VETERANS HEALTH 

CARE

Improvements 

Needed in 

Operationalizing 

Strategic Goals and 

Objectives

Report to Congressional Requesters

October 2016

GAO-17-50

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-17-50, a report to 

congressional requesters

October 2016

VETERANS HEALTH CARE

Improvements Needed in Operationalizing 

Strategic Goals and Objectives

What GAO Found

The Department of Veterans Affairs’ (VA) Veterans Health Administration (VHA) 

uses a multi-step strategic planning process to develop its strategic goals and 

objectives, which includes two key steps—(1) identifying and assessing factors 

that may affect health care delivery, which is referred to as environmental 

scanning, and (2) holding the annual National Leadership Council (NLC) 

Strategic Planning Summit—according to officials. VHA officials told GAO that 

they leverage VA’s environmental scanning results in making decisions 

regarding VHA’s strategic goals and objectives and that VA’s central office has

historically had a role in aspects of VHA’s strategic planning process—such as 

participating in the NLC summit.

VHA relies on the VA medical centers (VAMC) that directly provide care to 

veterans and the Veterans Integrated Service Networks (VISN), regional entities 

to which the VAMCs report, to operationalize its strategic goals and objectives. 

However, certain limitations in VHA’s processes hinder VISNs’ and VAMCs’

efforts in operationalizing these goals and objectives. Specifically, 

• VHA has not specified VAMCs’ role and responsibilities in its strategic 

planning guidance, as it has for VISNs. For example, VHA’s directive for 

VISNs clearly states how VISN directors are to operationalize VHA’s 

operational plans; no such directive exists for VAMC officials. Similarly, VHA 

provided VISNs a strategic planning guide for operationalizing its current 

strategic plan, but did not provide a similar guide to the VAMCs.

• VHA has not developed detailed strategies for VISNs and VAMCs to use in 

operationalizing all of its strategic goals and objectives. According to leading 

practices for strategic planning, strategies should describe how strategic 

goals and objectives are to be achieved, including a description of the 

operational processes, staff skills, technology and other resources required. 

In September 2014, VHA published the Blueprint for Excellence to provide 

strategies for transforming VHA health care service delivery in response to 

concerns regarding the VHA wait-time crisis that year. However, it did not 

develop similar strategy documents for other years or for the other goals and 

objectives in its strategic plan. 

• VHA does not have an effective oversight process for ensuring and 

assessing the progress of VISNs and VAMCs in meeting VHA’s strategic 

goals and objectives. According to VHA officials, VHA relies on two methods 

for assessing performance towards meeting selected strategic goals and 

objectives. Specifically, VHA uses VISN and VAMC directors’ individual 

annual performance plans, as well as veteran survey information, to assess 

VHA’s performance towards meeting certain metrics, such as improving 

veterans’ access. However, it is unclear how these specific metrics are linked 

to assessing overall progress towards VHA’s strategic goals and objectives. 

As a result, VHA may not know to what extent VISNs’ and VAMCs’ efforts to 

operationalize its goals and objectives are adequately addressing top 

management concerns or department-wide strategic goals.

View GAO-17-50. For more information, 

contact Debra A. Draper at (202) 512-7114 or 

draperd@gao.gov.

Why GAO Did This Study

Veterans’ health care needs may 

change due to changes in veteran

demographics and other factors. 

Strategic planning, including identifying 

mission, vision, goals, and objectives, 

and operationalizing strategies to 

achieve those goals and objectives are 

essential for VHA to establish its 

strategic direction to respond to these 

changing demands and provide care in 

a dynamic environment.

GAO was asked to review VHA’s 

strategic planning. This report 

examines (1) VHA’s strategic planning 

process and (2) the extent to which

VHA operationalizes its strategic goals 

and objectives. GAO reviewed VHA 

strategic planning documents; and 

interviewed officials from VA and VHA 

central office, three VISNs selected to 

provide variation in geographic 

location, and nine VAMCs within these 

VISNs selected to provide variation in 

factors such as geographic location 

and facility complexity. GAO evaluated 

VHA’s actions against federal 

standards for internal control and 

leading practices for strategic planning.

What GAO Recommends

GAO recommends that VHA (1) 

specify VAMCs’ roles and 

responsibilities in operationalizing its

strategic goals and objectives, (2) 

develop detailed strategies to 

operationalize its goals and objectives, 

and (3) develop an oversight process 

to assess progress made. VA 

concurred with GAO’s 

recommendations.
Page i GAO-17-50 VHA Strategic Planning

Letter 1

Background 7

VHA Uses a Multi-Step Strategic Planning Process to Identify 

Strategic Goals and Objectives 12

VISNs and VAMCs Are Responsible for Operationalizing VHA’s 

Strategic Goals and Objectives, but VHA Has Not Developed 

Adequate Strategies or an Effective Oversight Process to 

Ensure Operationalization 14

Conclusions 19

Recommendations for Executive Action 20

Agency Comments and Our Evaluation 20

Appendix I VHA Strategic Plan FY 2013 – 2018 22

Appendix II Comments from the Department of Veterans Affairs 25

Appendix III GAO Contact and Staff Acknowledgments 32

Figure

Figure 1: Timeline of Factors that Have Affected or May Affect the 

Department of Veterans Affairs’ (VA) Veterans Health 

Administration’s (VHA) Strategic Goals and Objectives, 

during Fiscal Years (FY) 2013 – 2018 11

Contents
Page ii GAO-17-50 VHA Strategic Planning

Abbreviations

Choice Act Veterans Access, Choice, and Accountability Act of 

2014

FY fiscal year

GPRA Government Performance and Results Act of 1993

GPRAMA GPRA Modernization Act of 2010

NLC National Leadership Council

VA Department of Veterans Affairs

VAMC VA medical center

VHA Veterans Health Administration

VISN Veterans Integrated Service Network

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Page 1 GAO-17-50 VHA Strategic Planning

441 G St. N.W.

Washington, DC 20548

October 21, 2016

The Honorable Jeff Miller

Chairman

The Honorable Mark Takano

Acting Ranking Member

Committee on Veterans’ Affairs

House of Representatives

The Honorable Corrine Brown

House of Representatives

The Honorable Derek Kilmer

House of Representatives

The Department of Veterans Affairs’ (VA) Veterans Health Administration 

(VHA) operates one of the nation’s largest health care systems through 

its 168 VA medical centers (VAMC) and more than 1,000 outpatient 

facilities with a total budget of nearly $51 billion in fiscal year (FY) 2015.1

VHA provided care to about 6.7 million veterans in FY 2015, and the 

demand for its services is expected to grow in the coming years.

Due to changes in the veteran population, including increases in the 

number of women and those between the ages of 65 and 84, the health 

care needs of veterans may also change. These and other changes, such 

as innovations in technology and health care delivery, may affect VHA’s 

current strategies for accomplishing its mission to provide care to the 

nation’s veterans. Strategic planning—including identifying mission, 

vision, goals, and objectives, and operationalizing strategies to achieve 

those goals and objectives—is key to VHA’s ability to establish its 

 1

VAMCs manage outpatient facilities located within their respective medical centers; these 

outpatient facilities include community-based outpatient clinics and health care centers. 

Community-based outpatient clinics are located in areas surrounding VAMCs and provide 

primary care and some specialty care services that do not require a hospital stay. Health 

care centers are large multi-specialty outpatient clinics that provide surgical services in 

addition to other health care services. For the purpose of this report, when we mention 

VAMCs, we are referring to all of its components.

Letter
Page 2 GAO-17-50 VHA Strategic Planning

strategic direction and can help VHA anticipate and respond to this 

demand and provide care in a dynamic environment.2

We and others have expressed significant concerns about VHA’s 

management of its health care system, including VHA’s ability to 

effectively provide and oversee timely access to health care for veterans.3

These concerns have contributed to our conclusion that VA health care is 

a high-risk area, and we added it to our High-Risk List in 2015.4 To 

improve access to veterans’ health care, among other things, Congress 

enacted and the President signed into law the Veterans Access, Choice, 

and Accountability Act of 2014 (Choice Act).5 The Choice Act required VA 

to contract with a private entity to conduct an independent assessment of 

12 areas of its health care delivery system and management processes, 

including VHA’s leadership.6 The independent assessment report, which 

 2

Operationalizing in this context refers to the development and implementation of 

initiatives, programs, or actions that will be used to accomplish the organization’s goals 

and objectives. 

3

See, for example, GAO, VA Health Care: Actions Needed to Improve Newly Enrolled 

Veterans’ Access to Primary Care, GAO-16-328 (Washington, D.C.: Mar. 18, 2016) and 

GAO, VA Mental Health: Clearer Guidance on Access Policies and Wait-Time Data 

Needed, GAO-16-24, (Washington, D.C.: Oct. 28, 2015). See also, for example, the 

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, 

D.C.: Aug. 26, 2014) and the Department of Veterans Affairs, Access Audit, System-Wide 

Review of Access, Results of Access Audit Conducted May 12, 2014, through June 3, 

2014.

4

GAO, High Risk Series: An Update, GAO-15-290, (Washington, D.C.: February 2015). 

GAO maintains a High-Risk List to focus attention on government operations that it 

identifies as high risk due to their greater vulnerabilities to fraud, waste, abuse, and 

mismanagement or the need for transformation to address economy, efficiency, or 

effectiveness challenges.

5

Pub. L. No. 113-146, 128 Stat. 1754 (2014).

6

Pub. L. No. 113-146, § 201, 128 Stat. 1769. VHA commissioned the Centers for 

Medicare & Medicaid Services Alliance to Modernize Healthcare (operated by MITRE 

Corporation, a private entity) and the Institute of Medicine to conduct the assessment. 

Parts of the evaluation were subcontracted to other organizations, including the RAND 

Corporation.
Page 3 GAO-17-50 VHA Strategic Planning

VHA reported cost $68 million, was released in September 2015.7 It made 

recommendations across each of the 12 areas that support the report’s 

four systemic findings of (1) a disconnect in the alignment of demand, 

resources, and authorities; (2) uneven bureaucratic operations and 

processes; (3) non-integrated variations in clinical and business data and 

tools; and (4) leaders not fully empowered due to a lack of clear authority, 

priorities, and goals. For example, to address a disconnect in the 

alignment of demand, resources, and authorities, the report includes a 

recommendation to develop a governance board to define the strategic 

direction for VHA and to ensure accountability for the achievement of 

established performance measures.8

In addition to requiring the independent assessment, the Choice Act 

established the Commission on Care to examine veterans’ access to VA 

health care and to examine how best to organize VHA, locate health 

resources, and deliver health care to veterans during the next 20 years.9

The Commission on Care’s interim report was published on December 4, 

2015, and a final report with 18 recommendations was submitted to the 

President on June 30, 2016.10 These reports and their findings have 

identified not only the need for VHA to modify a significant number of its 

processes and procedures in the short term, but also the need for VHA to 

 7

See Centers for Medicare & Medicaid Services Alliance to Modernize Healthcare, 

Independent Assessment of the Health Care Delivery Systems and Management 

Processes of the Department of Veterans Affairs (Sept. 1, 2015).

8

See Independent Assessment, Volume I. According to VHA, the report contains a total of 

188 recommendations. 

9

Pub. L. No. 113-146, § 202, 128 Stat. 1773. The commission is comprised of 15 

members appointed by Congressional leaders or the President and its members must 

meet certain qualifications. For example, at least one member must represent an 

organization that represents veterans and at least one other member must have 

experience as senior management for a private integrated health care system with an 

annual gross revenue of more than $50,000,000.

10Commission of Care, Final Report of the Commission on Care (Washington, D.C.: June 

30, 2016). Although the report was dated June 30, 2016, it was not released until July 5, 

2016. The Choice Act requires the President to submit a report to the Senate and House 

Committees on Veterans’ Affairs and any other committees of Congress that the President 

considers appropriate within 60 days of the President’s receipt of the commission report.

The President responded to the Commission on Care report on September 1, 2016. In his 

response, the President concurred with 15 of the 18 recommendations made by the 

Commission on Care to transform veterans’ health care and directed VA to develop plans 

to complete their implementation.
Page 4 GAO-17-50 VHA Strategic Planning

implement long-term system-wide changes to help it meet its mission. For 

example, the Commission on Care reported that VHA lacks a long-term 

vision and continuity in the development and execution of plans and 

programs. To address these issues, the commission recommended 

establishing a board of directors to provide VHA overall governance, set 

long-term strategy, and direct and oversee the long-term transformation 

of VHA.

Based on concerns about VHA’s ability to manage its health care system 

and provide timely care, you asked us to conduct a management review 

of VHA that encompasses several key organizational components, 

including its strategic planning.11 This report examines

1. VHA’s strategic planning process and

2. the extent to which VHA operationalizes its strategic goals and 

objectives.

To examine VHA’s strategic planning process, we reviewed relevant 

documentation from VHA, such as policies and procedures describing the 

process and its alignment with VA’s strategic planning process. We 

reviewed external assessments of VHA, such as the independent 

assessment report, to identify potential factors that may hinder the 

delivery of health care services, including recommendations for 

addressing these concerns. We also reviewed documentation and 

interviewed officials from three Veterans Integrated Service Networks 

(VISN)—VISNs 2, 20, and 23—and nine VAMCs within these VISNs—

located in (1) Albany, New York; (2) Anchorage, Alaska; (3) Batavia, New 

York; (4) Bath, New York; (5) Boise, Idaho; (6) Fargo, North Dakota; (7) 

Hot Springs, South Dakota; (8) Minneapolis, Minnesota; and (9) Portland, 

Oregon—to gain insights into the role of VISNs and VAMCs in VHA’s 

 11For our work on organizational structure, see GAO, VA Health Care: Processes to 

Evaluate, Implement, and Monitor Organizational Structure Changes Needed, 

GAO-16-803 (Washington, D.C.: Sept. 27, 2016). We have additional ongoing work 

related to human capital and information technology, with reports forthcoming. 
Page 5 GAO-17-50 VHA Strategic Planning

strategic planning process.12 We selected the three VISNs to provide 

variation in geographic location, including one VISN that was also among 

those selected by VHA for realignment.13 We then selected three VAMCs 

within each of these VISNs to reflect a range of geography, such as rural 

vs. urban locations, and facility complexity levels, as well as if the VAMC 

had any strategic planning best practices as identified by the VISNs.14

The information we collected on strategic planning processes at the 

VISNs and VAMCs in our review is not generalizable system-wide. We 

also interviewed VHA and VA officials to discuss relevant roles and 

responsibilities in VHA’s strategic planning process—including officials 

from VHA’s Office of the Under Secretary for Health, Office of the 

Assistant Deputy Under Secretary for Health for Policy and Planning, and 

National Leadership Council (NLC); and VA’s Office of Policy.15

Additionally, we received information from the National Cemetery 

Administration and interviewed officials from Veterans Benefits 

Administration and representatives of veterans service organizations 

 12VHA organizes its system of care into regional networks called VISNs. Each VISN is 

responsible for managing and overseeing VAMCs within a defined geographic area and 

reporting to the Deputy Under Secretary for Health for Operations and Management within 

VHA’s central office. In October 2015, VHA began realigning its VISN network, which 

included merging several VISNs; when complete, this realignment will decrease the 

number of VISNs from 21 to 18. See GAO-16-803.

13VA announced a major organizational initiative in September 2014 called MyVA. As part 

of this initiative, the department established a single regional framework for its three 

administrations—VHA, the Veterans Benefits Administration, and the National Cemetery 

Administration—dividing the United States into five regions based on state boundaries. 

According to VA, this regional framework is intended to align the previously disparate 

organizational boundaries of VA’s administrations in order to promote internal coordination 

and to support the rollout of a Veteran Experience office dedicated to enhancing customer 

service capabilities across the department. Following the MyVA initiative’s implementation, 

VHA announced plans to realign and, in some cases, merge VISNs so that they are 

geographically aligned with MyVA’s regional boundaries, referred to as the VISN 

realignment.

14VA assigns each VAMC a complexity score derived from multiple variables to measure 

facility complexity arrayed along four categories, namely patient population served, clinical 

services offered, education and research complexity, and administrative complexity.

15The NLC is the advisory body for decision-making within VHA. It is composed of seven 

committees: (1) Healthcare Delivery Committee, (2) Healthcare Quality and Value 

Committee, (3) Information Technology Committee, (4) Resource Committee, (5) Strategic 

Direction Committee, (6) Veteran Experience Committee, and (7) Workforce Committee. 

The co-chairs of each committee are generally a network director and a program office 

leader for the applicable subject area.
Page 6 GAO-17-50 VHA Strategic Planning

about VHA’s strategic planning process, including their involvement, if 

any, in the process.16

To determine the extent to which VHA operationalizes its strategic goals 

and objectives, we reviewed relevant documentation from VHA that 

describes its processes, including how, if at all, VHA implements, 

oversees, communicates, evaluates, and revises its strategic goals and 

objectives as needed. We reviewed documents, including VHA’s FY 

2013-2018 strategic plan, and other documents, such as VHA directives 

and policies, that describe requirements and guidance for operationalizing 

VHA’s strategic goals and objectives. We interviewed VHA and VA 

officials to discuss relevant roles and responsibilities as they relate to 

operationalizing VHA’s strategic goals and objectives, including officials 

from VHA’s Office of the Under Secretary for Health, Office of the 

Assistant Deputy Under Secretary for Health for Policy and Planning, and 

NLC; and VA’s Office of Policy. We also reviewed documentation and 

interviewed officials from the three VISNs and nine VAMCs in our review 

to discuss their roles and responsibilities, including any challenges and 

best practices, in operationalizing VHA’s strategic goals and objectives. 

We also interviewed these officials on the extent to which VHA monitors 

their efforts.

For both of our reporting objectives, we assessed VHA’s strategic 

planning process and its efforts to operationalize its strategic goals and 

objectives against relevant federal internal control standards.17 We also 

assessed its efforts against leading practices in federal strategic planning, 

including (1) leading practices for planning at lower levels within federal 

agencies, including individual programs or initiatives, based on practices 

required of federal departments under the Government Performance and 

Results Act of 1993 (GPRA), as enhanced by the GPRA Modernization 

 16We interviewed representatives from the following veterans service organizations: 

American Legion, Disabled American Veterans, Iraq and Afghanistan Veterans of 

America, and Paralyzed Veterans of America.

17GAO, Standards for Internal Control in the Federal Government GAO/AIMD-00-23.3.1 

(Washington, D.C.: November 1999) and GAO, Standards for Internal Control in the 

Federal Government GAO-14-704G (Washington, D.C.: September 2014). Internal control 

is a process effected by an entity’s oversight body, management, and other personnel that 

provides reasonable assurance that the objectives of an entity will be achieved.
Page 7 GAO-17-50 VHA Strategic Planning

Act of 2010 (GPRAMA)18 and (2) related leading practices that our past 

work has identified.19

We conducted this performance audit from September 2015 through 

October 2016 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.

In carrying out its mission of providing services to veterans, VA’s 

programs are administered through its three major administrations—VHA, 

Veterans Benefits Administration, and National Cemetery 

Administration—and VA engages all of its administrations in its strategic 

planning process. VA’s Office of Policy is responsible for ensuring 

integration, collaboration, and cooperation across VA with regard to policy 

and strategy development. This office also leads VA’s strategic planning 

efforts and is involved with managing VA’s governance process. Within 

the Office of Policy, the Policy Analysis Services, the Strategic Studies 

Group, and the Strategic Planning Service support this work. In March 

 18GPRA, Pub. L. No. 103-62, 107 Stat. 285 (1993); GPRAMA, Pub. L. No. 111-352, 124 

Stat. 3866 (2011). Among other things, executive agencies, including VA, are required to 

develop long-term strategic plans every 4 years, each of which must include certain 

components, such as a mission statement and general goals and objectives, and are 

required to make their plans available to the public, with notice to the President and the 

Congress. The next strategic plans are due in February 2018. We have previously 

identified related leading practices in GAO’s past work. See GAO, Agencies’ Strategic 

Plan Under GPRA: Key Questions to Facilitate Congressional Review, 

GAO/GGD-10.1.16, (Washington, D.C.: May 1997), Managing For Results: Critical Issues 

for Improving Federal Agencies’ Strategic Plans, GAO/GGD-97-180 (Washington, D.C.: 

Sept. 16, 1997), Environmental Justice: EPA Needs to Take Additional Actions to Help 

Ensure Effective Implementation, GAO-12-77 (Washington, D.C.: Oct. 6, 2011). For more 

information on how GPRA and GPRAMA may be used as leading practices at lower levels 

within federal agencies, see GAO, Foreign Aid Reform: Comprehensive Strategy, 

Interagency Coordination, and Operational Improvements Would Bolster Current Efforts, 

GAO-09-192 (Washington, D.C.: Apr. 17, 2009).

19For example, see GAO, Managing for Results, Critical Issues for Improving Agencies’

Strategic Plans, GAO/GGD-97-180 (Washington, D.C.: Sept. 16, 1997) and Agencies 

Strategic Plans under GPRA: Key Questions to Facilitate Congressional Review,

GAO/GGD-10.1.16 (Washington, D.C.: May 1997).

Background
Page 8 GAO-17-50 VHA Strategic Planning

2014, VA published its current strategic plan, Department of Veterans 

Affairs FY 2014 - 2020 Strategic Plan, which identifies the department’s 

mission, values, and three strategic goals.

Within VHA, the Office of the Assistant Deputy Under Secretary for Health 

for Policy and Planning supports and advises several VHA offices—the 

offices of the Under Secretary for Health, Principal Deputy Under 

Secretary for Health, and the Deputy Under Secretary for Health for 

Policy and Services—on the development and implementation of VHA 

policy, strategic planning, and forecasting.20 VHA’s Under Secretary for 

Health directs all aspects of VHA’s health care system, including its 

annual budget and overseeing the delivery of care to veterans, as well as 

the health care professionals and support staff that deliver that care.

In December 2012, VHA published its current strategic plan, VHA 

Strategic Plan FY 2013 – 2018, which identifies its mission and vision and 

guides budgeting, performance management, and service alignment 

across VHA, and its plans for how to provide for the health care needs of 

veterans.21 (See app. I.) The plan also outlines VHA’s three goals and 17 

objectives that are to be used to guide planning, budgeting, performance 

management, and service alignment across VHA; those three goals are 

to: (1) provide veterans personalized, proactive, patient-driven health 

care, (2) achieve measurable improvements in health outcomes, and (3) 

align resources to deliver sustained value to veterans. VHA Directive 

1075: Strategic Planning Process is VHA’s most current strategic 

planning guidance, and it outlines how VHA will identify its strategic 

 20VHA’s Office of the Assistant Deputy Under Secretary for Health for Policy and Planning 

is comprised of three major program units: (1) the Office of Policy Analysis and 

Forecasting, which provides data and analyses to support VHA strategic and capital 

planning, policy, and budget decisions; (2) the Office of Rural Health, which collaborates 

with other VHA program offices, and federal, state and local partners, on the use of 

available and emerging technologies, the establishment of new access points to care, and 

the employment of strategies to increase health care options for rural veterans; and (3) the 

Office of Strategic Planning and Analysis, which provides data and analyses to facilitate 

strategic planning and decision making across VA.

21See Department of Veterans Affairs, Veterans Health Administration, VHA Strategic

Plan FY 2013 – 2018.
Page 9 GAO-17-50 VHA Strategic Planning

priorities and establish and execute its strategic plan, as well as identifies 

roles and responsibilities in this process.22

In recent years, VA and VHA have established several new initiatives, 

activities, and priorities in response to changes in internal and external 

factors—including VHA leadership changes, congressional concerns 

regarding veterans’ access to care, and the placement of VHA on our 

High-Risk List. Specifically, VA and VHA have developed the following 

new initiatives and priorities in the last 2 years:

• MyVA: This VA-wide initiative was launched in July 2015 and is aimed 

towards transforming the veterans’ experience. VA has developed five 

priorities for this initiative: (1) improving the veteran’s experience, (2) 

improving the employee experience, (3) improving internal support 

services, (4) establishing a culture of continuous improvement, and 

(5) enhancing strategic partnerships.23

• “The Under Secretary for Health’s Five Priorities:” VHA’s Under 

Secretary for Health established these priorities after being appointed 

to his position in July 2015. The five priorities are to (1) improve 

access, (2) increase employee engagement, (3) establish consistent 

best practices, (4) build a high-performing network (which includes VA 

and non-VA providers), and (5) rebuild the trust of the American 

people.

• “The Secretary’s 12 Breakthrough Priorities:” These priorities describe 

focus areas for the MyVA initiative and were first presented in a 

January 2016 testimony by the Secretary of VA to the Senate 

Committee on Veterans’ Affairs. Several of these priorities—such as 

improving the veterans experience, increasing access to health care, 

 22Department of Veterans Affairs, Veterans Health Administration, VHA Directive 1075: 

Strategic Planning Process, (March 10, 2014).

23See Department of Veterans Affairs, MyVA Integrated Plan (MIP) (July 30, 2015).
Page 10 GAO-17-50 VHA Strategic Planning

and improving community care—are relevant to health care delivery in 

VHA.24

Additionally, in September 2014, VHA developed the Blueprint for 

Excellence, which presents strategies for transforming VHA health care 

service delivery in response to concerns regarding the VHA access and 

wait-time crisis that year.25 These strategies, which are linked to the goals 

and objectives in VHA’s current strategic plan, include operating a health 

care network that anticipates and meets the unique needs of enrolled 

veterans, in general, and the service disabled and most vulnerable 

veterans, and delivering high-quality, veteran-centered care that 

compares favorably to the best of private sector in measured outcomes, 

value, access, and patient experience. More recently, VHA developed a 

crosswalk for internal discussion documenting how the various VA and 

VHA initiatives, activities, and priorities—such as MyVA, Blueprint for 

Excellence strategies, the Under Secretary for Health’s Five Priorities, 

and the Commission on Care report—relate to each other. See fig. 1 for a 

timeline of internal and external factors that have affected or may affect 

VHA’s strategic goals and objectives.

 24See Department of Veterans Affairs, VA’s Transformation Strategy: Examining the Plan 

to Modernize VA: Before the Senate Committee on Veterans’ Affairs, 114th Cong., 2nd

sess. (2016) (statement of Robert McDonald, Secretary, U.S. Department of Veterans 

Affairs). The other priorities include delivering a unified veteran experience, modernizing 

contact centers, improving the compensation and pension exam process, developing a 

simplified appeals process, continuing progress in reducing veteran homelessness, 

improving the employee experience, staffing critical positions, transforming Office of 

Information Technology, and transforming the supply chain.

25See Department of Veterans Affairs, Veterans Health Administration, Blueprint for 

Excellence (Sept. 21, 2014). 
Page 11 GAO-17-50 VHA Strategic Planning

Figure 1: Timeline of Factors that Have Affected or May Affect the Department of Veterans Affairs’ (VA) Veterans Health 

Administration’s (VHA) Strategic Goals and Objectives, during Fiscal Years (FY) 2013 – 2018
Page 12 GAO-17-50 VHA Strategic Planning

VHA conducts a strategic planning process annually and through this 

process also established its current strategic plan. According to officials, 

VHA’s current strategic plan was developed through its FY 2012 strategic 

planning process. VHA officials told us that they currently do not have 

plans to revise VHA’s current strategic plan or develop a new one, but

may, however, develop an operational plan that will cascade from and 

operationalize VA’s strategic plan.26 VHA officials told us that they do plan 

to continue to use their current annual strategic planning process to 

identify VHA’s future strategic goals and objectives.

According to VHA officials, VHA’s strategic planning process includes two 

key steps—(1) assessing the environment, which VHA refers to as 

environmental scanning, and (2) holding the annual NLC Strategic 

Planning Summit.27 These steps are consistent with leading practices in 

strategic planning.28 VHA conducts environmental scanning to identify 

and assess factors that may affect its future health care delivery. 

According to VHA policy, data from VHA’s environmental scan, such as 

the projected number of veterans to be served, are to be used by VHA in 

developing its goals and objectives. In addition, the results from VHA’s 

environmental scanning are to be used by VHA’s Office of Policy and 

Planning and VHA program offices, in strategic decision making.

In addition to environmental scanning, the NLC Strategic Planning 

Summit is also key to VHA’s strategic planning process, in that it is the 

primary forum through which VHA leadership identifies and discusses the 

strategic goals and objectives for the next year. The NLC is responsible 

for recommending new or revised strategic goals and objectives and for 

formulating strategies to achieve them. VHA’s Office of Policy and 

Planning coordinates the summit and invites various stakeholders to 

attend—such as officials from VHA central office, including program 

offices; VA central office; Veterans Benefits Administration; National 

 26The requirement for executive agencies—including executive departments such as 

VA—to develop strategic plans does not pertain to VHA. See, 5 U.S.C. § 306(f).

27Other components of VHA’s annual strategic planning process include capital asset, 

workforce, and budget planning. See VHA Directive 1075: Strategic Planning Process, 

(March 10, 2014).

28For example, see GAO, Executive Guide: Effectively Implementing the Government 

Performance Act, GAO/GGD-96-118 (Washington, D.C.: June 1996), 14-16. 

VHA Uses a MultiStep Strategic 

Planning Process to

Identify Strategic 

Goals and Objectives
Page 13 GAO-17-50 VHA Strategic Planning

Cemetery Administration; VISNs; and representatives of veterans service 

organizations. Veterans Benefits Administration and National Cemetery 

Administration officials indicated that they have varied levels of 

participation. Veterans Benefits Administration officials told us that they 

have historically attended several days of the summit, and National 

Cemetery Administration officials indicated that they may listen to the 

VHA’s general body sessions during the summit. Even though officials 

from both administrations indicated they believe their input and 

coordination with VHA regarding its strategic planning was sufficient, 

Veterans Benefits Administration officials noted that increased 

engagement in VHA’s strategic planning process would be beneficial, 

given the direct correlation between veterans’ disability compensation 

ratings assigned by them and the subsequent care delivered from VHA.

During the course of the summit, the NLC determines if changes to VHA’s 

strategic goals and objectives are needed. If there are changes, VHA’s 

Office of Policy and Planning drafts a document, gathers additional 

stakeholder feedback, and presents the document to VHA’s Under 

Secretary for Health for approval.

VHA also obtains and uses information from VA to inform its strategic 

planning process. For example, according to VA and VHA officials, VHA’s 

environmental scanning process is, and has historically been, health-care 

focused, and is adjunct to the broad environmental scanning process 

conducted by VA. Officials noted that though distinct processes, VA’s and 

VHA’s environmental scanning processes are interrelated. VHA officials 

told us that they leverage VA’s environmental scanning results in making 

decisions regarding VHA’s strategic goals and objectives. Additionally, VA 

officials have historically been invited to participate in VHA’s NLC 

Strategic Planning Summit, including the 2016 summit. VA’s draft report 

of its environmental scanning identified changes in the veteran 

population, including growth in the number of veteran enrollees aged 65 

and older, which VA officials reiterated at the 2016 NLC summit.
Page 14 GAO-17-50 VHA Strategic Planning

VISNs and VAMCs have responsibility for operationalizing VHA’s 

strategic goals and objectives, including its strategic plan, according to 

VHA officials. Operationalizing involves putting strategic goals and 

objectives into use by an organization, and includes developing initiatives, 

programs, or actions that will be used to accomplish those goals and 

objectives.29 VISNs and VAMCs must allocate resources, develop day-today activities, and create policies as part of that process.

However, we found that VHA provides limited guidance for VAMCs in how 

to operationalize VHA’s strategic goals and objectives. First, VHA has not 

clearly identified VAMCs’ responsibilities in operationalizing its strategic 

goals and objectives as it has for VISNs. For example, VHA Directive 

1075 states that VISN directors are to be responsible for: developing 

 29Program offices, which include the Office of Patient Care Services and the Office of 

Public Health, also contribute to VHA’s strategic planning process by developing some of 

the programs and actions that VISNs and VAMCs use to provide health care services to 

veterans. Per VHA Directive 1075, these programs and actions use information from 

VHA’s environmental scanning process, NLC committee recommendations, and VISN 

operational plans. In addition, program offices are responsible for contributing to VHA’s 

strategic planning process by providing information on new technology, future health and 

business practices, benchmarking, and special population demographics. Program offices 

also serve as subject matter experts to NLC committees in their respective program areas.

VISNs and VAMCs 

Are Responsible for 

Operationalizing 

VHA’s Strategic Goals 

and Objectives, but 

VHA Has Not 

Developed Adequate 

Strategies or an 

Effective Oversight 

Process to Ensure 

Operationalization

VISNs and VAMCs Have 

Responsibility for 

Operationalizing VHA’s 

Strategic Goals and 

Objectives, but VHA Has 

Not Defined VAMCs’ Role
Page 15 GAO-17-50 VHA Strategic Planning

operational plans; annually tracking and reporting accomplishments in 

support of the VHA strategic plan; regularly updating plans to address 

local issues, such as geographic-specific needs; and providing input to 

inform future VHA goals, objectives, and strategies. However, there are 

no such stated responsibilities for VAMCs. According to federal internal 

control standards, successful organizations should assign responsibility to 

discrete units, and delegate authority to achieve organizational objectives. 

VHA and VISN officials told us that it is inferred that the VAMCs are part 

of the overall process even though there is no specific policy or guidance 

for VAMCs. All three VISNs in our review reported developing operational 

plans or strategies to operationalize VHA’s goals and objectives at the 

VISN level, but two of the nine VAMCs in our review had not developed 

such strategies.

Second, in FY 2013, VHA provided VISNs with a strategic planning guide 

for operationalizing the current strategic plan, but did not provide a similar 

guide for VAMCs. According to the guide, its purpose was to assist VISNs 

in outlining a multi-year plan that aligned with VHA’s current strategic plan 

and provide relevant information regarding the development of strategies, 

the process for conducting a strategic analysis, and the time frame for 

providing strategic planning information, such as strategies, to VHA 

central office.

The lack of guidance for VAMCs may hinder them from effectively 

operationalizing VHA’s strategic goals and objectives, and may lead to 

inconsistencies in time frames, documentation, and data used for the 

strategic planning process. For those VAMCs in our review that 

developed strategies to operationalize VHA’s strategic goals and 

objectives, for example, almost all developed local strategies on a fiscalyear cycle, which aligns with VHA’s budgeting and strategic planning 

processes, but one VAMC developed strategies on a calendar-year cycle. 

Although there is no requirement for VAMCs to conduct strategic planning 

on a specific timeline, per leading practices for strategic planning, 

organizations should align their activities, core processes, and resources 

to ensure achievement of the agency’s objectives.30 In addition, per 

federal internal control standards, management should effectively 

 30See GAO/GGD-96-118.
Page 16 GAO-17-50 VHA Strategic Planning

communicate information throughout the organization, as the organization 

performs key activities in achieving the objectives of the organization.31

VHA has not developed adequate strategies or an effective oversight 

process to ensure VHA’s strategic goals and objectives are effectively 

operationalized. Specifically, VISNs and VAMCs lack consistently 

developed strategies for operationalizing VHA’s strategic goals and 

objectives, and existing performance assessments are limited in 

measuring progress towards meeting these goals and objectives.

Lack of consistently developed strategies. VHA has not 

consistently developed strategies for VISNs and VAMCs to use in 

operationalizing its strategic goals and objectives. Strategies should 

describe how a strategic plan’s goals and objectives are to be 

achieved, and should include a description of the operational 

processes, staff skills, use of technology, as well as the resources—

such as, human, capital, and information—required. Among other 

things, our previous work has shown that strategies should have 

clearly defined milestones, outline how an organization will hold 

managers and staff accountable for achieving its goals, and be linked 

to the day-to-day activities of the organization.32 In addition, individual 

strategies should be linked to a specific goal or objective. In 

September 2014, VHA published the Blueprint for Excellence to 

provide strategies for transforming VHA health care service delivery in 

response to concerns regarding the VHA wait-time crisis that year.33

However, VHA did not develop a similar document for the other 

strategic planning years despite the development of multiple strategic 

documents, such as the Under Secretary for Health’s five priorities.

Without developing adequate strategies to correspond to all of its 

strategic goals and objectives, the VISNs and VAMCs have limited 

guidance to help them operationalize VHA’s strategic goals and 

objectives. Moreover, the day-to-day activities and initiatives 

developed by VISNs and VAMCs may not appropriately align with 

 31See GAO-14-704G.

32See GAO/GGD-10.1.16, GAO/GGD-97-180, GAO-12-77, and GAO-13-174.

33See Department of Veterans Affairs, Veterans Health Administration, Blueprint for 

Excellence (Sept. 21, 2014). 

VHA Has Not Developed 

Adequate Strategies or an 

Effective Oversight 

Process to Ensure 

Operationalization of Its 

Strategic Goals and 

Objectives
Page 17 GAO-17-50 VHA Strategic Planning

those goals and objectives. A direct alignment between strategic 

goals and their associated strategies is important in assessing an 

organization’s ability to achieve those goals.

No process for ensuring and assessing progress in meeting all 

of VHA’s strategic goals and objectives. As our previous work has 

shown, assessments can provide feedback to an organization on how 

well day-to-day activities and programs developed to operationalize 

strategic goals and objectives contribute to the achievement of those 

goals and objectives. Specifically, formal assessments are to be 

objective and measure the results, impact, or effects of a program or 

policy, as well as the implementation and results of programs, 

operating policies, and practices; they can also help in determining 

the appropriateness of goals or the effectiveness of strategies. 34

However, VHA does not have effective oversight process for ensuring 

that VISNs and VAMCs are meeting all of its strategic goals and 

objectives.

According to VHA officials, there are currently two methods for 

assessing VHA’s performance towards meeting selected strategic 

goals and objectives. One method is VISN and VAMC directors’

individual annual performance plans. For FY 2016, these plans 

present VHA’s strategies for providing a successful health care 

delivery system, including those outlined in its Blueprint for 

Excellence. The directors’ plans include performance metrics, which 

VHA, as well as VISNs and VAMCs, can use to measure 

demonstrated progress of a VISN or VAMC in meeting these 

strategies. However, multiple strategic goals and objectives have 

been communicated to the field, such as the Under Secretary for 

Health’s five priorities, and it is not clear how these goals align with 

the strategies in the current directors’ performance plans or how 

progress towards them can be assessed. A VHA official, who is a 

member of the workgroup reviewing VHA’s performance metrics, told 

us that over the years, performance metrics were added to the 

director performance plans as problems or needs arose without 

considering the overall purpose of the metric. VHA officials reported 

that they have reviewed the current plans and have revised them. 

According to a VHA official, the new plans will have fewer metrics, 

and will be more strategically focused on VA’s and VHA’s strategic 

 34See GAO/GGD-10.1.16, and GAO/GGD-97-180.
Page 18 GAO-17-50 VHA Strategic Planning

priorities, such as the Under Secretary for Health’s five priorities.35

According to VHA officials, implementation is planned for October 1, 

2016. However, it is not clear how these metrics will be linked to the 

strategic goals and objectives in VHA’s current strategic plan.

Veterans’ satisfaction with VA’s health care system is the second 

method for assessing VHA’s performance towards meeting strategic 

goals and objectives, according to VHA officials. VHA currently 

collects information from a survey of veterans that addresses two of 

VA’s priority goals, including improving access to health care, as 

experienced by the veteran.36 According to VHA officials, for the 

veterans’ access goal, there is a large degree of alignment between 

the department-wide goal and how VHA measures its progress 

towards meeting some of its access goals and objectives in its 

strategic plan. However, it is not clear how VAMCs and VISNs are to 

use veterans’ satisfaction to assess progress toward meeting other 

goals and objectives that have been communicated to them—such as 

the Under Secretary for Health’s five priorities that are not focused on 

access. VHA officials told us that no additional VHA-level 

assessments had been conducted to measure progress towards 

meeting strategic goals and objectives. Though VHA has performance 

information from VISN and VAMC directors’ performance plans and 

veteran satisfaction surveys, the performance of the agency toward 

meeting VA’s and VHA’s other strategic goals and objectives may 

help provide a more complete picture of overall effectiveness.

In addition to a lack of adequate strategies and an effective oversight 

process, a large number of vacant, acting, and interim positions at some 

of the VISNs and VAMCs in our review have also created challenges for 

VHA in operationalizing its strategic goals and objectives. For example, 

officials from one VISN reported that acting and interim senior leadership 

positions within a facility in their region have had an effect on the 

operations of the VAMC, including the operationalization of VHA’s 

 35Per the VISN and VAMC director performance plan guidance, VHA leadership are to 

use appropriate performance measurement resources, operational indicators, and analytic 

tools, to continually monitor the broad range of operational, quality, safety, financial, and 

organizational health indicators that are necessary for a successful health care delivery 

system.

36The other priority goal is reducing the number of homeless veterans and is being 

addressed through collaboration with the Department of Housing and Urban Development, 

the Department of Labor, and the Veterans Benefits Administration. 
Page 19 GAO-17-50 VHA Strategic Planning

strategic goals and objectives. They added that the acting and interim 

senior leaders did not feel empowered to make long-term decisions 

regarding the operations of the medical center because they did not know 

how long they would hold the position. The Under Secretary for Health 

told us that one of VHA’s top priorities for 2016 is to fill 90 percent of 

VAMC director positions with permanent appointments by the end of the 

year. The Under Secretary added that filling these positions would help 

address the current gaps in leadership and provide stability for the 

VAMCs.37

As the demand for health care by our nation’s veterans increases, and 

concerns about VA’s health care system persist, it is essential that VHA 

conduct the necessary strategic planning to achieve its goals and 

objectives. VHA has established a strategic planning process to identify 

strategic goals and objectives for accomplishing its mission, and VISNs 

and VAMCs are expected to operationalize these goals and objectives. 

However, VHA has not delineated a role for VAMCs in this process as it 

has for VISNs. Moreover, the lack of adequate strategies to 

operationalize VHA’s strategic goals and objectives, as well as the lack of 

an effective oversight process for assessing progress, may hinder the 

achievement of VHA’s goals and objectives. Without consistently 

developed strategies, the day-to-day activities and initiatives that are 

developed to operationalize VHA’s strategic goals and objectives may not 

appropriately align with those goals and objectives. This may result in 

VHA not being able to determine if it is adequately addressing top 

management concerns or department-wide strategic goals. Further, 

because VHA does not have an effective process to assess progress in 

meeting its strategic goals and objectives, it does not have needed

information on how well the day-to-day activities and programs of VISNs 

and VAMCs are contributing to their achievement.

 37As of August 16, 2016, there were 124 out of 140 (89 percent) VAMC director positions 

currently filled within VHA. VHA recently launched a national recruitment announcement to 

fill the remaining 16 director positions.

Conclusions
Page 20 GAO-17-50 VHA Strategic Planning

We recommend that the Secretary of Veterans Affairs direct the Under 

Secretary for Health to take the following three actions:

1. Define the roles and responsibilities of VAMCs in operationalizing 

VHA’s strategic goals and objectives; this could be accomplished by 

establishing roles and responsibilities for VAMCs similar to how VHA 

defines roles and responsibilities for VISNs in VHA Directive 1075 and 

by developing guidance for VAMCs similar to guidance developed for 

VISNs.

2. Consistently develop strategies that can be used by VISNs and 

VAMCs to operationalize VHA’s goals and objectives, ensuring that 

they clearly link directly to VHA’s goals and objectives.

3. Develop an oversight process to assess progress made in meeting 

VHA’s strategic goals and objectives, including feedback on how well 

activities and programs are contributing to achieving these goals and 

objectives.

We provided VA with a draft of this report for its review and comment. In 

its written comments, reproduced in appendix II, VA concurred with our 

three recommendations, and described the actions it is taking to 

implement them by September 2017. VA described the role that 

community-based outpatient clinics and health care centers play as 

critical health care access points for veterans and commented that our 

draft report does not mention these access points as components of 

VAMC service delivery systems. While our report draft noted the role of 

community-based outpatient clinics and health care centers in VA’s 

service delivery system, we clarified that these facilities are components 

of VAMCs. VA also commented that our report draft does not mention the 

essential role that VHA program offices play in contributing to and 

implementing the VHA strategic plan. Our report states that program 

offices contribute to VHA’s strategic planning process by developing 

some of the programs and actions that VISNs and VAMCs use to provide 

health care services to veterans. VA also provided technical comments, 

which we incorporated as appropriate.

As agreed with your office, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies of this report to appropriate 

congressional committees, the Secretary of Veterans Affairs, the Under 

Secretary for Health, and other interested parties. In addition, the report 

will be available at no charge on the GAO website at http://www.gao.gov.

Recommendations for 

Executive Action

Agency Comments

and Our Evaluation
Page 21 GAO-17-50 VHA Strategic Planning

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices 

of Congressional Relations and Public Affairs may be found on the last 

page of this report. GAO staff who made key contributions to this report 

are listed in appendix III.

Debra A. Draper

Director, Health Care
Appendix I: VHA Strategic Plan FY 2013 – 2018

Page 22 GAO-17-50 VHA Strategic Planning

Appendix I: VHA Strategic Plan FY 2013 –

2018
Appendix I: VHA Strategic Plan FY 2013 – 2018

Page 23 GAO-17-50 VHA Strategic Planning
Appendix I: VHA Strategic Plan FY 2013 – 2018

Page 24 GAO-17-50 VHA Strategic Planning

Source: VHA I GAO-17-50
Appendix II: Comments from the Department 

of Veterans Affairs

Page 25 GAO-17-50 VHA Strategic Planning

Appendix II: Comments from the Department 

of Veterans Affairs
Appendix II: Comments from the Department 

of Veterans Affairs

Page 26 GAO-17-50 VHA Strategic Planning
Appendix II: Comments from the Department 

of Veterans Affairs

Page 27 GAO-17-50 VHA Strategic Planning
Appendix II: Comments from the Department 

of Veterans Affairs

Page 28 GAO-17-50 VHA Strategic Planning
Appendix II: Comments from the Department 

of Veterans Affairs

Page 29 GAO-17-50 VHA Strategic Planning
Appendix II: Comments from the Department 

of Veterans Affairs

Page 30 GAO-17-50 VHA Strategic Planning
Appendix II: Comments from the Department 

of Veterans Affairs

Page 31 GAO-17-50 VHA Strategic Planning
Appendix III: GAO Contact and Staff 

Acknowledgments

Page 32 GAO-17-50 VHA Strategic Planning

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

In addition to the contact named above, Janina Austin, Assistant Director; 

Kelli A. Jones, Analyst-in-Charge; Jennie Apter; and LaKendra Beard

made key contributions to this report. Also contributing were George 

Bogart, Christine Davis, Jacquelyn Hamilton, and Vikki Porter.

Appendix III: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(100348)
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