VA HEALTH CARE

Improved Monitoring 

Needed for Effective 

Oversight of Care for 

Women Veterans

Report to Congressional Requesters

December 2016

GAO-17-52

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-17-52, a report to 

congressional requesters

December 2016

VA HEALTH CARE

Improved Monitoring Needed for Effective 

Oversight of Care for Women Veterans

What GAO Found

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

does not have accurate and complete data on the extent to which its medical 

centers comply with environment of care standards for women veterans. VHA 

policy requires its medical facilities, including VA medical centers, to meet 

environment of care standards related to the privacy, safety, and dignity of 

women veterans. VHA Central Office relies on medical centers to conduct regular

inspections and to report instances of noncompliance, which are compiled in a

VHA database. However, almost all the noncompliance GAO identified through 

inspections at six VA medical centers it visited had not been reported or recorded 

in the VHA database, and compliance rates ranged from 65 percent to 81 

percent. For example, GAO found a lack of auditory privacy at check-in clerk 

stations and a lack of privacy curtains in examination rooms, as required by VHA 

policy. GAO also found weaknesses in VHA’s oversight of the environment of 

care for women, including a lack of thorough inspections and limited verification 

of facility-reported data which results in inaccurate and incomplete data. As a

result, the privacy, safety, and dignity of women veterans may not be guaranteed 

when they receive care at VA facilities. Federal internal control standards for 

monitoring call for management to establish activities to monitor the quality of 

performance over time and promptly resolve any identified issues.

GAO’s analysis of VHA data shows that nationally the number of VHA full-timeemployee equivalent gynecologists and the number of women’s health primary 

care providers—VHA primary care providers specially trained in women’s health

care services, such as breast exams—increased by 3 percent and 15 percent 

respectively, from fiscal year 2014 through fiscal year 2015, and those 

percentages exceeded the 1 percent growth in women veteran enrollment during 

the same period. However, about 27 percent of VA medical centers and health 

care systems lacked an onsite gynecologist and about 18 percent of VA facilities

providing primary care lacked a women’s health primary care provider, according 

to VHA data. VHA officials said not all facilities require onsite gynecologists and 

facilities may authorize gynecological services from non-VA providers. They

acknowledged a shortage of at least 675 women’s health primary care providers 

and have a plan to train at least 535 providers by the end of fiscal year 2016.

The Veterans Choice Program (Choice) is a primary option for veterans to 

receive care from non-VA providers in the community if care cannot be provided 

at VA facilities. While the number of obstetricians and gynecologists under 

Choice has increased, some areas lack these providers, according to a VHA 

analysis. While VHA monitors access-related Choice performance measures 

(such as timely appointment scheduling) for all veterans, it does not have such 

measures for women veterans’ sex-specific care, such as mammography, 

maternity care, or gynecology. VHA’s data show poor performance on accessrelated performance measures for all veterans, and GAO found cases where 

women veterans’ maternity care was significantly delayed, suggesting that 

veterans, including women, face challenges receiving timely access to care. 

Federal internal control standards for monitoring call for management to establish 

activities to monitor the quality of performance over time and promptly resolve 

any identified issues.

View GAO-17-52. For more information, 

contact Randall B. Williamson at (202) 512-

7114 or williamsonr@gao.gov

Why GAO Did This Study

In 2010, GAO found a number of 

weaknesses related to care for 

women veterans at VA medical 

facilities. GAO was asked to update 

that study. This report examines (1) 

the extent that VA medical centers

complied with requirements related to 

the environment of care for women 

veterans and VHA’s oversight of that 

compliance; (2) what is known about 

the availability of VHA medical 

providers who can provide sexspecific care for women veterans at 

VA facilities; and (3) VHA’s efforts to 

provide and monitor access to sexspecific care for women veterans 

through Choice. To do this work, GAO 

reviewed VHA data on environment of 

care deficiencies; the number, 

location, and availability of VHA and 

Choice medical providers; women 

veteran enrollment; and Choice

access-related performance 

measures. In addition, GAO inspected 

the environment of care for 

compliance with VHA policy at a 

nongeneralizable sample of six VA 

medical centers, which were selected 

to achieve variation in different care 

models, the size of the women 

veterans’ population, and 

geographical locations. GAO also 

interviewed VHA Central Office and 

VA medical center officials.

What GAO Recommends

GAO recommends that VA (1) 

strengthen the policies and guidance 

for its environment of care inspection 

process and (2) monitor women 

veterans’ access to sex-specific care 

under current and future community 

care contracts. VA concurred with 

GAO’s recommendations.
Page i GAO-17-52 VA Women Veterans’ Health Care

Letter 1

Background 6

VHA Lacks Complete and Accurate Data on VAMC Compliance 

with Environment of Care Requirements for Women Veterans 

and Does Not Consistently Identify or Address Noncompliance 11

While the Number of VHA Gynecologists and Women’s Health 

Primary Care Providers Has Increased Overall, Availability Was 

Limited in Some Locations 20

While the Number of Obstetricians and Gynecologists 

Participating in Choice Networks Has Increased, VHA Does Not 

Have Performance Measures for Monitoring Access to SexSpecific Care under Choice 25

Conclusions 31

Recommendations for Executive Action 32

Agency Comments 32

Appendix I Comments from the Department of Veterans Affairs 35

Appendix II Veterans Health Administration (VHA) Environment of Care 

Requirements Inspected by GAO 38

Appendix III Veterans Affairs Medical Center (VAMC) Compliance with 

Environment of Care Requirements 40

Appendix IV Veterans Health Administration (VHA) Gynecologist Availability 44

Appendix V Veterans Affairs (VA) Clinics Without a Women’s Health Primary Care 

Provider 45

Appendix VI GAO Contact and Staff Acknowledgments 46

Contents
Page ii GAO-17-52 VA Women Veterans’ Health Care

Tables

Table 1: Compliance Rates with Selected Veterans Health 

Administration Environment of Care Requirements across 

Six Veterans Affairs Medical Centers (VAMC), December 

2015 – March 2016 13

Table 2: Veterans Choice Program Third-Party Administrator 

(TPA) Average Monthly Performance on Select Veterans 

Health Administration (VHA) Access-Related Performance 

Measures, August 2015-May 2016 29

Table 3: Selected VHA Environment of Care Requirements 

Inspected by GAO for Compliance, 2015-2016 38

Table 4: Selected VAMC Compliance with Selected Veterans 

Health Administration (VHA) Requirements Related to the 

Outpatient Environment of Care for Women Veterans, 

December 2015-March 2016 40

Table 5: Selected VAMC Compliance with Selected VHA 

Requirements Related to the Inpatient Environment of 

Care for Women Veterans, December 2015-March 2016 42

Table 6: Selected VAMC Compliance with Selected VHA 

Requirements Related to the Residential Treatment 

Program Environment of Care for Women Veterans, 

December 2015-March 2016 43

Table 7: VHA Gynecologist Clinical Care Full-Time-Employee 

Equivalent (FTEE) per 1,000 Women Veteran Enrollees 

and Completed Gynecology Appointments, Nationally and 

by Veterans Integrated Service Network (VISN), Fiscal 

Years 2014 and 2015 44

Table 8: Number and Percentage of VA Community-Based 

Outpatient Clinics that Provide Primary Care Lacking a 

Women’s Health Primary Care Provider and Women 

Veteran Enrollment, Nationally and by Veterans 

Integrated Service Network (VISN), Fiscal Year 2015 45

Figures

Figure 1: Outpatient Compliance Rates of Six Veterans Affairs 

Medical Centers (VAMC) with Selected Environment of 

Care Requirements for Women Veterans, December 

2015-March 2016 14

Figure 2: Examples of Examination Rooms For Women Veterans 

at Department of Veterans Affairs Medical Centers 

(VAMC) 16
Page iii GAO-17-52 VA Women Veterans’ Health Care

Figure 3: Location and Concentration of Veterans Choice Program 

(Choice) Obstetricians and Gynecologists as of May 2016 

and Department of Veterans (VA) Locations Providing 

Gynecology as of September 2015, Veterans Integrated 

Service Network (VISN) 19 27

Abbreviations

Choice Veterans Choice Program

FTEE full-time employee equivalent

PC3 Patient-Centered Community Care

TPA third party administrator

VA Department of Veterans Affairs

VAMC Veterans Affairs medical center

VHA Veterans Health Administration

VISN Veterans Integrated Service Network

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Page 1 GAO-17-52 VA Women Veterans’ Health Care

441 G St. N.W.

Washington, DC 20548

December 2, 2016

Congressional Requesters

According to the Department of Veterans Affairs (VA), women are the 

fastest growing subpopulation of veterans. According to VA officials, in 

2016, almost 10 percent of the total veteran population is female—over 2 

million women—and by 2020, VA estimates that this proportion will rise to 

almost 11 percent.1 Women veterans seeking care through VA’s national 

health care system, which is operated by the Veterans Health 

Administration (VHA), are eligible to receive a full range of health care 

services—including services specific to their sex, such as breast 

examinations, cervical cancer screenings and treatment, and obstetric 

care. When these and other services are not available at VA medical 

facilities—including health care systems, VA medical centers (VAMC), 

and community-based outpatient clinics—or within required driving 

distances or time frames, VA may purchase care from non-VA providers 

through its care in the community programs, such as the Veterans Choice 

Program (Choice).2

Given the growth in the number of women veterans, in 2010 we examined 

the availability of VHA health care services for women.3 We found 

variation in the types of sex-specific health care services available to 

women veterans at VA medical facilities.4 We also found that none of the 

 1

As of January 1, 2016, all positions and occupations in the armed forces are open to 

women, including previously closed combat positions, which could contribute to the 

increase in the women veteran population. See GAO, Military Personnel: DOD Is 

Expanding Combat Service Opportunities for Women, but Should Monitor Long-Term 

Integration Process, GAO-15-589 (Washington, D.C.: July 20, 2015). 

2

VA health care systems are made up of multiple VAMCs. Established under the Veterans 

Access, Choice, and Accountability Act of 2014, Choice authorizes care for eligible 

veterans through eligible non-VA providers under certain circumstances. Pub. L. No. 113-

146, § 101, 128 Stat. 1754, 1755-65 (2014).

3

See GAO, VA Health Care: VA Has Taken Steps to Make Services Available to Women 

Veterans, but Needs to Revise Key Policies and Improve Oversight Processes, 

GAO-10-287 (Washington, D.C.: March 31, 2010). We provided preliminary findings in 

2009; see GAO, VA Health Care: Preliminary Findings on VA’s Provision of Health Care 

Services to Women Veterans, GAO-09-884T (Washington, D.C.: July 14, 2009) and VA 

Health Care: Preliminary Findings on VA’s Provision of Health Care Services to Women 

Veterans, GAO-09-899T (Washington, D.C.: July 16, 2009). 

4

For example, while all VAMCs visited offered the full range of basic sex-specific services 

for women, some VA community-based outpatient clinics did not.

Letter
Page 2 GAO-17-52 VA Women Veterans’ Health Care

19 VA medical facilities we visited were in compliance with VHA’s policies 

that govern the environment of care for women veterans.5 These VHA 

policies require all VA medical facilities to adhere to certain standards 

intended to ensure women’s privacy, safety, and dignity when they 

receive care. The standards relate to, for example, ensuring auditory 

privacy at check-in and in interview areas, the location of exam rooms, 

and the presence of privacy curtains in exam and inpatient rooms.6

In our 2010 report, we recommended that VA take several steps to 

strengthen VHA’s provision and oversight of services for women 

veterans. VA agreed with our recommendations and has made progress 

in addressing issues raised. For example, VHA introduced a policy in 

2010 requiring that all women veterans treated at VA medical facilities 

have access to a primary care provider specially trained in women’s 

health care services, known as a women’s health primary care provider. 

However, there are still concerns that VHA may not be fully meeting the 

health care needs of women veterans. For example, a Congressional 

hearing in April 2015 raised concerns about gaps in the services available 

for women veterans in VA medical facilities.7 In addition, we and others 

have expressed significant concerns about VHA’s management of its 

health care system, including VHA’s ability to effectively provide timely 

access to health care for veterans. In 2014, a series of events called into 

question the ability of veterans to gain timely access to care from VHA 

medical facilities. As a result of these and other systemic problems, we 

concluded that VA health care is a high-risk area and added it to our High 

Risk List in 2015.8

 5

The environment of care refers to the setting in which patients receive health care 

services. According to VHA Directive 1608, Comprehensive Environment of Care 

Program, VA medical facilities must provide a safe, clean, functional, and high quality 

environment for veterans, their families, visitors, and employees. 

6

The scope of services VHA requires to be provided to women veterans, including 46 

requirements for the environment of care to ensure the privacy, safety, and dignity of 

women veterans, is outlined in a VHA handbook. See Department of Veterans Affairs, 

Health Care Services for Women Veterans, VHA Handbook 1330.01 (Washington, D.C.: 

May 21, 2010).

7

See Examining Access and Quality of Care and Services for Women Veterans: Hearing 

before the H. Comm. on Veterans’ Affairs, 114th Cong. (2015).

8

See GAO, High Risk Series: An Update, GAO-15-290 (Washington, D.C.: Feb. 11, 2015). 
Page 3 GAO-17-52 VA Women Veterans’ Health Care

We were asked to follow-up on our 2010 report and assess VA’s progress 

in providing a full range of health care services for women veterans. This 

report examines:

1. the extent to which VAMCs complied with requirements related to the 

environment of care for women veterans, and VHA’s oversight of 

medical facilities’ compliance with these requirements;

2. what is known about the availability of VHA medical providers who 

can provide sex-specific care for women veterans at VA medical 

facilities; and,

3. VHA’s efforts to provide and monitor access to sex-specific care for 

women veterans through Choice.

To examine the extent to which VAMCs comply with requirements related 

to the environment of care for women veterans, we reviewed VHA Central 

Office’s database of VAMC self-reported instances of noncompliance in 

the environment of care for six selected VAMCs for fiscal years 2015 and 

2016. We selected VAMCs located in Baltimore and Perry Point, 

Maryland; Gainesville and Lake City, Florida; Cincinnati, Ohio; and 

Cheyenne, Wyoming.

9 We chose these sites to represent different 

models of care for women veterans, diverse regions of the country, urban 

and rural locations, and a range in the percentage of the state population 

made up by women veterans.10 For these selected VAMCs, we 

conducted site visits to inspect the environment of care in waiting areas 

as well as in procedure and examination areas across various outpatient, 

inpatient, and residential treatment units where women veterans can 

 9

We limited our review to VAMCs because the VA Office of the Inspector General has 

been conducting similar inspections of women’s health programs, including the 

environment of care, at VA community-based outpatient clinics. According to an official, 

the clinics that the VA Office of the Inspector General evaluates each year represent a 

randomized, generalizable sample, and 78 percent of the 93 clinics the VA Office of the 

Inspector General evaluated in fiscal year 2014 provided adequate privacy for women 

veterans.

10In accordance with VHA Handbook 1330.01, Health Care Services for Women Veterans, 

a VA facility may choose one or more of three primary care clinic models to meet the 

needs of women veterans. In one model, women veterans are seen by a women’s health 

primary care provider within a sex-neutral primary care clinic. In a second model, primary 

care services for women veterans are offered by women’s health primary care providers in 

a separate but shared space that may be located within or adjacent to mixed-sex primary 

care clinic areas. In a third model, primary care services are provided by a women’s health 

primary care provider in an exclusive and separate space, including a separate entrance 

into the clinical area and a separate waiting room.
Page 4 GAO-17-52 VA Women Veterans’ Health Care

receive health care services.11 We developed a standardized data 

collection instrument containing the VHA environment of care 

requirements we reviewed during our inspections to determine whether 

each requirement in every applicable setting was in compliance.12 The 

findings of our site visits cannot be generalized to other VAMCs. To 

examine VHA’s oversight of medical facilities’ compliance with 

requirements related to the environment of care for women veterans, we 

reviewed VHA policies on the environment of care rounds process and 

related internal inspections. We also reviewed the findings from 

contracted evaluations of women’s health programs at VA medical 

facilities.13 Finally, we interviewed officials from the VHA administrative 

office that oversees compliance in the environment of care at VA medical 

facilities and from the selected VAMCs about VHA oversight and the 

implementation of environment of care policies. We examined this 

evidence in the context of federal internal control standards for monitoring 

and control environment.14

To examine what is known about the availability of VHA medical providers 

who can provide sex-specific care for women veterans, we analyzed 

available VHA data on the number, location, and the availability of 

women’s health primary care providers and gynecologists in fiscal years 

2014 and 2015. We also reviewed VHA data on women veteran 

 11Outpatient clinics are health care settings in which patients receive services without 

being admitted overnight, such as a primary care clinic. Inpatient units are health care 

settings in which patients are admitted and require at least one overnight stay. Residential 

treatment programs provide rehabilitative and clinical care to veterans for a wide range of 

illnesses or rehabilitative care needs which may include mental health and substance use 

disorders, co-occurring medical conditions, and psychosocial needs. The care through 

these residential treatment programs is provided 24 hours a day, 7 days a week.

12See Appendix II for a list of the requirements we reviewed, which were a part of the data 

collection instrument. We selected a subset of 33 requirements from VHA Handbook 

1330.01 Health Care Services for Women Veterans to ensure that there were no 

redundancies in our reporting and that we were reporting observations that we could 

verify. We inspected for 20 requirements in outpatient clinics, 6 requirements in inpatient 

units, and 7 requirements in residential treatment units.

13In fiscal year 2010, VHA Central Office contracted with Booz Allen Hamilton to conduct 

comprehensive independent evaluations of the women’s health programs at all VAMCs 

and VA health care systems over 5 years. In fiscal year 2014, Atlas Research became the 

lead contractor, with Booz Allen Hamilton as the subcontractor.

14See 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 5 GAO-17-52 VA Women Veterans’ Health Care

enrollment and the number of completed VA women’s health and 

gynecology appointments for fiscal years 2014 and 2015. We assessed 

the reliability of the data sources by reviewing relevant documentation, 

interviewing knowledgeable agency officials, or reviewing the data for 

missing values and outliers. Through these steps, we determined that the 

data were sufficiently reliable for the purposes of this reporting objective. 

In addition, we interviewed VHA Central Office and medical facility 

officials involved in coordinating and providing health care to women 

veterans, including women veterans program managers and clinicians at 

the six VAMCs we visited.

To examine VHA’s efforts to provide and monitor access to sex-specific 

care for women veterans through Choice, we reviewed VHA data on the 

number of obstetricians and gynecologists in Choice networks from May 

2015 through May 2016. We also reviewed the results of a 2016 VHA 

study analyzing the number and location of Choice obstetricians and 

gynecologists in Veterans Integrated Service Networks (VISN) 10 and 19 

as of May 2016 and the VA medical facilities where gynecology is 

available in those VISNs.15 For these two VISNs, we compared the 

reported number and location of Choice obstetricians and gynecologists 

in May 2016 with the number of non-VA community providers that VA 

medical facilities in these VISNs sent women veterans to for obstetrics or 

gynecology services in fiscal year 2014, prior to the introduction of Choice 

in November 2014.16 We focused on VISNs 10 and 19 because, as a part 

of this study, we conducted site visits to VAMCs in these VISNs, located 

in Cincinnati, Ohio and Cheyenne, Wyoming.17 In addition, these VISNs 

 15Carey, Evan; Paula Langner and Michael Ho. “VACA Spatial Evaluation of Specialty 

Care Relevant To Female Veterans: Quantitative Results (Version 2, updated 5/16/2016).” 

VISNs are regional networks containing individual VAMCs or groups of VAMCs, known as 

health care systems. VISNs oversee the day-to-day functions of VA medical facilities 

within their boundaries. 

16We counted the number of providers that VA medical facilities disbursed payments to in 

fiscal year 2014 for obstetrics or gynecology care and used this as a proxy for availability 

of these services in the community.

17VA is currently in the process of reorganizing its VISNs. When we refer to VISNs 10 and 

19 in this report, the boundaries of those VISNs as of fiscal year 2015 apply. In fiscal year 

2015, VISN 10 included most of Ohio and parts of Indiana and Kentucky, and VISN 19 

included most of Montana, Wyoming, Colorado; Utah; and parts of Idaho, Nevada, North 

Dakota, Nebraska, and Kansas. By the end of fiscal year 2018, VISN 10 is expected to 

contain most of Ohio and Indiana; Michigan; and a small portion of Kentucky; VISN 19 is 

expected to contain most of Montana, Wyoming, Colorado, and Oklahoma; Utah; and 

parts of Idaho, Nevada, Nebraska, and Kansas. 
Page 6 GAO-17-52 VA Women Veterans’ Health Care

allow for comparisons of urban and rural areas. We also reviewed VHA 

data on women veteran enrollment in 2014 and 2016 and third-party 

administrator (TPA) performance data on Choice access to care and 

network adequacy from August 2015 through May 2016.18 In addition, for 

illustrative purposes, we identified three examples of sex-specific care 

obtained by women veterans under Choice from a review of veteran 

medical records associated with an ongoing GAO study examining the 

implementation of Choice.19 We assessed the reliability of these data 

sources by reviewing relevant documentation, interviewing 

knowledgeable agency officials or reviewing the data for missing values 

and outliers. Through these steps, we determined that the data were 

sufficiently reliable for the purposes of this reporting objective. We also 

interviewed VHA officials responsible for monitoring Choice and officials 

from the TPAs. We examined this evidence in the context of federal 

internal control standards for monitoring.20

We conducted our performance audit from October 2015 to December

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.

VA’s national health care system is one of the largest in the United States 

and provides enrolled veterans—including women veterans—with a full 

range of services including primary care, mental health care, inpatient 

care, and residential treatment. VA’s national health care system is 

 18To implement Choice, VA modified contracts it had previously awarded to two TPAs to 

develop regional networks of community providers. These providers agree to treat 

veterans based on set payment rates and the terms of the agreement made between the 

provider and the TPA. The TPAs responsible for administering Choice are Health Net 

Federal Services and TriWest Healthcare Alliance. VA’s performance data show the 

extent to which the TPAs met the performance standards associated with access to care 

and network adequacy measures.

19As a part of our ongoing review of Choice implementation, we are examining the extent 

to which veterans are able to access health care services through Choice within required 

time frames. We are reviewing records maintained by VHA and the TPAs for a random, 

nongeneralizable sample of 196 Choice authorizations for care between January and April 

2016.

20See GAO-14-704G. 

Background
Page 7 GAO-17-52 VA Women Veterans’ Health Care

organized into regionally organized VISNs containing individual VAMCs 

and health care systems made up of multiple VAMCs. In addition, VAMCs 

operate VA community-based outpatient clinics that provide basic primary 

care services on site. VHA is responsible for oversight of the provision of 

health care at all VA medical facilities.

Through its medical facilities, VA provides a wide range of sex-specific 

health care services to women veterans. Basic women’s primary care 

services are typically provided by women’s health primary care providers 

who are trained in providing sex-specific primary care to women 

veterans.21 Women’s health primary care providers must maintain clinical 

competency through ongoing education and training and by having a 

certain percentage of women veterans on their patient panel.22 Sexspecific primary care for women veterans includes breast examinations, 

cervical cancer screenings, management of contraceptive medications, 

and menopause management. More specialized sex-specific care for 

women is typically provided by a gynecologist. Services provided by a 

VHA gynecologist include treatment of menstrual disorders, fertility 

assessments, treatment of gynecological malignancies, and performance 

of gynecological procedures such as colposcopy.

 21In 2010, VHA introduced a policy requiring that all women veterans treated at VA 

medical facilities have access to a women’s health primary care provider. Typically, newly 

enrolled veterans are automatically assigned to women’s health primary care providers

unless they prefer to be assigned to a different primary care provider for a reason such as 

earlier scheduling availability. Women veterans enrolled in VA health care prior to 2010 

may choose to remain with their longstanding primary care provider or ask to switch to a 

women’s health primary care provider.

22A panel is a group of patients assigned to a given VHA provider, who is responsible for 

supervising the patients’ care. According to VHA policy, the panel of a women’s health 

primary care provider should have at least 10 percent women. VHA has established a 

baseline panel size of 1,200 patients for its primary care physicians. Nurse practitioners 

and physician assistants are generally assigned a panel of patients that is 75 percent of 

the physician panel size. To account for the unique needs of women veterans during 

appointments, VHA recommends that women’s health primary care providers’ panels be 

reduced by the number of unique patients equal to 20 percent of the total number of 

women veterans in the panel. For more information about VHA’s use of panel sizes to 

manage its primary care workload, see GAO, VA Primary Care: Improved Oversight 

Needed to Better Ensure Timely Access and Efficient Delivery of Care, GAO-16-83 

(Washington, D.C.: Oct. 8, 2015). 

Women’s Health Care at 

VA Medical Facilities
Page 8 GAO-17-52 VA Women Veterans’ Health Care

VHA requires all facilities to follow certain standards related to the 

environment of care in accordance with agency policy and Joint 

Commission standards.23 VHA policies specify privacy, dignity, sense of 

security, and safety considerations that all clinical spaces in VA medical 

facilities must meet.

To ensure compliance with environment of care standards, VHA directs 

VAMCs to conduct weekly inspections of the facility (known as 

environment of care rounds), and all patient care areas must be inspected 

twice every fiscal year.24 An environment of care rounds team made up of 

representatives from various facility departments—such as nursing, police 

service, and environmental management—is responsible for identifying 

any instances of noncompliance. The women veterans program 

manager—a staff person at each VAMC or health care system who is 

responsible for helping to coordinate services for women veterans—is a 

member of the environment of care rounds team and is responsible for 

ensuring compliance with requirements related to women veterans. The 

environment of care rounds coordinator is responsible for examining

rounds data and closing the inspection on an online tool, which then 

automatically sends a notification to the appropriate medical facility 

departments to address instances of noncompliance; this data then also 

becomes available to officials at VHA Central Office.25 According to VHA 

policy, noncompliance must be addressed within 14 days, including 

developing an action plan, if necessary. VHA Central Office maintains a 

database that contains all noncompliance reports and periodically follows 

up with facilities to check on the status of open reports.

If veterans cannot receive timely care within VA or need care that a VA 

medical facility cannot provide, VHA is authorized to purchase care for 

veterans from non-VA providers, known as VA care in the community. 

Non-VA care is frequently used for women veterans because some VA 

 23The Joint Commission is an independent, not-for-profit organization that accredits and 

certifies nearly 21,000 health care organizations and programs in the United States. It is 

the nation’s oldest and largest standards-setting and accrediting body in health care, and 

it is governed by a 32-member board that includes physicians, administrators, nurses, 

employers, quality experts, a consumer advocate, and educators. 

24Department of Veterans Affairs, Environment of Care (EOC) Assessment and 

Compliance Rounding Process Guide, Version 0.7 (August 3, 2014).

25Some VAMCs record inspection information on handheld tablets with picture capabilities 

so instances of noncompliance may be documented.

Environment of Care at VA 

Medical Facilities

VA Care in the Community 

Programs
Page 9 GAO-17-52 VA Women Veterans’ Health Care

medical facilities do not offer certain types of sex-specific health care, 

such as mammography or maternity care.26 According to VHA, based on 

fiscal year 2014 data—the latest available data at the time of our review—

women utilize more non-VA outpatient care than men. Veterans may be 

referred to a care in the community program by a VHA clinician, but VA 

medical facility staff must determine the veteran’s eligibility before 

authorization for care is granted. Current VA care in the community 

options include:

• Veterans Choice Program. Choice was established in November 

2014 under the Veterans Access, Choice, and Accountability Act of 

2014. According to VHA policy, it typically must be the first option 

considered for providing care in the community to veterans. According 

to VHA data from March 2016, the majority of care in the community

authorizations are for Choice.27 After a veteran is authorized for 

Choice, the TPA that administers the relevant Choice network is 

responsible for (1) contacting the veteran to determine whether she 

would like to receive Choice care, (2) identifying community providers 

in the TPA’s network who can meet the veteran’s needs and asking 

the veteran if she wants to see a specific provider, (3) scheduling an 

appointment, and (4) ensuring that the veteran’s appointment is within 

 26For example, a VA medical facility may not have sufficient demand for a provider to 

provide sex-specific services onsite. As of August 2016, according to VHA, 59 VA medical 

facilities provide mammography services, of which 56 provide diagnostic mammography. 

In addition, as of August 2016, two VA health care systems offer prenatal care. However, 

no VA medical facilities provide obstetrical care, that is, care related to the delivery of 

babies.

27Certain categories of care are not provided through Choice, such as dental care, chronic 

dialysis treatments, long-term care, and hospice care, and may be provided through other 

community care arrangements. A veteran is eligible for Choice care if he or she is enrolled 

in the VA health care system and any of the following apply: the veteran attempts, or has 

attempted, to schedule an appointment with a VHA provider, but VHA is unable to 

schedule an appointment within 30 days from the veteran’s preferred date or the date 

such care or services are deemed clinically necessary, if such period is shorter; the 

veteran lives more than 40 miles driving distance from the nearest VA facility with a fulltime primary care physician; the veteran lives in a state or territory without a full-service 

VA medical facility and resides more than 20 miles from such a facility; the veteran resides 

in a location other than one in Guam, American Samoa, or the Republic of the Philippines, 

and must travel by air, boat, or ferry to the VA facility that is closest to his or her home; the 

veteran faces an unusual or excessive burden in traveling to a VA facility based on 

geographical challenges, environmental factors, or a medical condition that affects the 

ability to travel; or other factors as determined by the Secretary of VA, such as the nature 

or simplicity of the care required, the frequency that such care is needed, or the need for 

the veteran to travel with an attendant.
Page 10 GAO-17-52 VA Women Veterans’ Health Care

specified time frames.28 Specifically, after the TPAs have confirmed 

veterans would like to receive Choice care, the TPAs are contractually 

required to, among other things:

• schedule appointments within 5 business days (for routine care) 

from the time the veteran agrees to participate in Choice or within 

2 business days (for urgent care) of accepting the authorization 

from the referring VA medical facility;

• ensure that veterans receive care within 30 days of scheduling an 

appointment for routine care or within 2 business days (for urgent 

care) of accepting the authorization from the referring VA medical 

facility;29

• return authorizations to the referring VA medical facility when 

appointments cannot be scheduled within required time frames; 

and

• track the number of authorizations for which they did not schedule 

appointments for veterans and the reasons why.

• Patient-Centered Community Care (PC3). In September 2013, VHA 

awarded contracts to two TPAs to develop regional networks of 

community providers of specialty care, mental health care, limited 

emergency care, and maternity and limited newborn care when such 

care is not feasibly available from a VA medical facility. VHA and the 

TPAs began implementing the PC3 program in October 2013, and it 

was fully implemented nationwide as of April 2014. In August 2014, 

VHA expanded the PC3 program to allow community providers of 

primary care to join the networks. PC3 is a program VHA created 

 28In addition, after the completion of each episode of Choice care, the TPAs must obtain 

medical documentation from the veteran’s community provider and return it to VA so that 

the documentation can be added to the veteran’s VHA electronic health record for care 

coordination purposes. 

29The TPAs’ contracts permit routine Choice appointments to take place outside this 30-

calendar-day time frame if VA documented that the veteran’s preferred date (that is, the 

date the veteran wants to be seen) was outside the 30-day time frame. Additional 

exceptions exist for (1) veterans who were referred to Choice because the next available 

appointment with a VA provider was more than 30 days from the clinically indicated date 

or the veteran’s preferred date, and (2) veterans who live more than 40 miles driving 

distance from a VA facility with a full-time primary care physician. For the veterans who 

are referred to Choice due to wait times for appointments with VA providers, the TPAs 

must ensure that Choice appointments for routine care take place within 30 calendar days 

of the clinically indicated date on the authorization VA sent. For the veterans who are 

referred to Choice due to the 40 mile driving distance, the TPAs must ensure that Choice 

appointments for routine care take place within 30 calendar days of the veteran’s 

preferred date.
Page 11 GAO-17-52 VA Women Veterans’ Health Care

under existing statutory authorities, not a program specifically enacted 

by law, like Choice. Currently, the two TPAs that administer PC3 also 

administer Choice. The regional networks built for PC3 provided a 

basis upon which the Choice networks were established.

• Individually authorized care. VA medical facilities may approve 

individual authorizations for care in the community from providers who 

agree to see VA patients. Historically, individually authorized care was 

the primary means by which VHA provided care in the community to 

veterans.

Choice is scheduled to expire in August 2017, or when appropriations for 

the program are expended, whichever occurs first. The upcoming 

expiration of Choice does not extend to VHA’s other care in the 

community programs, which VHA has proposed to consolidate into a 

single program.30

VHA Central Office lacks complete and accurate data on the extent to 

which VAMCs are in compliance with environment of care requirements. 

VHA relies on VAMC staff to self-report their facilities’ level of compliance 

with environment of care requirements; however, almost all of the 

noncompliance that we identified at the six VAMCs we visited was not 

reported to VHA Central Office. In addition, during site visits, we found 

that levels of compliance with VHA’s environment of care requirements 

for women veterans varied.

 30According to VA, VHA’s proposal to consolidate its community care programs will 

require congressional legislation in order to implement. 

VHA Lacks Complete 

and Accurate Data on 

VAMC Compliance 

with Environment of 

Care Requirements 

for Women Veterans 

and Does Not 

Consistently Identify 

or Address 

Noncompliance
Page 12 GAO-17-52 VA Women Veterans’ Health Care

VHA Central Office does not have complete and accurate information on 

VAMCs’ compliance with the environment of care requirements for 

women veterans and, as discussed later, does not verify the data it 

receives from facilities. Based on our inspections, we observed 155 

instances of noncompliance at six VAMCs we visited, and almost all (152) 

of these instances had not been reported to VHA Central Office and 

entered into its database, according to our analysis of VHA data. For four 

of the VAMCs we visited, none of the instances of noncompliance we 

observed had been reported to VHA Central Office. Because VHA Central 

Office uses this database to track facility compliance, the accuracy of the 

data is vital for the agency to perform its oversight duties effectively.

Among the six VAMCs we visited, based on our inspections, we observed 

varying levels of compliance with selected VHA requirements related to 

the environment of care for women veterans, ranging from 65 percent to 

81 percent.31 Across all six VAMCs, outpatient clinics had lower rates of 

compliance than inpatient units and residential treatment programs. 

Specifically, outpatient clinics complied with 74 percent of selected VHA 

requirements related to the environment of care for women veterans; in 

comparison, inpatient units and residential programs across the six 

VAMCs each complied with 96 percent of selected VHA requirements. 

(See table 1.) The number of instances where requirements were 

applicable varies by facility, due to facility size and types of services

available. In addition, at the time of our inspections, circumstances may 

have precluded us from observing each requirement in every instance; for 

example, some exam rooms may have been occupied or some clinics 

were not open. VHA requires VAMCs to comply with its environment of 

care requirements in all instances where they are applicable. (See 

appendix III for VAMC compliance rates by each individual requirement

we inspected.)

 31While VHA policy requires 100 percent compliance, the rates of compliance among the 

six selected VAMCs we inspected between December 2015 and March 2016 were 

generally higher than the rates of compliance among the 19 VA medical facilities we 

reviewed in 2010. See Appendix II for a full list of selected VHA requirements that we 

inspected for compliance. None of the six VAMCs we visited for this review were included 

in the sample of sites we visited for our 2010 review. See GAO-10-287.

VHA Lacks Complete and 

Accurate Data on VAMC 

Compliance with 

Environment of Care 

Requirements for Women 

Veterans
Page 13 GAO-17-52 VA Women Veterans’ Health Care

Table 1: Compliance Rates with Selected Veterans Health Administration 

Environment of Care Requirements across Six Veterans Affairs Medical Centers

(VAMC), December 2015 – March 2016

Outpatient 

Clinics

Inpatient 

Units 

Residential 

Programs

Total number of 

requirements GAO 

inspected for compliance

567 81 48

Total number of 

requirements GAO found in 

compliance

417 78 46

Rate of compliance 74 percent 96 percent 96 percent

Source: GAO | GAO-17-52

Note: We collected this information using a data collection instrument during site visits to VAMCs 

from December 2015 through March 2016.

• Outpatient setting. Across the six selected VAMCs, rates of 

compliance with the selected outpatient environment of care 

requirements varied. Figure 1 shows how frequently each of the 

VAMCs was in compliance with the applicable environment of care 

requirements in the outpatient areas we reviewed.
Page 14 GAO-17-52 VA Women Veterans’ Health Care

Figure 1: Outpatient Compliance Rates of Six Veterans Affairs Medical Centers (VAMC) with Selected Environment of Care 

Requirements for Women Veterans, December 2015-March 2016

Notes: We collected this information using a data collection instrument during site visits to VAMCs

from December 2015 through March 2016. Not applicable indicates either that the requirement was 
Page 15 GAO-17-52 VA Women Veterans’ Health Care

not applicable to any units within the facility or that we were unable to observe the requirement in any 

of the facility units given the circumstances at the time of our inspection.

a

At the time of our inspections, circumstances in the clinic environment may have precluded us from 

observing this requirement in every applicable instance. For example, some exam rooms or 

restrooms may have been occupied by patients at the time of our inspection, or some clinics may only 

be open on certain days of the week and were closed at the time of our inspection.

Some common areas of noncompliance that we observed in outpatient 

clinics included the following:

• Lack of auditory privacy at check-in clerk station. VHA policy 

requires that check-in clerk stations must be positioned in a way 

that protects the privacy of patients who are checking in. However, 

over one-third (14 out of 40) of all check-in stations we observed 

across the selected VAMCs were located in such close proximity 

to the waiting room area that conversations between the patient 

and the check-in clerk could be heard by other patients. Only one 

of the six VAMCs we visited ensured adequate auditory privacy at 

the check-in clerk station in all outpatient clinical settings.

• Lack of auditory privacy in procedure and testing areas. VHA 

policy requires that patients be assured auditory privacy while they 

are in procedure and testing areas to help protect the 

confidentiality of their health conditions and treatments. However, 

in over one-third (11 out of 32) of all outpatient clinics in the 

selected VAMCs, we observed at least one examination room

from which conversations between a patient and provider could be 

heard from the hallway despite a closed door. Only one of the six 

VAMCs that we visited was fully compliant with VA’s requirement 

of auditory privacy in all procedure and testing areas.

• Privacy curtains not present in all examination rooms. VHA 

policy requires that all examination rooms be equipped with a 

privacy curtain. However, in over one-quarter (8 out of 28) of all 

outpatient clinics that we observed where this requirement was 

applicable, at least one examination room where women veterans 

could be asked to disrobe was missing a privacy curtain. 

Additionally, in many exam rooms where privacy curtains were 

present, the curtains were positioned in a way that did not 

adequately shield adjustable exam tables. Figure 2 (right) shows 

an example of an examination room we inspected that was 

missing a privacy curtain.32 In addition, the examination room 

 32The upper left hand corner of the figure shows the upper portion of the curtain, which 

connects to the ceiling track, but the bottom portion, which provides the layer of privacy for 

the patient, is not present.
Page 16 GAO-17-52 VA Women Veterans’ Health Care

featured an adjustable exam table placed with the foot facing the 

door. Both of these are inconsistent with VHA policy.

Figure 2: Examples of Examination Rooms For Women Veterans at Department of Veterans Affairs Medical Centers (VAMC)

Notes: We collected this information during site visits to VAMCs from December 2015 through March 

2016. For the incorrect example, the upper left hand corner of the figure shows the upper portion of 

the curtain, which connects to the ceiling track, but the bottom portion, which provides the layer of 

privacy for the patient, is not present.

• Sanitary products not available in all women’s restrooms.

According to VHA policy, sanitary napkins and tampons must be 

made available in all women’s restrooms. However, in over half 

(40 out of 69) of all women’s restrooms that we inspected across 

the six selected VAMCs, there were no sanitary napkins or 

tampons provided. One facility official stated that she places 

sanitary products only in the restrooms that are most frequently 

used by women, but this is inconsistent with VHA policy.

• Unrestricted access to examination and procedure areas.

According to VHA policy, access to clinic examination and 

procedure areas must be limited only to authorized clinic staff and 

patients with appointments. However, 38 percent (15 out of 39) of 

the examination and procedure areas that we observed across the 

selected VAMCs either had unlocked doors that allowed for 

unrestricted access or were adjacent to other unrestricted clinic 
Page 17 GAO-17-52 VA Women Veterans’ Health Care

hallways, potentially allowing non-clinic staff or individuals that are 

not patients into the exam area.

• Inpatient setting. The only instances of noncompliance that we 

observed in inpatient units were the following:

• Two out of the 12 units we visited did not have privacy curtains 

available in every examination room.

• While visiting one unit, we observed a staff member entering a

patient room without knocking.

• Residential treatment programs. The only instances of 

noncompliance that we observed in residential treatment programs 

were the following:

• One out of the seven programs we visited did not have 

appropriate private space for women veterans to visit with 

children.

• While visiting one program, we observed a staff member entering 

a patient room without knocking.

We found weaknesses in VHA’s oversight processes of the environment 

of care rounds and related policies. Specifically, we identified the 

following weaknesses:

• Environment of care rounds not always conducted in a thorough 

manner. VHA requires all patient care areas in a medical facility to be 

inspected twice per fiscal year. According to an official at one facility, 

when environment of care rounds are conducted at a time of day 

when care is being provided, the rounds team will not inspect 

examination rooms and other areas that are being used. As a result, 

the environment of care rounds team may not inspect every room in a 

facility twice per fiscal year, as required. Additionally, we found that 

the checklist—which was developed by an environment of care field 

advisory committee and is used across VAMCs to conduct the 

environment of care rounds—lists only 22 requirements for the 

environment of care, while VHA’s women’s health handbook contains 

46 requirements.33 For example, the checklist does not require 

inspection teams to examine whether clinical procedure and testing 

areas have auditory privacy. In our review of the six selected VAMCs, 

we found that all six exhibited noncompliance with women’s health 

 33VHA Handbook 1330.01, Health Care Services for Women Veterans. 

VHA’s Oversight 

Processes Do Not 

Consistently Identify or 

Address Noncompliance 

Due to Weaknesses in 

Environment of Care 

Rounds and Related 

Policies
Page 18 GAO-17-52 VA Women Veterans’ Health Care

handbook requirements that are not included on the environment of 

care rounds checklist.

• Responsibility for addressing noncompliance not always clear.

At three of the selected VAMCs we visited, facility staff were unable to 

identify the medical center department, such as engineering or 

building maintenance, responsible for correcting identified instances 

of noncompliance with certain environment of care policies. Without 

clearly delineated roles and responsibilities, instances of 

noncompliance are not addressed in a timely manner. For example, at 

one selected VAMC, we observed a privacy curtain missing from a 

primary care exam room. The provider who uses this room explained 

that she reported this noncompliance to the facility’s maintenance 

department but was told that the replacement of the curtain was not 

the responsibility of the maintenance department. When we spoke 

with the provider, it had been 6 months since she had reported the 

noncompliance, and the issue had still not been addressed. 

Furthermore, this instance of noncompliance was also among those 

that the VAMC had not reported to VHA Central Office.

• No systematic process to verify that medical facilities conduct 

thorough reviews and fully report noncompliance issues. VHA 

Central Office does not have a systematic process to independently 

verify the compliance information it receives from VAMCs. According 

to an agency official, VHA is largely dependent on the environment of 

care rounds coordinator at each facility to report information on 

instances of noncompliance to VHA by entering this information into 

VHA’s data system. However, VHA does not verify the accuracy and 

completeness of this information. VHA Central Office officials told us 

that they do conduct periodic site visits to VAMCs to review the work 

done by facilities’ maintenance departments, and that one component 

of these reviews is examining the VAMCs’ compliance with 

environment of care standards. According to VHA officials, only 4 of 

these visits were conducted in fiscal year 2015, and 9 of the 12 visits 

scheduled for fiscal year 2016 were conducted by June 2016. In 

addition, the sites to be reviewed are not selected randomly but 

instead are selected based on a request from VAMC or VISN 

leadership.34

 34According to VHA officials, sites are usually chosen for review based on a request from 

the site itself or from VISN leadership as a proactive measure to gauge strengths and 

weaknesses and to obtain guidance on how to improve.
Page 19 GAO-17-52 VA Women Veterans’ Health Care

In our 2010 report, we found similar problems with data accuracy and a

lack of clarity in delegated responsibilities.35 Specifically, none of the 

medical facilities we visited had fully reported their noncompliance, and 

we recommended that the agency establish a process to independently 

validate facilities’ self-reported compliance with environment of care 

requirements for women veterans. At the time, VA agreed with our 

recommendation, and agency officials told us that VHA Central Office 

directed VAMCs to report, on a quarterly basis, information on their 

noncompliance with the environment of care standards. Agency officials 

also told us that VHA Central Office directed VISNs to verify this 

information by conducting separate environment of care rounds as part of 

the VISNs’ oversight of VAMCs. However, our current findings suggest 

that there are weaknesses in the operational effectiveness of these 

actions. Additionally, according to VHA Central Office officials, as of July 

2016, VISNs are not conducting these rounds and verifying the extent of 

compliance among VAMCs. We have previously expressed significant 

concerns about inadequate oversight and accountability within VA, 

including that VHA’s oversight efforts have been impeded by the agency’s 

reliance on facilities’ self-reported data, which lack independent validation 

and are often inaccurate or incomplete.36

This failure to verify reported information is inconsistent with federal 

internal control standards for monitoring, which call for management to 

establish activities to monitor the quality of performance over time and 

promptly resolve the findings of audits and other reviews.37 Additionally, 

the lack of thorough inspections and of clearly delegated responsibilities 

is also inconsistent with federal internal control standards for control 

environment, which require management to establish an organizational 

structure, assign responsibility, and delegate authority to achieve agency 

objectives and to evaluate performance and hold individuals accountable 

for their internal control responsibilities. By not acting in accordance with 

federal internal control standards, VHA does not have reasonable 

assurance that its facilities are meeting the agency’s standards when 

delivering care to women veterans.

 35See GAO-10-287. 

36See GAO, VA Health Care: Management and Oversight of Consult Process Need 

Improvement to Help Ensure Veterans Receive Timely Outpatient Specialty Care, 

GAO-14-808 (Washington, D.C.: September 30, 2014).

37See GAO-14-704G. 
Page 20 GAO-17-52 VA Women Veterans’ Health Care

Our analysis of VHA data shows that the number of VHA gynecologists 

increased about 3 percent nationally from fiscal year 2014 to fiscal year 

2015. Specifically, in fiscal year 2014, there was the equivalent of about 

75 full-time gynecologists, and in fiscal year 2015, the number increased 

to the equivalent of about 77 full-time gynecologists.38 While the increase 

in gynecologists exceeded the rate at which women veterans enrolled in 

VA’s national health care system for the same time period, it remains 

unclear whether the number of current VHA gynecologists is sufficient to 

meet demand and whether the distribution of these gynecologists across 

VA medical facilities is optimal.39 Thirty-nine of 145 VAMCs or VA health 

care systems in fiscal year 2015 (about 27 percent) did not have an 

 38These data reflect only the clinical time that gynecologists spent seeing patients. In 

addition, many gynecologists do not work full time at VA medical facilities, indicating that 

the count of VHA gynecologists is higher than the number of full-time employee 

equivalents. While VHA gynecologists may have been trained in obstetrics, VA medical 

facilities do not provide obstetrical care, that is, care related to the delivery of babies. As of 

August 2016, two VA health care systems offer prenatal care.

39From fiscal year 2014 to fiscal year 2015, the number of women veteran enrollees 

increased about 1 percent, from about 670,000 to about 680,000. VHA medical 

appointment wait times may be one indicator of demand. We did not examine wait times 

data because we have previously found issues related to their reliability. See GAO, VA

Health Care: Actions Needed to Improve Newly Enrolled Veterans’ Access to Primary 

Care, GAO-16-328 (Washington, D.C.: Mar. 18, 2016); VA Mental Health: Clearer 

Guidance on Access Policies and Wait-Time Data Needed, GAO-16-24 (Washington, 

D.C.: Oct. 28, 2015); GAO-14-808; and VA Health Care: Reliability of Reported Outpatient 

Medical Appointment Wait Times and Scheduling Oversight Need Improvement, 

GAO-13-130 (Washington, D.C.: Dec. 21, 2012). According to a VHA official, some VA 

medical facilities without an onsite gynecologist may provide telemedicine gynecology 

through a gynecologist based at a neighboring VA medical facility.

While the Number of 

VHA Gynecologists 

and Women’s Health 

Primary Care 

Providers Has 

Increased Overall, 

Availability Was 

Limited in Some 

Locations

The Number of VA 

Gynecologists Has 

Increased Over Time, but 

More than a Quarter of 

VAMCs and VA Health 

Care Systems Did Not 

Have an Onsite 

Gynecologist
Page 21 GAO-17-52 VA Women Veterans’ Health Care

onsite gynecologist. VHA Central Office officials said that, based on 

workload, not all VA medical facilities need an onsite gynecologist, and 

women veterans may receive necessary gynecological services through a 

care in the community program.40

At facilities where onsite gynecology was available, the number of VHA 

gynecologists available to treat women veterans varied. In fiscal year 

2015, the number of full-time equivalent gynecologists (for VAMCs or VA 

health care systems that had them) ranged from 3.18 (Gainesville,

Florida) to 0.02 (Dayton, Ohio), which corresponds to less than 1 hour per 

week. VA data also show that the number of completed gynecology 

appointments increased across VA, from about 81,000 in fiscal year 2014 

to about 85,000 in fiscal year 2015—an increase of about 5 percent. The 

increase in completed gynecology appointments suggests a greater 

overall utilization of gynecology services in VA medical facilities. (See 

appendix IV for more information on the number of full-time equivalent 

gynecologists by VISN and the number of completed gynecology 

appointments by VISN.)

Our analysis of VHA data indicates that the number of women’s health 

primary care providers increased by almost 15 percent from fiscal year 

2014 through fiscal year 2015. Specifically, in fiscal year 2014, there were 

2,130 providers, and in fiscal year 2015, there were 2,439 providers.41

The increase in providers significantly outpaced the increase in women 

veteran enrollment (1 percent) during the same time period. In addition, 

VHA data show that the number of completed women’s health 

appointments increased across VHA, from about 304,000 in fiscal year 

2014 to about 331,000 in fiscal year 2015—an increase of about 9 

percent.

 40We contacted eight locations that did not have an onsite gynecologist, according to the 

data, and received responses from five locations. Women veterans program managers 

from two of the five locations said their facilities continued to lack an onsite gynecologist 

as of August 2016 because the demand for such services did not warrant an onsite 

provider. According to the women veterans program managers, these facilities typically 

refer women veterans to neighboring VA medical facilities, or to Choice or another care in 

the community program. 

41This is a count of women’s health primary care providers and does not reflect their 

clinical availability to see patients. 

The Number of VHA 

Women’s Health Primary 

Care Providers Has 

Increased Over Time, but 

Almost One-Fifth of VA 

Clinics Offering Primary 

Care Lacked Such a 

Provider
Page 22 GAO-17-52 VA Women Veterans’ Health Care

VHA data show that a women’s health primary care provider was 

available to see veterans about 31 clinical hours per week, on average, at 

the end of fiscal year 2015.42 However, that availability included any 

clinical time women’s health primary care providers spent seeing male 

veterans.43 Because women’s health primary care providers see both 

men and women, according to VHA, it is highly likely that a typical 

women’s health primary care provider was available for less than 31 

hours per week to see women veterans. When VHA adjusted clinical 

availability data by the proportion of women veterans seen for primary 

care at each VA medical facility, the data show that a women’s health 

primary care provider’s availability was estimated at about 6 hours per 

week, on average, at the end of fiscal year 2015.44 Fiscal year 2015 was 

the first year for which VHA collected and validated data on the clinical 

availability of women’s health primary care providers, and according to 

VHA officials, the data are considered preliminary and not yet robust 

enough to compare with the demand for services.45

Despite the increase in providers nationally, VHA data show that 17 

percent of VA community-based outpatient clinics that provide primary 

care and 3 percent of VAMCs or VA health care systems lacked a 

 42According to VHA, primary care clinics, including women’s health clinics, run in half-day 

clinic sessions (made up of 4 clinical hours), with two half-day clinic sessions making up a 

full-day clinic session (8 clinical hours). In any given week, the maximum number of clinic 

sessions is 10 and the maximum number of clinical hours is 40. 

43According to VHA policy, the panel of a women’s health primary care provider should 

have at least 10 percent women. VHA has established a baseline panel size of 1,200 

patients for its primary care physicians. Nurse practitioners and physician assistants are 

generally assigned a panel of patients that is 75 percent of the physician panel size. To 

account for the unique needs of women veterans during appointments, VHA recommends 

that women’s health primary care providers’ panels be reduced by the number of unique 

patients equal to 20 percent of the total number of women veterans in the panel.

44This calculated estimate assumes that a women’s health primary care provider sees 

women veterans proportionate to the number of women seen for primary care (traditional 

primary care or a women’s health clinic) at a given VAMC or VA health care system.

45Whether the clinical capacity of women’s health primary care providers at a VA medical 

facility is sufficient depends, in part, on the number of women veterans enrolled at a VA 

medical facility and the full-time employee equivalency of those providers. A VHA official 

said a clinical capacity goal for a women’s health primary care provider would be 

approximately 40 clinical hours for every 1,000 women veterans, or the equivalent of one 

full-time provider with a full panel size.
Page 23 GAO-17-52 VA Women Veterans’ Health Care

women’s health primary care provider at the end of fiscal year 2015.46

Specifically, 151 out of 881 outpatient clinics that provide primary care 

and 4 out of 155 VAMCs lacked a women’s health primary care provider 

at the end of fiscal year 2015.47 (See appendix V for more information on 

the number of outpatient clinics that provide primary care lacking a 

women’s health primary care provider.) At least 1 of the 4 VAMCs lacking 

a women’s health primary care provider also lacked an onsite 

gynecologist based on VHA fiscal year 2015 data.48

The fact that nearly 18 percent of VAMCs and outpatient clinics providing 

primary care lacked a women’s health primary care provider in fiscal year 

2015 suggests that VHA may face challenges ensuring that all women 

veterans have timely access to these providers, as required under VHA 

policy.49 Specifically, each VA medical facility must ensure that eligible 

women veterans have access to comprehensive medical care that is 

comparable to care provided to male veterans, and veterans should not 

wait more than 30 days from either the date an appointment is deemed 

clinically appropriate by a VA provider or, if no such clinical determination 

has been made, the date a veteran prefers to be seen for care. A VHA 

official told us that if a women’s health primary care provider is not 

available at a veteran’s local facility, women veterans can seek sexspecific care at other VA medical facilities, though in these cases women 

veterans may face longer wait times and potentially longer driving 

 46VHA also monitors the percentage of women veterans assigned to women’s health 

primary care providers. The percentage of women veterans assigned to women’s health 

primary care providers has increased nationally from 68 percent in fiscal year 2014 to 

about 70 percent in fiscal year 2015, representing a percentage point increase of about 2 

percent. This increase can be explained, in large part, due to automatic assignment of 

new women veteran enrollees to women’s health primary care providers. According to 

VHA officials, the overall goal is assignment of 85 percent of women veterans to these 

providers. VA officials said they do not expect 100 percent of women veterans to be 

assigned to women’s health primary care providers because previously enrolled women 

veterans may prefer to stay with their existing primary care provider and receive sexspecific care separately from a women’s health primary care provider, if desired.

47These VAMCs are located in Perry Point, Maryland; St. Louis (John Cochran), Missouri; 

San Antonio, Texas; and, Fort Meade, South Dakota.

48The Fort Meade, South Dakota VAMC had no gynecology full-time equivalents. In 

addition, as of February 2016, the Perry Point, Maryland VAMC did not have an onsite 

gynecologist, according to facility data.

49See VHA Handbook 1330.01, Health Care Services for Women Veterans and VHA 

Directive 1230, Outpatient Scheduling Processes and Procedures.
Page 24 GAO-17-52 VA Women Veterans’ Health Care

distances.50 Eligible women veterans may also receive care through 

Choice or another care in the community program.

In our interviews with VHA officials, they acknowledged a shortage of 

women’s health primary care providers at VA medical facilities. A VHA 

official told us that facilities have difficulty recruiting and retaining primary 

care providers who are interested and proficient in caring for women 

veterans, particularly in rural areas. According to an agency memo, VHA 

needs at least 675 additional women’s health primary care providers, 

under a guiding principle that each VA medical facility—VAMCs and 

community-based outpatient clinics—should have, at a minimum, two 

women’s health primary care providers. In addition, according to the 

agency memo, VA medical facilities with 2,000 or more women veteran 

enrollees should have the equivalent of an additional one full-time 

women’s health primary care provider for every 1,000 women veteran 

enrollees or fraction thereof. According to the memo, these providers do 

not all have to be new hires, but could be drawn from VHA’s existing pool 

of primary care providers and trained to provide sex-specific care. 

According to VHA, existing providers may participate in a VHA-sponsored 

women’s health training to become women’s health primary care 

providers, unless providers already possess the necessary training and 

experience.51

While VHA has taken steps to hire and train additional women’s health 

primary care providers, these efforts have not yet yielded a sufficient 

number of such providers. According to VHA, as of August 2016, using 

funding from the Veterans Access, Choice, and Accountability Act of 

2014, VHA had hired 45 women’s health-specific providers, including 11 

gynecologists, since September 30, 2015.52 However, due to subsequent 

turnover in staff as well as growth in the demand for services, VHA 

reported that the number of women’s health primary care providers 

needed to meet VHA’s criteria of a minimum of two per VA medical facility 

has remained approximately the same. A VHA official told us that the 

 50See GAO-16-328; GAO-16-24; GAO-14-808; and GAO-13-130. 

51According to VHA policy, providers who had seen female patients in a sufficient volume 

in previous and recent work experiences would be exempt from VHA training and could be 

designated as women’s health primary care providers. 

52In addition, under the Veterans Access, Choice, and Accountability Act of 2014, VHA 

hired 3,532 primary care medical professionals since September 30, 2015, according to 

officials. This number includes physicians (469), physician assistants, and nurses. 
Page 25 GAO-17-52 VA Women Veterans’ Health Care

agency has a plan to train existing VHA providers so that there will be at 

least 500 additional women’s health primary care providers in fiscal year 

2016. According to VHA documents, 305 providers attended the agency’s

national training program in the spring and summer of 2016, and a VHA 

official said an additional 230 providers will be trained by the end of fiscal 

year 2016 at nine different VA locations across the country.

Our analysis of VHA data show that the number of obstetricians and 

gynecologists participating in Choice networks nationally increased 

significantly from about 6,200 in May 2015 to 10,100 in May 2016, an 

increase of about 64 percent.53 While the number of obstetricians and 

gynecologists increased, some geographic areas lacked these types of 

providers, which provided access challenges for women veterans seeking 

care. For example,

• our analysis of VHA data for VISN 19 indicated that as of May 2016, 

there were almost 33 percent more community obstetricians and 

gynecologists participating in Choice (615) compared to the number of 

 53VHA data on the number of women veterans authorized under Choice for obstetrical and 

gynecological services are not readily available due to limitations of VHA’s electronic 

health record and due to differences in how the TPAs counted authorizations. 

While the Number of 

Obstetricians and 

Gynecologists 

Participating in 

Choice Networks Has 

Increased, VHA Does 

Not Have 

Performance 

Measures for 

Monitoring Access to 

Sex-Specific Care 

under Choice

Obstetricians and 

Gynecologists 

Participating in Choice 

Networks Have Increased 

Nationally, though Some 

Geographic Areas Lack 

These Types of Providers
Page 26 GAO-17-52 VA Women Veterans’ Health Care

these providers (464) who delivered care to women veterans through 

individually authorized care prior to the implementation of Choice in 

fiscal year 2014.54 However, according to a VHA analysis of VISN 19 

based on May 2016 data, certain areas within VISN 19 lacked these 

providers. (See fig. 3).55 Specifically, VHA’s analysis found that two 

VA medical facilities in Montana offered gynecology services, and 

there were no VHA or Choice obstetricians and gynecologists located 

north and east of Billings, Montana.56 Parts of central Utah also 

lacked VHA or Choice obstetricians and gynecologists. The Salt Lake 

City/Provo/Ogden area was the only area in Utah that offered VHA 

gynecology services, and Choice providers were also concentrated in 

this area. According to the analysis, the areas lacking Choice 

obstetricians and gynecologists generally had fewer veterans (male 

and female) relative to other areas of these states.

 54In fiscal year 2015, VISN 19 included most of Montana, Wyoming, and Colorado; Utah; 

and parts of Idaho, Nevada, North Dakota, Nebraska, and Kansas. About 67 percent of 

Choice obstetricians and gynecologists were within VA medical facility service areas 

where gynecology was available through VA, suggesting, in theory, that 33 percent were 

extending potential access to veterans living outside of VHA’s gynecology service areas. 

From fiscal year 2014 through fiscal year 2016, women veteran enrollment in VISN 19 

increased by about 5 percent. 

55Carey, Evan; Paula Langner and Michael Ho. “ VACA Spatial Evaluation of Specialty 

Care Relevant to Female Veterans: Quantitative Results (Version 2, updated 5/16/2016).”

56According to VHA, VA medical facilities do not provide obstetrical care, that is, care 

related to the delivery of babies. As of August 2016, two VA health care systems offer 

prenatal care. 
Page 27 GAO-17-52 VA Women Veterans’ Health Care

Figure 3: Location and Concentration of Veterans Choice Program (Choice) Obstetricians and Gynecologists as of May 2016 

and Department of Veterans (VA) Locations Providing Gynecology as of September 2015, Veterans Integrated Service 

Network (VISN) 19 

Notes: VISNs are regional networks containing individual VA medical centers (VAMC) or groups of 

VAMCs, known as health care systems. VISNs oversee the day-to-day functions of VA medical 

facilities within their boundaries. VA service areas are roughly the 40 miles surrounding a VA medical 

facility. Urban areas indicated are approximate. While the Choice provider data used are from fiscal 

year 2016, the boundaries of VISN 19 as depicted are as of fiscal year 2015. VA is currently in the 

process of reorganizing its VISNs. By the end of fiscal year 2018, VISN 19 is expected to contain 
Page 28 GAO-17-52 VA Women Veterans’ Health Care

most of Montana, Wyoming, Colorado, and Oklahoma; Utah; and parts of Idaho, Nevada, Nebraska, 

and Kansas.

• Our analysis of VA data for VISN 10 showed that there were 4 percent 

fewer non-VA community obstetricians and gynecologists participating 

in Choice as of May 2016 (431) than there were providers who 

delivered care to women veterans through individually-authorized care 

prior to the implementation of Choice (451).57 According to a VHA 

analysis of VISN 10 based on May 2016 data, 15 percent of Choice 

obstetricians and gynecologists in VISN 10 are located outside of 

VHA’s gynecology service areas—the roughly 40 miles surrounding a 

VA medical facility—suggesting that most Choice obstetricians and 

gynecologists in VISN 10 are not extending significant access to 

veterans living outside of VHA’s gynecology service areas.

VHA lacks performance measures for the availability under Choice of sexspecific care, such as mammograms, maternity care, or gynecology. In 

contrast, for another VA care in the community program, PC3—a program 

that the Choice TPAs also administer—VHA has performance measures 

to evaluate women veterans’ access to mammography and maternity 

care, sex-specific services that are not routinely provided at most VA 

medical facilities.58 Specifically, as part of PC3, VHA monitors women 

veterans’ driving distances to obtain mammograms and maternity care 

services as a measure of network adequacy.59 One VHA official 

responsible for monitoring the TPAs’ performance on Choice contract 

requirements told us that the PC3 performance measures specific to sex-

 57In fiscal year 2015, VISN 10 included most of Ohio and parts of Indiana and Kentucky. 

From fiscal year 2014 through fiscal year 2016, women veteran enrollment in VISN 10 

decreased by almost 1 percent. 

58VHA awarded contracts in September 2013 to Health Net Federal Services and TriWest 

Healthcare Alliance to administer PC3. These contracts required each TPA to develop a 

regional network of providers, including physicians, to deliver care to veterans when care 

cannot be delivered at a VA medical facility, among other reasons. VHA modified the PC3 

contracts it had previously awarded to these TPAs in 2014 to implement Choice.

59In addition, under PC3, VHA monitors the driving time all veterans experience to access 

care. According to a VHA document, the network adequacy standard to enable access is 

a maximum commute time of 45, 100, and 180 minutes for urban, rural, and highly rural

dwellers, respectively.

VHA Does Not Have 

Performance Measures for 

Monitoring Access to SexSpecific Care under 

Choice
Page 29 GAO-17-52 VA Women Veterans’ Health Care

specific care were simply overlooked in the haste to implement Choice.60

VHA could monitor driving distances for women veterans to receive 

mammograms and maternity care services delivered through Choice, as 

the TPAs currently collect these data as part of PC3, according to VHA 

officials.

While VHA doesn’t have performance standards for sex-specific care 

under Choice, it does have performance standards for all care delivered 

through Choice. For example, VHA’s contracts with the two TPAs require 

the timely scheduling and completion of appointments, and VHA also 

monitors the rates at which the TPAs return Choice authorizations to VHA 

medical facilities without appointments. However, VHA data show that the 

TPAs did not meet VHA’s performance standards for providing timely 

access for veterans, including women veterans.61 See table 2 for TPA 

average monthly performance under Choice for certain access-related 

performance measures.

Table 2: Veterans Choice Program Third-Party Administrator (TPA) Average 

Monthly Performance on Select Veterans Health Administration (VHA) AccessRelated Performance Measures, August 2015-May 2016

Percentage

VHA Performance Measure TPA 1 TPA 2

VHA 

Performance 

Standard

Routine appointments scheduled within 

5 days

70 69 100 

Urgent appointments scheduled within 

48 hours

47 49 N/Aa

Routine appointments taking place 

within 30 days

82 70 90 or greater

 60In August 2014, Congress passed the Veterans Access, Choice, and Accountability Act 

of 2014, which created Choice. The act required VA to issue interim final regulations on 

the implementation of Choice within 90 days of enactment, and VHA began referring 

veterans to Choice in November 2014. VHA officials also said that after reviewing 

information from sources such as veteran surveys and feedback from regional VA 

business improvement managers, they did not think driving time for women veterans to 

mammography and maternity care appointments was a concern.

61In response to these issues, VHA has directed the TPAs to submit action plans detailing 

the steps they will take to improve veterans’ access to care. Additional evaluation of TPA 

performance and VHA oversight of Choice is being further examined in an ongoing GAO 

review, due to be released in the late winter of 2017.
Page 30 GAO-17-52 VA Women Veterans’ Health Care

Percentage

VHA Performance Measure TPA 1 TPA 2

VHA 

Performance 

Standard

Urgent appointments taking place within 

48 hours

14 24 100b

Authorizations that are unable to be 

fulfilled and are returned to VHAc 4 4 2 or less

Source: GAO analysis of VHA data. | GAO-17-52

Notes: Since the Veterans Choice Program was implemented, contract requirements have been 

modified over time. The measures and standards listed in this table are as of May 2016.

a

According to a VHA official, effective June 2016, VHA established a performance standard of 97.5 

percent for this measure.

b

According to a VHA official, effective June 2016, VHA modified this performance standard to 97.5 

percent.

c

According to a VHA official, the TPAs count authorizations that are returned for the following 

reasons: (1) no network provider was available for the requested service; (2) the provider requested 

by VHA or the veteran was outside of the network; (3) the veteran declined the provider because the 

provider was outside of established commute standards; (4) VHA requested a return because of TPA 

inactivity; (5) the veteran was scheduled with the incorrect provider or type of care.

If VHA monitored access to sex-specific Choice care for women veterans, 

it is possible that delays in care would be identified and actions could be 

taken to minimize future occurrence. For example, if VHA were 

monitoring sex-specific Choice care, it might have identified the three 

cases of delayed maternity care through Choice we found as part of an 

ongoing review of 196 Choice authorizations for care (of both men and 

women) from early calendar year 2016. In one case, almost a month and 

a half elapsed from the time of the veteran’s initial pregnancy confirmation 

appointment at VA (when she was 6 weeks pregnant) to when the Choice 

authorization was sent by the VA facility to the TPA for scheduling. It then 

took two additional weeks for the TPA to attempt to schedule a prenatal 

appointment; by that point, she was almost 15 weeks pregnant. At 18 

weeks pregnant, she finally scheduled her initial prenatal appointment 

herself, almost 3 months after her pregnancy was confirmed at VHA. In 

another case, about a week and a half elapsed from the time the 

veteran’s Choice authorization was created (when she was 6 to 7 weeks 

pregnant) to when the VA facility sent it to the TPA for scheduling. It then 

took the TPA nearly a month to reach the veteran and determine if she 

wanted to participate in Choice. After the veteran agreed to participate in 

Choice, it took more than 2 weeks for the TPA to schedule an 

appointment. The veteran was about 14 weeks pregnant by the time her 

first appointment was scheduled.
Page 31 GAO-17-52 VA Women Veterans’ Health Care

Federal standards of internal control for monitoring call for management 

to establish activities to monitor the quality of performance over time and 

promptly resolve the findings of audits and other reviews. VHA does not 

currently have performance measures for sex-specific care under Choice.

While VA does monitor access to Choice care for all veterans, the past

performance of TPAs on access-related measures highly suggests that 

veterans have problems obtaining timely access to these services as 

required under Choice. Since women are more likely to use non-VA care 

than male veterans, according to VHA, the lack of timely access to 

Choice care may affect women veterans more so than male veterans. In 

addition, we found instances where women veterans’ care under Choice 

was significantly delayed and we found a lack of participating 

obstetricians and gynecologists in some areas, both of which further 

underscore the importance of VHA’s ability to monitor access to sexspecific care for women veterans. Without performance measures, VHA 

does not have reasonable assurance that women veterans can obtain 

timely access to sex-specific care.

Our review shows that, despite some progress since 2010, VHA still has 

a significant problem ensuring that its medical facilities are complying with 

VHA’s environment of care requirements, which are intended to protect 

the privacy, safety, and dignity of women veterans when they receive 

care. This lack of oversight reflects long-standing weaknesses in the 

policies and guidance for the environment of care rounds inspections 

process, including how data is collected by facility staff and what 

information is reported to VHA Central Office. For example, facility staff 

do not inspect all applicable areas within the facility and the list of 

requirements they inspect does not include all requirements in the VHA 

women’s health handbook. In addition, responsibilities for addressing 

noncompliance are not clearly delegated, and VHA does not verify the 

noncompliance information it receives from its facilities. These 

weaknesses are similar to those we identified in our 2010 report, and the 

problems have persisted even though VHA agreed with our previous 

recommendations to strengthen oversight of its environment of care 

standards. These findings further underscore the agency’s continued lack 

of adequate oversight and accountability, which resulted in our adding VA 

health care to our High Risk List in 2015.62 If VHA does not strengthen its 

environment of care inspections policies, it will remain unable to provide 

 62See GAO-15-290.

Conclusions
Page 32 GAO-17-52 VA Women Veterans’ Health Care

reasonable assurance that it is protecting the privacy, safety, and dignity 

of women veterans who receive care at VA medical facilities.

Our review also suggests that VHA faces challenges ensuring that 

women veterans have access to sex-specific care at its own medical 

facilities and through community providers participating in Choice. VHA 

has acknowledged that there are an insufficient number of women’s 

health primary care providers across the national health system, and 

some services, such as mammography, maternity care, and gynecology, 

are not offered at many VA medical facilities. To the extent that VA 

medical facilities cannot deliver sex-specific services, women veterans 

will need to receive these services through Choice or other care in the 

community programs. However, VHA does not monitor access for women 

to sex-specific care through Choice. Unless VHA establishes 

performance measures that monitor access to sex-specific services, VHA 

will not have reasonable assurance that women veterans have adequate 

access to these services.

To improve care for women veterans, we recommend that the Secretary 

of Veterans Affairs direct the Under Secretary for Health to take the 

following two actions:

• Strengthen the environment of care inspections process and VHA’s 

oversight of this process by expanding the list of requirements that 

facility staff inspect for compliance to align with VHA’s women’s health 

handbook, ensuring that all patient care areas of the medical facility 

are inspected as required, clarifying the roles and responsibilities of 

VA medical facility staff responsible for identifying and addressing 

compliance, and establishing a process to verify that noncompliance 

information reported by facilities to VHA Central Office is accurate and 

complete.

• Monitor women veterans’ access to key sex-specific care services—

mammography, maternity care, and gynecology—under current and 

future community care contracts. For those key services, monitoring 

should include an examination of appointment scheduling and 

completion times, driving times to appointments, and reasons 

appointments could not be scheduled with community providers.

We provided a draft of this report to VA for review and comment. While 

VA was reviewing a draft of this report, the agency requested further 

Recommendations for 

Executive Action

Agency Comments
Page 33 GAO-17-52 VA Women Veterans’ Health Care

clarification on the scope of our second recommendation; as a result, we 

revised the recommendation to be more clear and specific. In its written 

comments, which are reproduced in appendix I, VA concurred with our 

recommendations. VA stated it will charter a workgroup to examine 

issues related to VA facility compliance with environment of care

requirements for women veterans. VA also said it is focused on providing 

community care to all eligible veterans and will ensure that future 

community care contracts incorporate areas for improvement based on 

lessons learned. VA also provided technical comments, which we 

incorporated as appropriate.

We are sending copies of this report to the appropriate congressional 

committees, the Secretary of Veterans Affairs, the Under Secretary for 

Health, and other interested parties. In addition, the report is available at 

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

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

me at (202) 512-7114 or williamsonr@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 VI.

Randall B. Williamson

Director, Health Care
Page 34 GAO-17-52 VA Women Veterans’ Health Care

List of Congressional Requesters

The Honorable Johnny Isakson

Chairman

The Honorable Richard Blumenthal

Ranking Member

Committee on Veterans’ Affairs

United States Senate

The Honorable Jeff Miller

Chairman

The Honorable Mark Takano

Acting Ranking Member

Committee on Veterans’ Affairs

House of Representatives

The Honorable Dean Heller

United States Senate

The Honorable John McCain

United States Senate

The Honorable Corrine Brown

House of Representatives

The Honorable Mike Coffman

House of Representatives
Appendix I: Comments from the Department of 

Veterans Affairs

Page 35 GAO-17-52 VA Women Veterans’ Health Care

Appendix I: Comments from the Department 

of Veterans Affairs
Appendix I: Comments from the Department of 

Veterans Affairs

Page 36 GAO-17-52 VA Women Veterans’ Health Care
Appendix I: Comments from the Department of 

Veterans Affairs

Page 37 GAO-17-52 VA Women Veterans’ Health Care
Appendix II: Veterans Health Administration 

(VHA) Environment of Care Requirements 

Inspected by GAO

Page 38 GAO-17-52 VA Women Veterans’ Health Care

Table 3: Selected VHA Environment of Care Requirements Inspected by GAO for Compliance, 2015-2016

Outpatient Clinics Inpatient Units Residential Programs

Does the check-in clerk station have auditory 

privacy?

Is patient-identifiable information not visible 

in hallways?

Are client records not left unattended?

Are patient names not posted in public areas? Are patient records not left unattended? Are female bathrooms either private 

or lockable if accessible from unit 

hallways or other public spaces?

Are patient names not called out loudly? When doors are closed, do staff knock and 

wait until they are invited to enter?

Are female bedrooms located in a 

separate and secured area of the unit 

or located near main staff offices or 

nursing stations?

Are sanitary napkin and tampon dispensers 

available in the women’s public restrooms 

nearest to this clinic or unit?

Are privacy curtains present in all rooms 

(mental health units are exempt)?

Is there appropriate private space 

available for female veterans to visit 

with children?

Are disposal bins available in the women’s 

public restrooms nearest to this clinic or unit?

Are rooms assigned either to only one client 

or to same-sex clients (except in facilities 

where spouses share rooms)?

When doors are closed, do staff 

knock and wait until they are invited to 

enter?

Are baby changing tables available in women’s 

public restrooms nearest to this clinic or unit?

Do women patients have access to womenonly toilet and shower facilities in close 

proximity to the patients’ rooms?

Are rooms assigned either to only one 

client or to same-sex clients (except in 

facilities where spouses share 

rooms)?

Does the interview/intake area have auditory 

privacy?

Do women have door locks, access 

bar codes, or controlled access ID 

card scanners?

Is the access to hallways restricted for 

patients/staff not using or working in that clinic 

area?

Is patient-identifiable information not visible in 

hallways?

When doors are closed, do staff knock and wait 

until they are invited to enter?

Do restrooms not open into a public waiting 

room or high traffic corridor?

Are privacy curtains present in all examination 

rooms?

Are examination tables placed with the foot 

facing away from the door?

Do procedure and testing areas have auditory 

privacy?

Is a women’s restroom available within or in 

close proximity to this clinic?

Are sanitary napkin and tampon dispensers 

available in the women’s restroom nearest to 

this clinic?

Are disposal bins available in the women’s 

restroom nearest to this clinic?

Appendix II: Veterans Health Administration 

(VHA) Environment of Care Requirements 

Inspected by GAO 
Appendix II: Veterans Health Administration 

(VHA) Environment of Care Requirements 

Inspected by GAO

Page 39 GAO-17-52 VA Women Veterans’ Health Care

Outpatient Clinics Inpatient Units Residential Programs

Is special consideration given to privacy and 

dignity in gynecology?

Is special consideration given to privacy and 

dignity in radiology dressing areas (e.g., 

mammography)?

Is special consideration given to privacy and 

dignity in ultrasound, transvaginal ultrasound 

testing, etc.?

Source: VHA Handbook 1330.01: Health Care Services for Women Veterans | GAO-17-52

Note: We developed a standardized data collection instrument with the above requirements to inspect 

for compliance on site visits to Veteran Affairs medical centers from December 2015 through March 

2016.
Appendix III: Veterans Affairs Medical Center 

(VAMC) Compliance with Environment of Care 

Requirements

Page 40 GAO-17-52 VA Women Veterans’ Health Care

Table 4: Selected VAMC Compliance with Selected Veterans Health Administration (VHA) Requirements Related to the 

Outpatient Environment of Care for Women Veterans, December 2015-March 2016

Percentage

VAMC A VAMC B VAMC C VAMC D VAMC E VAMC F Total

Waiting areas

Does the check-in clerk 

station have auditory 

privacy?

80 64 33 67 60 100 65

Are patient names not 

posted in public areas?

100 91 100 100 100 100 98

Are patient names not 

called out loudly?a 33 100 67 100 50 100 84

Are sanitary napkin and 

tampon dispensers 

available in the women’s 

public restrooms nearest to 

this clinic or unit?

25 70 67 29 20 50 47

Are disposal bins available 

in the women’s public 

restrooms nearest to this 

clinic or unit?

100 100 83 86 40 100 86

Are baby changing tables 

available in women’s public 

restrooms nearest to this 

clinic or unit?

50 40 100 50 40 25 51

Patient examination and 

procedure areas

Does the interview/intake 

area have auditory privacy?

100 83 100 100 100 100 96

Is the access to hallways 

restricted for patients/staff 

not using or working in that 

clinic area?

80 73 67 56 20 67 62

Is patient-identifiable 

information not visible in 

hallways?

100 91 100 100 100 100 97

When doors are closed, do 

staff knock and wait until 

they are invited to enter?a

100 100 67 75 100 n/a 86

Do restrooms not open into 

a public waiting room or 

high traffic corridor?

60 73 33 100 40 67 65

Are privacy curtains present 

in all examination rooms?

75 71 40 86 75 100 71

Appendix III: Veterans Affairs Medical Center

(VAMC) Compliance with Environment of 

Care Requirements
Appendix III: Veterans Affairs Medical Center 

(VAMC) Compliance with Environment of Care 

Requirements

Page 41 GAO-17-52 VA Women Veterans’ Health Care

Percentage

VAMC A VAMC B VAMC C VAMC D VAMC E VAMC F Total

Are examination tables 

placed with the foot facing 

away from the door?

50 83 100 83 67 50 75

Do procedure and testing 

areas have auditory 

privacy?

100 60 67 71 50 50 66

Is a women’s restroom 

available within or in close 

proximity to this clinic?

100 100 83 100 100 100 97

Are sanitary napkin and 

tampon dispensers 

available in the women’s 

restroom nearest to this 

clinic?

40 64 50 0 0 50 36

Are disposal bins available 

in the women’s restroom 

nearest to this clinic?

80 91 50 67 60 50 73

Is special consideration 

given to privacy and dignity 

in gynecology?

n/a 100 100 100 100 n/a 100

Is special consideration 

given to privacy and dignity 

in radiology dressing areas 

(e.g., mammography)?

100 0 100 100 n/a n/a 83

Is special consideration 

given to privacy and dignity 

in ultrasound, transvaginal 

ultrasound testing, etc.?

0 n/a 100 100 n/a n/a 67

Total VAMC compliance 74 79 72 76 59 76 74

Source: GAO | GAO-17-52

Notes: We collected this information using a data collection instrument during site visits to VAMCs 

from December 2015 through March 2016. n/a indicates either that the requirement was not 

applicable to any units within the facility or that we were unable to observe the requirement in any of 

the facility units given the circumstances at the time of our inspection.

a

At the time of our inspections, circumstances in the clinic environment may have precluded us from 

observing this requirement in every applicable instance. For example, some exam rooms or 

restrooms may have been occupied by patients at the time of our inspection, or some clinics may only 

be open on certain days of the week and were closed at the time of our inspection.
Appendix III: Veterans Affairs Medical Center 

(VAMC) Compliance with Environment of Care 

Requirements

Page 42 GAO-17-52 VA Women Veterans’ Health Care

Table 5: Selected VAMC Compliance with Selected VHA Requirements Related to the Inpatient Environment of Care for 

Women Veterans, December 2015-March 2016

Percentage

VAMC A VAMC B VAMC C VAMC D VAMC E VAMC F Total

Is patient-identifiable 

information not visible in 

hallways?

100 100 100 100 100 100 100

Are patient records not left 

unattended?

100 100 100 100 100 100 100

When doors are closed, do 

staff knock and wait until 

they are invited to enter?a

100 100 n/a 100 100 50 89

Are privacy curtains present 

in all rooms (mental health 

units are exempt)?

100 100 100 100 33 100 83

Are rooms assigned either 

to only one client or to 

same-sex clients (except in 

facilities where spouses 

share rooms)?

100 100 100 100 100 100 100

Do women patients have 

access to women-only toilet 

and shower facilities in 

close proximity to the 

patients’ rooms?

100 100 100 100 100 100 100

Total VAMC compliance 100 100 100 100 88 91 96

Source: GAO | GAO-17-52

Notes: We collected this information using a data collection instrument during site visits to VAMCs 

from December 2015 through March 2016. n/a indicates either that the requirement was not 

applicable to any units within the facility or that we were unable to observe the requirement in any of 

the facility units given the circumstances at the time of our inspection.

a

At the time of our inspections, circumstances in the clinic environment may have precluded us from 

observing this requirement in every applicable instance. For example, some exam rooms or 

restrooms may have been occupied by patients at the time of our inspection, or some clinics may only 

be open on certain days of the week and were closed at the time of our inspection.
Appendix III: Veterans Affairs Medical Center 

(VAMC) Compliance with Environment of Care 

Requirements

Page 43 GAO-17-52 VA Women Veterans’ Health Care

Table 6: Selected VAMC Compliance with Selected VHA Requirements Related to the Residential Treatment Program 

Environment of Care for Women Veterans, December 2015-March 2016

Percentage

VAMC A VAMC B VAMC C VAMC Da VAMC E VAMC F Total

Are client records not left 

unattended?

100 100 100 —- 100 100 100

Are female bathrooms either 

private or lockable if 

accessible from unit 

hallways or other public 

spaces?

100 100 100 —- 100 100 100

Are female bedrooms 

located in a separate and 

secured area of the unit or 

located near main staff 

offices or nursing stations?

100 100 100 —- 100 100 100

Is there appropriate private 

space available for female 

veterans to visit with 

children?

100 100 67 —- 100 100 86

When doors are closed, do 

staff knock and wait until 

they are invited to enter?b

100 100 100 —- 0 n/a 83

Are rooms assigned either 

to only one client or to 

same-sex clients (except in 

facilities where spouses 

share rooms)?

100 100 100 —- 100 100 100

Do women have door locks, 

access bar codes, or 

controlled access ID card 

scanners?

100 100 100 —- 100 100 100

Total VAMC compliance 100 100 95 —- 86 100 96

Source: GAO | GAO-17-52

Notes: We collected this information using a data collection instrument during site visits to VAMCs 

from December 2015 through March 2016. n/a indicates either that the requirement was not 

applicable to any units within the facility or that we were unable to observe the requirement in any of 

the facility units given the circumstances at the time of our inspection.

a

There is no residential treatment program at VAMC D.

b

At the time of our inspections, circumstances in the clinic environment may have precluded us from 

observing this requirement in every applicable instance. For example, some exam rooms or 

restrooms may have been occupied by patients at the time of our inspection, or some clinics may only 

be open on certain days of the week and were closed at the time of our inspection.
Appendix IV: Veterans Health Administration 

(VHA) Gynecologist Availability

Page 44 GAO-17-52 VA Women Veterans’ Health Care

Table 7: VHA Gynecologist Clinical Care Full-Time-Employee Equivalent (FTEE) per 1,000 Women Veteran Enrollees and 

Completed Gynecology Appointments, Nationally and by Veterans Integrated Service Network (VISN), Fiscal Years 2014 and 

2015

Clinical care FTEE per 1,000 women veteran enrollees Completed gynecology appointments

Location

Fiscal year

2014

Fiscal year

2015

Percent change

(percent)

Fiscal year 

2014

Fiscal year 

2015

Percent change

(percent)

VISN 1 0.09 0.11 26 2,288 2,636 15

VISN 2 0.10 0.14 38 1,130 1,339 18

VISN 3 0.19 0.26 36 4,215 4,553 8

VISN 4 0.12 0.12 0 2,354 2,131 -9

VISN 5 0.03 0.03 -9 1,116 1,169 5

VISN 6 0.09 0.11 19 7,474 8,912 19

VISN 7 0.07 0.09 33 6,922 7,632 10

VISN 8 0.22 0.22 0 14,284 14,167 -1

VISN 9 0.10 0.09 -14 2,874 3,285 14

VISN 10 0.26 0.15 -41 1,871 1,944 4

VISN 11 0.09 0.07 -21 2,557 2,405 -6

VISN 12 0.15 0.16 6 3,271 2,997 -8

VISN 15 0.05 0.09 89 1,285 1,579 23

VISN 16 0.10 0.07 -24 5,984 5,785 -3

VISN 17 0.06 0.05 -24 4,407 2,992 -32

VISN 18 0.08 0.07 -22 2,472 3,856 56

VISN 19 0.10 0.06 -38 2,977 3,563 20

VISN 20 0.08 0.05 -42 2,576 2,860 11

VISN 21 0.16 0.16 0 2,887 2,826 -2

VISN 22 0.14 0.15 6 6,246 6,750 8

VISN 23 0.05 0.06 16 1,809 1,914 6

Total 0.11 0.11 -1 80,999 85,295 5

Source: GAO analysis of VHA data. | GAO-17-52

Notes: VHA gynecologist clinical care FTEE data reflect only the clinical time that was spent seeing 

patients. Clinical care FTEE per 1,000 women veteran enrollees figures were rounded to 2 decimal 

places and percent change calculations were rounded to the nearest whole number. Some 

calculations may not add up due to rounding.

Appendix IV: Veterans Health Administration 

(VHA) Gynecologist Availability
Appendix V: Veterans Affairs (VA) Clinics 

Without a Women’s Health Primary Care 

Provider

Page 45 GAO-17-52 VA Women Veterans’ Health Care

Table 8: Number and Percentage of VA Community-Based Outpatient Clinics that 

Provide Primary Care Lacking a Women’s Health Primary Care Provider and Women 

Veteran Enrollment, Nationally and by Veterans Integrated Service Network (VISN), 

Fiscal Year 2015

Location 

Number (percentage) of clinics without a 

women’s health primary care provider

Women veteran 

enrollment

VISN 1 7 (16) 20,109

VISN 2 6 (18) 12,093

VISN 3 4 (14) 14,791

VISN 4 10 (20) 25,479

VISN 5 4 (24) 29,908

VISN 6 2 (7) 54,568

VISN 7 9 (20) 62,690

VISN 8 10 (18) 54,296

VISN 9 15 (28) 27,190

VISN 10 3 (9) 19,839

VISN 11 2 (6) 23,544

VISN 12 0 (0) 21,094

VISN 15 12 (20) 22,049

VISN 16 5 (8) 58,278

VISN 17 5 (14) 47,707

VISN 18 8 (18) 30,791

VISN 19 5 (12) 24,593

VISN 20 13 (30) 35,241

VISN 21 11 (26) 27,317

VISN 22 4 (13) 38,919

VISN 23 16 (26) 24,353

Total 151 (17) 678,517

Source: GAO analysis of Veterans Health Administration data. | GAO-17-52

Note: Women veteran enrollment total includes enrollees not associated with a specific VISN.

Appendix V: Veterans Affairs (VA) Clinics 

Without a Women’s Health Primary Care 

Provider
Appendix VI: GAO Contact and Staff 

Acknowledgments

Page 46 GAO-17-52 VA Women Veterans’ Health Care

Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov

In addition to the contact named above, Marcia A. Mann (Assistant 

Director), Stella Chiang (Analyst-in-Charge), Carolyn Fitzgerald, Arushi 

Kumar, and Alexis MacDonald made key contributions to this report. Also 

contributing were Krister Friday, Jacquelyn Hamilton, Emily Wilson, and 

Vikki Porter.

Appendix VI: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(100352)
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