GAO

United States General Accounting Office

Chairman, Subcommittee on Oversight

and Investigations, Committee on

Veterans’ Affairs, House of

Representatives

November 2000 VA HEALTH CARE

Expanding Food

Service Initiatives

Could Save Millions

GAO-01-64

Page 1 GAO-01-64 Reducing Inpatient VA Food Service Costs

Contents

Letter 3

Appendixes Appendix I: Scope and Methodology 30

Appendix II: Locations Converting From Nutrition and Food Service

to Veterans Canteen Service Workers, April 2000 33

Appendix III: Comments From the Department of Veterans Affairs 34

Appendix IV: Comments From the American Federation of

Government Employees 39

Appendix V: GAO Contact and Staff Acknowledgments 45

Related GAO Products 46

Figures Figure 1: Reduction in Average Daily Inpatient Census,

FY 1995–FY 1999 6

Figure 2: VA Decrease in Food Service Workers, FY 1995–FY 1999 7

Figure 3: VA Inpatient Food Production Locations in Chicago Area 10

Figure 4: VA Inpatient Locations: Food Production Consolidations

and Candidates for Consolidation 12

Abbreviations

AFGE American Federation of Government Employees

NFS Nutrition and Food Services

OMB Office of Management and Budget

SPV Subsistence Prime Vendor

VA Department of Veterans Affairs

VCS Veterans Canteen Service
Page 2 GAO-01-64 Reducing Inpatient VA Food Service Costs
Page 3 GAO-01-64 Reducing Inpatient VA Food Service Costs

United States General Accounting Office

Washington, D.C. 20548 Letr

November 30, 2000

The Honorable Terry Everett

Chairman

Subcommittee on Oversight and Investigations

Committee on Veterans’ Affairs

House of Representatives

Dear Mr. Chairman:

The Department of Veterans Affairs (VA) provides food service for more

than 36,000 inpatients daily in its hospitals, nursing homes, and

domiciliaries.1 VA’s Nutrition and Food Services (NFS) program spends

about $324 million annually to provide these services in 177 inpatient

locations. About 70 percent of these expenditures are for the cost of labor

of 7,000 NFS wage-grade employees2 who cook and prepare food;

distribute food to patients; and retrieve and wash plates, trays, and

utensils.3

As agreed with your office, we assessed three major initiatives VA has

taken to lower the costs of its inpatient food services: (1) consolidation of

food production, (2) employing Veterans Canteen Service (VCS) workers to

provide inpatient food services, and (3) competitive sourcing to determine

if it is more cost effective to maintain services in-house or contract with the

private sector.4 We assessed the extent to which these initiatives have

reduced costs in some inpatient locations and what additional savings may

be possible if these initiatives are implemented in other locations.5

1

A VA domiciliary is a residential rehabilitation and health maintenance center for veterans

who do not require hospital or nursing home care but are unable to live independently

because of medical or psychiatric disabilities.

2

Numbers of employees in this report refer to full-time equivalent employees.

3

These costs represent the direct production and distribution costs of inpatient food

services. We excluded the clinical dietetic, technical, and administrative costs of NFS

dietitians and other general schedule employees.

4

VCS is a unit of VA that has authority to provide, at reasonable prices, merchandise and

services (for example, food and vending machines) at VA inpatient locations and other

health care locations (38 U.S.C. 7801).

5

For baseline data on VA’s inpatient food services, see VA Health Care: Food Service

Operations and Costs at Inpatient Facilities (GAO/HEHS-00-17, Nov. 19, 1999).
Page 4 GAO-01-64 Reducing Inpatient VA Food Service Costs

To conduct our work, we obtained data on food services from VA’s 22

health care networks for all VA’s inpatient locations for fiscal year 1999. We

also obtained data from VA headquarters officials and conducted site visits

and telephone interviews with local VA officials and with contractors. (See

app. I for a complete description of our scope and methodology.) Our work

was performed between October 1999 and November 2000 in accordance

with generally accepted government auditing standards.

Results in Brief To reduce the costs of inpatient food service operations over the past two

decades, about one-fifth of VA’s 177 inpatient locations have consolidated

food production, shifted to VCS workers, or contracted with private-sector

food service organizations. If VA systematically evaluated these options

and implemented the most cost-effective one at each inpatient location, VA

could save an estimated $79 million annually—about one-quarter of its

inpatient food service expenditures.

To enhance efficiency, VA has consolidated 28 food production locations

into 10. These locations transport food to other inpatient locations,

generally within 90 minutes’ driving distance. Currently, VA operates 63

unconsolidated production locations that are within similar driving

distance of another production location. Our assessment suggests that

consolidating these 63 locations into 29 production locations could save an

estimated $12 million annually. To achieve these savings, VA could be

required to make a one-time investment of an estimated $11 million for

equipment.

In addition, VA recently began to employ VCS workers, whose wage rates

are lower than NFS employees, to provide inpatient food services at nine

inpatient locations. The wage differences result from differences in how

wage rates for their respective pay schedules are determined, but both are

federal government employees with the same standard government benefit

coverage. VCS job descriptions are similar to those of NFS and both receive

similar training when providing inpatient food services. When VCS workers

provide inpatient food services, NFS dietitians continue to ensure that

patients at these locations receive quality nutrition as part of VA’s health

care program. Three other inpatient locations are scheduled to make the

change from NFS to VCS employees. Before these changes, VCS only

provided retail food services for employees, visitors, and outpatients at

these and other inpatient locations. NFS employees still provide inpatient

food service at 166 other inpatient locations; our assessment suggests that

having VCS employees provide inpatient food services at these 166
Page 5 GAO-01-64 Reducing Inpatient VA Food Service Costs

locations could save an estimated $67 million annually in addition to $12

million in estimated savings from consolidations.

VA also currently uses food service contractors to a limited extent.

Contractors provide food service at two VA long-term-care inpatient

locations that do not have VCS retail food services. VA may be able to

reduce costs through competitive sourcing at other locations to determine

if in-house or private sector operation is more cost effective. We cannot

estimate potential savings from competitive sourcing because of

uncertainty regarding the availability of interested contractors at each VA

location, the price of contractor services, and variability by location in VA’s

ability to decrease the costs of its in-house service delivery as part of a

competitive process. Difficulty in estimating potential savings is

compounded by NFS’s limited contracting experience and VCS’s

unwillingness to combine its retail business with NFS inpatient business

when contractors are solicited.

We recommend that VA systematically assess each inpatient food operation

to determine if consolidation, employment of VCS workers, competitive

sourcing, or a combination of these options would reduce costs while

maintaining quality, and then implement the least-costly options in a timely

manner. VA agreed in principle and stated that it has already initiated

actions to implement these recommendations. However, VA did not provide

concrete plans or timelines for implementing the least-costly options. By

contrast, the American Federation of Government Employees, AFL-CIO

(AFGE) opposed the use of all three options we recommended that VA

assess, citing a number of concerns. Foremost, AFGE questioned whether

VA should focus its cost containment strategies on efforts that, in its view,

could further impoverish current workers or compromise food quality.

While we understand and appreciate AFGE’s legitimate concerns about

current workers’ wages and employment and the quality of food provided

to veterans, we believe VA can adequately address these concerns when

implementing our recommendations.

Background In 1995, VA began transforming its delivery and management of health care

to expand access to care and increase efficiency. As part of this

transformation VA decentralized decision-making and budgeting authority

to 22 Veterans Integrated Service Networks, which became responsible for

managing all VA health care. The networks and their health care locations

became responsible for responding to changing inpatient food service

needs and for maintaining or improving quality.
Page 6 GAO-01-64 Reducing Inpatient VA Food Service Costs

Since 1995, the networks have focused on providing care in the most

appropriate setting by following headquarters’ guidance and responding to

performance measurement incentives. This has resulted in an increase in

outpatient care and a decrease in inpatient care. The inpatient average

daily census numbers have declined by 35 percent during this period (see

fig. 1).

Figure 1: Reduction in Average Daily Inpatient Census, FY 1995–FY 1999

Source: VA.

Because the decreased number of inpatients meant less need for food

services, VA downsized its inpatient food service staff by about 22 percent

as a result of actions taken by networks and inpatient locations (see fig. 2).

0

10,000

20,000

30,000

40,000

50,000

60,000

1995 1996 1997 1998 1999

56,283

50,812

42,798

39,685

36,510

Fiscal Year

Average Daily Census
Page 7 GAO-01-64 Reducing Inpatient VA Food Service Costs

Figure 2: VA Decrease in Food Service Workers, FY 1995–FY 1999

Note: Numbers of employees refer to full-time equivalent (FTEE) positions.

Source: GAO calculations based on data from VA.

Unlike most health care systems, VA divides its food service operations

into inpatient and retail operations, usually with separate kitchens and staff

at each inpatient location. The NFS program, funded by appropriations, is

responsible for ensuring that VA’s inpatients receive quality nutrition as an

integrated part of their health care. VCS is generally responsible for

providing food and other retail services to outpatients, visitors, and

employees at VA’s health care delivery locations. Although the law

authorizes VCS to receive appropriations, VCS has operated for many years

solely on funds earned from sales.

As with direct health care services, VA’s networks have also explored ways

to improve services that support health care, such as food service

operations. While VA networks have the option to focus exclusively on

improving the efficiency of in-house provision of food service, they also

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

1995 1996 1997 1998 1999

8958.7

8571.5

7786.1

7319.6

6977.8

FTEEs

Fiscal Year
Page 8 GAO-01-64 Reducing Inpatient VA Food Service Costs

have the option of competing their in-house operations versus contractors

to improve efficiency. VA could do this through the Office of Management

and Budget (OMB) Circular A-76 process. In the A-76 process, the

government identifies the work to be performed—described in the

performance work statement—and prepares an in-house cost estimate,

based on its most efficient organization, to compare with the best offer

from the private sector.

Additional

Consolidation of Food

Production Locations

Could Save Millions of

Dollars

To enhance the efficiency of food service, VA has consolidated food

production (the cooking and preparation of food) for 28 inpatient locations

into kitchens at 10 VA inpatient locations. One of these consolidations took

place in the Central Texas Healthcare System and resulted in elimination of

food production at two facilities. This example illustrates key elements of

the consolidation process. Before consolidation, the Temple, Waco, and

Marlin locations each produced their own food for average daily inpatient

populations of 664, 679, and 74, respectively. After consolidation, food for

Waco and Marlin was produced at Temple because adequate space was

available and driving distances (the time needed to transport food) to the

receiving locations were less than 90 minutes. The consolidation was

phased in over about 3 years and completed in 1998. The consolidation

required one-time equipment purchases of about $1 million and resulted in

recurring annual labor savings of about $1.3 million.6 Labor savings were

achieved by a reduction of 32 employees, primarily through attrition and

buyouts.

The Central Texas Healthcare System produces food in one location and

transports it to other locations using an advance food preparation and

delivery system. Food is prepared in advance and chilled for serving up to 5

days later. The chilled food can be transported in refrigerated trucks from

one location to another without losing freshness or becoming unsafe. The

food is reheated at the location where it is served. VA reports that patient

satisfaction at the Central Texas Health Care System is higher, as measured

by patient surveys, since consolidation. VA’s NFS dietitians continue to

have responsibility for ensuring food quality and that the nutrition needs of

patients are met.

6

No equipment purchase was required at Waco because it already had the equipment needed

for food delivery and reheating.
Page 9 GAO-01-64 Reducing Inpatient VA Food Service Costs

Additional VA health care regions provide opportunities for consolidation.

For example, four VA locations in the Chicago area are within a 1-hour

drive of one another (see fig. 3); in fact, three are within 20 minutes of each

other. Yet all four continue to prepare their own food for inpatients. The

Chicago network is developing plans for food consolidation for some of

these locations.
Page 10 GAO-01-64 Reducing Inpatient VA Food Service Costs

Figure 3: VA Inpatient Food Production Locations in Chicago Area

30

34

45

52

231

41

14 45

55

55

80

88

90

80

Lake

Michigan

North Chicago

Chicago Hines (Lakeside)

Chicago

(Westside)

ILLINOIS

WISCONSIN

ILLINOIS

INDIANA

94

0

0 10 Miles

10 KM

12

20

41
Page 11 GAO-01-64 Reducing Inpatient VA Food Service Costs

Source: GAO analysis.

Overall, VA currently has 63 unconsolidated production locations within 90

minutes’ drive of another production location.7 Our analysis suggests that

VA could increase its efficiency by consolidating food production for these

63 locations into 29 production locations (see fig. 4).8 These consolidations

could save an estimated $12 million annually from a reduction of 348

employees, with as many as 38 positions eliminated in a single location. To

achieve these savings, we estimate that VA may have to make a one-time

investment of an estimated $11 million to purchase advance food

preparation and delivery equipment. (One-time expenditures are held to

this amount because 24 of the potential consolidation locations already

own the advance food delivery equipment, which makes up the bulk of

equipment costs.)

7

We define consolidation as one VA location preparing at least 80 percent of the food

consumed at another location. Some consolidations do not reach 100 percent production at

one location for consumption at another because some receiving locations continue to

prepare certain food items, such as breakfasts or salads.

8

Some of these 29 locations already produce food for other VA locations.
Page 12 GAO-01-64 Reducing Inpatient VA Food Service Costs

Figure 4: VA Inpatient Locations: Food Production Consolidations and Candidates for Consolidation
Page 13 GAO-01-64 Reducing Inpatient VA Food Service Costs
Page 14 GAO-01-64 Reducing Inpatient VA Food Service Costs

Source: GAO analysis.

Making the changes required to consolidate food production requires

management commitment to a process that may take several years and

much effort to achieve but one that could yield significant savings.

Network officials indicated in our survey of VA’s health care networks that

29 production locations are considering or planning to consolidate food

production. In commenting on a draft version of this report, VA stated that

networks 1 (Boston), 3 (Bronx), 8 (Bay Pines), 12 (Chicago), and 22 (Long

Beach) have conducted feasibility studies to consider consolidated

production. VA has already consolidated some food production locations in

these networks. However, these networks could potentially consolidate 14

additional locations into 7 locations.

VA’s actual savings from consolidations could exceed our estimates for two

reasons. First, VA’s Central Texas Health Care System consolidation, from

which we obtained a benchmark for estimating potential savings, does not

appear to have yet achieved its full savings potential, which suggests that

our savings may be understated. VA officials have indicated that several

food service positions will not be filled when they become vacant. Some

positions were retained to minimize involuntary separation of employees.

Second, we used a 90-minute driving distance to determine potential

consolidations and it seems possible that VA could elect to use greater

distances. For example, the VA facility in Dayton is preparing and

delivering food as far as Butler, Pennsylvania—a 6-hour drive. The Dayton

facility has technologies that can keep food safely chilled for more than 30

days. In addition, two facilities in Texas that are about a 2-hour drive from

one another are currently in the process of consolidating their food

systems. Using greater travel distances could allow more facilities to be

consolidated, thereby increasing cost savings.

Expanded

Employment of VCS

Workers Could Save

Millions of Dollars

VA can save millions of dollars in labor costs by employing VCS workers,

rather than NFS workers, to provide inpatient food service. These savings

can be achieved because these workers are paid, on average, about 30

percent less than NFS wage grade employees. The wage differences

between the two result from differences in how wage rates for their

respective pay schedules are determined.9 VCS job descriptions are similar

9

The Office of Personnel Management developed the criteria used for both wage rate

schedules under 5 U.S.C. 5341.
Page 15 GAO-01-64 Reducing Inpatient VA Food Service Costs

to those of NFS and both receive similar training when providing inpatient

food services. VCS workers are federal government employees paid under

the Non Appropriated Funds Regular Wage Rate Schedule. NFS workers

are also federal government employees but are paid under the Federal

Wage System Regular and Special Production Facilitating Wage Rate

Schedule. Both VCS and NFS employees have the same standard

government benefit coverage. VA is able to employ VCS workers to provide

inpatient services through NFS agreements with VCS under the Economy

Act.10

Recently, nine VA locations began to employ VCS workers rather than NFS

workers to provide inpatient food services (see app. II for a list of these

locations). In some of these locations, VCS employees provide all inpatient

food services; in others VCS workers are only beginning to be included in

inpatient food services. In all cases, NFS dietitians continue to ensure food

service quality. Before these changes to VCS inpatient food service, VCS

had only provided retail food service at these locations.

Three of the locations converting to VCS labor were at Marion, Illinois, and

the Jefferson Barracks and John Cochran locations in St. Louis, Missouri.

These examples illustrate different stages of VCS conversion and different

sizes of health care facilities.

VA began its VCS conversion in Marion, Illinois, in 1997. Today, Marion

employs mostly VCS workers to serve an average daily census of 95

patients. VA reports that patient satisfaction is higher, as measured by

patient surveys, than it was before and that NFS dietitians continue to be

responsible for quality. When the conversion to VCS employees is

complete, VA estimates that $375,000 a year could be saved through

reductions in wage costs. NFS workers have left Marion inpatient food

service through normal attrition, including retirement, moving to other VA

jobs, or leaving VA voluntarily. Personnel changes were monitored by the

facility’s Labor Management Partnership Council, which included union

representation. Those employees who remain retain their NFS salaries.

St. Louis’s two locations began VCS integration in 1999. Today the

consolidated St. Louis locations serve an average daily census of 301

10The Economy Act (31 U.S.C. 1535) permits one government agency or a unit within an

agency to purchase services from a unit in the same agency or another agency when in the

best interest of the government.
Page 16 GAO-01-64 Reducing Inpatient VA Food Service Costs

inpatients by employing NFS employees and a VCS manager. Other VCS

employees are being recruited. When fully implemented, VA estimates that

St. Louis could save $803,000 in wage costs annually. St. Louis expects to

follow Marion’s experience in protecting current NFS employees’ job

security and salary and phasing in VCS conversion.

Our analysis suggests that VA could lower labor costs by an estimated $67

million annually (in addition to the estimated $12 million consolidation

savings discussed earlier) if less-expensive VCS workers are employed in

place of NFS workers at 166 additional locations. The Marion and St. Louis

experiences suggest that the full extent of these savings would be realized

over a number of years as VCS conversion is phased in. However, some

savings can be achieved in the first year of implementation. Currently, NFS

wage grade workers provide inpatient food services at these 166 locations.

VCS employees could cook and prepare food, distribute food to patients,

and retrieve and wash dishes, trays, and utensils for inpatients at these

locations while NFS dietitians continue to assure quality.

Three locations—Kansas City, Leavenworth, and Topeka—are scheduled to

begin conversion to VCS inpatient food service provision. In our survey of

VA health care networks, VA officials indicated that another location is

considering conversion. Making the changes required to convert to VCS

inpatient food service provision requires management commitment to a

process that may take several years and much effort to achieve but has the

potential for significant cost savings.

Actual savings may vary from our estimates because of many local factors

at each inpatient location. To determine actual savings through the use of

VCS employees, VA would need to conduct studies of each inpatient food

location and weigh alternatives for providing the lowest-cost food service

while maintaining quality. VA would also need to incorporate in this

process consideration of the effect such changes could have on other VA

priorities, such as maintaining job opportunities for veterans and

compensated work therapy patients.

A key element of such a study is recognition that VA’s inpatient food service

operations are developing along the lines of other hospital food service

operations, which are changing the nature of the hospital food service

industry. This includes the use of more pre-prepared food products, less

need for specialized cooking skills, and more reliance on computer

ordering for preparation and placement of food on patient trays. All of

these processes reduce both the need for a higher-skilled work force and
Page 17 GAO-01-64 Reducing Inpatient VA Food Service Costs

the degree of training needed to successfully produce and distribute

hospital food, whether VA inpatient food service is provided by NFS or

VCS. NFS and VCS managers agree that employees can be trained more

quickly today than in the past to provide inpatient food services. VCS

managers also believe that higher turnover rates for lower-paid employees

would not adversely affect services.

VA May Be Able to

Achieve Additional

Savings by Using

Competitive Sourcing

VA uses private contractors for inpatient food services at two inpatient

locations—Sodexho Marriott at its Anchorage domiciliary and SkyChef at

the Honolulu nursing home. These locations have no VCS retail food

services and have only a long-term-care inpatient mission. In addition, both

locations began inpatient food services with a contractor rather than with

NFS employees.

While VA has used competitive sourcing only to a limited extent, our

analysis suggests that VA may be able to lower costs by determining if inhouse or private sector provision of food services is more cost effective. VA

could realize additional savings by competing, through the use of OMB’s

Circular A-76, the costs of government provision of these services versus

the costs of private-sector provision. Our work at the Department of

Defense shows that, by competitive sourcing under OMB Circular A-76,

costs decline through increased efficiencies whether the government or the

private sector wins the competition to provide services.11 This work

indicates that savings are probable for VA, but we cannot estimate potential

savings from competitive sourcing because of uncertainty regarding the

availability of interested contractors at each VA location, the price of

contractor services, and the extent to which VA food services units are able

to decrease their operating costs in a competitive process.12

Savings from competitive sourcing might be higher if VA expanded

competitive sourcing to include locations that combine NFS inpatient and

VCS retail operations. When food contractors provide services to non-VA

hospitals, they usually operate both inpatient and retail as one operation

11See DOD Competitive Sourcing: Some Progress but Continuing Challenges Remain in

Meeting Program Goals (GAO/NSIAD-00-106, Aug. 8, 2000) for a discussion of the benefits of

competing various efficiency options using the OMB Circular A-76 process.

12See DOD Competitive Sourcing: Savings Are Occurring, but Actions Are Needed to

Improve Accuracy of Savings Estimates (GAO/NSIAD-00107, Aug. 8, 2000) for a discussion

of calculating savings under the OMB Circular A-76 process.
Page 18 GAO-01-64 Reducing Inpatient VA Food Service Costs

and most of their profits come from retail sales, according to food service

contractors with whom we spoke.

However, VA may not offer the most attractive business opportunity for

food contractors for two reasons. First, VCS opposes consideration of

contracting for retail food services because it uses profits from a minority

of profitable locations to subsidize operations at the remainder. Moreover,

VCS believes that some of its other retail activities, such as vending of

toiletries and personal articles that are not generally provided by food

service contractors, are not viable without retail food. This is important to

VCS because it receives no appropriations and funds its operations based

on revenues earned.

Second, the small size of VA inpatient workloads at many locations may be

less attractive to contractors because there is less opportunity to spread

fixed costs over higher volume. For example, 27 percent of VA locations

have an average daily census of less than 100 inpatients, and 56 percent

have an average daily census of less than 200. However, it may be possible

for potential contractors to combine food services at smaller locations with

services at other nearby VA and non-VA locations to generate higher

volume.

To achieve savings through competitive sourcing, VA would need to

conduct studies of each inpatient food location to weigh alternatives for

providing the lowest-cost food service while maintaining quality. In these

studies, VA would need to consider the effect such changes could have on

other VA priorities, such as maintaining job opportunities for veterans and

compensated work therapy patients. To date, however, VA has done little to

explore either its own experience with using contractors or contractor

interest. Although fostering competition among government and private

contractors to provide food services can be a time-consuming process, it

offers opportunities to create more efficient and less costly operations

when in-house organizations win the competition, or savings when private

competitors win. This process can be demanding, however, and requires

strong management commitment to achieve.

VA could foster competition among government and private providers in

the provision of inpatient food service by using the competitive process of

OMB’s Circular A-76. VA could compete all its food service operations or

any part of these services at each location. VA could consider competitive

sourcing alone or in combination with consolidation or use of VCS

employees, as we discussed earlier.
Page 19 GAO-01-64 Reducing Inpatient VA Food Service Costs

Conclusions VA has opportunities to save millions of dollars by systematically

considering consolidating food production, employing VCS workers to

provide inpatient food services, and competitive sourcing. VA already has

experience in implementing these options at a number of locations,

although VA’s experience with food service contractors is limited. VA has

not, however, systematically compared these options at all 177 inpatient

locations. Using a systematic approach to assess available options at each

location would allow VA to provide food service at the lowest cost

consistent with maintaining quality.

Recommendations for

Executive Action

We recommend that the Acting Secretary of Veterans Affairs direct the

Under Secretary for Health to direct the 22 networks to (1) systematically

assess each inpatient food service location to determine if consolidation,

employment of VCS workers, competitive sourcing, or a combination of

these options would reduce costs while maintaining quality; and (2)

implement the least-costly options in a timely manner.

Agency Comments and

Our Evaluation

We received written comments on a draft of this report from VA’s Acting

Secretary and the National President of AFGE. Their comments and our

responses are discussed in the following sections. The comments in their

entirety from VA and AFGE are in appendixes III and IV, respectively.

Department of Veterans

Affairs

VA agreed in principle with our recommendations, noting that it is already

consolidating food production locations, converting to VCS inpatient food

service provision, and using competitive sourcing. VA should be

commended for its progress to date. However, VA has not systematically

assessed each of these options at each location as we recommend. VA

stated that the three options we identified are part of its Nutrition and Food

Service strategic plan for improving quality and cost effectiveness. In our

review of the plan, we found the VCS option to be clearly identified.

However, the consolidation option discussed in the plan appears to deal

with NFS consolidation with other services rather than consolidating food

production locations and we found no reference to competitive sourcing.

In addition, we found no reference to the systematic assessments we

recommend. We believe the strategic plan could help VA implement our

recommendations if the plan clearly specified that all three options we
Page 20 GAO-01-64 Reducing Inpatient VA Food Service Costs

identified to reduce costs are to be systematically assessed for each

location.

Although VA agreed with our recommendation for timely implementation,

it provided no operational plan or timeline for conducting the assessments

we recommended. VA states that it is assessing the feasibility and

subsequent implementation of these options at a deliberate pace to

carefully consider relevant factors. We agree that VA should carefully

consider these factors but believe the recommended assessments should

be completed as expeditiously as possible. Delay means that millions of

dollars per year may be spent unnecessarily on food services.

VA expressed several specific concerns on a number of issues.

Consolidation of food production. VA raised issues regarding (1) the need

to do a study at each location, (2) transportation of perishable food, (3)

costs, (4) VA’s Subsistence Prime Vendor (SPV) program, and (5)

integration of NFS employees with environmental management services.

First, VA stated that studies of food consolidation have already been done

in Veterans Integrated Services Networks 1 (Boston), 3 (Bronx), 8 (Bay

Pines), 12 (Chicago), and 22 (Long Beach), suggesting that additional

studies are not needed at each location in these networks. We commend

VA’s efforts to study ways to reduce costs in these networks. However,

based on our discussions with NFS officials at several of these networks

and reviews of several of these studies, we disagree that VA has

systematically assessed all three options in each network. VA focused more

on the potential for consolidations, but this option may be even more costeffective if implemented in conjunction with the use of VCS employees or

competitive sourcing in these networks. Because VA has not assessed all

three options, it may not have identified the least-costly options in each

network.

Second, VA stated that the safety of transporting perishable food products

and related logistics are key factors in determining the viability of

consolidating VA facility food production. VA’s statement suggests that, as a

result, fewer locations may be able to consolidate than we estimated and

that the speed of consolidation could be slow. We agree that VA needs to

carefully consider these factors, but we factored in the transportation and

logistical issues in our analysis based on VA’s experience. As discussed in

the report, VA has successfully addressed these factors in 28 other

locations that are comparable to the potential locations we identified.

Therefore, we do not view such factors as reasons for not moving ahead
Page 21 GAO-01-64 Reducing Inpatient VA Food Service Costs

expeditiously but rather as factors that require strong management

commitment in order to realize potential savings.

Third, VA stated that large capital investment costs for equipment and

space are key factors affecting the viability of potential consolidations.

Again, we agree. However, investment costs must be assessed within the

context of potential savings. For example, once fully implemented the

savings realized in 1 year under the consolidation of food services in the

Central Texas Healthcare System exceeded the investment costs, making

that consolidation viable. We included in our assessments of the viability of

consolidation at other VA locations the costs of a blast chill system of food

production, such as that operated by the Central Texas Healthcare System,

and the costs of the related advanced food delivery equipment.13 Therefore,

the potential consolidation locations we identified could result in annual

savings greater than the required investment costs within a reasonable time

period.

Fourth, VA also stated that its SPV program needs to be considered in

consolidation decisions. The SPV program reduces the costs of food items

through high-volume purchases by all of VA and certain other government

agencies. We agree that the SPV program should be considered in

consolidation decisions at each location, but we are doubtful that this

would affect a decision on whether to consolidate. Our review of

consolidations showed that savings result from reduced labor costs, not

reduced food costs. Moreover, we are doubtful that the SPV program will

affect food costs in a consolidation because the same number of patients

will be fed whether consolidation occurs or not and all VA locations already

participate in the SPV program.

Fifth, VA stated that integration of NFS employees with environmental

management services should be considered in consolidations. NFS

integration with environmental management services includes having some

employees work in both services so that an employee with downtime in

food services can work in environmental services and vice-versa. Again, we

agree that this factor should be considered in consolidations at each

location, but it is unclear how this would affect a consolidation decision.

While integrating NFS workers with other services can reduce food

production costs without consolidation by shifting unneeded staff time and

charges to other services, it is unlikely to reduce costs to the degree they

13The blast chill system can chill food for up to 5 days before the food is consumed.
Page 22 GAO-01-64 Reducing Inpatient VA Food Service Costs

would be reduced in consolidation. Consolidation reduces costs primarily

through economies of scale whereby fewer workers in one location can

produce food for patients in two or more locations than the smallest

number of workers combined could produce food separately at each

location. Therefore, consolidation would provide greater cost savings. In

addition, NFS integration with environmental management services could

be included in a consolidation.

Employing VCS workers. VA raised issues regarding (1) time needed to

phase in conversions, (2) variability in savings by location, (3) separation

costs, and (4) training costs.

First, VA stated in its comments, and we agree, that the savings from

converting to VCS workers would take years to fully achieve. However, VA

officials told us that some savings are possible in the first year of

implementation. The magnitude of savings possible makes it worth the

effort even if several years are required to fully achieve savings. Our report

reflects this point. Our savings estimate of $67 million represents the total

potential annual cost reductions for employing VCS workers to provide

inpatient food services and not the savings that could be realized in fiscal

year 2001. VA would not realize the full savings at each location for a

number of years because VCS workers would only be phased in when NFS

workers left through normal attrition such as retirement, voluntarily

leaving for other VA jobs, or for jobs outside VA.

Second, VA stated that potential savings from employing VCS workers to

provide inpatient food services would vary from location to location,

making it difficult to project a total cost benefit at this time. We agree that

actual savings achieved would likely vary from location to location.

However, we estimated total potential savings assuming that VA’s locations

could save an average of about 30 percent of combined wage and benefit

costs. This rate approximates the rate VA is realizing in its conversion to

VCS employees at Marion, Illinois. VCS headquarters managers and

network and facility officials in the VCS conversions studied agreed that

using a 30 percent savings rate is reasonable for estimating nationwide

savings.

Third, VA also suggests that our estimated savings for employing VCS

workers are overstated because of additional separation costs for NFS

employees that would be required to implement this option. We do not

agree. In the VCS conversions we reviewed, NFS workers typically

continue working until they leave through normal attrition including
Page 23 GAO-01-64 Reducing Inpatient VA Food Service Costs

retirement, moving to other jobs in VA, or leaving VA voluntarily. Thus, no

special separation costs are incurred.

Fourth, VA states that training costs could reduce our estimated savings.

VA said these training costs would be for (1) NFS workers who leave food

service to take other VA jobs, (2) VCS employees who replace NFS

employees, and (3) part-time workers providing food service. We do not

agree that these costs would reduce our estimated savings. As previously

discussed, in VCS conversions NFS workers are expected to leave through

normal attrition such as retirement, voluntarily leaving for other VA jobs, or

voluntarily leaving for jobs outside VA. The training for NFS employees

taking other jobs would be required whether NFS or non-NFS employees

were hired for those jobs. Similarly, training for VCS employees replacing

NFS employees would be required whether the replacements were VCS or

other employees. Finally, both VCS and NFS already use many part-time

workers and VA indicates it will continue this strategy. As a result, these

training costs would be required in any event and are not additional costs.

Competitive sourcing. Although VA concurred with our recommendation to

consider competitive sourcing as an option in providing food services, VA

raised concerns about the opportunities to use contractors in VA’s inpatient

settings. We agree, as stated in the report, that VA may not offer the most

attractive business opportunity for food contractors because of VA’s unique

structure for providing inpatient and retail food services separately at its

locations and because of the small inpatient workload at most locations.

Because of these and other uncertainties we could not estimate the number

of locations that could benefit from competitive sourcing or the potential

savings. Nonetheless, we believe that competitive sourcing should be

considered because of its potential to increase efficiency. As previously

discussed, our work in other areas has shown that the competitive sourcing

process reduces costs through increased efficiency whether the

government or a contractor wins the competition to provide services.

American Federation of

Government Employees

AFGE opposed all three options we included for study in our

recommendations, expressing a number of concerns regarding these

options. AFGE’s overarching concern is whether VA should focus its cost

containment strategies on efforts that, in its view, could further impoverish

current workers or compromise food quality. While we understand and

appreciate AFGE’s legitimate concerns about current workers’ wages and

employment and the quality of food provided to veterans, we believe VA

can adequately address these concerns when implementing our
Page 24 GAO-01-64 Reducing Inpatient VA Food Service Costs

recommendations. In the past, VA has demonstrated the ability to

implement comparable options without adversely affecting food service

workers. Further, our discussions with VA officials indicate that they

remain sensitive to the importance of taking appropriate steps to prevent

adverse effects on current food service workers.

We discuss AFGE’s specific concerns below.

Employing VCS workers. AFGE expressed six concerns about employing

VCS workers in place of NFS workers to provide inpatient food service.

First, AFGE stated that our estimate of $67 million in annual savings from

employing VCS workers is misleading. AFGE said that the savings we

estimated would be a one-time occurrence and establish a new baseline

once achieved. We do not agree. Because there is no specific appropriation

for inpatient food services, VA will not return savings from its food service

operations to the U.S. Treasury and thereby establish a new lower baseline

budget for VA. Rather, VA retains the savings achieved through

management efficiencies in its budget, thereby making the savings

available for other purposes in each subsequent year.

Second, AFGE suggested that part of the savings we estimated are based

on the government paying less for its match of employee health care

premiums because lower-paid VCS employees will less frequently

participate in government-sponsored health care plans than NFS

employees. We did not assume that government costs would be less

because fewer VCS workers would participate in government-sponsored

health care plans than NFS workers. Information provided by VA shows

that the proportion of NFS and VCS workers currently purchasing health

insurance through government plans is 32 and 25 percent, respectively.

Third, AFGE said that our estimated savings for VA in employing VCS

workers are overstated because they do not include increased federal costs

for programs such as Medicaid, the Earned Income Tax Credit, the CHIP

(Children’s Health Insurance Program), Head Start, Housing and Urban

Development rent subsidies, and other expenses related to increasing the

ranks of the working poor. We disagree that our savings are overstated

because our assessment of VA’s recent experience suggests there would be

little or no additional costs to other federal programs as a result of VCS

conversion. Based on VA’s experience to date, no NFS worker has had his

or her wages reduced or lost employment under the VCS conversions we

reviewed and no VCS worker was required to accept lower wages and

benefits than they already had or could obtain elsewhere. In VCS
Page 25 GAO-01-64 Reducing Inpatient VA Food Service Costs

conversions, NFS workers are being replaced as a result of normal

attrition, including retirement, voluntarily moving to other jobs in VA, or

voluntarily leaving for non-VA jobs. As such, the departing NFS workers

would have the same impact on other federal programs as if there were no

VCS conversion. Current VCS workers who replace NFS workers maintain

their wages and benefits and therefore have no impact on other federal

programs. Newly-hired VCS workers who replace NFS workers choose

VCS over other employment opportunities. Presumably, wages for these

new workers are competitive with wages in jobs these workers otherwise

would have taken.

Fourth, AFGE raised questions regarding the legality of VCS providing

inpatient food services in place of NFS employees under the Economy Act.

AFGE questioned if VCS could enter into an agreement under the Economy

Act and supervise civil service employees, such as NSF employees, and if

VCS and NFS employees with similar job descriptions could be paid

different wages. We found no legal deficiency in these areas under VA’s use

of the Economy Act. An “instrumentality of the United States,” VCS is

authorized to receive and has received appropriated funds credited to a

revolving fund. VCS’s revolving fund is a permanent, indefinite

appropriation available to cover its operating expenses. Therefore, we

agree with VA that VCS can be a party to an agreement under the Economy

Act. In addition, VCS employees hold “excepted” positions within the

federal civil service and are not barred from supervising NFS employees.

Finally, VCS employee positions are exempt under 38 U.S.C. 7802 (5) from

requirements of title 5 of the United States Code regarding equal pay and

VCS employees are subject to a different pay scale than NFS employees.

Fifth, AFGE said that it will take years to realize the estimated savings. We

agree that it will take years to fully realize these savings, as our discussion

of Marion and St. Louis indicate, but some savings can begin to accrue in

the first year of implementation. Moreover, the amount of savings possible

makes it worth the effort even if several years are required to fully achieve

them.

Sixth, AFGE said that higher VCS turnover rates will create problems for

converting to VCS provision of inpatient food services. We do not agree.

Based on experience to date, VCS managers at headquarters and at Marion

have stated that turnover has not affected their ability to provide inpatient

food services or affected quality.
Page 26 GAO-01-64 Reducing Inpatient VA Food Service Costs

Consolidation of food production. AFGE expressed two concerns related

to consolidation of food production and incorrectly stated that we said that

VCS opposes consolidation. First, AFGE said that our estimates of kitchen

consolidation savings are overstated because we underestimate the

financial and practical costs of losing in-house food production. We do not

agree. Our savings estimates account for additional costs required by

consolidation that were identified by VA officials and representatives of the

food service industry who have consolidated food production locations. As

we discuss in our evaluation of the Central Texas Healthcare System, our

savings model is conservative and probably understates savings.

Second, AFGE stated that consolidations lower the quality of food

provided to veterans. For example, AFGE expresses concerns regarding

frozen food and other issues. We disagree. As we discussed in the report,

VA reports that patient satisfaction increased at the Central Texas

Healthcare System after consolidation, as measured by improvements in

the taste and temperature of food. The Central Texas Healthcare System

received an award from VA headquarters for reducing costs and

maintaining quality in its consolidation activities. The award included

citations for (1) provision of consistently high-quality meals, (2)

improvements in timeliness, (3) increased patient satisfaction, and (4)

maintenance of quality controls. Moreover, in all VA locations that

consolidate, NFS dietitians continue to have quality control responsibility

to ensure that veterans’ nutrition needs are met.

AFGE also stated that we noted that VCS opposes privatization and

centralization. We said that VCS opposes privatizing the services it

provides, but we did not say that VCS opposes consolidation. In fact, VCS

officials told us that VCS does not oppose consolidation.

Competitive sourcing. AFGE expressed five concerns about competitive

sourcing. First, AFGE stated that there is no evidence that contracting

saves money. We believe it is important to distinguish between an objective

to contract and an objective to compete government versus private service

provision. Our recommendation is that VA consider competitively sourcing

food service operations rather than outright contracting as an end in itself.

Competitive sourcing can result in the government either retaining its

position as service provider, or contracting with a private provider. As we

have discussed, our work shows that competitive sourcing reduces cost

through increased efficiency. The costs are reduced whether government

or the private contractor wins the competition. We believe it would be a
Page 27 GAO-01-64 Reducing Inpatient VA Food Service Costs

mistake to eliminate the competitive sourcing option for reducing VA’s

costs.

Second, AFGE expressed concern as to whether VA would use the OMB

Circular A-76 process for competitive sourcing or contract without the

benefit of a public-private competition. We agree that VA could, under

limited circumstances specified in OMB’s Circular A-76, convert to contract

performance without cost comparison. However, our recommendation to

VA was that it consider competitive sourcing rather than contracting. VA

agreed in principal with our recommendation.

Third, AFGE also expressed concern about the quality of food service

under contracting. We do not share AFGE’s concern because the same

quality controls VA currently uses for in-house provision of food service

could be included and enforced in the contract if a private firm chooses to

compete and wins the competition under competitive sourcing. We note

that some of VA’s medical affiliates, including major university hospitals,

provide inpatient food service through contractors.

Fourth, AFGE expressed concern that veterans currently employed in VA’s

in-house food production could lose their jobs if a contractor wins the

competition. We agree this is possible. As stated in the report, we believe

that VA should include this as a consideration in its assessments of food

service at each location. We note, however, that government employees

adversely affected by decisions under the OMB A-76 process competition

often are offered positions with winning contractors. VA could specify, as

other agencies have, that a contractor hire such employees if it wins the

competitive sourcing competition.

Fifth, AFGE stated that there is little opportunity for a contractor to

provide services less expensively than VA if VA uses lower-paid VCS

employees. AFGE believes that the only way to lower costs in contracting

is to lower wages and does not believe this is possible if a contractor is

competing with VCS’s wage rates. We disagree. Competitive sourcing is an

incentive to both government and the contractor to increase efficiency as

much as possible to achieve cost reductions. These increased efficiencies

can be achieved through improvements in process operations that reduce

the amount of capital or human resources needed to process the same

workload.
Page 28 GAO-01-64 Reducing Inpatient VA Food Service Costs

As arranged with your staff, we are sending copies of this report to the

Honorable Hershel W. Gober, Acting Secretary of Veterans Affairs;

interested congressional committees; and other interested parties. We will

make copies available to others upon request.

If you have any questions about this report, please call me at (202) 512-

7101. Other staff who contributed to this report are listed in appendix V.

Sincerely yours,

Stephen P. Backhus

Director, Health CareVeterans’ and

Military Health Care Issues
Page 29 GAO-01-64 Reducing Inpatient VA Food Service Costs
Page 30 GAO-01-64 Reducing Inpatient VA Food Service Costs

Appendix I

Scope and Methodology ApApenednxidexiIs

We reviewed the Department of Veterans Affairs (VA) inpatient food

services for fiscal year 1999 to assess potential savings nationwide if VA

were to implement system-wide the three types of initiatives it has used in

some of its VA inpatient health care locations: (1) consolidating food

production, (2) employing Veterans Canteen Service (VCS) rather than

Nutrition and Food Service (NFS) workers to provide inpatient food

services, and (3) competitive sourcing.

We interviewed VA headquarters officials in NFS, VCS, the Office of

General Counsel, and other offices. We obtained documents from

headquarters on the consolidation of food service, the use of VCS labor,

and contracting with private food service contractors.

We obtained data on food services at each inpatient location by surveying

each Veterans Integrated Service Network. We obtained information on

food service needs, how VA provides services, costs, and number of meals

at each VA inpatient location. Networks and locations also provided us

with information on advance food technologies and excess capacity, and

with additional information on consolidating food services, the use of VCS,

and private contractors.

We also obtained additional data through interviews, documents, and

physical inspections of kitchen facilities and food delivery at VA locations.

We visited Veterans Integrated Service Network 17 (Dallas) locations in

Temple, Marlin, Waco, and Dallas. We also visited locations in Marion,

Illinois, and Jefferson Barracks and John Cochran in St. Louis, Missouri, in

Veterans Integrated Network 15 (Kansas City).

To estimate savings from consolidation, we first identified areas with

multiple food production locations, using the criterion that two or more

locations were located within 90 minutes’ driving distance of each other.

We then examined the combined workloads and costs of unconsolidated

locations in these markets to determine whether savings could be achieved

through consolidation. Locations were considered to be already

consolidated if they received 80 percent or more of their food from another

location or produced 80 percent or more of the food for another location.

Our analysis of VA cost data and discussions with VA officials suggested

that the ratio of employees to the average number of daily patients (average

daily inpatient census) is an appropriate measure for benchmarking

savings in food services. We confirmed this relationship using 1999 data by

regressing average daily patients on total employees. The resulting model
Appendix I

Scope and Methodology

Page 31 GAO-01-64 Reducing Inpatient VA Food Service Costs

showed that the average daily patients accounted for 86 percent of the

variation in staffing.

We computed savings estimates for the consolidations using the staffing

ratio of one employee per 6.7 average daily patients. This staffing ratio was

achieved by the Central Texas Healthcare System after completing

consolidation of inpatient food services at Temple, Marlin, and Waco. To

validate this measure we spoke to VA officials representing both NFS and

VCS, who agreed that using the Central Texas Healthcare System staffing

ratio after consolidation was a reasonable, perhaps conservative, estimate

of achievable staffing levels. Some VA production locations, in fact, are

more efficient (lower ratio of employees to the average number of daily

patients) than operations at the Central Texas Healthcare System.

To calculate total savings from food consolidation we first multiplied the

total average number of daily patients of the proposed market by the

Central Texas Healthcare System staffing ratio (one employee per 6.7

average daily patients) to arrive at a projected employee total for the

consolidated market.1 We then subtracted this projected total from the

fiscal year 1999 employee total of the individual locations in an area to

determine the number of employees not needed, if any. Cost savings for the

area were computed by multiplying the number of positions saved by the

average salary costs of NFS wage grade, including benefits, within each

market. We aggregated savings from each market to determine the total

savings from food consolidation.

The one-time investment for equipment was estimated by assuming that

one location in each consolidated area required an advance food

preparation system and every location required an advance food delivery

system. To project the total cost of advance food preparation equipment (a

fixed cost that includes items such as the blast chiller), we multiplied the

cost of Central Texas Healthcare System’s advance food preparation

system (purchase amount adjusted to 1999 dollars) by the number of

locations within areas that required this system. We calculated the total

cost for the advance food delivery systems (a variable cost that includes

items such as reheating carts, trays, and plates) by multiplying the total

average daily patients of locations without this system by Central Texas

1

We adjusted the average daily inpatient census workload of locations where NFS provides

noninpatient meals (or provides meals to non-VA locations) by adding one inpatient to the

average daily inpatient census for three noninpatient meals served daily.
Appendix I

Scope and Methodology

Page 32 GAO-01-64 Reducing Inpatient VA Food Service Costs

Healthcare System’s cost per average daily patients (adjusted to 1999

dollars).

We calculated the costs of transporting food from a central location using

data obtained from the Central Texas Healthcare System. To project the

total costs of transportation for the consolidated areas, we multiplied the

annual cost of one leased refrigerated truck by the total number of

consolidated areas. Because this cost recurs each year, we subtracted this

cost from the annual recurring savings from consolidation.

We determined the potential savings from converting from NFS to VCS

labor by applying a 30 percent savings reduction to NFS employee costs.

VCS salaries are based on the Department of Defense’s survey of food

service worker wages in a local area, and are competitive with the private

sector. Nationally, NFS salaries average about 70 percent of total NFS food

production costs. VCS salaries are normally about 30 percent below NFS

salaries. VCS headquarters established this percentage, and network and

facility officials have agreed that using a 30 percent savings rate is

reasonable.

We also conducted a literature review of the food services industry,

interviewed selected non-VA food service officials and officials from the

private vendor sector and food service industry organizations, and visited

contractor food production facilities.

We validated survey data used to construct cost estimates by comparing

questionable data supplied on the 1999 survey with VA data sources. When

necessary, we also contacted survey respondents and/or VA officials to

clarify or correct data. We performed our review between October 1999

and November 2000 in accordance with generally accepted government

auditing standards.
Page 33 GAO-01-64 Reducing Inpatient VA Food Service Costs

Appendix II

Locations Converting From Nutrition and

Food Service to Veterans Canteen Service

Workers, April 2000 ApendxiI

a

NFS dietitians continue to provide quality assurance but are not part of the inpatient food service

workforce.

b

Food is produced at Tampa, Florida, location.

c

VCS food manager is on staff at the St. Louis consolidated locations; recruiting continues for other

VCS positions.

d

Most food is produced at St. Louis Jefferson Barracks location.

VA inpatient

location

Year conversion

agreement signed

Percentage VCS

inpatient food

service workforcea

1999 Average daily

census

Martinez, California 1996 100 97

Marion, Illinois 1997 70 95

Poplar Bluff, Missouri 1998 41 50

Wichita, Kansas 1998 21 36

Columbia, Missouri 1999 13 88

Mather, California 1999 100 9

Orlando, Floridab 1999 100 10

St. Louis Jefferson

Barracks, Missouric 1999 0d 218

St. Louis John

Cochran, Missouric 1999 0d 83
Page 34 GAO-01-64 Reducing Inpatient VA Food Service Costs

Appendix III

Comments From the Department of Veterans

Affairs ApendxiI
Appendix III

Comments From the Department of Veterans

Affairs

Page 35 GAO-01-64 Reducing Inpatient VA Food Service Costs
Appendix III

Comments From the Department of Veterans

Affairs

Page 36 GAO-01-64 Reducing Inpatient VA Food Service Costs
Appendix III

Comments From the Department of Veterans

Affairs

Page 37 GAO-01-64 Reducing Inpatient VA Food Service Costs
Appendix III

Comments From the Department of Veterans

Affairs

Page 38 GAO-01-64 Reducing Inpatient VA Food Service Costs
Page 39 GAO-01-64 Reducing Inpatient VA Food Service Costs

Appendix IV

Comments From the American Federation of

Government Employees ApendxiIV
Appendix IV

Comments From the American Federation of

Government Employees

Page 40 GAO-01-64 Reducing Inpatient VA Food Service Costs
Appendix IV

Comments From the American Federation of

Government Employees

Page 41 GAO-01-64 Reducing Inpatient VA Food Service Costs
Appendix IV

Comments From the American Federation of

Government Employees

Page 42 GAO-01-64 Reducing Inpatient VA Food Service Costs
Appendix IV

Comments From the American Federation of

Government Employees

Page 43 GAO-01-64 Reducing Inpatient VA Food Service Costs
Appendix IV

Comments From the American Federation of

Government Employees

Page 44 GAO-01-64 Reducing Inpatient VA Food Service Costs
Page 45 GAO-01-64 Reducing Inpatient VA Food Service Costs

Appendix V

GAO Contact and Staff Acknowledgments ApendxiV

’

GAO Contact Paul R. Reynolds, (202) 512-7109

Staff

Acknowledgments

Deborah L. Edwards, James C. Musselwhite, William R. Stanco, John R.

Kirstein, Thomas A. Walke, Elsie M. Picyk, Susan Lawes, John G. Brosnan,

and Roger J. Thomas contributed to this report.
Page 46 GAO-01-64 Reducing Inpatient VA Food Service Costs

Related GAO Products

VA Laundry Service: Consolidations and Competitive Sourcing Could Save

Millions (GAO/01-61, Nov. 30, 2000).

VA Health Care: VA Is Struggling to Respond to Asset Realignment

Challenges (GAO/T-HEHS-00-91, Apr. 6, 2000).

VA Health Care: VA Is Struggling to Address Asset Realignment Challenges

(GAO/T-HEHS-00-88, Apr. 5, 2000).

VA Health Care: Laundry Service Operations and Costs (GAO/HEHS-00-16,

Dec. 21, 1999).

VA Health Care: Food Service Operations and Costs at Inpatient Facilities

(GAO/HEHS-00-17, Nov. 19, 1999).

Veterans’ Health Care: Fiscal Year 2000 Budget (GAO/HEHS-99-189R, Sept.

14, 1999).

VA Health Care: Improvements Needed in Capital Asset Planning and

Budgeting (GAO/HEHS-99-145, Aug. 13, 1999).

VA Health Care: Challenges Facing VA in Developing an Asset Realignment

Process (GAO/T-HEHS-99-173, July 22, 1999).

VA Health Care: Progress and Challenges in Providing Care to Veterans

(GAO/T-HEHS-99-158, July 15, 1999).

Veterans’ Affairs: Progress and Challenges in Transforming Health Care

(GAO/T-HEHS-99-109, Apr. 15, 1999).

VA Health Care: Capital Asset Planning and Budgeting Need Improvement

(GAO/T-HEHS-99-83, Mar. 10, 1999).

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