18
percent is outpatient care and 6 is inpatient. So, we would
expect to see increased demand for our services for those
veterans who had benefited----
Senator Murray. So, what you are saying is that States that
expanded Medicaid, that it is now at threat of being taken
away, those families would--how many people would that be that
would increase the demand at the VA?
Dr. Clancy. I would actually have to track it back to get
you some good numbers, but could do that. This was an analysis
done by some policy researchers working with academic
colleagues, because I was wondering about the differential
impact.
Senator Murray. Mm-hmm. Can you get us any studies you have
done on the effects of the ACA on veterans' care or on the VA
workload, for the record?
Dr. Clancy. Mm-hmm.
[Responses were not received within the Committee's
timeframe for publication.]
Senator Murray. Because I think that would be really
important to know.
OK. Dr. Clancy, I did note that at the end of your
testimony you state that the VA will address the GAO
recommendations in conjunction with implementing the
Secretary's 10-point plan and implementing the President's
priorities.
I have been watching, because I believe that actions speak
louder than words, the President's actions, and I have seen
him, at the VA, leave almost every senior position in the
department without a permanent official in place. He is
refusing to personally meet with major veterans' organizations.
He has implemented a hiring freeze that prevents VBA from
hiring the staff needed to process veterans' claims. We know he
has raised money, allegedly, for veterans' charities and then
avoided giving to those groups until questioned. Those actions
I am deeply concerned about.
I did listen to him at the Joint Session of Congress a few
weeks back, when he said his budget, which is not out yet,
would somehow increase funding for veterans.
So, I wanted to ask you, is fixing the VA simply a matter
of more money to the VA, regardless of any policy or
leadership?
Dr. Clancy. I think that we need both the necessary
resources, the right strategy, and the right leadership. To
that end, I think your confirmation of Secretary Shulkin was a
really terrific move, because as he said to you at the time of
his hearing, he would not have a learning curve. I did not
realize just how much he meant that, but, you know, he has been
able to move very, very swiftly, in my experience in
transitions, which I think is going to be good for veterans.
I think you also heard him say ``not on my watch,'' in
terms of privatizing, and I have full confidence that he will
let you know if we need more resources to get the job done
right.
Senator Murray. I just think that that really matters.
Dr. Clancy. Yes.
Senator Murray. Obviously, we all love to say we are
getting more money. We would love to see that, but we need
leadership too, from the top on this----
Dr. Clancy. Yes.
Senator Murray [continuing]. And I do not know what that is
yet, and I am not talking about the Secretary.
Dr. Clancy. Yeah.
Senator Murray. So, I am concerned and I just wanted to
register that.
Dr. Draper, good to see you again. Thank you for all the
work you and GAO put into making sure we provide the best care
for our veterans.
Your testimony is very concerning, particularly the
apparent lack of urgency in VA's steps to get off the High-Risk
List. Not one of the five criteria in any of the areas of
concern GAO identified has been fully met by the VA. Can you
tell us how far along the VA should be now that it has been 2
years since it was first put on that High-Risk List?
Ms. Draper. Well, we are very concerned that 2 years later
we are not much further ahead, or the VA is not much further
ahead in addressing the issues. Let me just tell you a little
bit about what we have done in the past couple of years to
really express the need for urgency.
The Comptroller General met with the then Secretary
McDonald three times in the past couple of years. First was to
tell him they were being put on the High-Risk List, the second
time was that they were not making progress, the third time was
that they were not making progress and that he offered the
availability or access to subject matter experts within GAO
that could help them with some of their initiatives, like
contracting. We had a meeting in August between VA leadership
and GAO subject matter experts, and unfortunately, to date,
they really have not taken us up on accessing our subject
matter experts that could really help point them, in terms of
best practices. You know, we look across governments so we know
what works well, what does not.
Senator Murray. So, which agencies would you point them to,
to tell them to look at?
Ms. Draper. Well, it would really depend on what the issue
was, but we had pointed the high risk--the group--Dr. Clancy's
group to the Department of Homeland Security, which we feel has
done a nice job addressing the high-risk concerns. I think they
have a copy of their action plan and contact information
related to that particular area.
As I think Dr. Clancy said, the Comptroller General and
Secretary Shulkin did meet on March 3, to talk about the lack
of progress and concerns, and what they needed to do. The most
immediate thing to do was to have a viable action plan that
really provides a roadmap and lays out what they need to do and
how they are going to do it.
Senator Murray. OK. Thank you very much. Thank you, Mr.
Chairman.
STATEMENT OF HON. JOHN BOOZMAN,
U.S. SENATOR FROM ARKANSAS
Senator Boozman [presiding]. Thank you all so much for
being here, and I apologize for being late. I had to give a
little talk, and we had votes, and it was during the period
when the votes took up. You all know how these things are. We
do appreciate all of your hard work, and for coming over and
talking to us about these things that are so very important.
One of the areas that I really am concerned about, I think
all of us are concerned about, is the management of information
technology, which has been something that lots of people have
been working on. I have been here since 2001, on the VA
Committee in the House and now in the Senate, and this is just
something that has been difficult.
We talked about before, that, you know, there are
proprietary ways of doing this. I was pleased that recently, I
believe Dr. Shulkin said that we were going to be looking at
commercial applications. Is that correct?
Dr. Clancy. [No audible response.]
Senator Boozman. Dr. Clancy, in your testimony you
mentioned that the VA will take steps this year to address
patient scheduling and electronic health record systems. Again,
Secretary Shulkin has mentioned the VA was pursuing VSE as a
scheduling solution, as well as MASS, another scheduling tool.
It was my understanding that a go or no-go has been reached
regarding VSE. Can you talk to us a little bit about that?
Dr. Clancy. I am going to hand this to my partner, Dr. Lee,
who knows all of the details much more than I do. Thanks.
Senator Boozman. Very good. I have partners just like that.
Dr. Lee. Thank you, Senator, for the question. We are
currently moving ahead to implement a commercial scheduling
solution called MASS, the Medical Appointment Scheduling
System. We are currently piloting it right now at our site in
Boise.
I had the opportunity to see a demo of MASS a few weeks
ago, and I was really impressed. It is state-of-the-art, it is
so far advanced from where we are right now, and it will build
in all kinds of functionality for our patients that we do not
have right now, including rules and the ability to see what
services individual patients qualify for, inside the system.
Because it is so far advanced, it will take some time to
fully implement across the entire system, on the order of
probably several years, and because our current system is so
primitive--as you know it is from the '80s and it is a DOS-
based system with--just very difficult to use. In fact, I saw
our schedulers--I spent a day at a site watching some of our
primary care clinic schedulers use our system, and it is
cumbersome.
We needed an interim solution that we could quickly roll
out in the meantime, and that is the VistA Scheduling
Enhancement, VSE. A few weeks--last month, actually, we did
approve the national rollout of VSE as an interim scheduling
solution, and we are planning to have that be implemented
throughout the system through the summer.
Senator Boozman. Very good. That is a great step in the
right direction. That is encouraging.
Dr. Clancy, you also, in your testimony, you highlighted
the progress of the Joint Legacy Viewer. I believe that that is
available now to clinicians throughout the system, you know,
which is a good thing. Can you talk a little bit about how many
people are--how many clinicians are actually using it, and our
progress in that regard, or Dr. Lee?
Dr. Lee. Currently we have over 200,000 authorized users
for the Joint Legacy Viewer. This allows interoperability
between VA and DOD health records. We are exchanging daily, on
a daily basis, over 1.5 million data elements between VA and
DOD.
Just to speak about this from my own personal experience, I
am an ER doctor and I see patients at the DCVA in the ER there,
on the weekends. I have used Joint Legacy Viewer myself to find
records from DOD when I am seeing patients there. You can also
see records from the community. So, as more of our care is
provided in the community, we need to have that
interoperability with our community partners. You can also see
the records from the community, as long as they are
participating in our health information exchange.
Senator Boozman. Along with that, can you talk a little bit
about the enterprise Health Management Platform and how that is
going to become a major cog?
Dr. Lee. Yes, enterprise Health Management Platform, or
eHMP, allows us to have even better interoperability by adding
search, and also writes that functionality. JLV, the Joint
Legacy Viewer, currently is in read-only state. The eHMP,
brings all of the information together in one place. I have
also used this myself. It allows providers on the same care
team to communicate with each other. It can allow for clinical
decision support to be added to the system, where you have many
more tools in one place. This platform is really critical for
us, as the clinical users and providers, to take care of our
patients.
Senator Boozman. Very good. Well, we look forward to
hearing the progress, you know, as these things go forward. And
it certainly seems like a big step in the right direction.
Dr. Clancy. We could, if you were interested, I think
arrange a demonstration locally, for you or your staff.
Senator Boozman. Yeah, that would be great. Sure. Very
much.
Senator Tester.
Senator Tester. Thank you, Mr. Chairman. Real quick, the
incidences with servicemembers being sexually harassed on
Facebook and other websites, it is critically important that we
pay attention to what the heck is going on there, both from a
DOD perspective and a VA perspective. The DOD, I believe, will
bring the offenders to justice.
Dr. Clancy, as you know, the VA has the authority to
provide counseling services at med centers to active duty
servicemembers who have experienced military sexual trauma,
which would seem to include this type of abuse and harassment.
Is the VA taking any actions to make sure these servicemembers
can seek help from the VA?
Dr. Lee. I can say, Senator, that it is our policy to--
currently, to provide care for any servicemember or veteran who
has experienced military sexual trauma----
Senator Tester. OK.
Dr. Lee [continuing]. No matter where they enter our
system.
Senator Tester. OK. All right. Well, I would hope that you
would take the necessary steps to let people know that if they
have--we will call them challenges--that we are there, you are
there. OK?
I notice there are three docs on this panel. Are we all
medical doctors?
Ms. Parker. I am not.
Senator Tester. OK. So are there four docs? I did not see
her. Do we have four docs on the panel?
Ms. Parker. I am a Ph.D.
Senator Tester. Oh. OK. All right. Sounds good. The others
are medical doctors. OK.
One of the reasons--and correct me if I am wrong--that the
VA was put on the High-Risk List is because of improper
sterilization of equipment. Is that correct? [No audible
response.]
To me, as not a doctor, but as a patient, it is pretty
fundamental to good health care, and it seems to me it is
something that kind of takes me aback, to be quite frank with
you. I mean, if I was looking at a hospital that had these
kinds of problems, I would not step foot in the door.
So, the question is, does this still exist? I am talking
about improper sterilization.
Dr. Clancy. We have made enormous improvements in sterile
processing, while recognizing, at the same time, that it is an
area that needs careful attention at all times. Part of the
reason it needs careful attention is that what they are
sterilizing changes a lot. Scopes, for example, for
gastrointestinal procedures, keep changing and becoming more
sophisticated; each time those change the instructions that go
with it do too, and so forth.
Quite recently, the people in sterile processing actually
pointed out a problem, which we had to bring back to a device
manufacturer, and they were very, very appreciative. This had
to do with probes used for ultrasounds in sensitive areas, for
men and women. Because of what someone in sterile processing
had picked up, and noticed as part of their cleaning, they were
worried about a concern of increased contamination. They
flagged that right up through their supervisory chain, and we
ultimately got a call from the CEO of the company, saying thank
you. They have since changed their instructions for customers
in this country and around the world.
So, we have made dramatic improvements. When you talked
about seeing it when you walked in, you would not. It is an
area where----
Senator Tester. You are exactly right on that.
Dr. Clancy. Yeah.
Senator Tester. I mean, you would not see it, but if you
read about it?
Dr. Clancy. Yes. No, I would be very, very worried. It is
absolutely vital. It is not an area where we need innovation;
we need constant attention to detail. But, we also need for
those folks to be able to share their concerns, and I was quite
thrilled that recently they did that.
Senator Tester. No, that is good. It is very foundational
to good health care. I mean, you just cannot have one without
the other.
I am just going to close it out with this. Oftentimes, it
does not matter what business you are in; you want to do what
you have been doing because it is just moving right along and
you have got other things to think about.
Mike Missal, we spent a long time getting you confirmed as
IG, which is bad on us, by the way. You should have been
confirmed a long time ago. But, now that you are in there, I
would hope that the VA treats you with the highest respect and
integrity, because I believe you are a man of those qualities.
It is the same thing with the GAO. Gene Dodaro, your boss,
Ms. Draper, is a fine, fine man, and has incredible respect
within the Senate. I would just say that when they come forward
with the recommendations, even if you do not like them, then
tell this Committee that you think they are wrong. Then, we can
bring him in and talk to him some more, and if you think they
are right, fix it. OK?
That is it.
Dr. Clancy. That is fair.
Senator Tester. That is the best preaching job I have got
for today. Thank you for being here.
Senator Boozman. We appreciate your preaching job for
today, and we appreciate all of you for being here. Again, I
know you are busy but it is so, so very important that we
understand what is going on. So, thank you for being here.
The record will be open for the next 5 days. With that we
adjourn.
[Whereupon, at 3:32 p.m., the Committee was adjourned.]
------
Response to Posthearing Questions Submitted by Hon. Jon Tester to Debra
A. Draper, Ph.D., Director, Health Care Team, Government Accountability
Office
fort harrison report
Question 1. In one open recommendation from the September 2014 GAO
report on consults, VHA promised to complete a first round of VAMC
consult audits by September 2016. Was Fort Harrison included and what
were the results?
Response. While VHA has begun conducting its audits of consult
management activities, it has not yet finalized a report summarizing
the findings. Since the audits include all VAMCs, Fort Harrison should
be included, but we have not yet received a copy of the audit results,
which are expected to be finalized at the end of April 2017.
When VHA updated its national directive on consult processes and
procedures in August 2016, it required VAMCs to engage in twice yearly
audits of consult management activities and to report audit data to
their Veterans Integrated Service Networks (VISN).\1\ Specifically,
compliance and business integrity officers at each VAMC are responsible
for reviewing a statistically valid random sample of closed consults
(i.e., consults that have been completed, discontinued, or canceled).
---------------------------------------------------------------------------
\1\ See VHA Directive 1232(1), Consult Processes and Procedures
(Aug. 24, 2016, as amended on Sept. 23, 2016).
---------------------------------------------------------------------------
Compliance and business integrity officers from each VISN are
responsible for validating the data VAMCs report to VHA's Office of
Compliance and Business Integrity. Officials from VHA's Office of
Compliance and Business Integrity are responsible for examining audit
results to determine systemic causes and circumstances related to
delays in consults and the accuracy of consult documentation. They also
are responsible for identifying systemic trends, educational
opportunities, and recommending consult process improvements as
necessary.
In December 2016, VHA officials confirmed that VHA's Office of
Compliance and Business Integrity had completed data collection for its
initial audit of VAMC consult management activities in September 2016,
and at that time, they expected to finalize a baseline report detailing
the results of the audit in January 2017. VHA officials also told us in
December 2016 that they began the data collection for the second
national consult audit cycle in November 2016 and that they planned to
finalize a second national consult audit report in February 2017. We
received an update on the status of the consult audits in April 2017.
When we requested copies of the initial consult audit reports, VHA
officials told us that the analysis was not yet complete. They now
estimate that their first national consult audit report--which will
summarize the results of data collected during the first two audits--
will be finalized at the end of April 2017. They agreed to provide us a
copy of the report when it is ready. We will continue to meet with VHA
officials to discuss how they are using the results of nationwide
consult audits to inform their oversight of consult processes and
procedures across VHA, as well as to obtain documentation of these
efforts.
implementing recommendations
Question 2. As of the date of the hearing, how many open
recommendations does VA have?
Question 3. What progress is being made by VA in addressing these
recommendations, and do you believe that they have been cooperative in
this process?
Question 4. When VA and GAO agree on root problems but disagree on
the path to address those problems, how is that resolved?
Response. We are providing a combined response to questions 2, 3,
and 4, as all three relate to VA's progress in implementing GAO
recommendations related to veterans' health care.
As of the date of the hearing (March 15, 2017), there were 113 GAO
recommendations related to veterans' health care that VA had not yet
implemented. See the following table for additional information about
the status of the 255 recommendations related to veterans' health care
that were included in products we issued between January 1, 2010 and
March 15, 2017.
Status of GAO Recommendations Related to Department of Veterans Affairs
(VA) Health Care from January 1, 2010 through March 15, 2017
------------------------------------------------------------------------
Number of GAO
recommendations,
Status of recommendations Jan. 1, 2010 through
March 15, 2017
------------------------------------------------------------------------
Open because VA has not yet implemented them...... a 113
Closed because VA implemented them................ 128
Closed without VA implementing them b............. 14
---------------------
Total......................................... 255
------------------------------------------------------------------------
Source: GAO.
a Of these 113 recommendations, 32 have been open for 3 or more years.
b We close recommendations without agencies having implemented them
primarily if the recommendation is no longer valid because
circumstances have changed.
Since February 2015, when we designated VA health care as a high-
risk area, VA has increased its focus on implementing our
recommendations. At the time we added this issue to our High-Risk List
in 2015, VA had only implemented about 22 percent of our
recommendations related to VA health care. The rate at which VA has
implemented our recommendations has increased steadily since then, and
at the time of our February 2017 High Risk Update, VA had implemented
about 50 percent of our recommendations related to VA health care.
Since 2015, GAO staff have been routinely meeting about every 4 to
6 weeks with staff from VHA's Management Review Service (MRS) to
discuss the status of open GAO recommendations, and these meetings have
been cooperative and productive. MRS staff have prioritized for closure
GAO recommendations that have been open for 3 or more years, and they
are working to identify and support the actions VHA program offices
need to take to implement those recommendations. MRS staff have also
facilitated meetings between GAO teams and VHA subject matter experts.
The meetings help clarify actions VHA is taking, and allow for
discussions of documentation VHA should provide to GAO to support
closing a recommendation as implemented, as well as any ideas VA may
have for addressing the intent of the recommendation even if it does
not exactly match our recommendation wording.
In general, VA concurs with recommendations we have made, and it
has been rare for VA officials and GAO staff to disagree about how our
recommendations related to VA health care should be addressed.
Sometimes, we need VA to provide us additional evidence showing that
actions have actually been taken to address our recommendations (rather
than just planned). In a few instances, the actions VA took were too
late to meet the intent of our recommendation.
information technology
Question 5. The GAO report lays out a number of outdated IT
systems operating at VA right now. What do you think is the most
critical IT system for Secretary Shulkin to address immediately from
the perspective of risk to veterans?
Response. The use of IT is crucial to helping VA effectively serve
the Nation's veterans. Each year, the department spends more than $4
billion on IT and operates approximately 240 information systems. Many
of VA's unmet IT needs have a direct relationship to the quality and
safety of veterans' health care. However, GAO has not done work to
prioritize VA's IT needs and therefore has no basis to identify which
unmet IT needs are the most critical to address.
As we have reported for many years, VA has had difficulty managing
its information systems, raising questions about the effectiveness of
its operations and its ability to deliver intended outcomes needed to
help advance the department's mission. We have published a number of
reports about VA's need to address aging information technology (IT)
systems, including those related to delivering health care services to
veterans. For example, in addition to the VA IT systems we discussed in
the High Risk report, we also recently reported that VA is still using
two of the Federal Government's oldest legacy IT systems--both of which
have been in use for more than 50 years.\2\
---------------------------------------------------------------------------
\2\ One of these systems is the Personnel and Accounting Integrated
Data system, which automates time and attendance for employees,
timekeepers, payroll and supervisors. The other is the Benefits
Delivery Network, which tracks claims filed by veterans for benefits,
eligibility, and dates of death. See GAO, Information Technology:
Federal Agencies Need to Address Aging Legacy Systems, GAO-16-468
(Washington, DC: May 25, 2016).
---------------------------------------------------------------------------
VA's Office of Information and Technology (OI&T) has the important
responsibility of providing IT services across VA and managing the
department's IT assets and resources. VA has taken some steps to
mitigate IT management weaknesses we have identified in past reports,
such as transitioning oversight and accountability for IT projects to a
new project management process.
In addition to considering whether an IT improvement could help
mitigate risks to patient safety or quality of care, there are other
key factors for OI&T to take into account. According to Federal IT
investment best practices we have identified, OI&T should assess VA's
IT needs in light of criteria such as investment size, project
longevity, technical difficulty, project risk, business impact,
customer needs, cost-benefit analysis, organizational impact, and
expected improvement.\3\ As new VA leaders transition into roles at
OI&T, sustained management attention and organizational commitment will
be essential to ensuring VA's progress in the area of IT management.
---------------------------------------------------------------------------
\3\ See GAO, Information Technology Investment Management: A
Framework for Assessing and Improving Process Maturity, GAO-04-394G
(Washington, DC: Mar 1, 2004).
---------------------------------------------------------------------------
______
Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to
Debra A. Draper, Ph.D., Director, Health Care Team, Government
Accountability Office
mental health care
Question 6. Dr. Draper, the GAO highlights mental health care as
one area where inconsistent application of policies has created access
issues for veterans. Secretary Shulkin recently indicated the VA would
be offering urgent mental health care for former servicemembers with
less than honorable discharges: is the VA even equipped to expand into
providing such services? Do you have a general sense of whether or not
this will further exacerbate the problem of access for veterans to
mental health services?
Response. VA estimates that there are currently about 500,000
former servicemembers with other-than-honorable (OTH) discharges, and
according to DOD data, approximately 117,000 of these servicemembers
separated from active duty between fiscal years 2001 and 2014.\4\
However, it is difficult to determine whether offering urgent mental
health services to individuals with OTH discharges will negatively
affect veterans' access to VA mental health care because of continued
limitations of VA's appointment wait-time data. Without complete,
reliable data on the extent to which veterans who are already receiving
VA care are waiting for mental health care appointments, VHA lacks
assurance that it has sufficient capacity to expand services to
individuals with OTH discharges--even if it only offers urgent mental
health care to these individuals.
---------------------------------------------------------------------------
\4\ These 117,000 servicemembers with OTH discharges separated from
the Army, Navy, Marine Corps, or Air Force between fiscal years 2001
and 2014 (fiscal year 2014 data is as of June 2014). This data was
accessed from HTTP://WWW.DOD.MIL/PUBS/FOI/READING_ROOM/
STATISTICAL_DATA/14-F-0775_FY2001-2014_ACTIVE_ENLISTED_SEPARATIONS.XLSX
on January 29, 2016. This figure does not include servicemembers who
separated from the National Guard or Reserve.
---------------------------------------------------------------------------
For example, VHA has yet to implement our December 2012
recommendation to improve the reliability of its wait time measures
either by clarifying its scheduling policy to better define the desired
date (which at the time, was the name for the starting date that was
used to calculate wait times), or by identifying clearer wait time
measures that are not subject to interpretation and prone to scheduler
error.\5\ In July 2016, VA published a revised VHA outpatient
scheduling directive, which provided new instructions for scheduling
appointments. However, the new instructions, which form the basis for
measuring wait times, are still prone to scheduler interpretation,
making training vital to consistent and accurate implementation of the
policy. As of November 2016, VHA reported that the majority of staff
responsible for scheduling appointments had been trained on the new
directive and that separate training on a new scheduling system
enhancement was scheduled to begin in February 2017. We cannot assess
whether VHA scheduling staff are accurately implementing the new
scheduling policy until all relevant staff are trained on the new
system.
---------------------------------------------------------------------------
\5\ See GAO, VA Health Care: Reliability of Reported Outpatient
Medical Appointment Wait Times and Scheduling Oversight Need
Improvement, GAO-13-130 (Washington, DC: Dec 21, 2012).
---------------------------------------------------------------------------
In addition, in October 2015, we reported that the way that VHA
calculates veterans' wait times for full mental health evaluations
(using veterans' preferred dates instead of the dates veterans
initially request a referral to mental health care) may not reflect the
overall amount of time a veteran waits for care.\6\ Further, we found
that VHA's mental health wait time data may not be comparable over time
(due to definitional changes), or comparable between VAMCs, making it
difficult for VHA to provide effective oversight of access to mental
health care.
---------------------------------------------------------------------------
\6\ See GAO, VA Mental Health: Clearer Guidance on Access Policies
and Wait-Time Data Needed, GAO-16-24 (Washington, DC: October 28,
2015).
---------------------------------------------------------------------------
While there is uncertainty about the extent to which veterans are
experiencing wait times for mental health care, VA has engaged in
recent hiring initiatives to improve access to health care services.
For example, the Veterans Access, Choice, and Accountability Act of
2014 appropriated $5 billion to expand VA's capacity to deliver care to
veterans by hiring additional clinicians and improving the physical
infrastructure of VA's medical facilities.\7\ In addition, in our
October 2015 report on VA's mental health access, we reported that VA
was able to hire about 5,300 new clinical and non-clinical mental
health staff as a result of a two-part hiring initiative from June 2012
through December 2013. While about 1,600 of these hires were for newly
created mental health positions, about 2,300 filled existing vacancies
(or vacancies that opened during the hiring initiative).\8\ Officials
at the five VAMCs we visited as part of this review reported local
improvements in access to mental health services as a result of the
additional hiring, such as the ability to offer mental health services
in new locations.
---------------------------------------------------------------------------
\7\ Pub. L. No. 113-146, Sec. 801, 128 Stat. 1754 (2014).
\8\ The remaining staff hired as part of this initiative were
either non-clinical support staff or peer specialists (veterans with
mental health conditions who are in recovery and have been trained to
help others with mental health conditions).
---------------------------------------------------------------------------
VA exempted certain positions, including mental health providers,
from the January 2017 hiring freeze on executive branch employees in
order to meet the department's public safety responsibilities. This
exemption allowed VA to continue to recruit mental health providers,
although officials at VAMCs we visited for our October 2015 report told
us they faced several challenges in hiring and placing mental health
providers. These challenges included: (1) pay disparity with the
private sector; (2) competition among VAMCs for staff; (3) the lengthy
VHA hiring process; (4) a nationwide shortage of mental health
professionals; (5) a lack of space to provide care; and (6) a lack of
non-clinical support staff to relieve providers' administrative burden
and increase providers' clinical availability. Officials at four of the
five VAMCs we reviewed also stated that they were still unable to meet
overall demand for mental health care despite VHA's recent hiring
initiative.
______
Response to Posthearing Questions Submitted by Hon. Sherrod Brown to
Debra A. Draper, Ph.D., Director, Health Care Team, Government
Accountability Office
oversight and accountability
Question 7. Dr. Draper, in your testimony you raise concerns
regarding self-reported data from facilities and whether that data
could be independently corroborated. What steps would GAO recommend VA
take to ensure that the data collected and report to VACO can be
independently corroborated? There are concerns that the data reported
through SPOT and other systems do not properly reflect the day-to-day
safety, quality, and access concerns that have been raised by GAO over
the years.
Response. There are several actions VA can take to independently
corroborate self-reported data, including on-site inspections, pulling
samples of patient records for independent review, ensuring that
Veterans Integrated Service Networks (VISN) review reports generated by
VA medical centers, and assigning responsibility to appropriate levels
in the organization to verify data. When we added VA health care to the
High Risk List in 2015, we noted that reliance on self-reported data
contributed to weaknesses in VA's ability to hold its health care
facilities accountable and ensure that identified problems are resolved
in a timely and appropriate manner. We reiterated that concern in our
2017 high-risk report. Ensuring that self-reported data are reliable
can inform oversight decisions and help VA ensure that its corrective
actions are addressing the root causes of the problem, which is part of
our criteria for removal from the High-Risk List.
We have several open recommendations for actions VHA can take to
address our concern about reliance on self-reported data from VAMCs.
Addressing these open recommendations can not only serve to correct the
specific deficiency identified, but also help address the underlying
problem of inadequate oversight and accountability.
Descriptions of selected findings and open recommendations from
recent GAO reports are provided in the table below.
Summaries of Findings and Open Recommendations (as of April 7, 2017) from Selected GAO reports Addressing
Concerns with Reliance on Self-Reported Data at the Department of Veterans Affairs' (VA) Veterans Health
Administration (VHA)
----------------------------------------------------------------------------------------------------------------
Report Finding Summary Open Recommendation
----------------------------------------------------------------------------------------------------------------
GAO-17-242, VA Health Care: Actions We found that two of the four To help VHA achieve its objective of
Needed to Ensure Medical Facility selected Veterans Integrated reducing the risk of diversion
Controlled Substance Inspection Service Networks (VISN) in our through effective implementation
Programs Meet Agency Requirements review did not review their and oversight of the controlled
facilities' quarterly trend reports substance inspection program, the
of controlled substance Secretary of Veterans Affairs
inspections, as required by VHA. should direct the Under Secretary
Such reports identify inspection for Health to ensure that networks
program trends such as missed review their facilities' quarterly
inspections and areas for trend reports and ensure facilities
improvement. We found that one take corrective actions when
network that had reviewed the trend nonadherence is identified.
reports failed to follow up with a
facility to ensure it had submitted
missed trend reports.
----------------------------------------------------------------------------------------------------------------
GAO-17-52, VA Health Care: Improved We found VHA's lack of reliable data To improve care for women veterans,
Monitoring Needed for Effective meant that it could not ensure the Secretary of Veterans Affairs
Oversight of Care for Women medical center compliance with should direct the Under Secretary
Veterans requirements related to the for Health to strengthen the
environment of care for women environment of care inspections
veterans. These requirements process and VHA's oversight of this
include standards for privacy at process by expanding the list of
check-in and interview areas, requirements that facility staff
location of exam rooms, and the inspect for compliance to align
presence of privacy curtains in with VHA's women's health handbook,
exam and inpatient rooms. We found ensuring that all patient care
that only 3 of the 155 instances of areas of the medical facility are
noncompliance we observed during on- inspected as required, clarifying
site inspections of waiting, the roles and responsibilities of
procedure, and examination areas at VA medical facility staff
six VA medical centers were responsible for identifying and
reported to VA central office. addressing compliance, and
Because VA uses these data to track establishing a process to verify
facility compliance, their accuracy that noncompliance information
is vital for effective oversight. reported by facilities to VHA
Central Office is accurate and
complete.
----------------------------------------------------------------------------------------------------------------
GAO-14-808, VA Health Care: We found that VHA's limited To improve VHA's ability to
Management and Oversight of Consult oversight of consults impedes its effectively oversee the consult
Process Need Improvement to Help ability to ensure VA medical process, and help ensure VAMCs are
Ensure Veterans Receive Timely centers provide timely access to providing veterans with timely
Outpatient Specialty Care specialty care. For example, as access to outpatient specialty
part of its consult initiative, VHA care, the Secretary of Veterans
required VAMCs to review a backlog Affairs should direct the Interim
of thousands of unresolved Under Secretary for Health to
consults--those open more than 90 enhance oversight of VAMCs by
days--and if warranted to close routinely conducting independent
them. However, VHA did not require assessments of how VAMCs are
VAMCs to document their rationales managing the consult process,
for closing them. As a result, including whether they are
questions remain about whether appropriately resolving consults.
VAMCs appropriately closed these This oversight could be
consults and if VHA's consult data accomplished, for example, by VISN
accurately reflect whether veterans officials periodically conducting
received the care needed in a reviews of a random sample of
timely manner, if at all. consults as we did in the review we
conducted.
----------------------------------------------------------------------------------------------------------------
Source: GAO.
VHA has also taken some actions to implement recommendations that
will help address the concern about the reliability of self-reported
data. For example:
In 2015, as part of our review of VA's primary care
oversight, we found inaccuracies in VA's data on primary care panel
sizes, which are used to help medical centers manage their workload and
ensure that veterans receive timely and efficient care.\9\ We found
that while VA's primary care panel management policy required
facilities to ensure the reliability of their panel size data, it did
not assign responsibility for verifying data reliability to regional-
or national-level officials or require them to use the data for
monitoring purposes. As a result, VA could not be assured that local
panel size data were reliable, or whether its medical centers had met
VA's goals for efficient, timely, and quality care. We recommended that
VA incorporate an oversight process in its primary care panel
management policy that assigned responsibility, as appropriate, to
regional networks and central office for verifying and monitoring panel
sizes. In October 2016, VA reported that it had completed nationwide
deployment of new software for managing panel sizes, called Primary
Care Management Module (PCMM) Web, which is designed to enable better
management and monitoring of primary care panel sizes. In addition, in
September 2015 and December 2016, VA required all facilities to
validate their data on primary care panel sizes, as well as the number
of support staff and exam rooms. In February 2017, all but one VA
facilities certified that they had validated their data (the remaining
facility was still in the process of completing data validation
efforts), and we closed this recommendation as implemented.
---------------------------------------------------------------------------
\9\ See GAO, VA Primary Care: Improved Oversight Needed to Better
Ensure Timely Access and Efficient Delivery of Care, GAO-16-83
(Washington, DC: Oct. 8, 2015).
---------------------------------------------------------------------------
In our July 2015 report examining VHA's root cause
analysis (RCA) program for adverse events, officials from VHA's
National Center for Patient Safety (NCPS) told us that VAMCs sometimes
chose alternative processes, such as those based on Lean methods, to
address adverse events when an RCA was not required.\10\ NCPS officials
told us they supported VAMCs' use of these alternative processes when
appropriate, but acknowledged loss of information as the results of
these processes were not required to be entered into WebSPOT (VHA's
centralized RCA reporting system), or otherwise shared with NCPS.
However, VHA was unaware how many VAMCs used these alternative
processes. We recommended that VHA determine the extent to which VAMCs
are using alternative processes to address the root causes of adverse
events when an RCA is not required, and collect information from VAMCs
on the number and results of those alternative processes. In
September 2015, NCPS developed and fielded a survey to all medical
centers to assess what degree they were utilizing alternative processes
to address root causes of adverse events when a root cause analysis is
not required. NCPS was able to obtain data from 86 percent of medical
centers that demonstrated the types of alternative processes used and
how medical centers were using them. As a result, we closed this
recommendation as implemented.
---------------------------------------------------------------------------
\10\ See GAO, VA Health Care: Actions Needed to Assess Decrease in
Root Cause Analyses of Adverse Events, GAO-15-643 (Washington, DC: Jul.
29, 2015).
---------------------------------------------------------------------------
______
Response to Posthearing Questions Submitted by Hon. Jon Tester to
Michael J. Missal, Inspector General, U.S. Department of Veterans
Affairs
fort harrison report
Question 1. The recent report on Ft. Harrison indicated that steps
have been taken to improve consult timeliness. Are you confident those
steps are sufficient and do you believe they will appropriately address
factors that contribute to delays in care for veterans?
Response. In comments to our draft report (which are included in
the final report), leadership described ongoing steps to address
factors within the system's control that contributed to consult delays.
We will monitor system leadership's actions on these issues, which
include hiring additional staff to administratively process consults
and reducing the number of unnecessary consults. We anticipate that
completion of those steps will have a positive impact on timeliness of
care for some Montana veterans. However, consult delays for many
veterans will likely persist because of other factors outside the
system's control, including the adequacy of the provider network for
the Veteran's Choice Program. We highlighted our concerns about network
adequacy in another report, Review of VHA's Implementation of the
Veterans Choice Program (January 30, 2017), and made recommendations to
the Under Secretary for Health that will help to address nationwide
issues that hinder consult timeliness.
high risk list
Question 2. Have you met with Dr. Shulkin in his capacity as
Secretary? And have you received assurances of a high level of
engagement on these issues?
Response. Yes, I have met with Dr. Shulkin several times since he
was confirmed. We have a regularly scheduled monthly meeting. I have
also called him and requested a meeting when I felt that an issue
needed to be addressed. Also the OIG meets monthly with leaders in the
Veterans Health Administration.
implementing recommendations
Question 3. As of the day of the hearing, how many open
recommendations does VA have that are over 60 days old?
Response. As of March 15, 2017, there were 120 reports and 366
recommendations that had been open for greater than 60 days.
Question 4. What progress is being made by VA in addressing these
recommendations, and do you believe that they have been cooperative in
this process?
Response. Overall, VA is receptive to OIG recommendations and
provides action plans to correct the identified issues. At times,
however, VA may underestimate the time it takes for corrective actions
to be implemented and demonstrate a sustainable improvement.
Question 5. When VA and OIG agree on root problems but disagree on
the path to address those problems how is that resolved?
Response. If VA management concurs with a finding but non-concurs
with a recommendation, VA should provide an alternative course for
corrective action that VA believes is responsive to satisfying the
intent of the OIG recommendation. If the issuing OIG office agrees with
management's proposal, follow-up will be on the agreed-to corrective
action. If VA continues to non-concur with an OIG recommendation and
does not propose corrective action, the Assistant Inspector General of
the appropriate OIG Directorate will discuss the matter with the
Inspector General and the Deputy Inspector General for an OIG decision
on whether to submit the unresolved issues to the Deputy Secretary for
final resolution or to publish the final report without the concurrence
of VA on the findings and recommendations or without an implementation
plan acceptable to OIG.
In most instances, whenever VA and OIG disagree on an action plan
to implement a recommendation that VA has concurred with, both sides
will have productive discussions to address the issues.
information technology
Question 6. The GAO report lays out a number of outdated IT
systems operating at VA right now. What do you think is the most
critical IT system for Secretary Shulkin to address immediately from
the perspective of risk to veterans?
Response. We believe the following are some of most critical IT
systems that Secretary Shulkin should address that have a direct impact
on veterans:
Veterans Health Information Systems and Technology
Architecture (VistA)
VA's Outpatient Appointment Scheduling System--The OIG is
currently conducting an audit of the VistA Scheduling Enhancement (VSE)
which is considered the near-term solution for updating VA's archaic
scheduling system
Veterans Benefits Management System (VBMS)--VBMS is the
replacement for the Veterans Benefits Administration's (VBA) legacy
systems, Benefits Delivery Network (BDN) and Veterans Service Network
(VETSNET). BDN still has some functionality related to processing
entitlements for three of the five business lines (Compensation and
Pension, Education, and Vocational Rehabilitation and Employment).
Until there is confidence that VBMS can process payments, VA will have
to maintain these legacy systems which is a costly both in time, staff,
and funding.
Financial Management System (FMS)--While FMS is not
involved in direct patient care, it supports payments to vendors that
provide the goods and services the Veterans Health Administration needs
to operate, as well as keeps track of the status of VA's budgetary
resources.
______
Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to
Michael J. Missal, Inspector General, U.S. Department of Veterans
Affairs
appointment cancellations
Introduction: Mr. Missal, in your testimony you refer to OIG's
(June 2016) report that claimed supervisors at a VA facility in Houston
instructed staff to cancel appointments for veterans who were offered
appointments at alternative locations but declined. Even though staff
canceled these appointments, they were instructed to record them as
canceled by the veterans themselves.
Question 7. Do you have reason to believe that these kinds of
situations could have occurred in VA facilities in Hawaii or in other
states?
Response. We conducted investigations at over 100 VA facilities
regarding the manipulation of wait time data. We discovered that the
over-riding issue was the lack of training and understanding of VA's
policy regarding scheduling. We did review allegations received by the
OIG Hotline concerning Matasunga VA Medical Center (VAMC) in Honolulu,
Hawaii. The allegations were different from the scheme uncovered at the
Houston VAMC. Our Honolulu review did not develop any information that
management instructed staff to disregard patient desired dates when
inputting appointments.
Question 8. Can you discuss the recommendations that OIG made to
address these situations? How can we ensure that veterans, especially
veterans in rural communities who may have difficulty traveling to a
nearby VA facility, do not have their appointments canceled?
Response. We recommended the Veterans Integrated Service Network 16
Director provide scheduling staff training; improve scheduling audit
procedures for use of dates and appropriateness of the cancellation
type used; and take actions when the audits identify deficiencies.
VA facilities should follow VHA's Directive 1231, Outpatient Clinic
Practice Management, November 15, 2016, which states that staff should
determine which patients can be seen by another provider, and contact
patients that need to be rescheduled as soon as possible prior to their
scheduled appointment in order to avoid them arriving at the facility
without the ability to be seen.
______
Response to Posthearing Questions Submitted by Hon. Joe Manchin III to
John D. Daigh, Jr., M.D., CPA, Assistant Inspector General for
Healthcare Inspections, Office of Inspector General, U.S. Department of
Veterans Affairs
Question 9. Over the course of the Inspector General's reports,
what are the most pressing issues you have uncovered concerning opioid
prescribing in the VA? How is the VA addressing the concerns IG
investigations have discovered?
Response. The most pressing issue that VA providers must address is
the creation of an appropriate treatment plan for veterans who are
prescribed narcotic medications. One group of patients has a history of
chronic pain, co-morbid mental health issues, and a long history of
narcotic use. The other group of patients are relatively naive to
narcotic medications, and yet present with an acute pain syndrome, that
if not properly managed, may lead to a life of chronic narcotic use/
dependence.
VA has produced a number of directives and undertaken a number of
efforts to improve VA providers' ability to effectively treat these
veterans' symptoms to include the creation and dissemination of: a
Clinical Practice Guideline Management of Opioid Therapy for Chronic
pain, an Opioid Safety Initiative, an Opioid Safety Initiative Tool
Kit, a Pain Management Opioid Safety Education Guide, and a Pain
Management Opioid Safety Quick Reference Guide.
The OIG recommended that VA improve the supervision of providers to
ensure that the best insights of the most experienced VA providers can
influence the care of each veteran. In addition, the OIG encouraged VA
to partner with non-VA entities to improve clinical research trials in
these populations with the hope of improving the guidance providers can
offer over time. In discussions with VA leaders and providers, they
appear dedicated to addressing these issues by improving the
capabilities of VA providers and increasing reliance upon community
resources.
______
Response to Posthearing Questions Submitted by Hon. Sherrod Brown to
Michael J. Missal, Inspector General, U.S. Department of Veterans
Affairs
whistleblowers
Mr. Missal, thank you for the work that your office has done
investigating allegations of misconduct and mismanagement at the
Cincinnati VAMC. I look forward to reading the report, which should be
forthcoming. VA employees, acting as whistleblowers, raised concerns
and demanded change for our veterans. There are still concerns however
that VA employees who reach out through appropriate channels to raise
concerns are retaliated against. We've seen this over and over
throughout the system.
Question 10. What steps does OIG take to protect those interviewed
so that they don't face reprisal?
Response. The OIG takes all possible steps to protect the identity
of complainants. Often complainants have made similar complaints to
management, so it is possible for management to identify them. However,
we do not provide the identity of complainants, confidential sources,
or self-identified whistleblowers to VA. We advise complainants to
contact the Office of Special Counsel (OSC) regarding protection under
the Whistleblower Act. OSC is a separate Federal agency with authority
to review allegations of prohibited personnel practices, including
reprisal for whistleblowing. The VA OIG is certified by OSC as having
met the statutory obligations to inform the employees about the rights
and remedies under the Civil Service Reform Act, the Whistleblower
Protection Act, and the Whistleblower Protection Enhancement Act.
oversight and accountability
Question 11. Mr. Missal, has OIG received requests to review the
self-reporting processes at VAMCs?
Response. The OIG has completed numerous evaluations of the
accuracy of VA-reported data. For example, in our recent report, Audit
of Veteran Wait Time Data, Choice Access, and Consult Management in
VISN 6, we described our evaluation of the accuracy of wait time data
within the Veterans Integrated Service Network (VISN) 6 medical
facilities and through Choice. We raised concerns that VA-reported wait
time data understated the actual amount of time veterans waited for
health care services. To address our concerns, we made 10
recommendations, four to the Under Secretary for Health and six to the
VISN 6 Director. Last year, we reviewed whether information contained
in a letter from VISN 23 to Congressman Walz accurately reported
information on primary care staffing at the St. Cloud VA Health Care
System. In our report, Healthcare Inspection--Reported Primary Care
Staffing at St. Cloud VA Health Care System, we indicated that data
reported were inaccurate and that VISN and facility leadership
acknowledged that no data validation steps were taken prior to
submitting information to the Congressman. We made one recommendation
to the VISN Director to address the inaccuracies we identified.
______
Response to Posthearing Questions Submitted by Hon. Jon Tester to
Carolyn M. Clancy, M.D., Deputy Under Secretary for Health for
Organizational Excellence, U.S. Department of Veterans Affairs
fort harrison report
Question 1. GAO issued a consult audit in 2014 with 6
recommendations that are still open. In one open recommendation from
this report, VHA promised to complete a first round of VAMC consult
audits by September 2016. Was this completed, and what were Ft.
Harrison's results?
Response. All facilities, including Ft. Harrison, were included in
the two national consult audits (completed in September 2016 and
January 2017) conducted by the Office of Compliance and Business
Integrity (CBI). CBI is finalizing the results of these audits. The
findings will be published once the results are compiled.
Question 2. In another recommendation from the same report, VHA
indicated calls to share best practice with respect to consults were
forthcoming. If these happened, did Ft. Harrison participate? What
actions are continuing in VHA to share practices on consult management?
Response. To promote nationwide communication, VHA established a
system-wide process for identifying and sharing best practices.
Facility level consult steering committees were created and
participated in weekly national consult performance improvement calls.
VHA began holding national calls with these Veterans Integrated Service
Network (VISN) and facility consult points of contact (POC) on
November 14, 2014. Each week, more than 400 attendees participate in
these calls, which include training on consult policies and processes,
review of consult performance data, and presentations on best
practices. The calls also provide a forum for discussion and answering
questions, which are published for reference in a Frequently Asked
Questions (FAQ) document. In addition, VHA has created a Consult Cube
with many different Pyramid views enabling easy access to consult data
and developed a SharePoint page, which serves as a repository for all
consult policy documents, training materials, FAQs, and contact
information for VISN and facility consult experts and steering members.
VISN and facility staffs from all sites, including Ft. Harrison,
are invited to these calls. There has been significant leadership and
staff turnover at Ft. Harrison since calls started. When questioned
again in March, 2017, leadership was unsure if anyone was attending the
calls. This issue is currently in the process of being corrected.
Question 3. Overall, given the continued concern with consults,
what is VA doing to improve the consult process and ensure no
additional veterans are harmed by delays in care?
Response. VHA has taken many actions such as those listed below to
improve consult processes and ensure timeliness of care:
VHA finalized Directive 1232 ``Consult Processes and
Procedures'' in September 2016. VHA also distributed the Standard
Operating Procedure (SOP). These policy documents clarify procedures
for completing consults and provide guidance for tracking and
monitoring consults throughout the organization and provide the basis
for consult oversight.
A Consult Management Trigger report was developed to
measure VISN and facility consult performance. The Consult Trigger Tool
automatically sends notifications to leadership at facilities not
meeting requirements to assist in consult oversight and management.
VHA provided extensive national, VISN, and facility
consult training:
- October and November 2014, national training was provided to
facility level staff via webinars and to 975 employees via VA
eHealth University (VeHU) training. This training was also made
available in the Talent Management System (TMS).
- March, April, October, and November 2015, training with VISN
and facility leadership and staff of all VISNs was provided.
- Weekly consult best practice/training calls began in
November 2014. Over 400 consult POCs attended training calls.
- National consult training module #24762 was deployed in TMS.
As of August 2015, 97 percent of Licensed Independent
Practitioners (LIP) assigned the TMS training completed it. An
additional 12,740 staff who were not assigned the consult
training module in TMS also completed the training. Residents/
trainees were provided separate consult training by October 1,
2015.
- Approximately 60,000 schedulers and 600 VISN and facility
consult POCs and Group Practice Managers (GPM) completed
training on the Consult Directive. Updated LIP consult training
including training on the Consult Directive will be available
in TMS in April 2017. Residents/trainees will receive updated
mandatory consult training in July 2017.
VHA implemented the Consult Improvement Initiative (CII)
from March thru June 2016 to provide assistance to selected facilities
identified by the Consult Trigger tool as having issues in consult
processes and timeliness of completion. All participating facilities
demonstrated improvement by reducing consult process failures and
reducing delays.
CBI, in conjunction with the Office of Veteran's Access to
Care (OVAC), developed and implemented an independent consult audit
process. CBI reviewed all facilities reviewed in two national consult
audits. CBI will release the results once finalized. During FY 2017 and
until further notice, routine audits will be conducted by compliance
staff at a minimum of twice annually for the use of VHA's standardized
consultation process and to identify causes of delays of outpatient
specialty care consults.
Question 4. Can VHA certify that every employee who is involved in
the consult process has been trained on last year's new Directive 1232,
Consult Processes and Procedures? What training has been provided, and
what metrics will measure adherence to Directive 1231, Outpatient
Clinic Practice Management?
Response. Consult Directive Training was developed for the roles of
schedulers, VISN and facility consult POCs, GPMs, residents/trainees
and LIPs. Training for schedulers, facility consult POCs and GPMs was
delivered by live and recorded webinars and completion of training is
tracked in TMS. Approximately 600 facility consult POCs, GPMs, and
60,000 schedulers completed the training. This group is considered
complete.
Training content for LIPs has been updated and is in the process of
being delivered and tracked in TMS. Residents/trainees will be required
to take training on the Consult Directive as part of Mandatory Training
in July 2017. Consult Directive training is also included in current
Medical Support Assistant (MSA) and new MSA onboarding training and
will be part of recently-updated scheduling training modules in TMS
required for all new schedulers. Generally, as a result of the
training, VHA expects to see outcome improvements in areas such as the
time to schedule and complete clinical consults, the number of consults
linked to appointments, and improvements in the associated consult
process metrics.
high risk list
Question 5. Can you provide a timeline for when the root cause
analysis for each deficient area in GAO's report will be complete? VA
needs to have a well-established timeline.
Response. VA will submit the root cause analyses and VA corrective
action plan to GAO in June 2017. The corrective action plan will
include schedules and milestones for each initiative by which to gauge
VA's progress in achieving the desired outcomes.
implementing recommendations
Question 6. What progress is VA making in addressing the hundreds
of open recommendations?
Response. During the past 2 years, VHA closed 91 GAO
recommendations. GAO added 75 new recommendations during that same
timeframe. As of March 2017, VHA is actively working on 81 open
recommendations, of which GAO provided more than half during the past
12 months. VHA has completed actions on 20 recommendations and awaits
GAO's decision regarding closure.
Question 7. When VA and GAO or OIG agree on root problems but
disagree on the path to address those problems how is that resolved?
Response. In the event, GAO or the VA Office of Inspector General
(OIG) are seeking a different resolution than the actions VHA has
taken, VHA engages the OIG or GAO team in discussions regarding the
details of actions taken and provides evidence of the effectiveness of
those actions. Upon learning more detail, the OIG or GAO may find that
the actions have been effective and close the recommendation, on
occasion they request additional data collection over time to assess
for lasting effectiveness, or they specify what additional actions
would be needed to satisfy the intent of the recommendation.
Question 8. Does VA have any Department-level tracking of the
administration's open and oldest recommendations? If so, please provide
the name of the accountable office. What actions is Dr. Shulkin taking
to focus attention on these issues, or is this not a priority?
Response. VA's Office of Congressional and Legislative Affairs
maintains a list of open GAO recommendations. Dr. Shulkin appreciates
GAO's work to improve services to our Veterans and takes GAO's
recommendations to the Department very seriously. The Department's
Administrations and Staff Offices that have open recommendations are in
the process of implementing action plans outlined in the responses to
GAO draft and final reports.
staffing model
Question 9. Three OIG reports have been issued on staffing
shortages, and all have recommended VA create a staffing model that
considers demand and complexity and matches that to budget requests and
allocations. Why has this not yet been completed?
Response. As reported in the VHA concurrence to the OIG
Recommendation (Report No. 16-00351-453, 9/28/2017), VHA is pursuing
multiple courses of action. These include the following:
(1) Completion of the draft Specialty Care Clinical Staffing Model.
As noted, in the OIG report, this is a project to research, develop and
ultimately implement a cross-disciplinary staffing model. In
January 2015, the Under Secretary for Health chartered a working group
for a staffing model across all 25 Specialty Care disciplines, at all
VA medical centers, both inpatient and ambulatory. The objective of
this team is to develop a model that correlates Veteran population and
utilization with productivity and capacity, and then to cost. From
there, the model can be used to assist in both individual staffing
determination and for overall ``make/buy'' decision on expanding or
contracting clinics and other medical facilities.
The draft model is complete and is undergoing review by several VHA
senior leaders and by VA's OIG. The final draft will incorporate
feedback from each of these offices, which will then lead to field
validation and development of policy for implementation.
(2) Evaluation and enhancement of other VHA clinical staffing
models continues across multiple fields, including the Primary Care
Patient Aligned Care Team (PACT) model, Nurse Professionals, and
Medical Support Assistant staffing. Each of these efforts is making
significant progress in their respective arenas and is also being
connected with similar enhancements to hiring and onboarding practices.
Feedback will be solicited from field clinics to validate the ongoing
work.
The ongoing clinical staffing work at the James A. Lovell Federal
Health Care Center (FHCC) in Chicago, Illinois is another staffing
modeling activity, focused on leveraging best practices and common
strategies in a joint clinical environment. Since September 2016, a
team of Department of Defense (DOD) and VHA professionals have
regularly convened to review alignment of VHA and DOD staffing models
in such practice areas as Primary Care and Nursing. VHA is currently
exploring mechanisms to import staffing data from DOD, and incorporate
the information into VHA's productivity tools--regarded by both DOD and
VHA as a potential asset for productivity and integration. As the joint
VHA-DOD staffing strategy matures, VHA will examine the applicability
of DOD staffing techniques in VHA-specific environments.
information technology
Question 10. The GAO report lays out a number of outdated IT
systems operating at VA right now. How does Dr. Shulkin intend to
prioritize funding amongst the various systems that need to be upgraded
or replaced, and what role will OIT play in those decisions?
Response. The VA does have a large number of legacy systems and
have embarked on a strategy to prioritize the divestiture of legacy
systems. In FY 2017 we will retire the Bi-directional Health
Information Exchange (BHIE) and have started a project to divest our
legacy Financial Management System (FMS) and other ancillary financial
systems. We also have projects currently underway with our business
partners in VBA, NCA and BVA to retire the Benefits Delivery Network
(BDN), Burial Operations and Support System (BOSS), and Veterans
Appeals Control and Logistics System (VACOLS), respectively. The
Secretary will also announce the VA's path forward on Electronic Health
Record modernization by July 2017. Divestiture of legacy systems and
the modernization of the VA's IT infrastructure is one of our highest
priorities and we are aligning resources around these projects to
reflect that commitment. The process and decisionmaking has involved
close cooperation between the CIO and senior VA leadership by reviewing
and discussing the IT and operational risks associated with each
system.
Question 11. I understand that VA had a goal of having 50 percent
of the active IT projects on budget and on schedule by the end of 2016.
Did VA meet that goal? What is the new goal moving forward?
Response. VA has met the on-time rate of 50 percent of projects
being on budget for the end of 2016. VA has exceeded the on-time rate
of 50 percent of projects being on schedule for the end of 2016. At
this time, the goal is 50 percent for 2017.
Question 12. VA appears poised to make an announcement in early
Summer 2017 regarding its intent to procure a commercial electronic
health record as a replacement for VistA. Please describe how VA has
been consulting with the Department of Defense (DOD) during DOD's
ongoing EHR transition and what lessons VA has learned from that
implementation. Please describe the experience VHA and VHA patients who
are receiving care at Fairchild Air Force Base or any other facility
deploying the Cerner Millenium EHR have had to date.
Response. VA continues to consult and work closely with DOD to
learn lessons from its acquisition and ongoing implementation of the
Military Healthcare System (MHS) GENESIS efforts.
VA continues to consult and working closely with DOD to gather
information on the acquisition of MHS GENESIS. VA has received and
reviewed the business and clinical workflow models which were developed
as part of the MHS GENESIS scope of work. DOD has pledged to provide
additional information to VA as it becomes available through the DOD/VA
Interagency Program Office, in consultation with the functional and
program offices in the Defense Health Agency and Program Executive
Office, Defense Healthcare Management System.
VA has worked with DOD to obtain information on the acquisition of
MHS GENESIS, such as market research information, certain contract
clauses related to compliance with national health data standards and
basic contract structure, and request for proposal statements of work.
VA has also worked with DOD to receive business and clinical workflow
models developed as part of DOD's scope of work on the Department of
Defense Healthcare Management System Modernization (DHMSM) effort. VA
will receive additional information from DOD through the DOD/VA
Interagency Program Office (IPO) as information becomes available in
consultation with the functional and program offices in the Defense
Health Agency and Program Executive Office, Defense Healthcare
Management Systems.
As an example of VA and DOD's coordination, on October 26, 2016, VA
held an Electronic Health Record (EHR) Roundtable with the objective to
discuss EHR transformation best practices and lessons learned with
public and private sector health care industry leaders to inform the
way forward for VHA. This meeting included participation from external
partners including the Office of the National Coordinator and Colonel/
Dr. Aronson who has been the Chief Medical Information Officer for the
DHMSM. Key lessons learned included: 1) need for highly resource
intensive change management strategies; 2) best practices for
addressing legacy systems, including re-training of staff; and 3)
strategies, such as phased roll-outs, to mitigate impacts to patient
access.
Meetings and coordination between VA and DOD to ensure
interoperability and lessons learned are and will be ongoing throughout
the DHMSM/MHS GENESIS program.
Finally, VA officials were pleased to attend the ribbon cutting
ceremony and lessons learned sessions at the Fairchild Air Force Base
(AFB) in February 2017. An example of the lessons learned was the
central role organizational change management plays in any large
deployment of this kind. We do not have any information on VHA patients
receiving care at Fairchild AFB or another facility where MHS GENESIS
is deployed, but we will continue to monitor.
______
Response to Posthearing Questions Submitted by Hon. Richard Blumenthal
to Carolyn M. Clancy, M.D., Deputy Under Secretary for Health for
Organizational Excellence, U.S. Department of Veterans Affairs
Question 13. During last week's hearing, Dr. Lee responded to a
question on how the Department of Veterans Affairs (VA) provides care
to survivors of military sexual trauma (MST) by saying that VA's policy
is to provide care to Servicemembers, former Servicemembers with an
other than honorable (OTH) discharge for MST care regardless of how
they enter the VA system. Previous communications with both VA and
Department of Defense staff have indicated that these services are only
being provided to active duty Servicemembers, including members of the
National Guard and Reserves, and those with an OTH discharge at Vets
Centers but not at VA medical centers (VAMC) or Community-Based
Outpatient Clinics (CBOC). Could you please clarify whether such
services are available at VAMCs and CBOCs and if there are any
locations in which MST services are not available for active duty
Servicemembers and former Servicemembers with an OTH discharge?
Response. VA has been offering a full range of health care services
to Active Duty Servicemembers (ADSM) under sharing agreement authority
for many years; this care has been available at both VA medical centers
(VAMC) and community-based outpatient clinics (CBOC) depending on the
nature of specific sharing agreements. Services provided under this
authority likely have included care for conditions related to military
sexual trauma (MST), but because such care was provided under VA's
sharing agreement authority, not its MST treatment authority (as
specified in 38 United States code (U.S.C.) Sec. 1720D), it has not
historically been tracked as part of VA's national MST monitoring
efforts. ADSMs typically must receive a referral from TRICARE or a
military treatment facility to seek care at a VAMC or CBOC under the
sharing agreement authority.
The amendments to 38 U.S.C. Sec. 1720D in section 402 of the
Veterans Access, Choice, and Accountability Act of 2014, which became
effective on August 7, 2015, authorize VA to extend VA's MST-specific
treatment authority to ADSMs without the need for a DOD referral. 38
U.S.C. Sec. 1720D(a)(2). VA has implemented this discretionary
authority to permit ADSMs to receive counseling to overcome
psychological trauma resulting from MST at Vet Centers without a DOD
referral. Vet Center records are confidential and maintained
independent of DOD and VA medical records. Additionally, Vet Centers
have staff with particular expertise in MST and are located in the
community, apart from DOD installations. In addition to treatment
available to ADSMs under VA/DOD sharing agreements, VA is collaborating
with DOD to provide MST-related care and services to ADSMs at VAMCs and
CBOCs without the need for a referral.
Eligibility criteria and services available for former
Servicemembers with an Other Than Honorable (OTH) discharge are
separate and distinct from the above description pertaining to ADSMs.
In general, to qualify for VA health care, a former Servicemember must
meet the definition of a ``Veteran'' as this term is defined in 38
U.S.C. Sec. 101: ``a person who served in the active military, naval,
or air service, and who was discharged or released therefrom under
conditions other than dishonorable.'' An OTH discharge is not
necessarily a bar to receipt of VA services, and individuals with OTH
discharges can potentially receive VA health care, including MST-
related care, upon review of their discharge by the Veterans Benefits
Administration (VBA). If VBA determines that the individual qualifies
as a ``Veteran,'' the individual may enroll in VA's health care system
and be placed in the priority group for which he or she qualifies.
Former Servicemembers with OTH discharges may receive VA emergency care
pending these Veterans Benefits Administration reviews.
A former Servicemember with an OTH discharge who is subsequently
determined (by VBA) to be a ``Veteran,'' as described above, is
eligible to receive counseling and treatment to overcome psychological
trauma resulting from MST, as described in Sec. 1720D.
If VBA determines that the character of discharge is a bar to
receiving VA benefits, and thus that the individual does not qualify as
a ``Veteran,'' the individual is still eligible for VA health care
needed to treat a service-incurred or service-aggravated disability
(unless subject to one of the statutory bars to benefits set forth in
38 U.S.C. Sec. 5303(a)). See Section 2 of Public Law 95-126 (Oct. 8,
1977). VA is reviewing whether such an individual who is determined
pursuant to Sec. 1720D to have psychological trauma resulting from MST
would qualify for care for that trauma under section 2 of Public Law
95-126.
______
Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to
Carolyn M. Clancy, M.D., Deputy Under Secretary for Health for
Organizational Excellence, U.S. Department of Veterans Affairs
va scheduling system
Question 14. Dr. Clancy, in the testimony of Mr. Missal, he
indicates that VA's continued issues with their scheduling system stem
from the VA's failure to identify their requirements for such a system.
However, Secretary Shulkin has indicated that VA is giving up on the
in-house solution for a scheduling system and will be buying one off
the shelf-what measures will the VA be taking to ensure the produce
will integrate with the electronic health records of the VA, the Choice
program, and the DOD?
Response. In February 2017, VA announced it has decided to proceed
with rolling out VistA Scheduling Enhancement (VSE) as a low-cost,
temporary improvement to the current outdated scheduling system. VSE
will be VA's interim scheduling solution to fulfill requirements for
patient scheduling until a robust, commercial scheduling system can be
implemented. VSE provides a more user-friendly interface that makes it
easier to view available appointment times and reduces errors on entry.
This functionality improves our ability to schedule Veterans
efficiently and accurately.
VA will still pursue the Medical Appointment Scheduling System
(MASS) scheduling pilot as part of a longer term, comprehensive
strategy to modernize VA scheduling and meet all of VA's scheduling
needs, like resource-based scheduling. VA's overall electronic health
record modernization plan is set to be released this summer. VA will
roll out VSE nationally over the next several months as safely and
quickly as possible.
Question 15. Do you have a target date for complete
interoperability between the VA and the DOD? The move by the VA to
capitalize on using military treatment facilities will be a failure if
you cannot make the systems work seamlessly.
Response. VA and DOD systems are interoperable today. In
April 2016, VA and DOD were proud to certify to Congress that VA had
met the National Defense Authorization Act for Fiscal Year 2014
interoperability standards. But meeting those standards was only one
part of our ongoing work, not the end state. We continue to push our
interoperability efforts every day to include interoperability with the
private sector.
As of March 19, 2017, more than 236,000 VA health care and benefits
professionals have access to real-time EHR information, which they can
access from VA, DOD, and VA external partner facilities (including
private sector) where a patient has received care. On a daily basis,
approximately 1.5 million data elements are shared between DOD and VA.
The tool that provides this capability is called the DOD/VA Joint
Legacy Viewer (JLV). Since its implementation, JLV has allowed VA staff
to view more than 2.5 million records. VA's Enterprise Health
Management Program (eHMP) incorporates JLV's capabilities and provides
even more robust capabilities, including team management and
communications, task management, and clinical decision support. eHMP is
built upon an event-driven architecture and includes the ability to
search the comprehensive patient record for specific terms and
conditions.
______
Response to Posthearing Questions Submitted by Hon. Joe Manchin III to
Carolyn M. Clancy, M.D., Deputy Under Secretary for Health for
Organizational Excellence, U.S. Department of Veterans Affairs
Question 16. Two of the high risk issues identified by GAO are
ambiguous policies and inconsistent processes throughout the VA system.
If a policy or procedure is developed at the VA Central Office level in
Washington, DC, how is VA guaranteeing proper articulation of that new
policy to VA employees at the local level?
Response. First, VHA has developed a system to ensure field review
during development, so that policies produced by VA Central Office have
already been thoroughly analyzed and commented on by the field before
they are published. Under the new development process, each policy is
placed into a portal where field offices at the local and VISN level
can read and provide detailed comments on every aspect of the policy.
Although this process is still relatively new, it has already yielded
hundreds of comments and has led to major revisions of several
developing policies.
Second, after VHA publishes a policy, the policy is communicated
through a variety of means including an e-mail to all publication
control officers nationwide and specific communications, which are
developed by the responsible program office and tailored specifically
for the primary users of the policy.
The new development process was piloted in 2016 and put in place in
January 2017. We are continuing to assess how well it is working by
focusing on existing policies that need to be updated and recertified,
and we meet regularly to revise based on user experience. We also have
long-term plans to develop pre- and post-publication assessments,
metrics, feedback loops, and communication tools that will apply to all
national policy.
Question 17. The Inspector General Audit of VA's Recruitment,
Relocation and Retention (3R) Initiatives exposed a lack of oversight
and accountability in the program that had expensive consequences. If
certain individuals are taking advantage of this program, money is not
reaching essential recruitment programs needed for rural VA hospitals
and CBOCs, like those in West Virginia. What is the VA doing to
adequately monitor the critical 3R incentive program?
Response. There are various monitoring and reporting requirements
outlined in current VA policy regarding recruitment, relocation, and
retention incentives. On an annual basis, each servicing human
resources office is responsible for compiling a certification report
attesting to the strategic and prudent use of all incentives authorized
during the prior calendar year. The report requires information from
each incentive authorization, and the Network, Area, or Deputy
Assistant Secretary level or higher must sign-off. These reports are
submitted to the Deputy Assistant Secretary for Human Resources
Management and form the basis for a Department-wide report to the
Secretary.
In addition to the annual certification report, the VA Office of
Human Resources Management (OHRM) Compensation and Classification
Service extracts data from the human resources information system on a
quarterly basis to identify any trends or anomalies in usage. As
needed, the Compensation and Classification Service contacts servicing
human resources offices to verify information and to obtain copies of
authorizations or other relevant documents needed for the analysis.
Additionally, OHRM's Oversight and Effectiveness Service will
continue to review a facility's incentive authorizations during onsite
visits and reviews. This review includes verifying justifications and
authorizations and ensuring incentives are approved in accordance with
VA policies and Federal Government regulations.
There are also impending policy revisions that will strengthen
monitoring requirements for Recruitment, Relocation, and Retention
incentives. One of the proposed changes to the policy is the addition
of a template for the mandatory annual review of all recruitment,
relocation, and retention incentives. The Annual Certification on Usage
of Recruitment, Relocation, and Retention Incentives template was
developed to collect mandatory information on the usage of recruitment,
relocation, and retention incentives. Section 5 of this proposed
template requires a narrative description and information to the
following: Description of any workforce or succession planning efforts
used or proposed that have or will eliminate or reduce the use of
recruitment, relocation, or retention incentives. In addition to the
workforce or succession planning narrative, each report must provide
certification.
Question 18. Given the historically long process of agency removal
from the GAO's High-Risk List, how long do you anticipate it will take
VA to make it off the list? What do you need from Congress to expedite
this process?
Response. The average removal time from the High-Risk List is 9
years. VA will do everything possible to achieve success more rapidly
than average and keep the Committee informed about our progress.
VA requests Congress work with VA on Choice eligibility criteria,
pass VA accountability legislation and appeals modernization
legislation.
Question 19. West Virginia has a population with a high number of
veterans and a high number of individuals utilizing the Affordable Care
Act. If the ACA is repealed, it is safe to assume there will be changes
to coverage, deductibles, and out-of- pocket costs for many. How, if at
all, do you foresee the repeal of the Affordable Care Act affecting VA
Healthcare? For example, do you expect to see an uptick in enrollment?
Response. Changes in health insurance coverage, deductibles and
out-of-pocket costs as a result of Affordable Care Act (ACA) reform
depend largely upon how the ACA isrepealed and replaced. As such, we
cannot speculate as to how ACA repeal and replace might impact VA
health care. West
The chart below depicts the Veteran population in West Virginia
including Veterans enrolled in VHA, Medicare and Medicaid, as reported
in the 2015 American Community Survey.
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
______
Response to Posthearing Questions Submitted by Hon. Sherrod Brown to
Carolyn M. Clancy, M.D., Deputy Under Secretary for Health for
Organizational Excellence, U.S. Department of Veterans Affairs
sterilization
Question 20. Dr. Clancy, during your testimony you referenced
steps VA took to correct safety and quality concerns as it relates to
sterilization of medical equipment. This is an issue that many medical
facilities face and was a focal point during last year's allegations of
misconduct at the Cincinnati VAMC. Please provide me with an overview
of the sterilization concerns that VA has review this past year and the
steps taken to address each concern.
Response. The VA National Program Office for Sterile Processing
(NPOSP) ensures the safety of Veterans by developing national policy
and oversight of all sterile processing and high-level disinfection
activities for critical and semi-critical Reusable Medical Equipment
(RME).
During FY 2016, NPOSP conducted 81 site review inspections
identifying the continued need for oversight and auditing of RME on an
annual basis. NPOSP conducts facility site visits in collaboration with
subject matter experts to review and advise on sterile processing
activities and to provide special assistance when failures in sterile
processing activities might pose potential risks to Veterans. For
example, NPOSP diligently looks for errors in not only documentation
but sterile processing activities that do not meet manufacturer's
guidelines which could potentially pose a risk to Veterans. If NPOSP
discovers errors, they will apply corrective actions dependent on the
complexity of the error to ensure Veteran safety. In addition to
conducting site visits, NPOSP also provides guidance and policies for
facility and VISN-led inspections of sterile processing activities and
assists with the analysis of data to identify trends. Using the trends
and data from the facilities, NPOSP recommends corrective actions
across the health care system.
NPOSP conducts training and continuing education programs to ensure
competencies in the sterile processing workforce and develops national
policy and guidance for sterile processing activities. Such direction
and policy may include technical specifications, competency
assessments, oversight of sterile processing functions at the facility
level, and integration of sterile processing activities with other
clinical services.
NPOSP collaborates with the VA National Center for Patient Safety
(NCPS), Biomedical Engineering, Center for Engineering, Occupational
Safety and Health (CEOSH), Food and Drug Administration (FDA) and
multiple vendors/manufacturers to correct defects in design and
reprocessing of RME issues. During this past fiscal year, NPOSP offered
guidance and provided corrective action to ensure Veteran safety with
the following instruments used in VA facilities:
General Electric (GE) ultrasound Endocavity Transducer
(IC5-9D)
- The transducer could not be deemed bioburden free due to the
design of the instrument. NPOSP worked with GE to redesign the
transducer probe and update Instructions For Use (IFU).
Olympus rigid cystoscope bridge
- The bridge was identified to have defective adhesive material
that deteriorated after the sterilization process. NPOSP is
working with Olympus for corrective design options.
3M Attest Biological indicator
- The testing indicator was not compatible with the sterilizer.
NPOSP collaborated with the manufacturer to provide the correct
guidelines for use that meet quality assurance indicators of
VA.
Arobella Quostic Wound Therapy System Model AR1000
ultrasound debridement
- The design of the Arobella Quostic Wound Therapy System Model
AR1000 hand piece did not allow for proper reprocessing. NPOSP
provided guidance and discontinued using the old version of the
ultrasound hand piece nationally in VA and now only purchases
the up-to-date model from the manufacturer that could be
effectively reprocessed.
Conmed Hyfrecator
- The Hyfrecator was noted to only have 100 uses validated for
proper usage; however, the manufacturer representative failed
to inform end users that the hand piece must be disposed of,
tracked, and disposed of after 100 uses. NPOSP implemented a
national quality assurance program to ensure proper tracking
and disposal of the Hyfrecator. NPOSP also worked with the
manufacturer to create a sheath with correct guidelines for use
to ensure the sheath covered the Hyfrecator which protects
patients from biohazard material.
Parks Medical Doppler Probe
- The manufacturer only allows for the Doppler probe to be used
on intact, external skin only. NPOSP identified the Doppler was
being used intraoperatively with a sterile sheath that had not
been approved by the vendor. NPOSP implemented a national
quality assurance program to ensure proper usage of the Doppler
and education and training was provided for the end-user. VA no
longer uses the Doppler perioperative setting.
Custom Ultrasonics Automatic Endoscope Reprocessor (AER)
- The AER had not been validated for multiple high-level
disinfection solutions but was sold for the use of multiple
high-level disinfection solutions without any FDA validation.
NPOSP worked with FDA and Custom Ultrasonics to pull and
replace all AERs that did not meet FDA clearance.
same day access
Question 21. Dr. Clancy, in GAO's testimony Dr. Draper raises
concerns regarding access to same day care throughout VHA for veterans
in need of mental health and primary care. These findings are based on
GAO reports from 2015 and 2016. VHA says that there are same day
appointments for mental health and primary care in all facilities.
Please provide me with a snapshot from one day of all the VAMCs and
CBOCs in Ohio that illustrate same day availability for veterans.
What metrics are used to measure same day availability for veterans
and is there any way for a facility to report inaccurate data regarding
availability?
Response. Asking our Veteran patients to tell us about their
experience is the most important way to find out if a facility is
meeting same day service expectations. In VHA, one way this is done is
through the standardized survey called Consumer Assess of Health Care
Providers and Systems (CHAPS), a standardized tool used in the health
care industry. One of the CHAPS questions is, ``In the last 6 months,
when you made an appointment for a check-up or routine care with this
provider, how often did you get an appointment as soon as you needed?''
Since survey results report past performance, lag, and are
available less frequently, VHA is also using objective, process
measures believed to provide a daily snapshot of system performance in
achieving same day services for Veterans. One process measure is the
number of face-to-face appointments completed the same day they are
scheduled. VA recognizes not all appointments represented by this
measure meet the definition of ``same day services;'' however, many of
them are a result of same day requests from patients. This measure is
readily available to VA staff and actionable. The definition of same
day services includes not only requests from traditional face to face
visits but also responses to requests made by phone, secure messaging
email, and responses from appropriate support services such as
Pharmacy, Social Work, Nursing, etc. For this reason, VHA continues to
work to identify ways in which to measure these individual types of
same day services and develop more useful collective process and
outcome measures.
As of December 31, 2016, same day services in mental health and
primary care were made available at all medical centers across VHA.
This included those in Ohio, i.e., Chillicothe, Cincinnati, Cleveland,
Columbus and Dayton. Facilities have continued to work to expand same
day services to their CBOCs. In Ohio, a snapshot of same day services
availability as reported by facility leadership as of March 31, 2017,
is listed below.
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Primary Care Mental Health
----------------------------------------------------------------------------------------------------------------
(3V10) (538) Chillicothe VAMC Yes Yes
(3V10) (538GA) Athens Yes Yes
(3V10) (538GB) Portsmouth Yes Yes
(3V10) (538GC) Marietta Yes Yes
(3V10) (538GD) Lancaster Yes Yes
(3V10) (538GE) Cambridge Yes Yes
(3V10) (538GF) Wilmington Yes Yes
(3V10) (539) Cincinnati VAMC Yes Yes
(3V10) (539A4) Cincinnati VAMC-Fort Thomas No No
(3V10) (539GA) Bellevue Yes Yes
(3V10) (539GB) Clermont County Yes Yes
(3V10) (539GC) Dearborn Yes Yes
(3V10) (539GD) Florence Yes Yes
(3V10) (539GE) Hamilton Yes Yes
(3V10) (539GF) Georgetown Yes Yes
(3V10) (539QB) Highland Avenue No No
(3V10) (541) Louis Stokes Cleveland VAMC Yes Yes
(3V10) (541BY) Canton Yes Yes
(3V10) (541BZ) Youngstown Yes Yes
(3V10) (541GB) Lorain Yes Yes
(3V10) (541GC) Sandusky Yes Yes
(3V10) (541GD) David F Winder VA CBOC Yes Yes
(3V10) (541GE) McCafferty Yes Yes
(3V10) (541GF) Painesville Yes Yes
(3V10) (541GG) Akron Yes Yes
(3V10) (541GN) State Street Yes Yes
(3V10) (552) Dayton VAMC Yes Yes
(3V10) (552GA) Middletown Yes Yes
(3V10) (552GB) Lima Yes Yes
(3V10) (552GC) Richmond Yes Yes
(3V10) (552GD) Springfield Yes Yes
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