U.S. GOVERNMENT PUBLISHING OFFICE

31–207 PDF WASHINGTON : 2018

S. HRG. 115–323 

GAO’S HIGH-RISK LIST AND THE VETERANS 

HEALTH ADMINISTRATION 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FIFTEENTH CONGRESS 

FIRST SESSION 

MARCH 15, 2017 

Printed for the use of the Committee on Veterans’ Affairs 

( 

Available via the World Wide Web: http://www.fdsys.gov 

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

JOHNNY ISAKSON, Georgia, Chairman 

JERRY MORAN, Kansas 

JOHN BOOZMAN, Arkansas 

DEAN HELLER, Nevada 

BILL CASSIDY, Louisiana 

MIKE ROUNDS, South Dakota 

THOM TILLIS, North Carolina 

DAN SULLIVAN, Alaska 

JON TESTER, Montana, Ranking Member 

PATTY MURRAY, Washington 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

RICHARD BLUMENTHAL, Connecticut 

MAZIE K. HIRONO, Hawaii 

JOE MANCHIN III, West Virginia 

THOMAS G. BOWMAN, Staff Director 1

ROBERT J. HENKE, Staff Director 2

TONY MCCLAIN, Democratic Staff Director 

Majority Professional Staff 

Amanda Meredith 

Gretchan Blum 

Leslie Campbell 

Maureen O’Neill 

Adam Reece 

David Shearman 

Jillian Workman 

Minority Professional Staff 

Dahlia Melendrez 

Cassandra Byerly 

Jon Coen 

Steve Colley 

Simon Coon 

Michelle Dominguez 

Eric Gardener 

Carla Lott 

Jorge Rueda 

1Thomas G. Bowman served as Committee majority Staff Director through September 5, 

2017, after being confirmed as Deputy Secretary of Veterans Affairs on August 3, 2017. 2 Robert J. Henke became the Committee majority Staff Director on September 6, 2017. 

(III) 

C O N T E N T S 

MARCH 15, 2017 

SENATORS 

Page 

Tillis, Hon. Thom, U.S. Senator from North Carolina .......................................... 1 

Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana ...................... 1 

Rounds, Hon. Mike, U.S. Senator from South Dakota ......................................... 29 

Murray, Hon. Patty, U.S. Senator from Washington ........................................... 31 

Boozman, Hon. John, U.S. Senator from Arkansas .............................................. 33 

WITNESSES 

Draper, Debra A., Ph.D., Director, Health Care Team, Government Accountability Office ......................................................................................................... 2 

Prepared statement .......................................................................................... 5 

Response to posthearing questions submitted by: 

Hon. Jon Tester ............................................................................................. 37 

Hon. Mazie K. Hirono ................................................................................... 39 

Hon. Sherrod Brown ..................................................................................... 40 

Missal, Michael J., Inspector General, U.S. Department of Veterans Affairs; 

accompanied by John D. Daigh, Jr., M.D., CPA, Assistant Inspector General 

for Healthcare Inspections, Office of Inspector General ................................... 14 

Prepared statement .......................................................................................... 15 

Response to posthearing questions submitted by: 

Hon. Jon Tester ............................................................................................. 43 

Hon. Mazie K. Hirono ................................................................................... 44 

Hon. Joe Manchin III ................................................................................... 44 

Hon. Sherrod Brown ..................................................................................... 45 

Clancy, Carolyn M., M.D., Deputy Under Secretary for Health for Organizational Excellence, Veterans Health Administration, U.S. Department of Veterans Affairs; accompanied by Jennifer Lee, M.D., Deputy Under Secretary 

for Health for Policy and Services; and Amy Parker, Executive Director 

of Operations, Office of Management ................................................................. 21 

Prepared statement .......................................................................................... 22 

Response to request arising during the hearing by: 

Hon. Thom Tillis ........................................................................................... 27 

Hon. Jon Tester ............................................................................................. 28 

Hon. Patty Murray ........................................................................................ 32 

Response to posthearing questions submitted by: 

Hon. Jon Tester ............................................................................................. 46 

Hon. Richard Blumenthal ............................................................................ 49 

Hon. Mazie K. Hirono ................................................................................... 50 

Hon. Joe Manchin III ................................................................................... 51 

Hon. Sherrod Brown ..................................................................................... 53 

(1) 

GAO’S HIGH-RISK LIST AND THE VETERANS 

HEALTH ADMINISTRATION 

WEDNESDAY, MARCH 15, 2017 

U.S. SENATE, COMMITTEES ON VETERANS’ AFFAIRS, Washington, DC. 

The Committee met, pursuant to notice, at 2:30 p.m. in room 

418, Russell Senate Office Building, Hon. Thom Tillis, presiding. 

Present: Senators Boozman, Rounds, Tillis, Tester, Murray, and 

Brown. 

OPENING STATEMENT OF HON. THOM TILLIS, 

U.S. SENATOR FROM NORTH CAROLINA 

Senator TILLIS. I call the hearing to order. Thank you all for 

being here. Senator Isakson is out today and I will be standing in. 

Senator Boozman is at a meeting where he should be joining us 

and taking the gavel shortly. 

We all continue to wish the very best for Senator Isakson who 

is recovering from back surgery. He submitted a statement in a 

prior meeting. Although the reality is I am wearing this bow tie, 

which is a University of Georgia bow tie, because I am repaying a 

bet that I lost, but since I am sitting in his chair for a little bit 

today I am going to say I am doing it in honor of Senator Isakson. 

I would like to welcome the witnesses. Then, we are going to 

defer to Senator Tester to allow him to make his opening statement. He has a meeting outside, in the anteroom, which we will 

let him move to. I want to thank the witnesses on the panel today. 

Senator Tester, I will wait until after your opening statement, in 

the interest of time, to introduce the witnesses. 

OPENING STATEMENT OF HON. JON TESTER, 

RANKING MEMBER, U.S. SENATOR FROM MONTANA 

Senator TESTER. Thank you, Chairman Tillis. I very much appreciate the hospitality, and thank you all for being here today. 

As many of you know, we had a hearing on GAO’s High-Risk List 

a few weeks ago at the Homeland Security and Government Affairs 

Committee. During the questioning of the Comptroller, Gene 

Dodaro, who is a guy that I like a lot, who works really tirelessly 

to help agencies work more effectively and save taxpayer dollars, 

he told me that he was very concerned about the VA’s reaction to 

its inclusion on the list. 

Chief among his concerns is that the VA did not seem to move— 

did not seem overly interested in doing what it takes to be removed 

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cern the panelists and something that should concern everybody. 

Dr. Clancy, I would love to hear from you whether the VA is being 

productive in addressing those GAO concerns and whether there is 

an appropriate sense of urgency, because, I want to tell you, the 

fact that the VA has not fully met the action plan for getting off 

the list is worrisome in and of itself. 

Meanwhile, recent reports from the VA Inspector General, including one about VA in Montana that was released late last week, 

indicate that the problems that caused GAO to add it to this list 

are still occurring. According to that report—and the IG is here— 

according to that report, the IG found that steps have been taken 

to improve consult time, in addition, and address factors that contribute to future delays at Fort Harrison in Montana, but that is 

little solace to the four veterans who are identified in that report 

as being potentially harmed by the consult backlog. 

On behalf of them and the veterans seeking care at facilities 

across this country, we need to do better, the VA has to do better. 

I think you guys realize that, but I want you to know. 

I will hold everybody at the VA accountable for this. Secretary 

Shulkin knows this, and he also knows we will hold everybody in 

the leadership team accountable too, including the team at Fort 

Harrison. 

If done right, VA’s action and response to the GAO concerns can 

leave that agency and, more importantly, the veterans of this country in a better place, which is what we want. We want the best 

services and care for our veterans. 

I want to thank you again for calling this hearing. It is always 

good to work with the good Senator from North Carolina. This is 

an important topic and I think it has bipartisan support. 

Senator TILLIS. Thank you, Senator Tester. 

We are welcoming to the panel today Debra Draper, Ph.D., Director, Health Care Team, Government Accountability Office; Michael 

Missal, Inspector General, Department of Veterans Affairs. I think 

that he is accompanied by Dr. John Daigh—did I pronounce that 

correctly?—Assistant Inspector General for Healthcare Inspections, 

Office of the Inspector General; Carolyn M. Clancy, M.D., Deputy 

Under Secretary for Health for Organizational Excellence, Department of Veterans Affairs; Jennifer Lee, M.D., Deputy Under Secretary for Health for Policy and Services, Department of Veterans 

Affairs; and Amy Parker, Executive Director of Operations, Office 

of Management, Department of Veterans Affairs. 

If you all would like to begin with your opening statements; we 

will just go from left to right. If we can keep those tight so we can 

get to questions I would appreciate it. 

STATEMENT OF DEBRA A. DRAPER, Ph.D., DIRECTOR, HEALTH 

CARE TEAM, U.S. GOVERNMENT ACCOUNTABILITY OFFICE 

Ms. DRAPER. Chairman Tillis, Ranking Member Tester, and 

Members of the Committee. I appreciate the opportunity to be here 

today to discuss the status of veterans’ health care as a high-risk 

area. In my testimony today, I will focus on the concerns that led 

to this designation, what actions VA has taken in response, and 

what additional actions are needed to ensure progress and eventual 

removal from the list. 

3 

Veterans’ health care was added to GAO’s High-Risk List for the 

first time in 2015, because of concerns about VA’s ability to ensure 

the timeliness, cost-effectiveness, quality, and safety of the care 

provided to veterans. In designating veterans’ health care as high 

risk, we categorize our specific concerns into five categories: (1) ambiguous policies and inconsistent processes; (2) inadequate oversight and accountability: (3) information technology challenges; (4) 

inadequate training for VA staff; and (5) unclear resource needs 

and allocation priorities. 

At the time, we were also concerned that VA had not implemented more than 100 GAO recommendations related to veterans’ 

health care, and many had been open for three or more years. 

Last month, as we do every 2 years, at the start of each new 

Congress, we updated our High-Risk List and reported on progress 

made by each area on our list, including veterans’ health care. We 

assess progress and potential for removal from the list based on 

five criteria: leadership commitment; capacity, in terms of people 

and resources; an action plan; monitoring; and demonstrated 

progress. 

Our assessment is that VA has taken some, albeit exceedingly 

limited actions, to address the concerns that led to its high-risk 

designation. For example, some leadership actions have been 

taken, including the establishment of a task force, working groups, 

and a governance structure to address the concerns. Additionally, 

VA leadership provided us with an action plan in August, in which 

they acknowledged the deep-rooted nature of the concerns and stated that addressing these would require substantial time and work. 

Based on these actions, we concluded that VA had partially met 

the high-risk removal criteria of leadership commitment and an action plan, and had made no progress with regard to the other three 

criteria: capacity; monitoring; and demonstrated progress. 

I want to be very clear that even in the areas where VA has 

made some progress, there is a long path toward fully meeting the 

criteria. For example, the action plan submitted to us lacked many 

critical elements, including an analysis of the root causes for each 

of the categories of concern, a critical step to better understanding 

why the problem exists, and what specifically needs to be addressed; reasonable timelines, given the significant scope of the efforts needed; clear metrics necessary for measuring and monitoring 

progress; and finally, the plan lacked an assessment of the resources needed for implementation. 

We also continue to be concerned about the large number of open 

recommendations, and while VA has taken actions to address some 

of these, considerable work remains. As I noted at the time of its 

high-risk designation in 2015, VA had more than 100 open GAO 

recommendations related to veterans’ health care. Seventy-four 

new recommendations have been added since then. Currently, 

there are still more than 100 open recommendations and about a 

quarter of these have been open for three or more years. 

It is critical that VA resolve our recommendations in a timely 

manner, not only to remedy the specific weaknesses identified but 

because they may be symptomatic of larger underlying problems 

that also need to be addressed. 

4 

There are a number of actions that VA needs to immediately 

take to move forward. The most important of these are ensuring 

strong, department-level leadership support; developing a robust 

action plan that provides a clear roadmap for what needs to be 

done, when it will be done, how progress will be measured, and 

what resources are needed to ensure successful implementation; integrating VA’s response to its high-risk designation with other initiatives such as the Secretary’s 10-point plan; and resolving open 

recommendations in a timely manner. 

We are very concerned about VA’s exceedingly slow pace of 

progress. Unfortunately, as of today, VA is not much further ahead 

at addressing the concerns that led to its high risk designation 

than it was 2 years ago. The lack of progress raises several important questions, including how seriously VA is taking this, whether 

the right people with the right skills are being tasked to address 

the high risk concerns, and whether the overall responsibility for 

achieving removal from the High-Risk List is at the right organizational level within VA. 

Mr. Chairman, this concludes my opening remarks. I would be 

happy to answer any questions. 

[The prepared statement of Ms. Draper follows:] 

5 

PREPARED STATEMENT OF DEBRA A. DRAPER, DIRECTOR, HEALTH CARE, 

U.S. GOVERNMENT ACCOUNTABILITY OFFICE

CHAIRMAN ISAKSON, RANKING MEMBER TESTER, AND MEMBERS OF THE COMMITTEE: I am pleased to be here today to discuss the status of the Department of 

Veterans Affairs’ (VA) actions to address the concerns that led to the high-risk designation we made related to VA health care. We added managing risks and improving VA health care to our High Risk List in 2015 due to our concern about VA’s 

ability to ensure the cost-effective and efficient use of resources to improve the timeVerDate Mar 15 2010 16:25 Sep 24, 2018 Jkt 000000 PO 00000 Frm 00009 Fmt 6633 Sfmt 6621 Z:\ACTIVE\031517.TXT PAULIN

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1GAO, High Risk Series: An Update, GAO 15 290 (Washington, DC: Feb. 11, 2015). 

2GAO, High Risk Series: Progress on Many High-Risk Areas, While Substantial Efforts Needed on Others, GAO 17 317 (Washington, DC: Feb. 15, 2017). 3See, for example, GAO, VA Health Care: Actions Needed to Improve Newly Enrolled Veterans’ Access to Primary Care, GAO 16 328 (Washington, DC: Mar. 18, 2016) and GAO, VA 

Mental Health: Clearer Guidance on Access Policies and Wait-Time Data Needed, GAO 16 24 

(Washington, DC: Oct. 28, 2015). See also, for example, Department of Veterans Affairs, Office 

of Inspector General, Veterans Health Administration, Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System, Report No. 

14–02603–267 (Washington, DC: Aug. 26, 2014) and VA, Department of Veterans Affairs Access 

Audit, System-Wide Review of Access, Results of Access Audit Conducted May 12, 2014, through 

June 3, 2014. 4Pub. L. No. 113–146, 128 Stat. 1754. The $10 billion is meant to supplement VA’s medical 

services budget and is funded through a separate appropriations account, the Veterans Choice 

Fund. The 2014 law also appropriated $5 billion to expand VA’s capacity to deliver care to veterans by hiring additional clinicians and improving the physical infrastructure of VA’s medical 

facilities. 5 VA has purchased care from non-VA community providers through its care in the community 

programs since as early as 1945. VHA has numerous programs, including the Veterans Choice 

Program, through which it purchases VA care in the community services. 6See GAO, VA’s Health Care Budget: In Response to a Projected Funding Gap in Fiscal Year 

2015, VA Has Made Efforts to Better Manage Future Budgets, GAO 16 584 (Washington, DC: 

Jun. 3, 2016). In our 2016 report, the projected funding gap refers to the period in fiscal year 

2015 when VA’s obligations for medical services were projected to exceed its available budget 

authority for that purpose for that year. The Antideficiency Act prohibits agencies from incurring obligations in excess of available budget authority. 31 U.S.C. § 1341(a). An evaluation of 

whether an Antideficiency Act violation occurred in fiscal year 2015 was outside the scope of 

our work. 7 In particular, VA officials expected that the Veterans Choice Program would absorb much 

of the increased demand from veterans for health care services delivered by non-VA providers, 

but instead the slow utilization resulted in veterans continuing to receive care through previously established VA community care programs that drew funds from VA’s medical services 

appropriation account. 

liness, quality, and safety of health care for veterans.1 We expressed continued concerns about VA health care in our 2017 high-risk report.2

VA’s Veterans Health Administration (VHA) operates one of the largest health 

care delivery systems in the Nation, with 168 medical centers and more than 1,000 

outpatient facilities organized into regional networks. VA has faced a growing demand by veterans for its health care services—due, in part, to servicemembers returning from military operations in Afghanistan and Iraq and the needs of an aging 

veteran population—and that trend is expected to continue. The total number of veteran enrollees in VA’s health care system rose from 7.9 million to almost 9 million 

from fiscal year 2006 through fiscal year 2016. Over that same period, VHA’s total 

budgetary resources have increased substantially, from $37.8 billion in fiscal year 

2006 to $91.2 billion in fiscal year 2016. 

Although VA’s budget and enrollees have substantially increased for at least a 

decade, there have been numerous reports during this same period—by us, VA’s Office of the Inspector General, and others—of VA facilities failing to provide timely 

health care.3 In some cases, the delays in care or VA’s failure to provide care at 

all reportedly have resulted in harm to veterans. In response to these serious and 

longstanding problems with access to VA health care, the Veterans Access, Choice, 

and Accountability Act of 2014 was enacted, which provided temporary authority 

and $10 billion in funding through August 7, 2017 (or sooner, if those funds are exhausted) for veterans to obtain health care services from community (non-VA) providers to address long wait times, lengthy travel distances, or other challenges they 

may face accessing VA health care.4 Under this authority, VA introduced the Veterans Choice Program in November 2014, which offers veterans the option to receive 

hospital care and medical services from a non-VA provider when a VA facility cannot provide an appointment within 30 days, or when veterans reside more than 40 

miles from the nearest VA facility.5

In addition to concerns about timely access to care, VA faces challenges regarding 

the reliability, transparency, and consistency of its budget estimates for medical 

services, as well as weaknesses in tracking obligations for medical services and estimating budgetary needs for future years. These challenges were evident in 

June 2015, when VA requested additional funds from Congress because agency officials projected a fiscal year 2015 funding gap of about $3 billion in its medical services appropriation account.6 The projected funding gap was largely due to administrative weaknesses that slowed the utilization of the Veterans Choice Program in 

fiscal year 2015 and resulted in higher-than-expected demand for VA’s previously 

established VA community care programs.7 To address the projected funding gap in 

fiscal year 2015, the VA Budget and Choice Improvement Act provided VA temVerDate Mar 15 2010 16:25 Sep 24, 2018 Jkt 000000 PO 00000 Frm 00010 Fmt 6633 Sfmt 6621 Z:\ACTIVE\031517.TXT PAULIN
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8Pub. L. No. 114–41, Tit. IV, § 4004, 129 Stat. 443, 463–464 (2015). Specifically, VA was authorized to use the Veterans Choice Program appropriation to cover obligations incurred for the 

other specified medical services starting May 1, 2015, until October 1, 2015. 9See GAO 16 584. 

10 At the start of fiscal year 2016, VA issued a policy memorandum to its VAMCs requiring 

them to offer eligible veterans referrals to the Veterans Choice Program before they authorize 

care through VA’s previously established community care programs. 11 Each year, Congress provides funding for VA health care through the appropriations process. Specifically, Congress provides appropriations for the coming fiscal year (which begins October 1 of that year), as well as an advance appropriation for the following fiscal year. VA’s advance appropriation for fiscal year 2018 was enacted on September 29, 2016. Pub. L. No. 114– 

223, 130 Stat. 857, 869 (2016). 12GAO, Determining Performance and Accountability Challenges and High Risks, GAO 01 

159SP (Washington, DC: November 2000). 

porary authority to use up to $3.3 billion from the Veterans Choice Program appropriation for obligations incurred for other specified medical services.8 In our 

June 2016 report on VA’s health care budget, we reported that VA officials anticipated requesting another increase in funding for health care services in the budget 

request for fiscal year 2018.9 Over the course of fiscal year 2016, utilization of the 

Veterans Choice Program increased considerably, and the Veterans Choice Fund 

had a $4.5 billion remaining balance at the start of fiscal year 2017 to cover community care services.10 However, in February 2017, a VA official told us that VA would need an estimated $2 billion in addition to its fiscal year 2018 advance appropriation of about $70 billion to continue providing services.11

My statement today, which is based on our February 2017 High-Risk Series: 

Progress on Many High-Risk Areas, While Substantial Efforts Needed on Others, 

will address (1) actions VA has taken over the past 2 years to address the areas 

of concern that led us to place VA health care on our High-Risk List in 2015, (2) 

the number of open GAO recommendations related to VA health care, and (3) additional actions VA needs to take to address the concerns that led to the high-risk 

designation. We conducted the work on which this statement is based in accordance 

with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain sufficient, 

appropriate evidence to provide a reasonable basis for our findings and conclusions 

based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. 

BACKGROUND

Since 1990, we have regularly reported on government operations that we have 

identified as high risk due to their vulnerability to fraud, waste, abuse, and mismanagement, or the need for transformation to address economy, efficiency, or effectiveness challenges. Our high-risk program—which is intended to help inform the 

congressional oversight agenda and to guide efforts of the administration and agencies to improve government performance—has brought much-needed focus to problems impeding effective government and costing billions of dollars. In 1990, we designated 14 high-risk areas. Since then, generally coinciding with the start of each 

new Congress, we have reported on the status of progress to address previously designated high-risk areas, determined whether any areas could be removed or consolidated, and identified new high-risk areas. 

Since 1990, a total of 60 different areas have appeared on the High-Risk List, 24 

areas have been removed, and 2 areas have been consolidated. On average, highrisk areas that have been removed from the list remained on it for 9 years after 

they were initially added. Our experience has shown that the key elements needed 

to make progress in high-risk areas are top-level attention by the administration 

and agency leaders grounded in the five criteria for removal from the High-Risk 

List, as well as any needed congressional action. The five criteria for removal that 

we issued in November 2000 are as follows:12

• Leadership Commitment. The agency demonstrates strong commitment and top 

leadership support. • Capacity. The agency has the capacity (i.e., people and resources) to resolve the 

risk(s). • Action Plan. A corrective action plan exists that defines the root cause and solutions, and provides for substantially completing corrective measures, including steps 

necessary to implement solutions we recommended. • Monitoring. A program has been instituted to monitor and independently validate the effectiveness and sustainability of corrective measures. • Demonstrated Progress. The agency is able to demonstrate progress in implementing corrective measures and in resolving the high-risk area. 

8 

13GAO, High-Risk Series: Key Actions to Make Progress Addressing High-Risk Issues, GAO 

16 480R (Washington, DC: Apr. 25, 2016). 

These five criteria form a road map for efforts to improve and ultimately address 

high-risk issues. Addressing some of the criteria leads to progress, while satisfying 

all of the criteria is central to removal from the list. In our April 2016 report, we 

provided additional information on how agencies had made progress addressing 

high-risk issues.13 Figure 1 shows the five criteria for removal for a designated 

high-risk area and examples of actions taken by agencies as cited in that report. 

Importantly, the actions listed are not ‘‘stand alone’’ efforts taken in isolation from 

other actions to address high-risk issues. That is, actions taken under one criterion 

may also be important in meeting other criteria. For example, top leadership can 

demonstrate its commitment by establishing a corrective action plan including longterm priorities and goals to address the high-risk issue and using data to gauge 

progress—actions which are also vital to monitoring criteria. 

VA HAS MADE LIMITED PROGRESS IN ADDRESSING THE CONCERNS THAT LED TO THE

2015 VA HEALTH CARE HIGH-RISK DESIGNATION

VA officials have expressed their commitment to addressing the concerns that led 

to the high-risk designation for VA health care. As part of our work for the 2017 

high-risk report, we identified actions VA had taken, such as establishing a task 

force, working groups, and a governance structure for addressing the five areas of 

concern contributing to the designation: (1) ambiguous policies and inconsistent 

processes; (2) inadequate oversight and accountability; (3) information technology 

(IT) challenges; (4) inadequate training for VA staff; and (5) unclear resource needs 

and allocation priorities. For example, in July 2016, VA chartered the GAO High 

Risk List Area Task Force for Managing Risk and Improving VA Health Care to 

develop and oversee implementation of VA’s plan to address the root causes of the 

five areas of concern we identified in 2015. 


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14For more detailed analysis of VA’s actions in each of the five areas of concern, see GAO 

17 317. 15See GAO, VA Health Care: Actions Needed to Improve Newly Enrolled Veterans’ Access to 

Primary Care, GAO 16 328 (Washington, DC: Mar. 18, 2016); and GAO, VA Mental Health: 

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

Oct. 28, 2015). 

VA’s task force and associated working groups are responsible for developing and 

executing the department’s high-risk mitigation plan for each of the five areas of 

concern we identified. VA also executed two contracts with a total value of $7.8 million to support its actions to address the concerns behind the high-risk designation. 

These contracts—with the MITRE Corporation and Atlas Research, LLC—are intended to provide additional support for actions such as developing and executing 

an action plan, creating a plan to enhance VA’s capacity to manage the five areas, 

and assisting with establishing the management functions necessary to oversee the 

five high-risk-area working groups. 

On August 18, 2016, VA provided us with an action plan that acknowledged the 

deep-rooted nature of the areas of concern, and stated that these concerns would 

require substantial time and work to address. Although the action plan outlined 

some steps VA plans to take over the next several years to address the concerns 

that led to its high-risk designation, several sections were missing critical actions 

that would support our criteria for removal from the High-Risk List, such as analyzing the root causes of the issues and measuring progress with clear metrics. In 

our feedback to VHA on drafts of its action plan, we highlighted these missing actions and also stressed the need for specific timelines and an assessment of needed 

resources for implementation. For example, VA plans to use staff from various 

sources, including contractors and temporarily detailed employees, to support its 

high-risk-area working groups, so it is important for VA to ensure that these efforts 

are sufficiently resourced. 

Overall Rating for Managing Risks and Improving VA Health Care 

As we reported in the February 2017 high-risk report, when we applied the five 

criteria for High-Risk List removal to each of the areas of concern, we determined 

that VA has partially met two of the five criteria: leadership commitment and an 

action plan. VA has not met the other three criteria for removal: capacity to address 

the areas of concern, monitoring implementation of corrective actions, and demonstrating progress. It is worth noting that although both criteria were rated as partially met, the department made significantly less progress in developing a viable 

action plan than it has in demonstrating leadership commitment. Specifically, VA 

partially met the action plan criterion for only one of the five areas of concern— 

ambiguous policies and inconsistent processes—whereas VA partially met the leadership commitment criterion for four out of five areas of concern. 

The following is a summary of the progress VA has made in addressing the five 

criteria for removal from the High-Risk List for each of the five areas of concern 

we identified.14

Ambiguous Policies and Inconsistent Processes 

Summary of concern. When we designated VA health care as a high-risk area in 

2015, we reported that ambiguous VA policies led to inconsistent processes at local 

VA medical facilities, which may have posed risks for veterans’ access to VA health 

care. Since then, we highlighted the inconsistent application of policies in two recent 

reports examining mental health and primary care access at VA medical facilities 

in 2015 and 2016, respectively.15 In both reports, we found wide variation in the 

time that veterans waited for primary and mental health care, which was in part 

caused by a lack of clear, updated policies for appointment scheduling; therefore, we 

recommended that VA update these policies. These ambiguous policies contributed 

to errors made by appointment schedulers, which led to inconsistent and unreliable 

wait-time data. For mental health, we also found that two policies conflicted, leading to confusion among VA medical center staff as to which wait-time policy to follow. In 2015, VA resolved this policy conflict by revising its mental health handbook, but other inconsistent applications of mental health policy have not yet been 

addressed, such as our recommendation to issue guidance about the definitions used 

to calculate veteran appointment wait times, and communicate any changes to those 

definitions within and outside VHA. 

2017 assessment of VA’s progress. Based on actions taken since 2015, VA has partially met our criteria for removal from the High-Risk List for this area of concern 

for leadership commitment and action plan. VA has partially met the leadership 

commitment criterion because it established a framework for developing and reviewing policies—with the goal of ensuring greater consistency and clarity—and set 

10 

16GAO, VA Primary Care: Improved Oversight Needed to Better Ensure Timely Access and Efficient Delivery of Care, GAO 16 83 (Washington, DC: Oct. 8, 2015). 17GAO, Veterans Affairs Information Technology: Management Attention Needed to Improve 

Critical System Modernizations, Consolidate Data Centers, and Retire Legacy Systems, GAO 17 

408T (Washington, DC: Feb. 7, 2017). 

goals for making the policy-development process more efficient. VA has partially 

met the action plan criterion for this high-risk area of concern because its action 

plan described an analysis of the root causes of problems related to ambiguous policies and inconsistent processes, an important aspect of an action plan. However, VA 

has not met our criteria for removal from the High-Risk List for capacity, monitoring, and demonstrated progress for this area of concern because it has not addressed gaps that exist between its stated goals and available resources, addressed 

inconsistent application of policies at the local level, or demonstrated that its actions 

are linked to identified root causes. 

Inadequate Oversight and Accountability 

Summary of concern. In our 2015 high-risk report, we found that VA had problems holding its facilities accountable for their performance because it relied on selfreported data from facilities, its oversight activities were not sufficiently focused on 

compliance, and it did not routinely assess policy implementation. We continued to 

find a lack of oversight in our October 2015 review of the efficiency and timeliness 

of VA’s primary care. For example, we found inaccuracies in VA’s data on primary 

care panel sizes, which are used to help medical centers manage their workload and 

ensure that veterans receive timely and efficient care.16 We found that while VA’s 

primary care panel management policy required facilities to ensure the reliability 

of their panel size data, it did not assign responsibility for verifying data reliability 

to regional- or national-level officials or require them to use the data for monitoring 

purposes. As a result, VA could not be assured that local panel size data were reliable, or know whether its medical centers had met VA’s goals for efficient, timely, 

and quality care. We recommended that VA incorporate an oversight process in its 

primary care panel management policy that assigns responsibility, as appropriate, 

to regional networks and to VA’s central office for verifying and monitoring panel 

sizes. 

2017 assessment of VA’s progress. VA has partially met the leadership commitment criterion for this area of concern because it established a high-level governance 

structure and adopted a new model to guide the department’s oversight and accountability activities. However, VA has not met our criteria for removal from the 

High-Risk List for capacity, action plan, monitoring, or demonstrated progress for 

this area of concern because the department continues to rely on existing processes 

that contribute to inadequate oversight and accountability. 

Information Technology Challenges 

Summary of concern. In our 2015 high-risk report, we identified limitations in the 

capacity of VA’s existing IT systems, including the outdated, inefficient nature of 

certain systems and a lack of system interoperability as contributors to VA’s IT 

challenges related to VA health care. We have continued to report on the importance of VA working with the Department of Defense to achieve electronic health 

record interoperability. In August 2015, we reported on the status of these interoperability efforts and noted that the departments had engaged in several near-term 

efforts focused on expanding interoperability between their existing electronic health 

record systems. However, we were concerned by the lack of outcome-oriented goals 

and metrics that would more clearly define what VA and the Department of Defense 

aim to achieve from their interoperability efforts. Accordingly, we recommended that 

the departments establish a timeframe for identifying outcome-oriented metrics and 

define related goals for achieving interoperability. In February 2017, we reported 

that VA has begun to define an approach for identifying outcome-oriented metrics 

focused on health outcomes in selected clinical areas, and it also has begun to establish baseline measurements.17 We intend to continue monitoring the departments’ 

efforts to determine how these metrics define and measure the results achieved by 

interoperability between the departments. 

2017 assessment of VA’s progress. VA has partially met our leadership commitment criterion by involving top leadership from VA’s Office of Information & Technology in this area of concern, but it has not met our four remaining criteria for 

removing IT challenges from the High-Risk List. For example, VA has not demonstrated improvement in several capacity actions, such as establishing specific responsibilities for its new functions, improving collaboration between internal and external stakeholders, and addressing skill gaps. VA also needs to conduct a root 

11 

18GAO, Veterans Health Administration: Management Attention Is Needed to Address Systemic, Long-standing Human Capital Challenges, GAO 17 30 (Washington, DC: Dec. 23, 2016). 19GAO, VA Health Care: Processes to Evaluate, Implement, and Monitor Organizational Structure Changes Needed, GAO 16 803 (Washington, DC: Sept. 27, 2016). 20 In its action plan, VA reported adopting a framework in 2016 called ‘‘Managing for Results’’ 

to better connect VA’s requirements setting process (that forecasts veterans’ needs) with its 

process for developing the department’s budget. VA stated that full implementation of the 

framework will take place over several budget cycles. 

cause analysis that would help identify and prioritize critical actions and outcomes 

to address IT challenges. 

Inadequate Training for VA Staff 

Summary of concern. When identifying this area of concern in our 2015 high-risk 

report, we described several gaps in VA’s training, as well as burdensome training 

requirements. We have continued to find these issues in our subsequent work. For 

example, in our December 2016 report on VHA’s human resources (HR) capacity, we 

found that VA’s competency assessment tool did not address two of the three personnel systems under which VHA staff may be hired.18 We recommended that VHA 

(1) develop a comprehensive competency assessment tool for H.R. staff that evaluates knowledge of all three of VHA’s personnel systems and (2) ensure that all VHA 

H.R. staff complete it so that VHA may use the data to identify and address competency gaps among H.R. staff. Without such a tool, VHA will have limited insights 

into the abilities of its H.R. staff and will be ill-positioned to provide necessary support and training. 

2017 assessment of VA’s progress. VA has not met any of our criteria for removing 

this area of concern from the High-Risk List. VA intends to establish a comprehensive health care training management policy and a mandatory annual training process; however, as of December 2016, VA officials said they had not begun drafting 

a new policy to replace an outdated document from 2002 that contains training requirements that are no longer relevant. The high-level nature of the descriptions in 

the action plan and lack of action to update outdated policies and set goals for improving training shows that VA lacks leadership commitment to address the concerns that led to our inclusion of this area in the 2015 high-risk report. 

Unclear Resource Needs and Allocation Priorities 

Summary of concern. In our 2015 high-risk report, we described gaps in the availability of data needed for VA to identify the resources it needs and ensure they are 

effectively allocated across VA’s health care system as contributors to our concern 

about unclear resource needs and allocation priorities. We have continued to report 

on this concern. For example, in our September 2016 report on VHA’s organizational 

structure, we found that VA devoted significant time, effort, and funds to generate 

recommendations for organizational structure changes intended to improve the efficiency of VHA operations.19 However, the department then either did not act or 

acted slowly to implement the recommendations. Without robust processes for evaluating and implementing recommendations, there was little assurance that VHA’s 

delivery of health care to the Nation’s veterans would improve. We recommended 

that VA develop a process to ensure that it evaluates organizational structure recommendations resulting from internal and external reviews of VHA. This process 

should include documenting decisions and assigning officials or offices responsibility 

for ensuring that approved recommendations are implemented. We concluded that 

such a process would help VA ensure that it is using resources efficiently, monitoring and evaluating implementation, and holding officials accountable. 

2017 assessment of VA’s progress. VA’s actions have partially met our criterion for 

leadership commitment but not met the other four criteria for removing this area 

of concern from the High Risk List. VA’s planned actions do not make clear how 

VHA, as the agency managing VA health care, is or will be incorporated into VA’s 

new framework for the strategic planning and budgeting process.20 It is also not 

clear how the framework will be communicated and reflected at the regional network and medical center levels. VA also has not identified what resources may be 

necessary to establish and maintain new functions at the national and local levels, 

or established performance measures based on a root cause analysis of its unclear 

resource needs and allocation priorities. 

MORE THAN 100 GAO RECOMMENDATIONS FOR IMPROVING

VA HEALTH CARE REMAIN OPEN

Since we added VA health care to our High-Risk List in 2015, VA’s leadership has 

increased its focus on implementing our prior recommendations, but additional work 

12 

21Of the 178 recommendations, 134 were open because VA had not yet implemented them. 

Additionally, 39 had been closed because VA implemented them, and 5 had been closed without 

VA implementing them. We close recommendations without agencies having implemented them 

primarily if the recommendation is no longer valid because circumstances have changed. 22See GAO 17 317. 23Specifically, 112 recommendations are open because VA has not yet implemented them, 25 

of which have been open for 3 or more years. In addition, 127 recommendations were closed because VA implemented them, and 13 were closed without VA implementing them. 24 According to VA, MyVA intends to make changes to VA’s systems and structures to (1) improve the veteran experience, (2) improve the employee experience, (3) achieve support services 

excellence, (4) establish a culture of continuous performance improvement, and (5) enhance strategic partnerships. 

is still needed. Between January 2010 and February 2015 (when we first designated 

VA health care as a high-risk area), we made 178 recommendations to VA related 

to VA health care. When we made our designation in 2015, the department only had 

implemented about 22 percent of them.21 Since February 2015, we have made 74 

new recommendations to VA related to VA health care, for a total of 252 recommendations from January 1, 2010 through February 15, 2017 (when we issued the 2017 

high-risk report).22 VA has implemented about 50 percent of these recommendations. However, there continue to be more than 100 open recommendations related 

to VA health care, almost a quarter of which have remained open for 3 or more 

years.23 We believe that it is critical that VA implement our recommendations not 

only to remedy the specific weaknesses we previously identified, but because they 

may be symptomatic of larger underlying problems that also need to be addressed. 

Since the 2015 high-risk report, we have made new recommendations to VA relating 

to each of the five areas of concern. (See table 1.) 

Table 1: GAO Recommendations to the Department of Veterans Affairs (VA) Related to VA Health 

Care from January 1, 2010 through February 15, 2017, by Area of Concern 

VA health care area of concern 

Number of 

recommendations 

prior to GAO highrisk designation 

(Jan. 1, 2010 

through Feb. 11, 

2015)* 

Number of 

recommendations 

added since GAO 

high-risk designation (Feb. 11, 

2015 through Feb. 

15, 2017)* 

Cumulative 

number of GAO 

recommendations 

Jan. 1, 2010 

through Feb. 15, 

2017* 

Cumulative 

percentage of GAO 

recommendations 

VA has 

implemented, Jan. 

1, 2010 through 

Feb. 15, 2017 

Ambiguous policies and inconsistent processes ... 42 21 63 52 % 

Inadequate oversight and accountability .............. 63 36 99 51 

Information technology challenges ........................ 11 2 13 44 

Inadequate training for VA staff ........................... 6 8 14 43 

Unclear resource needs and allocation priorities 48 6 54 66 

Not assigned to an area of concern ..................... 8 1 9 44 

Total .............................................................. 178 74 252 50 % 

Source: GAO. GAO 17 473T. 

* Recommendation counts listed include both implemented and not implemented recommendations as of the dates indicated. 

SUSTAINED LEADERSHIP SUPPORT AND STRATEGIC FOCUS NEEDED TO

MEET HIGH-RISK REMOVAL CRITERIA

VA has taken an important step toward addressing our criteria for removal from 

the High-Risk List by establishing the leadership structure necessary to ensure that 

actions related to the High-Risk List are prioritized within the department. It is imperative, however, that VA demonstrate strong leadership support as it continues 

its transition under a new administration, address weaknesses in its action plan, 

and continue to implement our open recommendations. 

As a new administration sets its priorities, VA will need to integrate those priorities with its high-risk-related actions, and facilitate their implementation at the 

local level through strategies that link strategic goals to actions and guidance. In 

its action plan, VA separated its discussion of department-wide initiatives, like 

MyVA, from its description of High-Risk List mitigation strategies.24 We do not view 

high-risk mitigation strategies as separate from other department initiatives; actions to address the High-Risk List can, and should be, integrated in VA’s existing 

activities. 

VA’s action plan did not adequately address the concerns that led to the high-risk 

designation because it lacked root cause analyses for most areas of concern, as well 

as clear metrics and identified resources needed for achieving VA’s stated outcomes. 

This is especially evident in VA’s plans to address the IT and training areas of conVerDate Mar 15 2010 16:25 Sep 24, 2018 Jkt 000000 PO 00000 Frm 00016 Fmt 6633 Sfmt 6621 Z:\ACTIVE\031517.TXT PAULIN
13 

25The Veterans Access, Choice, and Accountability Act of 2014 established the Commission 

on Care to examine, assess, and report on veterans’ access to VA health care and to strategically 

examine how best to organize VHA, locate health resources, and deliver health care to veterans 

during the next 20 years. The Commission’s June 2016 report to the President included 18 recommendations to improve veterans’ access to care and, more broadly, to improve the quality and 

comprehensiveness of that care. On September 1, 2016, the President concurred with 15 of the 

18 recommendations and directed VA to implement them. 

cern. In addition, with the increased use of community care programs, it is imperative that VA’s action plan include a discussion of the role of community care in decisions related to policies, oversight, IT, training, and resource needs. VA will also 

need to demonstrate that it has the capacity to sustain efforts by devoting appropriate resources—including people, training, and funds—to address the high-risk 

challenges we identified. Until VA addresses these serious underlying weaknesses, 

it will be difficult for the department to effectively and efficiently implement improvements addressing the five areas of concern that led to the high-risk designation. 

We will continue to monitor VA’s institutional capacity to fully implement an action plan and sustain needed changes in all five of our areas of concern. To the extent we can, we will continue to provide feedback to VA officials on VA’s action plan 

and areas where they need to focus their attention. Additionally, we have ongoing 

work focusing on VA health care that will provide important insights on progress, 

including the policy development and dissemination process, implementation and 

monitoring of VA’s opioid safety, Veterans Choice Program implementation, physician recruitment and retention, and processes for enrolling veterans in VA health 

care. 

Finally, we plan to also continue to monitor VA’s efforts to implement our recommendations and recommendations from other reviews such as the Commission on 

Care.25 To this end, we believe that the following GAO recommendations require 

VA’s immediate attention: 

• improving oversight of access to timely medical appointments, including the development of wait-time measures that are more reliable and not prone to user error 

or manipulation, as well as ensuring that medical centers consistently and accurately implement VHA’s scheduling policy. 

• improving oversight of VA community care to ensure—among other things— 

timely payment to community providers. 

• improving planning, deployment, and oversight of VA/VHA IT systems, including identifying outcome-oriented metrics and defining goals for interoperability with 

DOD. 

• ensuring that recommendations resulting from internal and external reviews of 

VHA’s organizational structure are evaluated for implementation. This process 

should include the documentation of decisions and assigning officials or offices responsibility for ensuring that approved recommendations are implemented. 

Moreover, it is critical that Congress maintain its focus on oversight of VA health 

care to help address this high-risk area. Congressional committees responsible for 

authorizing and overseeing VA health care programs held more than 70 hearings 

in 2015 and 2016 to examine and address VA health care challenges. As VA continues to change its health care service delivery in the coming years, some changes 

may require congressional action—such as VA’s planned consolidation of community 

care programs after the Veterans Choice Program expires. Sustained congressional 

attention to these issues will help ensure that VA continues to improve its management and delivery of health care services to veterans. 

Chairman Isakson, Ranking Member Tester, and Members of the Committee, this 

concludes my statement. I would be pleased to respond to any questions you may 

have. 

Senator TILLIS. Thank you. 

Mr. Missal. 

14 

STATEMENT OF MICHAEL J. MISSAL, INSPECTOR GENERAL, 

U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED 

BY JOHN D. DAIGH, JR., M.D., CPA, ASSISTANT INSPECTOR 

GENERAL FOR HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR GENERAL 

Mr. MISSAL. Senator Tillis and Members of the Committee, 

thank you for the opportunity to discuss the work of the VA Office 

of Inspector General and how we provide effective oversight of VA 

programs and operations through independent audits, inspections, 

and investigations. I am accompanied by Dr. David Daigh, the Assistant Inspector General for Healthcare Inspections. 

The OIG seeks to prevent and detect fraud, waste, and abuse and 

make meaningful recommendations to drive economy, efficiency, 

and effectiveness throughout VA’s programs and operations. Our 

goal is to undertake impactful work that will assist VA in providing the appropriate and timely services and benefits that veterans so deservedly earned and ensuring the proper expenditure of 

taxpayer funds. 

I have had the great privilege of serving as the Inspector General 

since May 2, 2016. Since that time, I have fully immersed myself 

in the work, priorities, and policies of the OIG. We have made a 

number of enhancements since I started, in an effort to do more 

impactful work in a timelier manner. 

The OIG shares a similar mission with GAO. It is important that 

we have a strong relationship with GAO, to ensure we avoid duplication of effort as much as possible. To that end, one of the first 

things I did when I started was to meet with Comptroller General 

Dodaro, Dr. Draper, and his other senior staff. Our offices have had 

a number of communications since that time to promote coordination and more effective oversight of VA. 

GAO added VA health care to its biannual High-Risk List in 

2015, and it remains on the High-Risk List that was just issued in 

2017. GAO focused its concern in five broad areas. While our work 

is determined by what we believe is the most effective oversight of 

VA, a number of our reports addressed concerns in these same five 

areas. My written statement includes examples of OIG work in 

each of the areas that resulted in GAO placing VA health care on 

its High-Risk List. It should be noted that many of the OIG’s reports could fit into more than one area. I will highlight a few of 

those reports now. 

We have issued a number of reports in the past few years that 

include VA’s ambiguous policies and inconsistent processes. For example, our review of the Health Eligibility Center determined that 

VA had not effectively managed its business processes to ensure 

the consistent creation and maintenance of essential health care 

eligibility data. 

Proper oversight by management would ensure that programs 

and operations would work effectively and efficiently. Our September 2016 report on the Denver replacement medical center is an 

extremely costly example of the result of inadequate oversight. 

Through all phases of the project, we identified various factors that 

significantly contributed to delays and rising costs. This occurred 

due to a series of questionable business decisions and mismanagement by VA senior officials, resulting in a project years behind 

15 

schedule and costing more than twice the initial budget of $800 

million. 

We have frequently identified VA struggles to design, procure, 

and/or implement functional IT systems. IT security is continually 

reported as a material weakness in VA’s consolidated financial 

statements. Moreover, VA has a high number of legacy IT systems 

needing replacement. Furthermore, after years of effort focused on 

replacement of VA’s legacy scheduling software, a new scheduling 

system is still not in place. VA’s issues with scheduling software 

are related to the inability to define its requirements and determine if a commercial solution is available or if it must design the 

system. 

One prevailing theme of the OIG’s work related to wait times 

and scheduling issues was the inadequate, lack of, or incorrect 

training provided to VA staff responsible for scheduling appointments. As we have stated in reports that have been issued since 

the allegations at the Phoenix VA health care system surfaced in 

April 2014, the lack of training for schedulers, the lack of understanding of the process by their managers, and, in some cases, the 

disregard of VA scheduling policies created a system where services 

have not been provided timely, and in some situations, wait times 

were not accurately portrayed. VA needs to accurately forecast the 

demand for health care services in both the near term and the long 

term. 

In conclusion, the OIG is committed to providing effective oversight of the programs and operations of VA. We will continue to 

produce reports that provide VA, Congress, and the public with recommendations that we believe will help VA operate its programs 

and services in a manner that will effectively and timely deliver 

services and benefits to veterans and spend taxpayer money appropriately. 

Senator Tillis, this concludes my statement. Dr. Daigh and I 

would be happy to answer questions that you or other Members of 

the Committee may have. 

[The prepared statement of Mr. Missal follows:] 

PREPARED STATEMENT OF MICHAEL J. MISSAL, INSPECTOR GENERAL, 

U.S. DEPARTMENT OF VETERANS AFFAIRS

MR. CHAIRMAN, RANKING MEMBER TESTER, AND MEMBERS OF THE COMMITTEE, 

Thank you for the opportunity to discuss the work of the VA Office of Inspector General (OIG) and how the OIG provides effective oversight of VA programs and operations through independent audits, inspections, and investigations. The OIG seeks 

to prevent and detect fraud, waste, and abuse, and make meaningful recommendations to drive economy, efficiency, and effectiveness throughout VA programs and 

operations. Our goal is to undertake impactful work that will assist VA in providing 

the appropriate and timely services and benefits that veterans so deservedly earned, 

and ensuring the proper expenditure of taxpayer funds. I am accompanied by John 

D. Daigh, Jr., M.D., CPA, Assistant Inspector General for Healthcare Inspections. 

I have had the great privilege of serving as the Inspector General since May 2, 

2016. Since that time, I have fully immersed myself in the work, priorities, and policies of the OIG. We have made a number of enhancements since I started, including 

issuing a Mission, Vision, and Values statement; increasing transparency; creating 

a Rapid Response team in our Healthcare Inspections directorate; expanding our 

data analytics capabilities; and being more proactive in our review areas. I believe 

that these changes, as well as other enhancements we will make, will enable us to 

do additional impactful work in a more timely manner. 

The OIG shares an analogous mission with the Government Accountability Office 

(GAO). It is important that the VA OIG has a strong relationship with GAO to enVerDate Mar 15 2010 16:25 Sep 24, 2018 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6621 Z:\ACTIVE\031517.TXT PAULIN
16 

1 Audit of Veteran Wait Time Data, Choice Access, and Consult Management in VISN 6, 

March 2, 2017 

sure that we avoid duplication of effort as much as possible. To that end, one of the 

first things I did when I started was to meet with Comptroller General Dodaro and 

some of his senior staff. Our offices have communicated regularly since that time 

to promote coordination and more effective oversight of VA. 

In February 2015, GAO added Managing Risks and Improving VA Health Care 

to its biannual High Risk list. It focused its concerns in five broad areas: 

• Ambiguous policies and inconsistent processes, • Inadequate oversight and accountability, • Information technology challenges, • Inadequate training for VA staff, and • Unclear resource needs and allocation priorities. 

While our work is determined by what we believe is the most effective oversight 

of VA, a number of our reports address concerns in these same five areas. I will 

highlight a sampling of OIG work in each of the areas that resulted in GAO placing 

VA Health Care on its High Risk list. However, it should be noted that many of 

the OIG’s reports could fit in more than one area. 

AMBIGUOUS POLICIES AND INCONSISTENT PROCESSES

We have issued a number of reports in the past few years that include VA’s ambiguous policies and inconsistent processes. Our recent report 1 on wait time in one 

specific Veteran Integrated Service Network (VISN), we assessed the reliability of 

wait time data and timely access within VISN 6 which includes VHA facilities in 

North Carolina and Virginia. The objective of the audit was to determine whether 

VISN 6 facilities provided new patients timely access to health care within its medical facilities and through Choice, as well as to determine whether VISN 6 facilities 

appropriately managed consults. We reported that veterans who were authorized 

Choice care in VISN 6 did not consistently receive the authorized health care within 

30 days as required by Health Net’s contract with VA. 

We reviewed a statistical sample of 389 Choice authorizations provided to Health 

Net by VISN 6 medical facility staff during the first quarter of Fiscal Year (FY) 

2016. Based on our sample results, we estimated that for the approximately 34,200 

veterans who were authorized Choice care in VISN 6, approximately 22,500 veterans who received Choice care waited an average of 84 days to get their care 

through Health Net providers. We estimated it took VA medical facility staff an average of 42 days to provide the authorization to Health Net to begin the Choice process and an additional 42 days for veterans to receive the medical service through 

Health Net providers. We identified delays related to authorizations for primary 

care, mental health care, and specialty care. VHA’s Chief Business Officer addressed 

a potential cause for delay in creating appointments by executing a contract modification effective November 1, 2015. This change allowed Health Net to initiate 

phone contact with a veteran to arrange a Choice appointment, rather than require 

the veteran to contact Health Net as previous required. Our analysis showed that, 

while still untimely, this change lowered the percentage of veterans who waited 

more than 5 days for Health Net to create an appointment from 86 percent to 69 

percent. 

The Under Secretary for Health concurred with our 10 recommendations and provided a responsive action plan and milestones to address the recommendations regarding monitoring controls over scheduling requirements, wait time data, and access to health care and consult management. Our recommendations will help ensure 

staff use clinically indicated and preferred appointment dates consistently, medical 

facilities conduct required scheduler audits, and staffing resources are adequate to 

ensure timely access to health care. The report’s recommendations remain open. 

Another example, in September 2015, we reported in Review of Alleged Mismanagement at the Health Eligibility Center that VA’s Chief Business Office (CBO) 

had not effectively managed its business processes to ensure the consistent creation 

and maintenance of essential health care eligibility data. Due to the amount and 

age of the Enrollment System (ES) data, as well as lead times required to develop 

and implement software solutions, a multiyear project management plan was needed to address the accuracy of pending ES records and improve the usefulness of ES 

data. We offered 13 recommendations in the report including one focused on controls 

to ensure that future enrollment data are accurate and reliable before being entered 

into the Enrollment System. VA concurred with the recommendations and provided 

sufficient information to close all recommendations in October 2016. We have an ongoing review of the Health Eligibility Center focusing on the alleged lack of effective 

17 

governance over the Veterans Health Administration’s (VHA) execution of the 

health care enrollment program at its medical facilities. We expect to issue our report in late spring 2017. 

Another program that operates nationwide also had issues related to inconsistent 

implementation of policies is the Homeless Grant Per Diem Program. In a June 

2015 report, Audit of Homeless Providers Grant and Per Diem Case Management 

Oversight, we determined VA needed to clarify eligibility requirements across the 

program to ensure that all homeless veterans have equal access to case management services. Historically, homeless veterans ineligible for VA health care have not 

been excluded from the program. However, we questioned the application of the program’s eligibility criteria, and found the criteria were unclear and inconsistently applied. This was confirmed in our interviews of VA’s Office of General Counsel, program directors, network homeless coordinators, and liaisons, which revealed confusion occurred at all program levels. We made five recommendations, three of which 

involved establishing a definitive legal standard on program eligibility and ensuring 

that policies and controls matched that standard and were applied across the program. The recommendations dealing with policies and controls remain open. 

INADEQUATE OVERSIGHT AND ACCOUNTABILITY

Proper oversight by management ensures that programs and operations would 

work effectively and efficiently. Our September 2016 report, Review of the Replacement of the Denver Medical Center, Eastern Colorado Health Care System, on the 

management of the construction of a new VA medical center in the Denver area, 

is an extremely costly example of the result of inadequate oversight. We confirmed 

the project to build a new medical center in the Denver area has experienced significant and unnecessary cost overruns and schedule slippages. Originally estimated for 

2013 completion, it will not be ready before mid-to-late 2018, about 20 years after 

its need was identified. 

Through all phases of the project, we identified various factors that significantly 

contributed to delays and rising costs, including: 

• Inadequate planning and design, 

• Initiation of the construction phase without adequate design plans, 

• Changing the acquisition strategy mid-stream, and 

• Untimely change request processing. 

This occurred due to a series of questionable business decisions and mismanagement by VA senior officials. The report summarizes the significant management decisions and factors that resulted in a project years behind schedule and costing more 

than twice the initial budget of $800 million. We made five recommendations and 

VA management concurred with all recommendations. We recently requested information from VA on the implementation status of the recommendations and will 

keep them open until VA provides satisfactory evidence of implementation. 

In June 2016, we issued a report on allegations related to appointment cancellations at the Houston VA Medical Center, titled Review of Alleged Manipulation of 

Appointment Cancellations at VA Medical Center, Houston, Texas. We substantiated 

that two previous scheduling supervisors and a current director of two outpatient 

clinics instructed staff to input clinic cancellations incorrectly as canceled by the patient. We also confirmed that a current director of two CBOCs instructed staff, as 

recently as February 2016, to record an appointment as canceled by the patient if 

clinic staff at one CBOC offered to reschedule a veteran’s appointment at a different 

CBOC situated about 17 miles away and the veteran declined the appointment. The 

CBOC Director noted this was appropriate since the CBOC was still offering the patient an appointment. However, when interviewed regarding these cancellations, the 

CBOC Director acknowledged she instructed staff to cancel appointments by the patient if the veteran declined an appointment in the alternate location. We made six 

recommendations, including referring the matter to VA’s Office of Accountability Review (OAR), to determine what, if any, administrative actions should be taken based 

on the factual circumstances developed in our report. 

In December 2014, we released an audit related to VA’s National Call Center for 

homeless veterans, titled Audit of The National Call Center for Homeless Veterans. 

We reported that homeless and at-risk veterans who contacted the Call Center often 

experienced problems accessing a counselor and/or receiving a referral after completing the Call Center’s intake process. We reported: 

• Veterans could leave a message on an answering machine only 27 percent of 

the time period reviewed, 

• Veteran messages were not referred to VA medical facilities due to inaudible 

messages or no contact information in 16 percent of the time period reviewed, 

18 

• Veterans were not referred to VA medical facilities despite providing all the 

necessary information in 4 percent of the time period we reviewed. 

Moreover, the Call Center closed approximately 47 percent of referrals even 

though the VA medical facilities had not provided the Homeless veterans any support services. These missed opportunities occurred due to lapses in the Call Center’s 

management and oversight. We made seven recommendations, including implementing effective performance metrics to ensure homeless veterans receive needed 

services. We closed our report in September 2015 based on information received that 

all recommendations had been implemented. 

INFORMATION TECHNOLOGY CHALLENGES

As we reported in our list of VA’s Major Management Challenges within VA’s Annual Financial Report, we have frequently identified VA’s struggles to design, procure, and/or implement functional information technology (IT) systems. IT security 

is continually reported as a material weakness in the Consolidated Financial Statement audits that are conducted annually by the OIG’s independent auditing firm, 

CliftonLarsonAllen (CLA). 

VA has a high number of legacy systems needing replacement including the Financial Management System; Integrated Funds Distribution, Control Point Activity, 

Accounting and Procurement system; Veterans Health Information Systems and 

Technology Architecture, and the Benefits Delivery Network; After years of effort 

focused on replacement of VA’s legacy scheduling software, a new scheduling system 

is still not in place. VA’s issues with scheduling appointments are related to the inability to define its requirements and determine if a commercial solution is available 

or if it must design a system. Replacing systems has been a major challenge across 

the government and is not unique to VA. We have issued a number of reports outlining access issues and our work in this area is continuing. 

While the difficulties between VA’s electronic health record (EHR) and the Department of Defense’s EHR are well documented, the increased utilization of care 

in the community will present further IT challenges. To ensure that medical providers both inside and outside VA have the most complete and up-to-date information, VA needs to find a more effective method for sharing patients’ EHRs. We reported on the possibility of delays in care because of the difficulties in sharing medical records in the Urology Clinic at the Phoenix VA Health Care System in our October 2015 report, titled Healthcare Inspection, Access to Urology Service, Phoenix 

VA Health Care System, Phoenix, Arizona. Specifically, we identified approved authorizations for non-VA care coordination (NVCC) urological care and a notation 

that an authorization was sent to the non-VA provider. A scheduled date and time 

of an appointment with the non-VA urologist was often documented. However, we 

were unable to locate scanned documents from non-VA providers in these patients’ 

EHRs verifying that the patients had been seen for evaluations, and if seen, what 

the evaluations might have revealed. This finding suggested that the Phoenix VA 

Health Care System (PVAHCS) did not have accurate data on the clinical status of 

the patients who were referred for the specialty care. 

Further, with respect to scanning and reviewing outside clinical documents (for 

example, clinic notes, labs, or imaging results), when the services were provided by 

TriWest Health Care Alliance (TriWest), the treating providers’ office submitted this 

data to the TriWest Portal. To access that information, an NVCC staff member was 

required to log into the TriWest Portal to print and scan these records into the patients EHRs. This process was delayed because of the NVCC staffing shortages, 

which could have resulted in important clinical information not being reviewed for 

several months. We made three recommendations, including one specifically related 

to ensuring that non-VA care providers’ clinical documentation is available in the 

EHRs in a timely manner for PVAHCS providers to review. We closed our report 

in June 2016 after VA provided information that addressed the recommendations. 

In the area of IT security, VA uses personally identifiable information (PII), protected health information (PHI), and other sensitive information to deliver benefits 

to veterans and their dependents. Employees and contractors must safeguard this 

information. As we reported in our September 2015 report, Review of Alleged Data 

Sharing Violations at VA’s Palo Alto Health Care System, the VA Palo Alto Health 

Care System (VAPAHCS) did not ensure that contract staff had the appropriate 

background investigations or proper security and privacy awareness training before 

being granted access to VA patient information. Additionally, facility Information 

Security Officers were not involved prior to the contractor placing its software on 

a VA server. We made three recommendations to VAPAHCS management and a 

fourth recommendation that VA’s Office of Information Technology implement controls to ensure that unauthorized software is not procured or installed on VA netVerDate Mar 15 2010 16:25 Sep 24, 2018 Jkt 000000 PO 00000 Frm 00022 Fmt 6633 Sfmt 6621 Z:\ACTIVE\031517.TXT PAULIN
19 

2We considered delayed consults to be those that were not completed, canceled or discontinued within the expected timeframe. 

works without a formal risk assessment and approval to operate. We closed our report based on information provided that the recommendations were implemented. 

INADEQUATE TRAINING FOR VA STAFF

One prevailing theme of the OIG’s work related to wait times and scheduling 

issues was the inadequate, lack of, or incorrect training provided to VA staff responsible for scheduling appointments. We conducted extensive work related to allegations of wait time manipulation through FY 2015 and FY 2016 after the allegations 

at the PVAHCS surfaced in April 2014. As we have reported in more than 90 Administrative Summaries of Investigation and other reports that have been issued, 

the lack of training for schedulers and the lack of understanding of the process by 

their managers created a system in which long wait times were not accurately portrayed to management. 

In October 2016, we reported again that some confusion persists regarding appointments. The focus for this report was on consult management. In our report, Review of Alleged Consult Mismanagement at the Phoenix VA Health Care System, we 

substantiated that in 2015, PVAHCS staff inappropriately discontinued consults. We 

determined that staff inappropriately discontinued 24 percent of specialty care 

consults we reviewed. This occurred because staff were generally unclear about specific consult management procedures, and services varied in their procedures and 

consult management responsibilities. As a result, patients did not receive the requested care or they encountered delays in care. This report offered 14 recommendations including ensuring that staff are hired and trained appropriately. We are 

tracking VA’s progress on implementing all the recommendations. 

In January 2016, we determined that VHA did not provide medical facilities with 

adequate tools to reasonably estimate non-VA care (NVC) obligations in our report, 

Audit of Non-VA Medical Care Obligations. The facilities we visited used a combination of methods that were ineffective at ensuring NVC cost estimates were reasonable. The methods used to calculate estimated costs included Medicare or contract 

rates, historical costs, and the optional cost estimation tools provided by CBO. The 

accuracy of estimates varied widely among these methodologies. We made five recommendations including for VA to improve the cost estimate tools so that NVC cost 

estimates are produced consistently. The recommendations related to cost estimate 

tools remain open. 

UNCLEAR RESOURCE NEEDS AND ALLOCATIONS PRIORITIES

In March 2017, we published Consult Delays and Management Concerns, VA Montana Healthcare System, Fort Harrison, MT. We assessed the extent that patients 

experienced delays in obtaining consults, and the impact of any delays on patient 

outcomes. We reported that, for system consults ordered through VA Montana 

Healthcare System in FY 2015, there were apparent delays 2 for: • 11,073 of 26,293 patients (42 percent) with at least one in-house consult; • 11,863 of 21,221 patients (56 percent) with at least one non-VA care consult; 

and • 2,683 of 4,427 patients (61 percent) with at least one Choice consult. 

We found that delays among consults ordered in FY 2015 may have harmed four 

patients. Beginning in July 2015, system leadership initiated a focused effort to 

identify and resolve factors that contributed to consult delays, including hiring additional support staff to process consults. Despite this effort, we found evidence of persistent issues with completing consults timely in FY 2016 (through late August 2016). We also noted that system leadership initiated ongoing reviews to determine if patient harm occurred due to delays in care. 

We made two recommendations to the VA Montana Director to ensure that an external (non-system) source review the care of patients we identified who were potentially harmed by consult delays and that VA staff provide institutional disclosures, 

as appropriate. We also made a recommendation regarding ongoing efforts to improve consult timeliness. The VA Montana Director and the VISN 19 Director concurred with our three recommendations and provided a responsive action plan and 

milestones to address the recommendations. 

The OIG has repeatedly reported on VA’s legacy systems and how they impair VA 

operations. A key element to accurate planning is a financial system that provides 

timely information to VA leadership. As was reported in Audit of VA’s Financial 

Statements for Fiscal Years 2016 and 2015, VA’s complex, disjointed, and legacy financial management system architecture continues to deteriorate over time and no 

20 

3https://www.va.gov/oig/pubs/VAOIG–16–00351–453.pdf, September 28, 2016 

4OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages, 

January 30, 2015 5OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages, 

September 1, 2015 

longer meets the increasingly stringent and demanding financial management and 

reporting requirements mandated by the Department of the Treasury and the Office 

of Management Budget. VA continues to be challenged in its efforts to apply consistent and proactive enforcement of established policies and procedures throughout 

its geographically dispersed portfolio of legacy applications and systems. VA announced in October 2016 that it selected the Department of Agriculture as its Federal shared service provider to deliver a modern financial management solution to 

replace its existing core financial management system. When completed, this will 

be a major and critical effort for VA in modernizing its system architecture for financial management. 

The audit of VA’s FY 2016 Consolidated Financial Statements also identified 

Community Care obligations, reconciliations, and accrued expenses as a material 

weakness. Lack of tools to estimate non-VA Care costs, lack of controls to ensure 

timely deobligations, and the difficulty in reconciling non-VA Care authorizations to 

obligations in VA’s Financial Management System, make the accurate and timely 

management of purchased care funds challenging. In addition, the Office of Community Care (OCC) did not have adequate policies and procedures for its own monitoring activities. OCC’s activities were not integrated with VA and VHA Chief Financial Officer (CFO) responsibilities under Public Law (P.L.) 101–576, the Chief Financial Officers Act of 1990, to develop and maintain integrated accounting and financial management systems and provide policy guidance and oversight of all Community Care financial management personnel, activities, and operations. 

To address the difficulties in estimating costs, VA requested legislation that would 

allow VA to record an obligation at the time of payment rather than when care is 

authorized. In its consolidation plan, VA said this would likely reduce the potential 

for large deobligation amounts after the funds have expired. We recognize that the 

current process and system infrastructure are complex and do not provide for effective funds management. We caution that such a change alone—i.e., obligating funds 

at the time of payment—would not necessarily remove all of VA’s challenges in this 

area. VA would still need adequate controls to monitor accounting, reconciliation, 

and management information processes to ensure they effectively manage funds appropriated by Congress. 

VA needs to accurately forecast the demand for health care services in both the 

near term and the long term. The OIG is required by Section 301 of Public Law 

113–146, the Veterans Access, Choice, and Accountability Act of 2014, to review 

VHA occupations with the largest staffing shortages. We have issued three reports 

at this time and under the statute we will report for another two years. In our most 

recent report issued in September 2016,3 we identified (i) medical officer; (ii) nurse; 

(iii) psychologist; (iv) physician assistant; and (v) physical therapist/medical technician as five critical occupations with the largest staffing shortages. In our initial review 4 and our subsequent reviews,5 we continue to recommend VHA create a staffing model that considers demand and complexity, and matches that to budget requests and allocations. While VHA has continually concurred with the recommendation, their planned completion date is September 2017. Further delay will potentially result in missed opportunities to request appropriate funding when planning 

for the FY 2019 budget. 

CONCLUSION

The OIG is committed to providing effective oversight of the programs and operations of VA. A number of our reports address the five broad areas noted by GAO 

in placing VA Health Care on its High Risk list. We will continue to produce reports 

that provide VA, Congress, and the public with recommendations that we believe 

will help VA operate its programs and services in a manner that will effectively and 

timely deliver services and benefits to veterans and spend taxpayer money 

appropriately. 

Mr. Chairman, this concludes my statement and we would be happy to answer 

any questions that you or other Members of the Committee may have. 

Senator TILLIS. Thank you, Mr. Missal. 

Dr. Clancy. 

21 

STATEMENT OF CAROLYN M. CLANCY, M.D., DEPUTY UNDER 

SECRETARY FOR HEALTH AND ORGANIZATIONAL EXCELLENCE, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY JENNIFER 

LEE, M.D., DEPUTY UNDER SECRETARY FOR HEALTH FOR 

POLICY AND SERVICES; AND AMY PARKER, EXECUTIVE DIRECTOR OF OPERATIONS, OFFICE OF MANAGEMENT 

Dr. CLANCY. Good afternoon, Senator Tillis, Members of the 

Committee. Thank you for the opportunity to discuss VA’s efforts 

to improve the issues identified by the GAO when they placed VA 

health care on the High-Risk List in 2015. As you noted, I am accompanied by Dr. Jennifer Lee and Amy Parker. 

In its High-Risk List update, GAO identified managing risks and 

improving VA health care as a high-risk area and noted five associated issues, which we have detailed in our written statement, and 

Debra Draper just reiterated. 

On March 3, 2017, Secretary Shulkin met with Comptroller General Dodaro to convey VA leadership’s commitment to accelerating 

the changes required to meet all of GAO’s criteria for removal from 

the High-Risk List. Secretary Shulkin acknowledged the significant 

scope of the work that remains and committed to better integrate 

its high risk-related actions with the President’s priorities and ongoing VA transformation efforts. 

We immediately began working with GAO to follow through on 

Secretary Shulkin’s commitments and to ensure continued VA collaboration with our GAO colleagues. We take GAO’s work and the 

Inspector General’s very seriously and appreciate the advice and 

feedback we have received from them. We are pleased to have the 

opportunity to report on our progress to date and our plan to ultimately be removed from the list. 

Addressing these risks will provide a sustainable foundation for 

continued transformation of the Veterans Health Administration. 

We have made progress since being placed on the High-Risk List. 

Two years ago, VHA had over 800 policies and over half of these 

had expired. On average, it took about 340 days to produce national policy, and VHA lacked a consistent process for their development. Since that time, we have established a workgroup of all 

outcome executives, meeting every 2 weeks, tracking all policies 

and development, examining every step of the process, addressing 

barriers, and piloted and established a new lean process that would 

be completed within 120 days. 

There are now approximately 650 active policies. New policies 

are created and reviewed promptly, and essential policies on access, 

scheduling, and consultations have been completed, published, and 

widely disseminated. We have committed to completing GAO’s recommendations to ensure medical facility controlled substance inspection programs meet our requirements by October of this year. 

VHA also instituted a significant organizational transformation 

that aligned key offices, including offices of compliance and business integrity, medical audit, a new internal audit function, the 

management review service, and ethics, under a single combined 

Office of Integrity, led by a new leader, Assistant Deputy Under 

Secretary for Health, Dr. Gerard Cox, who reports to me. 

22 

The newly established Office of Internal Audit and Risk Assessment uses reports from VA’s Office of Inspector General, GAO, and 

the Office of Special Counsel to conduct further assessments into 

potential weaknesses in VA health care programs or care quality. 

During the past 2 years, in partnership with GAO, we conducted 

a comprehensive inventory of open recommendations and instituted 

a regular process for adjudicating closure based on documentation 

of completed actions, and linked them quite specifically to the risk 

areas identified by the GAO. Now, more than 45 percent of open 

recommendations were made, just in a year or less, and we have 

requested closure on 18 percent of the open recommendations. 

We have learned that integrating with or updating our veterans 

health information systems and technology architecture, known as 

VistA, is difficult and costly. We must be able to consistently access 

veteran information to succeed. We certified our interoperability 

with the Department of Defense on April 8, 2016. Today the Joint 

Legacy Viewer is available to all clinicians in every one of our facilities across the country, and we are also actively onboarding private sector partners into our health information exchange, because 

that is absolutely imperative for community care to work well. 

Mr. Chairman, transformation is a marathon, not a sprint. It 

takes several years to turn any organization around and we are 

acutely aware that most of the candidates on GAO’s High-Risk List 

have taken multiple years to meet that requirement. Secretary 

Shulkin is absolutely dedicated that we do this as rapidly as 

possible. 

While I am proud of the progress we have made in a short time, 

I am also acutely aware that we have much more work to do. I am 

grateful for the subject matter advice and consultation provided by 

Dr. Draper and her colleagues, and reiterate my commitment to 

working more closely with them. 

We look forward to working with you and Members of this Committee and to better serve our veterans, and to have committed to 

quarterly briefings to your staff. 

Thank you for the opportunity to testify and I look forward to 

your questions. 

[The prepared statement of Dr. Clancy follows:] 

PREPARED STATEMENT OF CAROLYN M. CLANCY, M.D., DEPUTY UNDER SECRETARY

FOR HEALTH FOR ORGANIZATIONAL EXCELLENCE, VETERANS HEALTH ADMINISTRA- TION, U.S. DEPARTMENT OF VETERANS AFFAIRS

GOOD AFTERNOON, CHAIRMAN ISAKSON, RANKING MEMBER TESTER, AND MEMBERS

OF THE COMMITTEE. Thank you for the opportunity to discuss the Department of 

Veterans Affairs’ (VA) efforts to improve the issues identified by the Government 

Accountability Office (GAO) that placed VA health care on the 2015 GAO High Risk 

List. I am accompanied today by Dr. Jennifer Lee, Deputy Under Secretary for 

Health for Policy and Services, and Amy Parker, Executive Director of Operations, 

Office of Management. 

INTRODUCTION

In its 2015 High Risk List Update, GAO identified ‘‘Managing Risks and Improving VA Health Care’’ as a high-risk area and noted five associated high-risk issues: 

• Ambiguous policies and inconsistent processes; 

• Inadequate oversight and accountability; 

• Information technology (IT) challenges; 

• Inadequate training for VA staff; and, 

• Unclear resources needs and allocation priorities. 

23 

We take GAO’s work seriously and appreciate the advice and feedback we have 

received from our colleagues. We are pleased to have the opportunity to report on 

our progress to date and our plan to be removed from the list. Addressing these 

risks will provide a sustainable foundation for continued transformation of the Veterans Health Administration (VHA). 

PROGRESS TO DATE BY RISK AREA

Ambiguous Policies 

• Two years ago, VHA had over 800 policies, and more than half had expired. On 

average, it took over 340 days to produce national policy, and VHA lacked a consistent process for policy development. Since that time, we have established a 

workgroup comprised of all outcome executives that meets every two weeks and 

tracks all policies in development. We examined every step of the process, addressed 

barriers, and piloted and established a new, lean process with an aspirational 

timeline of 120 days. Our new process incorporated review and comments from medical centers and administrative offices—something that had never been formally required in the past, and which addressed many of the gaps identified by GAO. We 

funded seven full-time contractors to support transformation. We identified and rescinded 112 expired policies and 20 additional policies that were no longer relevant. 

We completed work updating many policies imperative to addressing then-Under 

Secretary for Health Dr. David Shulkin’s five priorities, and are eliminating handbooks and manuals in an effort to simplify and streamline national policy. There 

are now approximately 650 active policies, including essential policies on access, 

scheduling, and consultations that were completed, published, and widely disseminated. We are also beginning to experience the unquantifiable benefits of culture 

change, as people in VA Central Office and the field become aware of these new 

processes, and the response has been overwhelmingly positive. 

Inadequate Oversight and Accountability 

• VHA instituted a significant organizational transformation that aligned several 

key offices including the Office of Compliance and Business Integrity, the Office of 

the Medical Inspector, the Office of Internal Audit and Risk Assessment, the Management Review Service, and the National Center for Ethics in Health Care. These 

offices are led by a newly established Assistant Deputy Under Secretary for Health 

for Integrity, Dr. Gerard Cox, who reports to the Deputy Under Secretary for Organizational Excellence. VHA also established a new Office of Internal Audit and Risk 

Assessment that uses reports from VA’s Office of Inspector General (OIG), GAO, 

and the U.S. Office of Special Counsel to conduct further assessments into potential 

weaknesses in VA health care programs or care quality. The expected outcomes 

from VHA’s integration of oversight and accountability activities are that: 1) VHA 

program offices, Veterans Integrated Service Networks (VISN), and facilities will 

possess a common understanding of how their oversight authorities, roles, and responsibilities align, 2) VHA will have a workforce well trained in oversight standards, 3) program offices, VISNs, and facilities will uniformly oversee policy implementation, and 4) VHA will have a culture that incorporates both values and process to solve policy concerns. 

• During the past two years VA, in partnership with GAO, conducted a comprehensive inventory of open recommendations and instituted a regular process for 

adjudicating closure based on documentation of completed actions. This adjudication 

process resulted in closure of 91 recommendations, and we have requested closure 

on 18 percent of open recommendations. We have systematically cleared out the 

backlog of old recommendations so that currently over 45 percent of our open recommendations were made during the past 12 months. An additional 30 percent of open 

recommendations are between 1- and 3-years old. 

INFORMATION TECHNOLOGY CHALLENGES

• VA has learned that integrating with or updating the Veterans Health Information Systems and Technology Architecture (VistA) is difficult and costly. VistA Evolution is a joint VHA and Office of Information and Technology project intended to 

improve the efficiency and quality of Veterans’ health care by modernizing VA’s 

health information systems, increase data interoperability with the Department of 

Defense (DOD) and network care partners, and reduce the time it takes to deploy 

new health information management capabilities. VistA Evolution funds have enabled critical investments in systems and infrastructure; supported interoperability, 

networking and infrastructure sustainment; continuation of legacy systems; and 

other efforts that are critical to maintenance and deployment. These investments 

will deliver value for Veterans and VA providers regardless of whether our path forVerDate Mar 15 2010 16:25 Sep 24, 2018 Jkt 000000 PO 00000 Frm 00027 Fmt 6633 Sfmt 6621 Z:\ACTIVE\031517.TXT PAULIN
24 

ward is to continue with VistA, shift to a commercial Electronic Health Record 

(EHR) as DOD is doing, or some combination of both. 

• Access to accurate Veteran information is one of our core responsibilities, and 

today the Joint Legacy Viewer (JLV) is available to all clinicians in every VA facility 

in the country. VA certified VA/DOD interoperability on April 8, 2016, in accordance 

with section 713(b)(1) of the National Defense Authorization Act for Fiscal Year 

2014 (Public Law 113–66). However, JLV is a read-only application. Leveraging this 

JLV interoperability infrastructure, the Enterprise Health Management Platform 

(eHMP) will ultimately replace JLV. eHMP is a cornerstone of the VistA Evolution 

Program, building on the capability for clinically actionable, patient-centric data pioneered by JLV. eHMP will fill clinical gaps in VA’s current tools, bridge the EHR 

modernization effort, and simplify VHA’s overall clinical user experience. Upon completion, eHMP will offer robust support for Veteran-centric health care, team-based 

health care, and quality driven health care while improving access based on clinical 

need. 

Inadequate Training for VA Staff 

• Training is vital to maintain a competent workforce and ensure that Veterans 

consistently receive timely, safe, high quality care. Training also requires a substantial investment of time and resources. From March to June 2016, then-Under Secretary for Health Dr. Shulkin directed a temporary moratorium on all Talent Management System (TMS) assignments not assigned by law or Executive Order. A detailed listing of previous training requirements was built to review all assignments, 

and comprehensive recommendations from across the organization were collected on 

existing training assignments. The VHA training policy was revised based on the 

results of this training review and is currently under evaluation. 

• As a result, all 32,326 VHA employee TMS assignments were reviewed, and 

more than 700,000 hours of training were targeted for potential removal along with 

possible savings of over $38.7 million in hourly equivalent staff salary. To continue 

this improvement, VHA’s new Mandatory Training Policy will be implemented this 

year in a phased rollout, with additional steps for review of content and comment 

from field-based experts. 

Unclear Resource Needs and Allocation Priorities 

• Key accomplishments for connecting strategy, requirements, programming, 

budgeting, and execution (since June 2015) include: 

• Completion of the Quadrennial Strategic Planning Process (QSPP)—Strategic 

Options and Alternative of Analysis Phases. Outputs from the QSPP informed our 

planning guidance. 

• Selection of the U.S. Department of Agriculture as a Federal Shared Service 

Provider to support the migration of a new financial management system (FMS). VA 

established a Financial Management Business Transformation program office and 

an Executive Steering Committee to manage the multi-year effort to improve VA’s 

financial management accuracy and transparency. 

• Issuance of FY 2019–2023 Programming Guidance as the disciplined framework 

to develop, assess, and prioritize multi-year requirements. VA successfully implemented two Managing for Results Programming cycles, which enhanced the connection of requirements and resources to support more defensible budget justifications. 

This included conducting Program Review Boards with senior leadership to assess 

gaps, impacts, and mitigations in advance of budget formulation. 

• Publication of the FY 2018–2022 Programming Decision Memorandum (PDM) 

to capture decisions from the Program Review Boards and inform budget formulation guidance. The PDM included senior leadership decisions for resource 

prioritization and enterprise-wide mitigations to garner efficiencies and optimize 

strategic outcomes. 

• Publication of a VA Cost Estimating Guide as a new financial policy outlining 

procedures for developing lifecycle estimates for programs that meet requirement 

thresholds. 

PATH FORWARD

On March 3, 2017, Secretary Shulkin met with Comptroller General Gene Dodaro 

to convey VA leadership’s commitment to accelerating the changes required to meet 

all of GAO’s criteria for removal from the High-Risk List. Secretary Shulkin acknowledged the significant scope of the work that remains and committed to better 

integrate its high-risk related actions with the President’s priorities and ongoing 

performance improvement initiatives. 

25 

VA immediately began working with GAO to follow through on Secretary 

Shulkin’s commitments to Comptroller General Dodaro and to ensure continued VA 

collaboration with our GAO colleagues. 

As we did in 2016, we will continue to place priority on implementing GAO’s and 

VA OIG’s recommendations using our new adjudication process. We have committed 

to completing GAO’s recommendations to ensure medical facility controlled substance inspection programs meet VA requirements by October 2017. VHA’s new office of Internal Audit and Risk Assessment will lead this work and will harmonize 

the policy, its implementation, training, and internal controls for required corrective 

actions to ensure consistent enterprise-wide management of controlled substances. 

We will buildupon our accomplishments for same-day access for Veterans with urgent problems in primary care or mental health, develop and disseminate a policy 

that builds on current guidance to the field, further improve our oversight of access 

to ensure all VA medical facilities consistently prioritize the needs of Veterans with 

urgent problems today, and transition to rely on Veterans’ reports in how we display 

information to the public on wait times. 

VA will work with GAO and Congress to redesign the Veterans Choice Program 

so it works for Veterans and community providers, improve oversight of VA community care to ensure Veterans receive the care they deserve, and ensure our community partners are paid in a timely fashion. 

VA needs Congressional action to extend the current Choice Program beyond August 7, 2017. VA also needs new legislation to: (1) provide standardized, clear eligibility criteria for Veterans to get care closer to home; (2) facilitate building a highperforming network of community care providers, which includes our DOD, other 

Federal, and academic affiliate partners as the foundation and reimburses for care 

using contemporary payment models; and (3) better coordinate benefits for Veterans, allowing VA to work directly with third-party insurers. We look to Congress 

and our stakeholders to help enact these changes for Veterans within six months 

so that once all the Choice funds are depleted, there will be a plan in place for Veterans to continue receiving uninterrupted community care. 

As described above, VA’s patient scheduling and EHR system requires significant 

improvement, and VA will take steps this year to address these needs. In addition, 

VA will improve oversight of the systems, to include establishing outcome-oriented 

metrics. VA’s relationship with DOD and our community providers is complex and 

evolving. We will work closely with DOD to improve interoperability of VA and DOD 

record systems, and with our community providers to ensure continuity of care for 

Veterans. VA will implement a process to develop, document, implement, and oversee organizational structure recommendations to ensure approved recommendations 

are implemented, outcomes are measured, and plans are adjusted as necessary. 

VA is a complex ‘‘system of systems,’’ and this is reflected in the root cause analysis work we have accomplished thus far. We will complete this analysis in 2017, 

integrating the health care high-risk area actions with the President’s priorities, the 

Secretary’s 10-Point Plan, and with VA’s ongoing performance improvement initiatives. We will use the results of the analysis to fine tune and speed up VA’s progress 

in managing its health care high-risks. 

VA efforts will buildupon each other across a period of years to develop a sustainable solution to each high-risk issue, as well as to put in place systems that dramatically reduce the chance that high-risk issues will reemerge. 

CONCLUSION

Mr. Chairman, transformation is a marathon, not a sprint. It takes several years 

to turn any organization around, and VA is no exception. While I am proud of the 

transformation VA has undergone in response to being placed on the High-Risk List, 

and the progress we have made, I am also acutely aware we have much more work 

to do to meet all five of GAO’s criteria for removal. I am grateful for the subject 

matter expert advice and consultation provided by Dr. Debra Draper and the GAO 

medical team; it has proved invaluable in helping VA achieve the progress we’ve 

made since 2015. We look forward to working with Congress and GAO to better 

serve our Veterans. Thank you for the opportunity to testify before the Committee. 

I look forward to your questions. 

Senator TILLIS. Thank you, Dr. Clancy. 

Are any of the other witnesses present intending to offer an 

opening statement? Here to answer questions? 

[No audible response.] 

Senator TILLIS. OK. Thank you. 

26 

Mr. Missal, I want to start with you. I want to get into some of 

your specific observations, and, Dr. Draper, this may relate to your 

lanes as well. 

When we do these evaluations, do we do it purely from the perspective of the regulatory, statutory construct as it exists today? Is 

there ever a focus on the possible root cause of some of the problems that need to be addressed being exacerbated by current rules 

or regulations, or do you accept that as the norm? 

Mr. MISSAL. No, we do not accept that as the norm. When we go 

into a project and we publish a report, I would like the reports to 

answer at least four questions. One, why we are doing this—and 

that may get to your question: is it a regulatory issue; is there 

something to put it in perspective? Two, what happened? Again, we 

should be accurate and fair as to what happened. Third, why something happened, and that really gets to the root cause of the problem. If a report is going to be a learning experience, helping VA 

improve, we really have to be pretty descriptive on why something 

happened. Then, fourth, who was responsible, so that if somebody 

did not perform as expected, that they could be held accountable. 

Senator TILLIS. Thank you for that. 

Dr. Clancy, I think you know that the Ranking Member and I 

worked together for the last couple of years, with Secretary McDonald, to take a look at the transformation effort, the breakthrough 

priorities, and getting updated on activities and actions there. I 

think that there is some progress to be made. 

One question that I have, with the transition now of Dr. Shulkin 

to the role of Secretary, are any of those priorities changing? Are 

there any efforts being made to try to accelerate? Are we still on 

the same path, and can you give us some update on where either 

those breakthrough policies or specific remediation measures in reaction to the Inspector General’s report are actually—are we making progress? In other words, where are we making traction? 

Dr. CLANCY. We have made a great deal of traction to the transformation known as MyVA, in terms of the fact that all of our facilities achieved same-day access. These are the major medical centers for urgent problems and primary care and mental health at 

the end of calendar year 2016. 

Senator TILLIS. How are we measuring that? I mean, how are we 

measuring things so that I can go back and get a review of the 100 

or so recommendations, I think a quarter of which are 3 years old. 

You referred in your opening comment to lean process. I like 

that, because I have done lean process design in the private sector. 

All those efforts are driven by metrics—current State metrics, future metrics, any of the metrics you are making positive progress 

along the way. 

Are there specific things that you can speak to or submit for the 

Committee’s purposes to look at quantitative, measurable changes 

that are in place, addressing the problems that are in the report? 

Dr. CLANCY. We have a great deal of information on quantifiable 

improvements in access, both in terms of wait times and veterans’ 

experience. There are reports of how often can they get care when 

they needed it right away, and so forth, and also plans in terms 

of future audits, because right at the end of calendar year 2016 is 

when we achieved that addition of same-day access. 

27 

Many of the priorities in the MyVA transformation are continuing. I expect, as Dr. Shulkin’s team comes together, that some 

may just simply move to become organizational efforts and not at 

that very high priority level, because they are underway. You 

would expect that in any transformation. I would imagine that has 

been part of your background prior to joining the U.S. Senate as 

well, but certainly we would be happy to take that for the record 

for a more complete picture. 

[Responses were not received within the Committee’s timeframe 

for publication.] 

Senator TILLIS. Thank you. Mr. Missal, I also appreciate the 

work that was done, looking specifically at VISN 6. That is a little 

bit closer to home, since that covers my geography. But, has there 

been any work done, in terms of even rethinking—in my estimation, a lot of the problems that exist with VA as a whole is how 

we are organized and the duplicative technology processes that we 

see out there, inconsistent experiences from VISN to VISN, and actually even within a VISN. 

Are there other things that we can do to really put the pressure 

on, and prioritizing in the right order? One of the concerns that I 

have with the number of recommendations for improvement, it is 

a target-rich environment for change. That is the good news. The 

bad news is if you are shooting at every target at the same time 

you are not going to hit any one of them. 

What is your view of the remedial measures that have gone into 

place, and whether or not the department is organizing properly to 

address the problems, and ultimately, over some period of time, get 

off the High-Risk List? 

Mr. MISSAL. We have looked at access to care in a number of different ways. Before the VISN 6 report, we had been looking at it 

facility by facility and it was hard to really get a sense of whether 

there are any themes, or is there a wider-spread problem other 

than at a particular facility. We obviously found significant problems at VISN 6. We are looking at another VISN, again, just to 

compare to see if it is a leadership issue at the VISN. Is it higher? 

Is it lower than that? 

We try to make recommendations that are meaningful, that 

hopefully you do not see the same mistake happen again. We are 

going to continue to do that, and we are also going to be looking 

at the whole governance structure as well, because I agree, that 

could be an issue that could help a lot by addressing it. 

Senator TILLIS. It just speaks to some of the impediments that 

are a part of the root cause of the problem. 

Ranking Member Tester. 

Senator TESTER. Thank you, Mr. Chairman. Mr. Missal, I appreciate your work at Fort Harrison. Since you have been confirmed 

I think you have done some very good work and I want to thank 

you for that. 

Dr. Clancy, I spoke with Secretary Shulkin about this already 

and I need to make it clear. The findings in the report, as I said 

in my opening statement, unacceptable. Debra, as you may remember, the GAO issued a report in September 2014 on consult management. You made six recommendations that are all still open, per 

your website. In one, the VHA promised to complete the first round 

28 

of VAMC consult audits by September 2016. Debra, was that 

completed? 

Ms. DRAPER. They have started the audit process. They provided 

us documentation in August, but we felt like the information provided was not complete. They did not provide all the documentation 

that we needed to assess the recommendations for closure, so we 

sent it back to them. Just recently they provided additional documentation; we are currently looking at what they provided so that 

we can assess whether the recommendation should be closed. 

But, in the information they provided to us, 75 percent of the 

VAMCs had done at least one audit—one consult. So, there is work 

to be done. 

Senator TESTER. Was Fort Harrison included in any of those 

results? 

Ms. DRAPER. They did not provide us detail. It was 75 percent 

of the VA medical centers. I think this is being done, spearheaded, 

through Dr. Clancy’s office. She may be able to tell you that. 

Senator TESTER. Go ahead, Dr. Clancy. 

Dr. CLANCY. Sure. I spoke with leadership from the facility and 

the network yesterday, and they have made substantial progress, 

about which I would be happy to provide specific details. What I 

heard that was more important was: in addition to the fact that 

they have already contacted three of the four veterans—the fourth 

they are having some difficulty reaching but will continue—— 

Senator TESTER. Right. 

Dr. CLANCY [continuing]. And had disclosed to them and their 

families what had happened, that they have not only made 

progress but are looking upstream now at how did we get here. 

Right? How might we use electronic consults to specialists, noting 

a shortage of some specialists across the State, in Montana, not 

just in VA. 

Senator TESTER. Yes, there are. 

Dr. CLANCY. And also looking at, are there ways that we might 

be training primary care clinicians? Are they referring to specialists too often, right, that they might be able to get extra expertise—— 

Senator TESTER. Got it. 

Dr. CLANCY [continuing]. If you have got a scarce resource. 

I do not hear that very often. You are aware that the entire leadership team has turned over there. 

Senator TESTER. I am. 

Dr. CLANCY. It was a very different tone then when I have spoken to leadership at that facility before. We will certainly keep you 

updated, as I know it is very high on Dr. Shulkin’s screen. 

Senator TESTER. That is good, and I do think we have upgraded 

the leadership team in a big, big way—you guys have, I should say, 

at Fort Harrison. 

Another VHA started calls to share best practices with respect 

to consults. Dr. Clancy, was Fort Harrison—did they participate in 

those calls too? 

Dr. CLANCY. I would have to double-check to be concrete about 

that, and I will take it for the record. Thanks. 

[Responses were not received within the Committee’s timeframe 

for publication.] 

29 

Senator TESTER. OK. All right. 

Mike, your report on Fort Harrison indicated that steps had been 

taken to improve consult timeliness. Are you confident that these 

steps are sufficient? 

Mr. MISSAL. You know, we have got recommendations. They have 

an opportunity to prove to us that the steps that they have agreed 

to take will be implemented. We look at all recommendations very 

closely, and if we believe additional work needs to be done we will 

do so. 

Senator TESTER. OK. All right. OK, that is fine. 

The High-Risk Report describes deficiencies in the action plan 

VHA submitted to address the high-risk status. Debra, can you articulate the impact these deficiencies are having on patient care 

within the VA? 

Ms. DRAPER. Yes. Well, basically, our high-risk work is a culmination of our work since 2010, so it reflects work in areas like 

access, which includes wait time and scheduling, the Choice Program, quality. So, in some of our work we have found that delays 

in care have put patients at risk, or veterans at risk for bad outcomes. I mean, I think there is sufficient evidence to suggest that 

when care is delayed or care is not received at all, for certain conditions, that the conditions worsen and then it becomes much more 

complex and costly to then treat that particular condition. 

I can give you a couple of examples in our mental health access 

report that we did in 2016. We found that for some veterans, when 

their mental health care was delayed, they decompensated and 

then their conditions became urgent and they then required urgent 

care, which sometimes resulted in hospitalization. We had other 

cases; for example, in the reprocessing of reusable medical equipment, if not cleaned properly or sterilized, it exposed many veterans to infectious diseases such as hepatitis. 

We have numerous examples, from the five areas that we have 

identified as the areas of concern in our high risk report, that are 

the underlying underpinnings that really, if not addressed sufficiently, raise the risk of harm for veterans. 

Senator TESTER. Thank you, Mr. Chairman. 

Senator TILLIS. Senator Rounds. 

HON. MIKE ROUNDS, U.S. SENATOR FROM SOUTH DAKOTA 

Senator ROUNDS. Thank you, Mr. Chairman. Mr. Missal, I would 

just like to start by asking a question about the hospital in Aurora, 

CO. It originally was set up with $600 and $700 million, as an estimate. Last time we checked, the estimated overrun was $1 billion. 

That has been more than a year ago. In your most recent review, 

is it still about $1 billion overrun or have we increased it since 

then? 

Mr. MISSAL. We have not done any additional work. There is 

going to be an additional cost once the facility is done to essentially 

move into the facility, so that amount has to be on top of the building costs as well. 

Senator ROUNDS. So, how much, in addition to the $1 billion 

overrun, are you estimating at this time, or are you anticipating, 

and how will they come up with the resources to pick up that cost? 

30 

Mr. MISSAL. I think it is going to be another—it was in our report, and my recollection it was somewhere around another $315 

million, but these are not construction funds. 

Senator ROUNDS. Did you look at—on another matter, have you 

looked at the Choice Program and the operation of the Choice 

Program? 

Mr. MISSAL. Yes. We have done a number of reports on Choice. 

Senator ROUNDS. When you did the review of Choice, did you 

look at the cost analysis of the administrative costs of Choice 

versus non-Choice activity? 

Mr. MISSAL. We did not examine it that closely. We looked at, 

certainly, the administrative burdens of Choice and whether or not 

it operated as a barrier for veterans, but we did not actually look 

at the cost of each. 

Senator ROUNDS. It seemed that—and the reason why I bring it 

up, it seems as though there may be a duplication of activity there, 

and I did not know whether or not you had found that or had addressed it at all. My understanding is that there is a third party 

which had been hired to actually do the administration of the 

Choice to begin with, in terms of the appointments, and then also 

for the billings on behalf of the physicians, and that same third 

party is the same organization that—like in our part of the country 

it is HealthNet, but HealthNet handles not only VA Choice but 

they also do TRICARE as well. 

They seem to work very well within TRICARE but when it comes 

to working with the VA, my understanding is that they have a substantially higher cost, not because HealthNet charges more but because they are required to work through additional layers. In fact, 

every single time a veteran goes to a facility or to a physician or 

to a provider, it is a review and a reauthorization as opposed to a 

continuation of an existing approval method. Is that correct? 

Mr. MISSAL. I believe that is correct. When we looked at Choice, 

we first looked at the implementation of Choice, which took it from 

the beginning of the program until September 30, 2015. We found 

a lot of administrative burdens and that the administration by VA 

caused significant delays. 

We then looked at it again, as part of our VISN 6 report, which 

went to the end of the calendar year, meaning December 31, 2015. 

Again, we saw some changes. It got a little better but there are 

still burdens. 

Senator ROUNDS. Just to continue along that same line, my understanding, also, is that although they are perfectly capable of 

making the review, delivering the requested payments through providers and so forth—we have had delays of up to 9 months for providers—it seems as though HealthNet is not the case where the 

problem is at. It actually goes into the VA and the VA then farms 

it back out for a second review, to be put back into their system, 

thus increasing the cost on a per claim basis by perhaps a tenfold 

factor. Were you able to look at that at all? 

Mr. MISSAL. We understand that they have changed the payments, where now they are doing bulk payments with the two 

third-party administrators, HealthNet and TriWest. So, they are 

constantly making changes to try to facilitate the payments. 

31 

Senator ROUNDS. Do you know if they are still duplicating the efforts that those two third parties are expected to do? 

Mr. MISSAL. I do not know precisely. I know they constantly are 

looking at it. We have not—we are taking a hard look now at it, 

but we—— 

Senator ROUNDS. Could I ask that in your next review you look 

to see, because it appears to me that Choice, one way or another, 

is going to continue on, and that we are going to continue to use 

third parties somewhere along the line. If that is the case, it seems 

inappropriate to have a duplication of efforts within the VA, simply 

to get things paid. Number 1, it seems to be a cost that we do not 

need, and second of all, it most certainly delays the payment to 

providers, which there is some reason why providers are not getting paid in a timely fashion. 

Mr. MISSAL. Right. We have an audit ongoing on the payments. 

We can add that in. 

Senator ROUNDS. OK. Thank you, sir. Thank you, Mr. Chairman. 

Senator TILLIS. Senator Murray. 

HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON 

Senator MURRAY. Mr. Chairman, thank you very much. Thank 

you to all of our panelists for being here today. 

Let me just say, veterans have really benefited from expanded 

access to affordable health insurance and the expanded Medicaid, 

in particular, under ACA. That progress is really in jeopardy as the 

American Health Care Act would effectively end the Medicaid expansion and eliminate the coverage that is helping so many of our 

veterans. This is more important now than ever, as the VA continues to struggle with wait times, and as we work to reform the 

way veterans receive care both in and outside the VA. 

Dr. Clancy, I wanted to ask you, what would happen to the workload on VA and veterans’ access to care if Congress repeals the Affordable Care Act? 

Dr. CLANCY. We will be looking at that very closely, Senator. 

What I can tell you is that we did a policy analysis that compared 

States that had expanded Medicaid under the ACA, compared with 

those that had not, and saw that that increased demand for our 

services, somewhere between 6 and 18 percent—the broad range 

just refers to type of services. I believe 18 percent is outpatient 

care and 6 is inpatient. So, we would expect to see increased demand for our services for those veterans who had benefited—— 

Senator MURRAY. So, what you are saying is that States that expanded Medicaid, that it is now at threat of being taken away, 

those families would—how many people would that be that would 

increase the demand at the VA? 

Dr. CLANCY. I would actually have to track it back to get you 

some good numbers, but could do that. This was an analysis done 

by some policy researchers working with academic colleagues, because I was wondering about the differential impact. 

Senator MURRAY. Mm-hmm. Can you get us any studies you 

have done on the effects of the ACA on veterans’ care or on the VA 

workload, for the record? 

Dr. CLANCY. Mm-hmm. 

32 

[Responses were not received within the Committee’s timeframe 

for publication.] 

Senator MURRAY. Because I think that would be really important 

to know. 

OK. Dr. Clancy, I did note that at the end of your testimony you 

state that the VA will address the GAO recommendations in conjunction with implementing the Secretary’s 10-point plan and implementing the President’s priorities. 

I have been watching, because I believe that actions speak louder 

than words, the President’s actions, and I have seen him, at the 

VA, leave almost every senior position in the department without 

a permanent official in place. He is refusing to personally meet 

with major veterans’ organizations. He has implemented a hiring 

freeze that prevents VBA from hiring the staff needed to process 

veterans’ claims. We know he has raised money, allegedly, for veterans’ charities and then avoided giving to those groups until questioned. Those actions I am deeply concerned about. 

I did listen to him at the Joint Session of Congress a few weeks 

back, when he said his budget, which is not out yet, would somehow increase funding for veterans. 

So, I wanted to ask you, is fixing the VA simply a matter of more 

money to the VA, regardless of any policy or leadership? 

Dr. CLANCY. I think that we need both the necessary resources, 

the right strategy, and the right leadership. To that end, I think 

your confirmation of Secretary Shulkin was a really terrific move, 

because as he said to you at the time of his hearing, he would not 

have a learning curve. I did not realize just how much he meant 

that, but, you know, he has been able to move very, very swiftly, 

in my experience in transitions, which I think is going to be good 

for veterans. 

I think you also heard him say ‘‘not on my watch,’’ in terms of 

privatizing, and I have full confidence that he will let you know if 

we need more resources to get the job done right. 

Senator MURRAY. I just think that that really matters. 

Dr. CLANCY. Yes. 

Senator MURRAY. Obviously, we all love to say we are getting 

more money. We would love to see that, but we need leadership 

too, from the top on this—— 

Dr. CLANCY. Yes. 

Senator MURRAY [continuing]. And I do not know what that is 

yet, and I am not talking about the Secretary. 

Dr. CLANCY. Yeah. 

Senator MURRAY. So, I am concerned and I just wanted to register that. 

Dr. Draper, good to see you again. Thank you for all the work 

you and GAO put into making sure we provide the best care for 

our veterans. 

Your testimony is very concerning, particularly the apparent lack 

of urgency in VA’s steps to get off the High-Risk List. Not one of 

the five criteria in any of the areas of concern GAO identified has 

been fully met by the VA. Can you tell us how far along the VA 

should be now that it has been 2 years since it was first put on 

that High-Risk List? 

33 

Ms. DRAPER. Well, we are very concerned that 2 years later we 

are not much further ahead, or the VA is not much further ahead 

in addressing the issues. Let me just tell you a little bit about what 

we have done in the past couple of years to really express the need 

for urgency. 

The Comptroller General met with the then Secretary McDonald 

three times in the past couple of years. First was to tell him they 

were being put on the High-Risk List, the second time was that 

they were not making progress, the third time was that they were 

not making progress and that he offered the availability or access 

to subject matter experts within GAO that could help them with 

some of their initiatives, like contracting. We had a meeting in August between VA leadership and GAO subject matter experts, and 

unfortunately, to date, they really have not taken us up on accessing our subject matter experts that could really help point them, 

in terms of best practices. You know, we look across governments 

so we know what works well, what does not. 

Senator MURRAY. So, which agencies would you point them to, to 

tell them to look at? 

Ms. DRAPER. Well, it would really depend on what the issue was, 

but we had pointed the high risk—the group—Dr. Clancy’s group 

to the Department of Homeland Security, which we feel has done 

a nice job addressing the high-risk concerns. I think they have a 

copy of their action plan and contact information related to that 

particular area. 

As I think Dr. Clancy said, the Comptroller General and Secretary Shulkin did meet on March 3, to talk about the lack of 

progress and concerns, and what they needed to do. The most immediate thing to do was to have a viable action plan that really 

provides a roadmap and lays out what they need to do and how 

they are going to do it. 

Senator MURRAY. OK. Thank you very much. Thank you, Mr. 

Chairman. 

STATEMENT OF HON. JOHN BOOZMAN, 

U.S. SENATOR FROM ARKANSAS 

Senator BOOZMAN [presiding]. Thank you all so much for being 

here, and I apologize for being late. I had to give a little talk, and 

we had votes, and it was during the period when the votes took up. 

You all know how these things are. We do appreciate all of your 

hard work, and for coming over and talking to us about these 

things that are so very important. 

One of the areas that I really am concerned about, I think all of 

us are concerned about, is the management of information technology, which has been something that lots of people have been 

working on. I have been here since 2001, on the VA Committee in 

the House and now in the Senate, and this is just something that 

has been difficult. 

We talked about before, that, you know, there are proprietary 

ways of doing this. I was pleased that recently, I believe Dr. 

Shulkin said that we were going to be looking at commercial applications. Is that correct? 

Dr. CLANCY. [No audible response.] 

34 

Senator BOOZMAN. Dr. Clancy, in your testimony you mentioned 

that the VA will take steps this year to address patient scheduling 

and electronic health record systems. Again, Secretary Shulkin has 

mentioned the VA was pursuing VSE as a scheduling solution, as 

well as MASS, another scheduling tool. It was my understanding 

that a go or no-go has been reached regarding VSE. Can you talk 

to us a little bit about that? 

Dr. CLANCY. I am going to hand this to my partner, Dr. Lee, who 

knows all of the details much more than I do. Thanks. 

Senator BOOZMAN. Very good. I have partners just like that. 

Dr. LEE. Thank you, Senator, for the question. We are currently 

moving ahead to implement a commercial scheduling solution 

called MASS, the Medical Appointment Scheduling System. We are 

currently piloting it right now at our site in Boise. 

I had the opportunity to see a demo of MASS a few weeks ago, 

and I was really impressed. It is state-of-the-art, it is so far advanced from where we are right now, and it will build in all kinds 

of functionality for our patients that we do not have right now, including rules and the ability to see what services individual patients qualify for, inside the system. 

Because it is so far advanced, it will take some time to fully implement across the entire system, on the order of probably several 

years, and because our current system is so primitive—as you 

know it is from the ’80s and it is a DOS-based system with—just 

very difficult to use. In fact, I saw our schedulers—I spent a day 

at a site watching some of our primary care clinic schedulers use 

our system, and it is cumbersome. 

We needed an interim solution that we could quickly roll out in 

the meantime, and that is the VistA Scheduling Enhancement, 

VSE. A few weeks—last month, actually, we did approve the national rollout of VSE as an interim scheduling solution, and we are 

planning to have that be implemented throughout the system 

through the summer. 

Senator BOOZMAN. Very good. That is a great step in the right 

direction. That is encouraging. 

Dr. Clancy, you also, in your testimony, you highlighted the 

progress of the Joint Legacy Viewer. I believe that that is available 

now to clinicians throughout the system, you know, which is a good 

thing. Can you talk a little bit about how many people are—how 

many clinicians are actually using it, and our progress in that regard, or Dr. Lee? 

Dr. LEE. Currently we have over 200,000 authorized users for the 

Joint Legacy Viewer. This allows interoperability between VA and 

DOD health records. We are exchanging daily, on a daily basis, 

over 1.5 million data elements between VA and DOD. 

Just to speak about this from my own personal experience, I am 

an ER doctor and I see patients at the DCVA in the ER there, on 

the weekends. I have used Joint Legacy Viewer myself to find 

records from DOD when I am seeing patients there. You can also 

see records from the community. So, as more of our care is provided in the community, we need to have that interoperability with 

our community partners. You can also see the records from the 

community, as long as they are participating in our health information exchange. 

35 

Senator BOOZMAN. Along with that, can you talk a little bit about 

the enterprise Health Management Platform and how that is going 

to become a major cog? 

Dr. LEE. Yes, enterprise Health Management Platform, or eHMP, 

allows us to have even better interoperability by adding search, 

and also writes that functionality. JLV, the Joint Legacy Viewer, 

currently is in read-only state. The eHMP, brings all of the information together in one place. I have also used this myself. It allows 

providers on the same care team to communicate with each other. 

It can allow for clinical decision support to be added to the system, 

where you have many more tools in one place. This platform is 

really critical for us, as the clinical users and providers, to take 

care of our patients. 

Senator BOOZMAN. Very good. Well, we look forward to hearing 

the progress, you know, as these things go forward. And it certainly seems like a big step in the right direction. 

Dr. CLANCY. We could, if you were interested, I think arrange a 

demonstration locally, for you or your staff. 

Senator BOOZMAN. Yeah, that would be great. Sure. Very much. 

Senator Tester. 

Senator TESTER. Thank you, Mr. Chairman. Real quick, the 

incidences with servicemembers being sexually harassed on 

Facebook and other websites, it is critically important that we pay 

attention to what the heck is going on there, both from a DOD perspective and a VA perspective. The DOD, I believe, will bring the 

offenders to justice. 

Dr. Clancy, as you know, the VA has the authority to provide 

counseling services at med centers to active duty servicemembers 

who have experienced military sexual trauma, which would seem 

to include this type of abuse and harassment. Is the VA taking any 

actions to make sure these servicemembers can seek help from the 

VA? 

Dr. LEE. I can say, Senator, that it is our policy to—currently, 

to provide care for any servicemember or veteran who has experienced military sexual trauma—— 

Senator TESTER. OK. 

Dr. LEE [continuing]. No matter where they enter our system. 

Senator TESTER. OK. All right. Well, I would hope that you 

would take the necessary steps to let people know that if they 

have—we will call them challenges—that we are there, you are 

there. OK? 

I notice there are three docs on this panel. Are we all medical 

doctors? 

Ms. PARKER. I am not. 

Senator TESTER. OK. So are there four docs? I did not see her. 

Do we have four docs on the panel? 

Ms. PARKER. I am a Ph.D. 

Senator TESTER. Oh. OK. All right. Sounds good. The others are 

medical doctors. OK. 

One of the reasons—and correct me if I am wrong—that the VA 

was put on the High-Risk List is because of improper sterilization 

of equipment. Is that correct? [No audible response.] 

To me, as not a doctor, but as a patient, it is pretty fundamental 

to good health care, and it seems to me it is something that kind 

36 

of takes me aback, to be quite frank with you. I mean, if I was 

looking at a hospital that had these kinds of problems, I would not 

step foot in the door. 

So, the question is, does this still exist? I am talking about improper sterilization. 

Dr. CLANCY. We have made enormous improvements in sterile 

processing, while recognizing, at the same time, that it is an area 

that needs careful attention at all times. Part of the reason it needs 

careful attention is that what they are sterilizing changes a lot. 

Scopes, for example, for gastrointestinal procedures, keep changing 

and becoming more sophisticated; each time those change the instructions that go with it do too, and so forth. 

Quite recently, the people in sterile processing actually pointed 

out a problem, which we had to bring back to a device manufacturer, and they were very, very appreciative. This had to do with 

probes used for ultrasounds in sensitive areas, for men and women. 

Because of what someone in sterile processing had picked up, and 

noticed as part of their cleaning, they were worried about a concern 

of increased contamination. They flagged that right up through 

their supervisory chain, and we ultimately got a call from the CEO 

of the company, saying thank you. They have since changed their 

instructions for customers in this country and around the world. 

So, we have made dramatic improvements. When you talked 

about seeing it when you walked in, you would not. It is an area 

where—— 

Senator TESTER. You are exactly right on that. 

Dr. CLANCY. Yeah. 

Senator TESTER. I mean, you would not see it, but if you read 

about it? 

Dr. CLANCY. Yes. No, I would be very, very worried. It is absolutely vital. It is not an area where we need innovation; we need 

constant attention to detail. But, we also need for those folks to be 

able to share their concerns, and I was quite thrilled that recently 

they did that. 

Senator TESTER. No, that is good. It is very foundational to good 

health care. I mean, you just cannot have one without the other. 

I am just going to close it out with this. Oftentimes, it does not 

matter what business you are in; you want to do what you have 

been doing because it is just moving right along and you have got 

other things to think about. 

Mike Missal, we spent a long time getting you confirmed as IG, 

which is bad on us, by the way. You should have been confirmed 

a long time ago. But, now that you are in there, I would hope that 

the VA treats you with the highest respect and integrity, because 

I believe you are a man of those qualities. 

It is the same thing with the GAO. Gene Dodaro, your boss, Ms. 

Draper, is a fine, fine man, and has incredible respect within the 

Senate. I would just say that when they come forward with the recommendations, even if you do not like them, then tell this Committee that you think they are wrong. Then, we can bring him in 

and talk to him some more, and if you think they are right, fix it. 

OK? 

That is it. 

Dr. CLANCY. That is fair. 

37 

1See VHA Directive 1232(1), Consult Processes and Procedures (Aug. 24, 2016, as amended 

on Sept. 23, 2016). 

Senator TESTER. That is the best preaching job I have got for 

today. Thank you for being here. 

Senator BOOZMAN. We appreciate your preaching job for today, 

and we appreciate all of you for being here. Again, I know you are 

busy but it is so, so very important that we understand what is 

going on. So, thank you for being here. 

The record will be open for the next 5 days. With that we adjourn. 

[Whereupon, at 3:32 p.m., the Committee was adjourned.] 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JON TESTER TO DEBRA

A. DRAPER, PH.D., DIRECTOR, HEALTH CARE TEAM, GOVERNMENT ACCOUNTABILITY

OFFICE

FORT HARRISON REPORT

Question 1. In one open recommendation from the September 2014 GAO report on 

consults, VHA promised to complete a first round of VAMC consult audits by September 2016. Was Fort Harrison included and what were the results? 

Response. While VHA has begun conducting its audits of consult management activities, it has not yet finalized a report summarizing the findings. Since the audits 

include all VAMCs, Fort Harrison should be included, but we have not yet received 

a copy of the audit results, which are expected to be finalized at the end of 

April 2017. 

When VHA updated its national directive on consult processes and procedures in 

August 2016, it required VAMCs to engage in twice yearly audits of consult management activities and to report audit data to their Veterans Integrated Service Networks (VISN).1 Specifically, compliance and business integrity officers at each 

VAMC are responsible for reviewing a statistically valid random sample of closed 

consults (i.e., consults that have been completed, discontinued, or canceled). 

Compliance and business integrity officers from each VISN are responsible for 

validating the data VAMCs report to VHA’s Office of Compliance and Business Integrity. Officials from VHA’s Office of Compliance and Business Integrity are responsible for examining audit results to determine systemic causes and circumstances related to delays in consults and the accuracy of consult documentation. 

They also are responsible for identifying systemic trends, educational opportunities, 

and recommending consult process improvements as necessary. 

In December 2016, VHA officials confirmed that VHA’s Office of Compliance and 

Business Integrity had completed data collection for its initial audit of VAMC consult management activities in September 2016, and at that time, they expected to 

finalize a baseline report detailing the results of the audit in January 2017. VHA 

officials also told us in December 2016 that they began the data collection for the 

second national consult audit cycle in November 2016 and that they planned to finalize a second national consult audit report in February 2017. We received an update on the status of the consult audits in April 2017. When we requested copies 

of the initial consult audit reports, VHA officials told us that the analysis was not 

yet complete. They now estimate that their first national consult audit report— 

which will summarize the results of data collected during the first two audits—will 

be finalized at the end of April 2017. They agreed to provide us a copy of the report 

when it is ready. We will continue to meet with VHA officials to discuss how they 

are using the results of nationwide consult audits to inform their oversight of consult processes and procedures across VHA, as well as to obtain documentation of 

these efforts. 

IMPLEMENTING RECOMMENDATIONS

Question 2. As of the date of the hearing, how many open recommendations does 

VA have? 

Question 3. What progress is being made by VA in addressing these recommendations, and do you believe that they have been cooperative in this process? 

38 

Question 4. When VA and GAO agree on root problems but disagree on the path 

to address those problems, how is that resolved? 

Response. We are providing a combined response to questions 2, 3, and 4, as all 

three relate to VA’s progress in implementing GAO recommendations related to veterans’ health care. 

As of the date of the hearing (March 15, 2017), there were 113 GAO recommendations related to veterans’ health care that VA had not yet implemented. See the following table for additional information about the status of the 255 recommendations 

related to veterans’ health care that were included in products we issued between 

January 1, 2010 and March 15, 2017. 

Status of GAO Recommendations Related to Department of Veterans Affairs (VA) Health Care 

from January 1, 2010 through March 15, 2017 

Status of recommendations 

Number of GAO 

recommendations, 

Jan. 1, 2010 through 

March 15, 2017 

Open because VA has not yet implemented them ................................................................................ a 113 

Closed because VA implemented them ................................................................................................. 128 

Closed without VA implementing themb ............................................................................................... 14 

Total ...................................................................................................................................... 255 

Source: GAO. 

a Of these 113 recommendations, 32 have been open for 3 or more years. 

bWe close recommendations without agencies having implemented them primarily if the recommendation is no longer valid because circumstances have changed. 

Since February 2015, when we designated VA health care as a high-risk area, VA 

has increased its focus on implementing our recommendations. At the time we 

added this issue to our High-Risk List in 2015, VA had only implemented about 22 

percent of our recommendations related to VA health care. The rate at which VA 

has implemented our recommendations has increased steadily since then, and at the 

time of our February 2017 High Risk Update, VA had implemented about 50 percent 

of our recommendations related to VA health care. 

Since 2015, GAO staff have been routinely meeting about every 4 to 6 weeks with 

staff from VHA’s Management Review Service (MRS) to discuss the status of open 

GAO recommendations, and these meetings have been cooperative and productive. 

MRS staff have prioritized for closure GAO recommendations that have been open 

for 3 or more years, and they are working to identify and support the actions VHA 

program offices need to take to implement those recommendations. MRS staff have 

also facilitated meetings between GAO teams and VHA subject matter experts. The 

meetings help clarify actions VHA is taking, and allow for discussions of documentation VHA should provide to GAO to support closing a recommendation as implemented, as well as any ideas VA may have for addressing the intent of the recommendation even if it does not exactly match our recommendation wording. 

In general, VA concurs with recommendations we have made, and it has been rare 

for VA officials and GAO staff to disagree about how our recommendations related 

to VA health care should be addressed. Sometimes, we need VA to provide us additional evidence showing that actions have actually been taken to address our recommendations (rather than just planned). In a few instances, the actions VA took were 

too late to meet the intent of our recommendation. 

INFORMATION TECHNOLOGY

Question 5. The GAO report lays out a number of outdated IT systems operating 

at VA right now. What do you think is the most critical IT system for Secretary 

Shulkin to address immediately from the perspective of risk to veterans? 

Response. The use of IT is crucial to helping VA effectively serve the Nation’s veterans. Each year, the department spends more than $4 billion on IT and operates 

approximately 240 information systems. Many of VA’s unmet IT needs have a direct 

relationship to the quality and safety of veterans’ health care. However, GAO has 

not done work to prioritize VA’s IT needs and therefore has no basis to identify 

which unmet IT needs are the most critical to address. 

As we have reported for many years, VA has had difficulty managing its information systems, raising questions about the effectiveness of its operations and its ability to deliver intended outcomes needed to help advance the department’s mission. 

We have published a number of reports about VA’s need to address aging information technology (IT) systems, including those related to delivering health care services to veterans. For example, in addition to the VA IT systems we discussed in the 

39 

2One of these systems is the Personnel and Accounting Integrated Data system, which 

automates time and attendance for employees, timekeepers, payroll and supervisors. The other 

is the Benefits Delivery Network, which tracks claims filed by veterans for benefits, eligibility, 

and dates of death. See GAO, Information Technology: Federal Agencies Need to Address Aging 

Legacy Systems, GAO–16–468 (Washington, DC: May 25, 2016). 3See GAO, Information Technology Investment Management: A Framework for Assessing and 

Improving Process Maturity, GAO–04–394G (Washington, DC: Mar 1, 2004). 4These 117,000 servicemembers with OTH discharges separated from the Army, Navy, Marine Corps, or Air Force between fiscal years 2001 and 2014 (fiscal year 2014 data is as of 

June 2014). This data was accessed from HTTP://WWW.DOD.MIL/PUBS/FOI/READING_ROOM/ 

STATISTICAL_DATA/14-F-0775_FY2001-2014_ACTIVE_ENLISTED_SEPARATIONS.XLSX on 

January 29, 2016. This figure does not include servicemembers who separated from the National 

Guard or Reserve. 5See GAO, VA Health Care: Reliability of Reported Outpatient Medical Appointment Wait 

Times and Scheduling Oversight Need Improvement, GAO–13–130 (Washington, DC: Dec 21, 

2012). 

High Risk report, we also recently reported that VA is still using two of the Federal 

Government’s oldest legacy IT systems—both of which have been in use for more 

than 50 years.2

VA’s Office of Information and Technology (OI&T) has the important responsibility of providing IT services across VA and managing the department’s IT assets 

and resources. VA has taken some steps to mitigate IT management weaknesses we 

have identified in past reports, such as transitioning oversight and accountability 

for IT projects to a new project management process. 

In addition to considering whether an IT improvement could help mitigate risks 

to patient safety or quality of care, there are other key factors for OI&T to take into 

account. According to Federal IT investment best practices we have identified, OI&T 

should assess VA’s IT needs in light of criteria such as investment size, project longevity, technical difficulty, project risk, business impact, customer needs, cost-benefit analysis, organizational impact, and expected improvement.3 As new VA leaders 

transition into roles at OI&T, sustained management attention and organizational 

commitment will be essential to ensuring VA’s progress in the area of IT management. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. MAZIE K. HIRONO TO

DEBRA A. DRAPER, PH.D., DIRECTOR, HEALTH CARE TEAM, GOVERNMENT AC- COUNTABILITY OFFICE

MENTAL HEALTH CARE

Question 6. Dr. Draper, the GAO highlights mental health care as one area where 

inconsistent application of policies has created access issues for veterans. Secretary 

Shulkin recently indicated the VA would be offering urgent mental health care for 

former servicemembers with less than honorable discharges: is the VA even 

equipped to expand into providing such services? Do you have a general sense of 

whether or not this will further exacerbate the problem of access for veterans to 

mental health services? 

Response. VA estimates that there are currently about 500,000 former servicemembers with other-than-honorable (OTH) discharges, and according to DOD data, 

approximately 117,000 of these servicemembers separated from active duty between 

fiscal years 2001 and 2014.4 However, it is difficult to determine whether offering 

urgent mental health services to individuals with OTH discharges will negatively 

affect veterans’ access to VA mental health care because of continued limitations of 

VA’s appointment wait-time data. Without complete, reliable data on the extent to 

which veterans who are already receiving VA care are waiting for mental health 

care appointments, VHA lacks assurance that it has sufficient capacity to expand 

services to individuals with OTH discharges—even if it only offers urgent mental 

health care to these individuals. 

For example, VHA has yet to implement our December 2012 recommendation to 

improve the reliability of its wait time measures either by clarifying its scheduling 

policy to better define the desired date (which at the time, was the name for the 

starting date that was used to calculate wait times), or by identifying clearer wait 

time measures that are not subject to interpretation and prone to scheduler error.5

In July 2016, VA published a revised VHA outpatient scheduling directive, which 

provided new instructions for scheduling appointments. However, the new instructions, which form the basis for measuring wait times, are still prone to scheduler 

interpretation, making training vital to consistent and accurate implementation of 

the policy. As of November 2016, VHA reported that the majority of staff responsible 

40 

6See GAO, VA Mental Health: Clearer Guidance on Access Policies and Wait-Time Data Needed, GAO–16–24 (Washington, DC: October 28, 2015). 

7Pub. L. No. 113–146, § 801, 128 Stat. 1754 (2014). 

8The remaining staff hired as part of this initiative were either non-clinical support staff or 

peer specialists (veterans with mental health conditions who are in recovery and have been 

trained to help others with mental health conditions). 

for scheduling appointments had been trained on the new directive and that separate training on a new scheduling system enhancement was scheduled to begin in 

February 2017. We cannot assess whether VHA scheduling staff are accurately implementing the new scheduling policy until all relevant staff are trained on the new 

system. 

In addition, in October 2015, we reported that the way that VHA calculates veterans’ wait times for full mental health evaluations (using veterans’ preferred dates 

instead of the dates veterans initially request a referral to mental health care) may 

not reflect the overall amount of time a veteran waits for care.6 Further, we found 

that VHA’s mental health wait time data may not be comparable over time (due to 

definitional changes), or comparable between VAMCs, making it difficult for VHA 

to provide effective oversight of access to mental health care. 

While there is uncertainty about the extent to which veterans are experiencing 

wait times for mental health care, VA has engaged in recent hiring initiatives to 

improve access to health care services. For example, the Veterans Access, Choice, 

and Accountability Act of 2014 appropriated $5 billion to expand VA’s capacity to 

deliver care to veterans by hiring additional clinicians and improving the physical 

infrastructure of VA’s medical facilities.7 In addition, in our October 2015 report on 

VA’s mental health access, we reported that VA was able to hire about 5,300 new 

clinical and non-clinical mental health staff as a result of a two-part hiring initiative 

from June 2012 through December 2013. While about 1,600 of these hires were for 

newly created mental health positions, about 2,300 filled existing vacancies (or vacancies that opened during the hiring initiative).8 Officials at the five VAMCs we 

visited as part of this review reported local improvements in access to mental health 

services as a result of the additional hiring, such as the ability to offer mental 

health services in new locations. 

VA exempted certain positions, including mental health providers, from the January 2017 hiring freeze on executive branch employees in order to meet the department’s public safety responsibilities. This exemption allowed VA to continue to recruit mental health providers, although officials at VAMCs we visited for our October 2015 report told us they faced several challenges in hiring and placing mental 

health providers. These challenges included: (1) pay disparity with the private sector; (2) competition among VAMCs for staff; (3) the lengthy VHA hiring process; (4) 

a nationwide shortage of mental health professionals; (5) a lack of space to provide 

care; and (6) a lack of non-clinical support staff to relieve providers’ administrative 

burden and increase providers’ clinical availability. Officials at four of the five 

VAMCs we reviewed also stated that they were still unable to meet overall demand 

for mental health care despite VHA’s recent hiring initiative. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. SHERROD BROWN TO

DEBRA A. DRAPER, PH.D., DIRECTOR, HEALTH CARE TEAM, GOVERNMENT AC- COUNTABILITY OFFICE

OVERSIGHT AND ACCOUNTABILITY

Question 7. Dr. Draper, in your testimony you raise concerns regarding self-reported data from facilities and whether that data could be independently corroborated. What steps would GAO recommend VA take to ensure that the data collected 

and report to VACO can be independently corroborated? There are concerns that the 

data reported through SPOT and other systems do not properly reflect the day-today safety, quality, and access concerns that have been raised by GAO over the 

years. 

Response. There are several actions VA can take to independently corroborate 

self-reported data, including on-site inspections, pulling samples of patient records 

for independent review, ensuring that Veterans Integrated Service Networks (VISN) 

review reports generated by VA medical centers, and assigning responsibility to appropriate levels in the organization to verify data. When we added VA health care 

to the High Risk List in 2015, we noted that reliance on self-reported data contributed to weaknesses in VA’s ability to hold its health care facilities accountable and 

ensure that identified problems are resolved in a timely and appropriate manner. 

We reiterated that concern in our 2017 high-risk report. Ensuring that self-reported 

41 

data are reliable can inform oversight decisions and help VA ensure that its corrective actions are addressing the root causes of the problem, which is part of our criteria for removal from the High-Risk List. 

We have several open recommendations for actions VHA can take to address our 

concern about reliance on self-reported data from VAMCs. Addressing these open 

recommendations can not only serve to correct the specific deficiency identified, but 

also help address the underlying problem of inadequate oversight and accountability. 

Descriptions of selected findings and open recommendations from recent GAO reports are provided in the table below. 

Summaries of Findings and Open Recommendations (as of April 7, 2017) from Selected GAO reports Addressing Concerns with Reliance on Self-Reported Data at the Department of Veterans 

Affairs’ (VA) Veterans Health Administration (VHA) 

Report Finding Summary Open Recommendation 

GAO-17-242, VA Health Care: Actions 

Needed to Ensure Medical Facility 

Controlled Substance Inspection Programs Meet Agency Requirements 

We found that two of the four selected 

Veterans Integrated Service Networks 

(VISN) in our review did not review 

their facilities’ quarterly trend reports 

of controlled substance inspections, as 

required by VHA. Such reports identify 

inspection program trends such as 

missed inspections and areas for improvement. We found that one network 

that had reviewed the trend reports 

failed to follow up with a facility to 

ensure it had submitted missed trend 

reports. 

To help VHA achieve its objective of 

reducing the risk of diversion 

through effective implementation 

and oversight of the controlled substance inspection program, the Secretary of Veterans Affairs should direct the Under Secretary for Health 

to ensure that networks review their 

facilities’ quarterly trend reports 

and ensure facilities take corrective 

actions when nonadherence is 

identified. 

GAO-17-52, VA Health Care: Improved 

Monitoring Needed for Effective Oversight of Care for Women Veterans 

We found VHA’s lack of reliable data 

meant that it could not ensure medical center compliance with requirements related to the environment of 

care for women veterans. These requirements include standards for privacy at check-in and interview areas, 

location of exam rooms, and the presence of privacy curtains in exam and 

inpatient rooms. We found that only 3 

of the 155 instances of noncompliance 

we observed during on-site inspections 

of waiting, procedure, and examination 

areas at six VA medical centers were 

reported to VA central office. Because 

VA uses these data to track facility 

compliance, their accuracy is vital for 

effective oversight. 

To improve care for women veterans, 

the Secretary of Veterans Affairs 

should direct the Under Secretary 

for Health to 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. 

42 

9See GAO, VA Primary Care: Improved Oversight Needed to Better Ensure Timely Access and 

Efficient Delivery of Care, GAO–16–83 (Washington, DC: Oct. 8, 2015). 10See GAO, VA Health Care: Actions Needed to Assess Decrease in Root Cause Analyses of Adverse Events, GAO–15–643 (Washington, DC: Jul. 29, 2015). 

Summaries of Findings and Open Recommendations (as of April 7, 2017) from Selected GAO reports Addressing Concerns with Reliance on Self-Reported Data at the Department of Veterans 

Affairs’ (VA) Veterans Health Administration (VHA)—Continued 

Report Finding Summary Open Recommendation 

GAO-14-808, VA Health Care: Management and Oversight of Consult Process Need Improvement to Help Ensure 

Veterans Receive Timely Outpatient 

Specialty Care 

We found that VHA’s limited oversight 

of consults impedes its ability to ensure VA medical centers provide timely 

access to specialty care. For example, 

as part of its consult initiative, VHA 

required VAMCs to review a backlog of 

thousands of unresolved consults— 

those open more than 90 days—and 

if warranted to close them. However, 

VHA did not require VAMCs to document their rationales for closing them. 

As a result, questions remain about 

whether VAMCs appropriately closed 

these consults and if VHA’s consult 

data accurately reflect whether veterans received the care needed in a 

timely manner, if at all. 

To improve VHA’s ability to effectively 

oversee the consult process, and 

help ensure VAMCs are providing 

veterans with timely access to outpatient specialty care, the Secretary 

of Veterans Affairs should direct 

the Interim Under Secretary for 

Health to enhance oversight of 

VAMCs by routinely conducting 

independent assessments of how 

VAMCs are managing the consult 

process, including whether they are 

appropriately resolving consults. 

This oversight could be accomplished, for example, by VISN officials periodically conducting reviews of a random sample of 

consults as we did in the review we 

conducted. 

Source: GAO. 

VHA has also taken some actions to implement recommendations that will help 

address the concern about the reliability of self-reported data. For example: 

• In 2015, as part of our review of VA’s primary care oversight, we found inaccuracies in VA’s data on primary care panel sizes, which are used to help medical 

centers manage their workload and ensure that veterans receive timely and efficient 

care.9 We found that while VA’s primary care panel management policy required facilities to ensure the reliability of their panel size data, it did not assign responsibility for verifying data reliability to regional- or national-level officials or require 

them to use the data for monitoring purposes. As a result, VA could not be assured 

that local panel size data were reliable, or whether its medical centers had met VA’s 

goals for efficient, timely, and quality care. We recommended that VA incorporate 

an oversight process in its primary care panel management policy that assigned responsibility, as appropriate, to regional networks and central office for verifying and 

monitoring panel sizes. In October 2016, VA reported that it had completed nationwide deployment of new software for managing panel sizes, called Primary Care 

Management Module (PCMM) Web, which is designed to enable better management 

and monitoring of primary care panel sizes. In addition, in September 2015 and December 2016, VA required all facilities to validate their data on primary care panel 

sizes, as well as the number of support staff and exam rooms. In February 2017, 

all but one VA facilities certified that they had validated their data (the remaining 

facility was still in the process of completing data validation efforts), and we closed 

this recommendation as implemented. 

• In our July 2015 report examining VHA’s root cause analysis (RCA) program for 

adverse events, officials from VHA’s National Center for Patient Safety (NCPS) told 

us that VAMCs sometimes chose alternative processes, such as those based on Lean 

methods, to address adverse events when an RCA was not required.10 NCPS officials told us they supported VAMCs’ use of these alternative processes when appropriate, but acknowledged loss of information as the results of these processes were 

not required to be entered into WebSPOT (VHA’s centralized RCA reporting system), or otherwise shared with NCPS. However, VHA was unaware how many 

VAMCs used these alternative processes. We recommended that VHA determine the 

extent to which VAMCs are using alternative processes to address the root causes 

of adverse events when an RCA is not required, and collect information from 

VAMCs on the number and results of those alternative processes. In September 2015, NCPS developed and fielded a survey to all medical centers to assess 

43 

what degree they were utilizing alternative processes to address root causes of adverse events when a root cause analysis is not required. NCPS was able to obtain 

data from 86 percent of medical centers that demonstrated the types of alternative 

processes used and how medical centers were using them. As a result, we closed this 

recommendation as implemented. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JON TESTER TO

MICHAEL J. MISSAL, INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS

FORT HARRISON REPORT

Question 1. The recent report on Ft. Harrison indicated that steps have been 

taken to improve consult timeliness. Are you confident those steps are sufficient and 

do you believe they will appropriately address factors that contribute to delays in 

care for veterans? 

Response. In comments to our draft report (which are included in the final report), 

leadership described ongoing steps to address factors within the system’s control 

that contributed to consult delays. We will monitor system leadership’s actions on 

these issues, which include hiring additional staff to administratively process 

consults and reducing the number of unnecessary consults. We anticipate that completion of those steps will have a positive impact on timeliness of care for some Montana veterans. However, consult delays for many veterans will likely persist because 

of other factors outside the system’s control, including the adequacy of the provider 

network for the Veteran’s Choice Program. We highlighted our concerns about network adequacy in another report, Review of VHA’s Implementation of the Veterans 

Choice Program (January 30, 2017), and made recommendations to the Under Secretary for Health that will help to address nationwide issues that hinder consult 

timeliness. 

HIGH RISK LIST

Question 2. Have you met with Dr. Shulkin in his capacity as Secretary? And 

have you received assurances of a high level of engagement on these issues? 

Response. Yes, I have met with Dr. Shulkin several times since he was confirmed. 

We have a regularly scheduled monthly meeting. I have also called him and requested a meeting when I felt that an issue needed to be addressed. Also the OIG 

meets monthly with leaders in the Veterans Health Administration. 

IMPLEMENTING RECOMMENDATIONS

Question 3. As of the day of the hearing, how many open recommendations does 

VA have that are over 60 days old? 

Response. As of March 15, 2017, there were 120 reports and 366 recommendations 

that had been open for greater than 60 days. 

Question 4. What progress is being made by VA in addressing these recommendations, and do you believe that they have been cooperative in this process? 

Response. Overall, VA is receptive to OIG recommendations and provides action 

plans to correct the identified issues. At times, however, VA may underestimate the 

time it takes for corrective actions to be implemented and demonstrate a sustainable improvement. 

Question 5. When VA and OIG agree on root problems but disagree on the path 

to address those problems how is that resolved? 

Response. If VA management concurs with a finding but non-concurs with a recommendation, VA should provide an alternative course for corrective action that VA 

believes is responsive to satisfying the intent of the OIG recommendation. If the 

issuing OIG office agrees with management’s proposal, follow-up will be on the 

agreed-to corrective action. If VA continues to non-concur with an OIG recommendation and does not propose corrective action, the Assistant Inspector General of the 

appropriate OIG Directorate will discuss the matter with the Inspector General and 

the Deputy Inspector General for an OIG decision on whether to submit the unresolved issues to the Deputy Secretary for final resolution or to publish the final report without the concurrence of VA on the findings and recommendations or without 

an implementation plan acceptable to OIG. 

In most instances, whenever VA and OIG disagree on an action plan to implement 

a recommendation that VA has concurred with, both sides will have productive discussions to address the issues. 

44 

INFORMATION TECHNOLOGY

Question 6. The GAO report lays out a number of outdated IT systems operating 

at VA right now. What do you think is the most critical IT system for Secretary 

Shulkin to address immediately from the perspective of risk to veterans? 

Response. We believe the following are some of most critical IT systems that Secretary Shulkin should address that have a direct impact on veterans: 

• Veterans Health Information Systems and Technology Architecture (VistA) 

• VA’s Outpatient Appointment Scheduling System—The OIG is currently conducting an audit of the VistA Scheduling Enhancement (VSE) which is considered 

the near-term solution for updating VA’s archaic scheduling system 

• Veterans Benefits Management System (VBMS)—VBMS is the replacement for 

the Veterans Benefits Administration’s (VBA) legacy systems, Benefits Delivery Network (BDN) and Veterans Service Network (VETSNET). BDN still has some 

functionality related to processing entitlements for three of the five business lines 

(Compensation and Pension, Education, and Vocational Rehabilitation and Employment). Until there is confidence that VBMS can process payments, VA will have to 

maintain these legacy systems which is a costly both in time, staff, and funding. 

• Financial Management System (FMS)—While FMS is not involved in direct patient care, it supports payments to vendors that provide the goods and services the 

Veterans Health Administration needs to operate, as well as keeps track of the status of VA’s budgetary resources. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. MAZIE K. HIRONO TO

MICHAEL J. MISSAL, INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS

APPOINTMENT CANCELLATIONS

Introduction: Mr. Missal, in your testimony you refer to OIG’s (June 2016) report 

that claimed supervisors at a VA facility in Houston instructed staff to cancel appointments for veterans who were offered appointments at alternative locations but 

declined. Even though staff canceled these appointments, they were instructed to 

record them as canceled by the veterans themselves. 

Question 7. Do you have reason to believe that these kinds of situations could 

have occurred in VA facilities in Hawaii or in other states? 

Response. We conducted investigations at over 100 VA facilities regarding the manipulation of wait time data. We discovered that the over-riding issue was the lack 

of training and understanding of VA’s policy regarding scheduling. We did review 

allegations received by the OIG Hotline concerning Matasunga VA Medical Center 

(VAMC) in Honolulu, Hawaii. The allegations were different from the scheme uncovered at the Houston VAMC. Our Honolulu review did not develop any information 

that management instructed staff to disregard patient desired dates when inputting 

appointments. 

Question 8. Can you discuss the recommendations that OIG made to address 

these situations? How can we ensure that veterans, especially veterans in rural 

communities who may have difficulty traveling to a nearby VA facility, do not have 

their appointments canceled? 

Response. We recommended the Veterans Integrated Service Network 16 Director 

provide scheduling staff training; improve scheduling audit procedures for use of 

dates and appropriateness of the cancellation type used; and take actions when the 

audits identify deficiencies. 

VA facilities should follow VHA’s Directive 1231, Outpatient Clinic Practice Management, November 15, 2016, which states that staff should determine which patients can be seen by another provider, and contact patients that need to be rescheduled as soon as possible prior to their scheduled appointment in order to avoid them 

arriving at the facility without the ability to be seen. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JOE MANCHIN III TO

JOHN D. DAIGH, JR., M.D., CPA, ASSISTANT INSPECTOR GENERAL FOR HEALTHCARE

INSPECTIONS, OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS

AFFAIRS

Question 9. Over the course of the Inspector General’s reports, what are the most 

pressing issues you have uncovered concerning opioid prescribing in the VA? How 

is the VA addressing the concerns IG investigations have discovered? 

45 

Response. The most pressing issue that VA providers must address is the creation 

of an appropriate treatment plan for veterans who are prescribed narcotic medications. One group of patients has a history of chronic pain, co-morbid mental health 

issues, and a long history of narcotic use. The other group of patients are relatively 

naive to narcotic medications, and yet present with an acute pain syndrome, that 

if not properly managed, may lead to a life of chronic narcotic use/dependence. 

VA has produced a number of directives and undertaken a number of efforts to 

improve VA providers’ ability to effectively treat these veterans’ symptoms to include the creation and dissemination of: a Clinical Practice Guideline Management 

of Opioid Therapy for Chronic pain, an Opioid Safety Initiative, an Opioid Safety 

Initiative Tool Kit, a Pain Management Opioid Safety Education Guide, and a Pain 

Management Opioid Safety Quick Reference Guide. 

The OIG recommended that VA improve the supervision of providers to ensure 

that the best insights of the most experienced VA providers can influence the care 

of each veteran. In addition, the OIG encouraged VA to partner with non-VA entities to improve clinical research trials in these populations with the hope of improving the guidance providers can offer over time. In discussions with VA leaders and 

providers, they appear dedicated to addressing these issues by improving the capabilities of VA providers and increasing reliance upon community resources. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. SHERROD BROWN TO

MICHAEL J. MISSAL, INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS

WHISTLEBLOWERS

Mr. Missal, thank you for the work that your office has done investigating allegations of misconduct and mismanagement at the Cincinnati VAMC. I look forward 

to reading the report, which should be forthcoming. VA employees, acting as whistleblowers, raised concerns and demanded change for our veterans. There are still 

concerns however that VA employees who reach out through appropriate channels 

to raise concerns are retaliated against. We’ve seen this over and over throughout 

the system. 

Question 10. What steps does OIG take to protect those interviewed so that they 

don’t face reprisal? 

Response. The OIG takes all possible steps to protect the identity of complainants. 

Often complainants have made similar complaints to management, so it is possible 

for management to identify them. However, we do not provide the identity of complainants, confidential sources, or self-identified whistleblowers to VA. We advise 

complainants to contact the Office of Special Counsel (OSC) regarding protection 

under the Whistleblower Act. OSC is a separate Federal agency with authority to 

review allegations of prohibited personnel practices, including reprisal for whistleblowing. The VA OIG is certified by OSC as having met the statutory obligations 

to inform the employees about the rights and remedies under the Civil Service Reform Act, the Whistleblower Protection Act, and the Whistleblower Protection Enhancement Act. 

OVERSIGHT AND ACCOUNTABILITY

Question 11. Mr. Missal, has OIG received requests to review the self-reporting 

processes at VAMCs? 

Response. The OIG has completed numerous evaluations of the accuracy of VAreported data. For example, in our recent report, Audit of Veteran Wait Time Data, 

Choice Access, and Consult Management in VISN 6, we described our evaluation of 

the accuracy of wait time data within the Veterans Integrated Service Network 

(VISN) 6 medical facilities and through Choice. We raised concerns that VA-reported wait time data understated the actual amount of time veterans waited for 

health care services. To address our concerns, we made 10 recommendations, four 

to the Under Secretary for Health and six to the VISN 6 Director. Last year, we 

reviewed whether information contained in a letter from VISN 23 to Congressman 

Walz accurately reported information on primary care staffing at the St. Cloud VA 

Health Care System. In our report, Healthcare Inspection—Reported Primary Care 

Staffing at St. Cloud VA Health Care System, we indicated that data reported were 

inaccurate and that VISN and facility leadership acknowledged that no data validation steps were taken prior to submitting information to the Congressman. We made 

one recommendation to the VISN Director to address the inaccuracies we identified. 

46 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JON TESTER TO CAROLYN M. CLANCY, M.D., DEPUTY UNDER SECRETARY FOR HEALTH FOR ORGANIZATIONAL EXCELLENCE, U.S. DEPARTMENT OF VETERANS AFFAIRS

FORT HARRISON REPORT

Question 1. GAO issued a consult audit in 2014 with 6 recommendations that are 

still open. In one open recommendation from this report, VHA promised to complete 

a first round of VAMC consult audits by September 2016. Was this completed, and 

what were Ft. Harrison’s results? 

Response. All facilities, including Ft. Harrison, were included in the two national 

consult audits (completed in September 2016 and January 2017) conducted by the 

Office of Compliance and Business Integrity (CBI). CBI is finalizing the results of 

these audits. The findings will be published once the results are compiled. 

Question 2. In another recommendation from the same report, VHA indicated calls 

to share best practice with respect to consults were forthcoming. If these happened, 

did Ft. Harrison participate? What actions are continuing in VHA to share practices 

on consult management? 

Response. To promote nationwide communication, VHA established a system-wide 

process for identifying and sharing best practices. Facility level consult steering 

committees were created and participated in weekly national consult performance 

improvement calls. VHA began holding national calls with these Veterans Integrated Service Network (VISN) and facility consult points of contact (POC) on November 14, 2014. Each week, more than 400 attendees participate in these calls, 

which include training on consult policies and processes, review of consult performance data, and presentations on best practices. The calls also provide a forum for 

discussion and answering questions, which are published for reference in a Frequently Asked Questions (FAQ) document. In addition, VHA has created a Consult 

Cube with many different Pyramid views enabling easy access to consult data and 

developed a SharePoint page, which serves as a repository for all consult policy documents, training materials, FAQs, and contact information for VISN and facility 

consult experts and steering members. 

VISN and facility staffs from all sites, including Ft. Harrison, are invited to these 

calls. There has been significant leadership and staff turnover at Ft. Harrison since 

calls started. When questioned again in March, 2017, leadership was unsure if anyone was attending the calls. This issue is currently in the process of being corrected. 

Question 3. Overall, given the continued concern with consults, what is VA doing 

to improve the consult process and ensure no additional veterans are harmed by 

delays in care? 

Response. VHA has taken many actions such as those listed below to improve consult processes and ensure timeliness of care: 

• VHA finalized Directive 1232 ‘‘Consult Processes and Procedures’’ in September 2016. VHA also distributed the Standard Operating Procedure (SOP). These 

policy documents clarify procedures for completing consults and provide guidance for 

tracking and monitoring consults throughout the organization and provide the basis 

for consult oversight. 

• A Consult Management Trigger report was developed to measure VISN and facility consult performance. The Consult Trigger Tool automatically sends notifications to leadership at facilities not meeting requirements to assist in consult oversight and management. 

• VHA provided extensive national, VISN, and facility consult training: 

– October and November 2014, national training was provided to facility level 

staff via webinars and to 975 employees via VA eHealth University (VeHU) 

training. This training was also made available in the Talent Management System (TMS). 

– March, April, October, and November 2015, training with VISN and facility 

leadership and staff of all VISNs was provided. 

– Weekly consult best practice/training calls began in November 2014. Over 400 

consult POCs attended training calls. 

– National consult training module #24762 was deployed in TMS. As of August 2015, 97 percent of Licensed Independent Practitioners (LIP) assigned the 

TMS training completed it. An additional 12,740 staff who were not assigned 

the consult training module in TMS also completed the training. Residents/ 

trainees were provided separate consult training by October 1, 2015. 

– Approximately 60,000 schedulers and 600 VISN and facility consult POCs 

and Group Practice Managers (GPM) completed training on the Consult Directive. Updated LIP consult training including training on the Consult Directive 

47 

will be available in TMS in April 2017. Residents/trainees will receive updated 

mandatory consult training in July 2017. 

• VHA implemented the Consult Improvement Initiative (CII) from March thru 

June 2016 to provide assistance to selected facilities identified by the Consult Trigger tool as having issues in consult processes and timeliness of completion. All participating facilities demonstrated improvement by reducing consult process failures 

and reducing delays. 

• CBI, in conjunction with the Office of Veteran’s Access to Care (OVAC), developed and implemented an independent consult audit process. CBI reviewed all facilities reviewed in two national consult audits. CBI will release the results once finalized. During FY 2017 and until further notice, routine audits will be conducted by 

compliance staff at a minimum of twice annually for the use of VHA’s standardized 

consultation process and to identify causes of delays of outpatient specialty care 

consults. 

Question 4. Can VHA certify that every employee who is involved in the consult 

process has been trained on last year’s new Directive 1232, Consult Processes and 

Procedures? What training has been provided, and what metrics will measure adherence to Directive 1231, Outpatient Clinic Practice Management? 

Response. Consult Directive Training was developed for the roles of schedulers, 

VISN and facility consult POCs, GPMs, residents/trainees and LIPs. Training for 

schedulers, facility consult POCs and GPMs was delivered by live and recorded 

webinars and completion of training is tracked in TMS. Approximately 600 facility 

consult POCs, GPMs, and 60,000 schedulers completed the training. This group is 

considered complete. 

Training content for LIPs has been updated and is in the process of being delivered and tracked in TMS. Residents/trainees will be required to take training on 

the Consult Directive as part of Mandatory Training in July 2017. Consult Directive 

training is also included in current Medical Support Assistant (MSA) and new MSA 

onboarding training and will be part of recently-updated scheduling training modules in TMS required for all new schedulers. Generally, as a result of the training, 

VHA expects to see outcome improvements in areas such as the time to schedule 

and complete clinical consults, the number of consults linked to appointments, and 

improvements in the associated consult process metrics. 

HIGH RISK LIST

Question 5. Can you provide a timeline for when the root cause analysis for each 

deficient area in GAO’s report will be complete? VA needs to have a well-established 

timeline. 

Response. VA will submit the root cause analyses and VA corrective action plan 

to GAO in June 2017. The corrective action plan will include schedules and milestones for each initiative by which to gauge VA’s progress in achieving the desired 

outcomes. 

IMPLEMENTING RECOMMENDATIONS

Question 6. What progress is VA making in addressing the hundreds of open recommendations? 

Response. During the past 2 years, VHA closed 91 GAO recommendations. GAO 

added 75 new recommendations during that same timeframe. As of March 2017, 

VHA is actively working on 81 open recommendations, of which GAO provided more 

than half during the past 12 months. VHA has completed actions on 20 recommendations and awaits GAO’s decision regarding closure. 

Question 7. When VA and GAO or OIG agree on root problems but disagree on 

the path to address those problems how is that resolved? 

Response. In the event, GAO or the VA Office of Inspector General (OIG) are 

seeking a different resolution than the actions VHA has taken, VHA engages the 

OIG or GAO team in discussions regarding the details of actions taken and provides 

evidence of the effectiveness of those actions. Upon learning more detail, the OIG 

or GAO may find that the actions have been effective and close the recommendation, 

on occasion they request additional data collection over time to assess for lasting 

effectiveness, or they specify what additional actions would be needed to satisfy the 

intent of the recommendation. 

Question 8. Does VA have any Department-level tracking of the administration’s 

open and oldest recommendations? If so, please provide the name of the accountable 

office. What actions is Dr. Shulkin taking to focus attention on these issues, or is 

this not a priority? 

48 

Response. VA’s Office of Congressional and Legislative Affairs maintains a list of 

open GAO recommendations. Dr. Shulkin appreciates GAO’s work to improve services to our Veterans and takes GAO’s recommendations to the Department very seriously. The Department’s Administrations and Staff Offices that have open recommendations are in the process of implementing action plans outlined in the responses to GAO draft and final reports. 

STAFFING MODEL

Question 9. Three OIG reports have been issued on staffing shortages, and all 

have recommended VA create a staffing model that considers demand and complexity and matches that to budget requests and allocations. Why has this not yet 

been completed? 

Response. As reported in the VHA concurrence to the OIG Recommendation (Report No. 16–00351–453, 9/28/2017), VHA is pursuing multiple courses of action. 

These include the following: 

(1) Completion of the draft Specialty Care Clinical Staffing Model. As noted, in 

the OIG report, this is a project to research, develop and ultimately implement a 

cross-disciplinary staffing model. In January 2015, the Under Secretary for Health 

chartered a working group for a staffing model across all 25 Specialty Care disciplines, at all VA medical centers, both inpatient and ambulatory. The objective of 

this team is to develop a model that correlates Veteran population and utilization 

with productivity and capacity, and then to cost. From there, the model can be used 

to assist in both individual staffing determination and for overall ‘‘make/buy’’ decision on expanding or contracting clinics and other medical facilities. 

The draft model is complete and is undergoing review by several VHA senior leaders and by VA’s OIG. The final draft will incorporate feedback from each of these 

offices, which will then lead to field validation and development of policy for implementation. 

(2) Evaluation and enhancement of other VHA clinical staffing models continues 

across multiple fields, including the Primary Care Patient Aligned Care Team 

(PACT) model, Nurse Professionals, and Medical Support Assistant staffing. Each 

of these efforts is making significant progress in their respective arenas and is also 

being connected with similar enhancements to hiring and onboarding practices. 

Feedback will be solicited from field clinics to validate the ongoing work. 

The ongoing clinical staffing work at the James A. Lovell Federal Health Care 

Center (FHCC) in Chicago, Illinois is another staffing modeling activity, focused on 

leveraging best practices and common strategies in a joint clinical environment. 

Since September 2016, a team of Department of Defense (DOD) and VHA professionals have regularly convened to review alignment of VHA and DOD staffing models in such practice areas as Primary Care and Nursing. VHA is currently exploring 

mechanisms to import staffing data from DOD, and incorporate the information into 

VHA’s productivity tools—regarded by both DOD and VHA as a potential asset for 

productivity and integration. As the joint VHA-DOD staffing strategy matures, VHA 

will examine the applicability of DOD staffing techniques in VHA-specific environments. 

INFORMATION TECHNOLOGY

Question 10. The GAO report lays out a number of outdated IT systems operating 

at VA right now. How does Dr. Shulkin intend to prioritize funding amongst the 

various systems that need to be upgraded or replaced, and what role will OIT play 

in those decisions? 

Response. The VA does have a large number of legacy systems and have embarked on a strategy to prioritize the divestiture of legacy systems. In FY 2017 we 

will retire the Bi-directional Health Information Exchange (BHIE) and have started 

a project to divest our legacy Financial Management System (FMS) and other ancillary financial systems. We also have projects currently underway with our business 

partners in VBA, NCA and BVA to retire the Benefits Delivery Network (BDN), 

Burial Operations and Support System (BOSS), and Veterans Appeals Control and 

Logistics System (VACOLS), respectively. The Secretary will also announce the VA’s 

path forward on Electronic Health Record modernization by July 2017. Divestiture 

of legacy systems and the modernization of the VA’s IT infrastructure is one of our 

highest priorities and we are aligning resources around these projects to reflect that 

commitment. The process and decisionmaking has involved close cooperation between the CIO and senior VA leadership by reviewing and discussing the IT and 

operational risks associated with each system. 

49 

Question 11. I understand that VA had a goal of having 50 percent of the active 

IT projects on budget and on schedule by the end of 2016. Did VA meet that goal? 

What is the new goal moving forward? 

Response. VA has met the on-time rate of 50 percent of projects being on budget 

for the end of 2016. VA has exceeded the on-time rate of 50 percent of projects being 

on schedule for the end of 2016. At this time, the goal is 50 percent for 2017. 

Question 12. VA appears poised to make an announcement in early Summer 2017 

regarding its intent to procure a commercial electronic health record as a replacement for VistA. Please describe how VA has been consulting with the Department 

of Defense (DOD) during DOD’s ongoing EHR transition and what lessons VA has 

learned from that implementation. Please describe the experience VHA and VHA 

patients who are receiving care at Fairchild Air Force Base or any other facility deploying the Cerner Millenium EHR have had to date. 

Response. VA continues to consult and work closely with DOD to learn lessons 

from its acquisition and ongoing implementation of the Military Healthcare System 

(MHS) GENESIS efforts. 

VA continues to consult and working closely with DOD to gather information on 

the acquisition of MHS GENESIS. VA has received and reviewed the business and 

clinical workflow models which were developed as part of the MHS GENESIS scope 

of work. DOD has pledged to provide additional information to VA as it becomes 

available through the DOD/VA Interagency Program Office, in consultation with the 

functional and program offices in the Defense Health Agency and Program Executive Office, Defense Healthcare Management System. 

VA has worked with DOD to obtain information on the acquisition of MHS GENESIS, such as market research information, certain contract clauses related to compliance with national health data standards and basic contract structure, and request for proposal statements of work. VA has also worked with DOD to receive 

business and clinical workflow models developed as part of DOD’s scope of work on 

the Department of Defense Healthcare Management System Modernization 

(DHMSM) effort. VA will receive additional information from DOD through the 

DOD/VA Interagency Program Office (IPO) as information becomes available in consultation with the functional and program offices in the Defense Health Agency and 

Program Executive Office, Defense Healthcare Management Systems. 

As an example of VA and DOD’s coordination, on October 26, 2016, VA held an 

Electronic Health Record (EHR) Roundtable with the objective to discuss EHR 

transformation best practices and lessons learned with public and private sector 

health care industry leaders to inform the way forward for VHA. This meeting included participation from external partners including the Office of the National Coordinator and Colonel/Dr. Aronson who has been the Chief Medical Information Officer for the DHMSM. Key lessons learned included: 1) need for highly resource intensive change management strategies; 2) best practices for addressing legacy systems, 

including re-training of staff; and 3) strategies, such as phased roll-outs, to mitigate 

impacts to patient access. 

Meetings and coordination between VA and DOD to ensure interoperability and 

lessons learned are and will be ongoing throughout the DHMSM/MHS GENESIS 

program. 

Finally, VA officials were pleased to attend the ribbon cutting ceremony and lessons learned sessions at the Fairchild Air Force Base (AFB) in February 2017. An 

example of the lessons learned was the central role organizational change management plays in any large deployment of this kind. We do not have any information 

on VHA patients receiving care at Fairchild AFB or another facility where MHS 

GENESIS is deployed, but we will continue to monitor. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. RICHARD BLUMENTHAL

TO CAROLYN M. CLANCY, M.D., DEPUTY UNDER SECRETARY FOR HEALTH FOR ORGANIZATIONAL EXCELLENCE, U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 13. During last week’s hearing, Dr. Lee responded to a question on how 

the Department of Veterans Affairs (VA) provides care to survivors of military sexual trauma (MST) by saying that VA’s policy is to provide care to Servicemembers, 

former Servicemembers with an other than honorable (OTH) discharge for MST care 

regardless of how they enter the VA system. Previous communications with both VA 

and Department of Defense staff have indicated that these services are only being 

provided to active duty Servicemembers, including members of the National Guard 

and Reserves, and those with an OTH discharge at Vets Centers but not at VA medical centers (VAMC) or Community-Based Outpatient Clinics (CBOC). Could you 

please clarify whether such services are available at VAMCs and CBOCs and if 

50 

there are any locations in which MST services are not available for active duty Servicemembers and former Servicemembers with an OTH discharge? 

Response. VA has been offering a full range of health care services to Active Duty 

Servicemembers (ADSM) under sharing agreement authority for many years; this 

care has been available at both VA medical centers (VAMC) and community-based 

outpatient clinics (CBOC) depending on the nature of specific sharing agreements. 

Services provided under this authority likely have included care for conditions related to military sexual trauma (MST), but because such care was provided under 

VA’s sharing agreement authority, not its MST treatment authority (as specified in 

38 United States code (U.S.C.) § 1720D), it has not historically been tracked as part 

of VA’s national MST monitoring efforts. ADSMs typically must receive a referral 

from TRICARE or a military treatment facility to seek care at a VAMC or CBOC 

under the sharing agreement authority. 

The amendments to 38 U.S.C. § 1720D in section 402 of the Veterans Access, 

Choice, and Accountability Act of 2014, which became effective on August 7, 2015, 

authorize VA to extend VA’s MST-specific treatment authority to ADSMs without 

the need for a DOD referral. 38 U.S.C. § 1720D(a)(2). VA has implemented this discretionary authority to permit ADSMs to receive counseling to overcome psychological trauma resulting from MST at Vet Centers without a DOD referral. Vet Center records are confidential and maintained independent of DOD and VA medical 

records. Additionally, Vet Centers have staff with particular expertise in MST and 

are located in the community, apart from DOD installations. In addition to treatment available to ADSMs under VA/DOD sharing agreements, VA is collaborating 

with DOD to provide MST-related care and services to ADSMs at VAMCs and 

CBOCs without the need for a referral. 

Eligibility criteria and services available for former Servicemembers with an 

Other Than Honorable (OTH) discharge are separate and distinct from the above 

description pertaining to ADSMs. In general, to qualify for VA health care, a former 

Servicemember must meet the definition of a ‘‘Veteran’’ as this term is defined in 

38 U.S.C. § 101: ‘‘a person who served in the active military, naval, or air service, 

and who was discharged or released therefrom under conditions other than dishonorable.’’ An OTH discharge is not necessarily a bar to receipt of VA services, and 

individuals with OTH discharges can potentially receive VA health care, including 

MST-related care, upon review of their discharge by the Veterans Benefits Administration (VBA). If VBA determines that the individual qualifies as a ‘‘Veteran,’’ the 

individual may enroll in VA’s health care system and be placed in the priority group 

for which he or she qualifies. Former Servicemembers with OTH discharges may receive VA emergency care pending these Veterans Benefits Administration reviews. 

A former Servicemember with an OTH discharge who is subsequently determined 

(by VBA) to be a ‘‘Veteran,’’ as described above, is eligible to receive counseling and 

treatment to overcome psychological trauma resulting from MST, as described in 

§ 1720D. 

If VBA determines that the character of discharge is a bar to receiving VA benefits, and thus that the individual does not qualify as a ‘‘Veteran,’’ the individual is 

still eligible for VA health care needed to treat a service-incurred or service-aggravated disability (unless subject to one of the statutory bars to benefits set forth in 

38 U.S.C. § 5303(a)). See Section 2 of Public Law 95–126 (Oct. 8, 1977). VA is reviewing whether such an individual who is determined pursuant to § 1720D to have 

psychological trauma resulting from MST would qualify for care for that trauma 

under section 2 of Public Law 95–126. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. MAZIE K. HIRONO TO

CAROLYN M. CLANCY, M.D., DEPUTY UNDER SECRETARY FOR HEALTH FOR ORGANIZATIONAL EXCELLENCE, U.S. DEPARTMENT OF VETERANS AFFAIRS

VA SCHEDULING SYSTEM

Question 14. Dr. Clancy, in the testimony of Mr. Missal, he indicates that VA’s 

continued issues with their scheduling system stem from the VA’s failure to identify 

their requirements for such a system. However, Secretary Shulkin has indicated 

that VA is giving up on the in-house solution for a scheduling system and will be 

buying one off the shelf-what measures will the VA be taking to ensure the produce 

will integrate with the electronic health records of the VA, the Choice program, and 

the DOD? 

Response. In February 2017, VA announced it has decided to proceed with rolling 

out VistA Scheduling Enhancement (VSE) as a low-cost, temporary improvement to 

the current outdated scheduling system. VSE will be VA’s interim scheduling soluVerDate Mar 15 2010 16:25 Sep 24, 2018 Jkt 000000 PO 00000 Frm 00054 Fmt 6633 Sfmt 6621 Z:\ACTIVE\031517.TXT PAULIN
51 

tion to fulfill requirements for patient scheduling until a robust, commercial scheduling system can be implemented. VSE provides a more user-friendly interface that 

makes it easier to view available appointment times and reduces errors on entry. 

This functionality improves our ability to schedule Veterans efficiently and accurately. 

VA will still pursue the Medical Appointment Scheduling System (MASS) scheduling pilot as part of a longer term, comprehensive strategy to modernize VA scheduling and meet all of VA’s scheduling needs, like resource-based scheduling. VA’s 

overall electronic health record modernization plan is set to be released this summer. VA will roll out VSE nationally over the next several months as safely and 

quickly as possible. 

Question 15. Do you have a target date for complete interoperability between the 

VA and the DOD? The move by the VA to capitalize on using military treatment 

facilities will be a failure if you cannot make the systems work seamlessly. 

Response. VA and DOD systems are interoperable today. In April 2016, VA and 

DOD were proud to certify to Congress that VA had met the National Defense Authorization Act for Fiscal Year 2014 interoperability standards. But meeting those 

standards was only one part of our ongoing work, not the end state. We continue 

to push our interoperability efforts every day to include interoperability with the 

private sector. 

As of March 19, 2017, more than 236,000 VA health care and benefits professionals have access to real-time EHR information, which they can access from VA, 

DOD, and VA external partner facilities (including private sector) where a patient 

has received care. On a daily basis, approximately 1.5 million data elements are 

shared between DOD and VA. The tool that provides this capability is called the 

DOD/VA Joint Legacy Viewer (JLV). Since its implementation, JLV has allowed VA 

staff to view more than 2.5 million records. VA’s Enterprise Health Management 

Program (eHMP) incorporates JLV’s capabilities and provides even more robust capabilities, including team management and communications, task management, and 

clinical decision support. eHMP is built upon an event-driven architecture and includes the ability to search the comprehensive patient record for specific terms and 

conditions. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JOE MANCHIN III TO

CAROLYN M. CLANCY, M.D., DEPUTY UNDER SECRETARY FOR HEALTH FOR ORGANI- ZATIONAL EXCELLENCE, U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 16. Two of the high risk issues identified by GAO are ambiguous policies 

and inconsistent processes throughout the VA system. If a policy or procedure is developed at the VA Central Office level in Washington, DC, how is VA guaranteeing 

proper articulation of that new policy to VA employees at the local level? 

Response. First, VHA has developed a system to ensure field review during development, so that policies produced by VA Central Office have already been thoroughly analyzed and commented on by the field before they are published. Under 

the new development process, each policy is placed into a portal where field offices 

at the local and VISN level can read and provide detailed comments on every aspect 

of the policy. Although this process is still relatively new, it has already yielded 

hundreds of comments and has led to major revisions of several developing policies. 

Second, after VHA publishes a policy, the policy is communicated through a variety of means including an e-mail to all publication control officers nationwide and 

specific communications, which are developed by the responsible program office and 

tailored specifically for the primary users of the policy. 

The new development process was piloted in 2016 and put in place in January 2017. We are continuing to assess how well it is working by focusing on existing 

policies that need to be updated and recertified, and we meet regularly to revise 

based on user experience. We also have long-term plans to develop pre- and postpublication assessments, metrics, feedback loops, and communication tools that will 

apply to all national policy. 

Question 17. The Inspector General Audit of VA’s Recruitment, Relocation and Retention (3R) Initiatives exposed a lack of oversight and accountability in the program that had expensive consequences. If certain individuals are taking advantage 

of this program, money is not reaching essential recruitment programs needed for 

rural VA hospitals and CBOCs, like those in West Virginia. What is the VA doing 

to adequately monitor the critical 3R incentive program? 

Response. There are various monitoring and reporting requirements outlined in 

current VA policy regarding recruitment, relocation, and retention incentives. On an 

annual basis, each servicing human resources office is responsible for compiling a 

52 

certification report attesting to the strategic and prudent use of all incentives authorized during the prior calendar year. The report requires information from each 

incentive authorization, and the Network, Area, or Deputy Assistant Secretary level 

or higher must sign-off. These reports are submitted to the Deputy Assistant Secretary for Human Resources Management and form the basis for a Department-wide 

report to the Secretary. 

In addition to the annual certification report, the VA Office of Human Resources 

Management (OHRM) Compensation and Classification Service extracts data from 

the human resources information system on a quarterly basis to identify any trends 

or anomalies in usage. As needed, the Compensation and Classification Service contacts servicing human resources offices to verify information and to obtain copies of 

authorizations or other relevant documents needed for the analysis. 

Additionally, OHRM’s Oversight and Effectiveness Service will continue to review 

a facility’s incentive authorizations during onsite visits and reviews. This review includes verifying justifications and authorizations and ensuring incentives are approved in accordance with VA policies and Federal Government regulations. 

There are also impending policy revisions that will strengthen monitoring requirements for Recruitment, Relocation, and Retention incentives. One of the proposed 

changes to the policy is the addition of a template for the mandatory annual review 

of all recruitment, relocation, and retention incentives. The Annual Certification on 

Usage of Recruitment, Relocation, and Retention Incentives template was developed 

to collect mandatory information on the usage of recruitment, relocation, and retention incentives. Section 5 of this proposed template requires a narrative description 

and information to the following: Description of any workforce or succession planning efforts used or proposed that have or will eliminate or reduce the use of recruitment, relocation, or retention incentives. In addition to the workforce or succession planning narrative, each report must provide certification. 

Question 18. Given the historically long process of agency removal from the GAO’s 

High-Risk List, how long do you anticipate it will take VA to make it off the list? 

What do you need from Congress to expedite this process? 

Response. The average removal time from the High-Risk List is 9 years. VA will 

do everything possible to achieve success more rapidly than average and keep the 

Committee informed about our progress. 

VA requests Congress work with VA on Choice eligibility criteria, pass VA accountability legislation and appeals modernization legislation. 

Question 19. West Virginia has a population with a high number of veterans and 

a high number of individuals utilizing the Affordable Care Act. If the ACA is repealed, it is safe to assume there will be changes to coverage, deductibles, and outof- pocket costs for many. How, if at all, do you foresee the repeal of the Affordable 

Care Act affecting VA Healthcare? For example, do you expect to see an uptick in 

enrollment? 

Response. Changes in health insurance coverage, deductibles and out-of-pocket 

costs as a result of Affordable Care Act (ACA) reform depend largely upon how the 

ACA isrepealed and replaced. As such, we cannot speculate as to how ACA repeal 

and replace might impact VA health care. West 

The chart below depicts the Veteran population in West Virginia including Veterans enrolled in VHA, Medicare and Medicaid, as reported in the 2015 American 

Community Survey. 


315q3VHAmiii1.eps
53 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. SHERROD BROWN TO

CAROLYN M. CLANCY, M.D., DEPUTY UNDER SECRETARY FOR HEALTH FOR ORGANI- ZATIONAL EXCELLENCE, U.S. DEPARTMENT OF VETERANS AFFAIRS

STERILIZATION

Question 20. Dr. Clancy, during your testimony you referenced steps VA took to 

correct safety and quality concerns as it relates to sterilization of medical equipment. This is an issue that many medical facilities face and was a focal point during 

last year’s allegations of misconduct at the Cincinnati VAMC. Please provide me 

with an overview of the sterilization concerns that VA has review this past year and 

the steps taken to address each concern. 

Response. The VA National Program Office for Sterile Processing (NPOSP) ensures the safety of Veterans by developing national policy and oversight of all sterile 

processing and high-level disinfection activities for critical and semi-critical Reusable Medical Equipment (RME). 

During FY 2016, NPOSP conducted 81 site review inspections identifying the continued need for oversight and auditing of RME on an annual basis. NPOSP conducts 

facility site visits in collaboration with subject matter experts to review and advise 

on sterile processing activities and to provide special assistance when failures in 

sterile processing activities might pose potential risks to Veterans. For example, 

NPOSP diligently looks for errors in not only documentation but sterile processing 

activities that do not meet manufacturer’s guidelines which could potentially pose 

a risk to Veterans. If NPOSP discovers errors, they will apply corrective actions dependent on the complexity of the error to ensure Veteran safety. In addition to conducting site visits, NPOSP also provides guidance and policies for facility and VISNled inspections of sterile processing activities and assists with the analysis of data 

to identify trends. Using the trends and data from the facilities, NPOSP recommends corrective actions across the health care system. 

NPOSP conducts training and continuing education programs to ensure competencies in the sterile processing workforce and develops national policy and guidance for sterile processing activities. Such direction and policy may include technical 

specifications, competency assessments, oversight of sterile processing functions at 

the facility level, and integration of sterile processing activities with other clinical 

services. 

NPOSP collaborates with the VA National Center for Patient Safety (NCPS), Biomedical Engineering, Center for Engineering, Occupational Safety and Health 

(CEOSH), Food and Drug Administration (FDA) and multiple vendors/manufacturers to correct defects in design and reprocessing of RME issues. During this past 

fiscal year, NPOSP offered guidance and provided corrective action to ensure Veteran safety with the following instruments used in VA facilities: 

• General Electric (GE) ultrasound Endocavity Transducer (IC5–9D) 

– The transducer could not be deemed bioburden free due to the design of the 

instrument. NPOSP worked with GE to redesign the transducer probe and update Instructions For Use (IFU). 

• Olympus rigid cystoscope bridge 

– The bridge was identified to have defective adhesive material that deteriorated after the sterilization process. NPOSP is working with Olympus for corrective design options. 

• 3M Attest Biological indicator 

– The testing indicator was not compatible with the sterilizer. NPOSP collaborated with the manufacturer to provide the correct guidelines for use that meet 

quality assurance indicators of VA. 

• Arobella Quostic Wound Therapy System Model AR1000 ultrasound debridement 

– The design of the Arobella Quostic Wound Therapy System Model AR1000 

hand piece did not allow for proper reprocessing. NPOSP provided guidance and 

discontinued using the old version of the ultrasound hand piece nationally in 

VA and now only purchases the up-to-date model from the manufacturer that 

could be effectively reprocessed. 

• Conmed Hyfrecator 

– The Hyfrecator was noted to only have 100 uses validated for proper usage; 

however, the manufacturer representative failed to inform end users that the 

hand piece must be disposed of, tracked, and disposed of after 100 uses. NPOSP 

implemented a national quality assurance program to ensure proper tracking 

and disposal of the Hyfrecator. NPOSP also worked with the manufacturer to 

create a sheath with correct guidelines for use to ensure the sheath covered the 

Hyfrecator which protects patients from biohazard material. 

54 

• Parks Medical Doppler Probe 

– The manufacturer only allows for the Doppler probe to be used on intact, external skin only. NPOSP identified the Doppler was being used intraoperatively 

with a sterile sheath that had not been approved by the vendor. NPOSP implemented a national quality assurance program to ensure proper usage of the 

Doppler and education and training was provided for the end-user. VA no 

longer uses the Doppler perioperative setting. • Custom Ultrasonics Automatic Endoscope Reprocessor (AER) 

– The AER had not been validated for multiple high-level disinfection solutions 

but was sold for the use of multiple high-level disinfection solutions without any 

FDA validation. NPOSP worked with FDA and Custom Ultrasonics to pull and 

replace all AERs that did not meet FDA clearance. 

SAME DAY ACCESS

Question 21. Dr. Clancy, in GAO’s testimony Dr. Draper raises concerns regarding 

access to same day care throughout VHA for veterans in need of mental health and 

primary care. These findings are based on GAO reports from 2015 and 2016. VHA 

says that there are same day appointments for mental health and primary care in 

all facilities. Please provide me with a snapshot from one day of all the VAMCs and 

CBOCs in Ohio that illustrate same day availability for veterans. 

What metrics are used to measure same day availability for veterans and is there 

any way for a facility to report inaccurate data regarding availability? 

Response. Asking our Veteran patients to tell us about their experience is the 

most important way to find out if a facility is meeting same day service expectations. In VHA, one way this is done is through the standardized survey called Consumer Assess of Health Care Providers and Systems (CHAPS), a standardized tool 

used in the health care industry. One of the CHAPS questions is, ‘‘In the last 6 

months, when you made an appointment for a check-up or routine care with this 

provider, how often did you get an appointment as soon as you needed?’’ 

Since survey results report past performance, lag, and are available less frequently, VHA is also using objective, process measures believed to provide a daily 

snapshot of system performance in achieving same day services for Veterans. One 

process measure is the number of face-to-face appointments completed the same day 

they are scheduled. VA recognizes not all appointments represented by this measure 

meet the definition of ‘‘same day services;’’ however, many of them are a result of 

same day requests from patients. This measure is readily available to VA staff and 

actionable. The definition of same day services includes not only requests from traditional face to face visits but also responses to requests made by phone, secure 

messaging email, and responses from appropriate support services such as Pharmacy, Social Work, Nursing, etc. For this reason, VHA continues to work to identify 

ways in which to measure these individual types of same day services and develop 

more useful collective process and outcome measures. 

As of December 31, 2016, same day services in mental health and primary care 

were made available at all medical centers across VHA. This included those in Ohio, 

i.e., Chillicothe, Cincinnati, Cleveland, Columbus and Dayton. Facilities have continued to work to expand same day services to their CBOCs. In Ohio, a snapshot of 

same day services availability as reported by facility leadership as of March 31, 

2017, is listed below. 

Primary Care Mental Health 

(3V10) (538) Chillicothe VAMC .................................................................... Yes Yes 

(3V10) (538GA) Athens .................................................................................... Yes Yes 

(3V10) (538GB) Portsmouth ............................................................................. Yes Yes 

(3V10) (538GC) Marietta .................................................................................. Yes Yes 

(3V10) (538GD) Lancaster ............................................................................... Yes Yes 

(3V10) (538GE) Cambridge .............................................................................. Yes Yes 

(3V10) (538GF) Wilmington ............................................................................. Yes Yes 

(3V10) (539) Cincinnati VAMC .................................................................... Yes Yes 

(3V10) (539A4) Cincinnati VAMC-Fort Thomas ............................................... No No 

(3V10) (539GA) Bellevue .................................................................................. Yes Yes 

(3V10) (539GB) Clermont County .................................................................... Yes Yes 

(3V10) (539GC) Dearborn ................................................................................. Yes Yes 

(3V10) (539GD) Florence .................................................................................. Yes Yes 

(3V10) (539GE) Hamilton ................................................................................. Yes Yes 

(3V10) (539GF) Georgetown ............................................................................. Yes Yes 

(3V10) (539QB) Highland Avenue .................................................................... No No 

55 

Primary Care Mental Health 

(3V10) (541) Louis Stokes Cleveland VAMC ............................................... Yes Yes 

(3V10) (541BY) Canton .................................................................................... Yes Yes 

(3V10) (541BZ) Youngstown ............................................................................ Yes Yes 

(3V10) (541GB) Lorain ..................................................................................... Yes Yes 

(3V10) (541GC) Sandusky ................................................................................ Yes Yes 

(3V10) (541GD) David F Winder VA CBOC ...................................................... Yes Yes 

(3V10) (541GE) McCafferty .............................................................................. Yes Yes 

(3V10) (541GF) Painesville .............................................................................. Yes Yes 

(3V10) (541GG) Akron ...................................................................................... Yes Yes 

(3V10) (541GN) State Street ............................................................................ Yes Yes 

(3V10) (552) Dayton VAMC .......................................................................... Yes Yes 

(3V10) (552GA) Middletown ............................................................................. Yes Yes 

(3V10) (552GB) Lima ....................................................................................... Yes Yes 

(3V10) (552GC) Richmond ............................................................................... Yes Yes 

(3V10) (552GD) Springfield .............................................................................. Yes Yes 

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