VA Health Care: Processes to Evaluate, Implement, and Monitor Organizational Structure Changes Needed
Published: 2016-09-27T00:00:00

Fast Facts:
The Veterans Health Administration (VHA) is in the midst of its largest geographic realignment in more than 20 years. The realignment resulted in some staff redundancies—2 or more staff doing the same job, also called "double-encumbered" positions. Regional network directors told us they were frustrated with the lack of guidance from VHA's central office about how to resolve this and other challenges they faced.
We examined VHA's recent realignment and made recommendations to improve how VHA evaluates and executes organizational structure changes.

Highlights:
section_title: Why GAO Did This Study
paragraphs: GAO and others have expressed concerns about VHA's management of its health care system. In response, VA initiated a new regional framework to improve internal coordination and customer service, and VHA initiated an effort to realign its VISNs.
GAO was asked to review VHA's organizational structure—the operating units, processes, and other components used to achieve agency objectives. This report examines the extent to which (1) VHA has a process for evaluating recommended organizational structure changes to determine actions needed and implementing them as appropriate; and (2) VHA monitored and provided guidance for implementing the VISN realignment. GAO reviewed VHA documents, reviewed internal and external assessments of VHA, and interviewed officials from VHA central office and all VISNs. GAO evaluated VHA's actions against relevant federal standards for internal control.
section_title: What GAO Found
paragraphs: Recent internal and external reviews of Veterans Health Administration (VHA) operations have identified deficiencies in its organizational structure and recommended changes that would require significant restructuring to address, including eliminating and consolidating program offices and reducing VHA central office staff. However, VHA does not have a process that ensures recommended organizational structure changes are evaluated to determine appropriate actions and implemented. This is inconsistent with federal standards for internal control for monitoring, which state that management should remediate identified internal control deficiencies on a timely basis. GAO found instances where VHA actions in response to recent recommendations for organizational structure changes were incomplete, not documented, or not timely. For example, VHA chartered a task force to develop a detailed plan to implement selected recommendations from the independent assessment of VHA's operations required by the Veterans Access, Choice, and Accountability Act of 2014; according to VHA, the assessment cost $68 million. It found, among other things, that VHA central office programs and staff had increased dramatically in recent years, resulting in a fragmented and “silo-ed” organization without any discernible improvement in business or health outcomes. It recommended restructuring and downsizing VHA's central office. The task force of 18 senior Department of Veterans Affairs (VA) and VHA officials conducted work over about 6 months, but did not produce a documented implementation plan or initiate implementation of recommendations. Without a process that documents the assessment, approval, and implementation of organizational structure changes, VHA cannot ensure that it is making appropriate changes, using resources efficiently, holding officials accountable for taking action, and maintaining documentation of decisions made.
VHA central office's monitoring of the Veterans Integrated Service Networks (VISN) realignment—a recent and significant organizational structure change—has been limited, and the office has provided little implementation guidance. In October 2015, VHA began to implement a realignment of its VISN boundaries, which involves decreasing the number of VISNs from 21 to 18 and reassigning some VA medical centers (VAMC) to different VISNs. VHA officials anticipate this process will be completed by the end of fiscal year 2018. VHA officials on the task force implementing the realignment told GAO they thought VISNs could implement the realignment independently without the need for close monitoring. VHA also did not provide guidance to address VISN and VAMC challenges that could have been anticipated, including challenges with services and budgets, double-encumbered positions (two officials in the same position in merging VISNs), and information technology. Further, VHA officials said they do not have plans to evaluate the realignment. VHA's actions are inconsistent with federal internal control standards for monitoring (management should establish monitoring activities, evaluate results, and remediate identified deficiencies) and risk assessment (management should identify, analyze, and respond to changes that could affect the system). Without adequate monitoring, including a plan for evaluating the VISN realignment, VHA cannot be certain that the changes being made are effectively addressing deficiencies; nor can it ensure lessons learned can be applied to future organizational structure changes.
section_title: What GAO Recommends
paragraphs: GAO recommends that VHA (1) develop a process to ensure that organizational structure recommendations are evaluated for implementation; and (2) evaluate the implementation of the VISN realignment to determine and correct deficiencies, and apply lessons learned to future organizational structure changes, such as possible changes to VISN staffing models. VA concurred with GAO's recommendations.

section_title: Letter
paragraphs: The Veterans Health Administration (VHA), within the Department of  Veterans Affairs (VA), operates one of the nation’s largest health care  systems, with 168 VA medical centers (VAMC), more than 1,000  outpatient facilities, and a total health care budget of nearly $51 billion in  fiscal year 2015. VHA provided care to about 6.7 million veterans in  fiscal year 2015 and the demand for its services is expected to grow in  the coming years.
VHA’s organizational structure—the operating units, processes, and other  components used to achieve agency objectives—is governed by its  senior leadership. This leadership team, which is led by the Under  Secretary for Health, manages more than 40 clinical programs and  administrative offices, including those that allow veterans to obtain care  from a network of non-VA providers. It also oversees VHA’s field  operations, comprised of Veterans Integrated Service Networks (VISN)  that manage networks of VAMCs and outpatient facilities.
We and others have expressed significant concerns about VHA’s  management of its health care system, including VHA’s ability to  effectively provide and oversee timely access to health care for veterans.  In addition, in 2014, a series of events called into question the ability of  veterans to gain timely access to care from VHA medical facilities. As a  result of these and other systemic problems, we concluded that VA health  care is a high-risk area and added it to our High Risk List in 2015.
In response to criticism that VHA was not succeeding in providing timely  health care services to veterans, VA announced a major organizational  initiative in September 2014 called MyVA. As part of this initiative, the  department established a single regional framework for its three  administrations—VHA, the Veterans Benefits Administration, and the  National Cemetery Administration—dividing the United States into five  regions based on state boundaries. According to VA, this regional  framework is intended to align the previously disparate organizational  boundaries of VA’s administrations in order to promote internal  coordination and to support the rollout of a Veterans Experience office  dedicated to enhancing customer service capabilities across the  department. Following the MyVA initiative’s implementation, VHA  announced plans to realign and, in some cases, merge VISNs so that  they are geographically aligned with MyVA’s regional boundaries  (hereafter referred to as the VISN realignment). In addition, Congress  passed the Veterans Access, Choice, and Accountability Act of 2014  (Choice Act) to, among other things, improve veterans’ timely access to  care by expanding veterans’ ability to obtain care from non-VA providers.
Based on questions about VHA’s ability to oversee its health care system  and provide timely care, you asked us to conduct a management review  of VHA that encompassed several key organizational components,  including its organizational structure. This report examines the extent to  which  1.  VHA has a process for evaluating recommended organizational  structure changes to determine actions needed and implementing  them as appropriate; and  2.  VHA’s central office monitored and provided guidance for its field  operations implementing the VISN realignment.
To determine the extent to which VHA has a process for evaluating  recommended organizational structure changes to determine actions  needed and implementing them as appropriate, we reviewed relevant  documentation from VHA, including organizational charts, directives,  position descriptions, and memos to identify current policy and practice  with regard to organizational structure changes. We also reviewed related  internal and external assessments of VHA to determine deficiencies  identified and recommendations made. Specifically, we reviewed two  assessments that were required by the Choice Act—the Independent  Assessment of the Health Care Delivery Systems and Management  Processes of the Department of Veterans Affairs (Independent  Assessment) and the Final Report of the Commission on Care. We also  reviewed a report produced by an internal VHA task force chartered by  the then Interim Under Secretary for Health to evaluate VHA’s  governance structure, the Task Force on Improving Effectiveness of VHA  Governance (which we will refer to as the governance task force  hereafter). We interviewed VHA officials, including officials from VHA’s  National Leadership Council, other VHA senior leadership such as the  Under Secretary for Health, and VISN and VAMC officials on their  involvement in organizational structure changes. We evaluated VHA’s  actions against federal internal control standards related to monitoring.
To determine the extent to which VHA’s central office provided monitoring  and guidance to its field operations implementing the VISN realignment,  we reviewed relevant documentation from VHA, VISN, and VAMC  officials, including organizational charts, position descriptions, directives,  and memos. We also reviewed related internal and external assessments  of VHA’s organizational structure. We interviewed VHA central office  officials involved in the VISN realignment. We also interviewed directors  from all 21 VISNs that existed prior to the VISN realignment, and directors  from six selected VAMCs, about the extent to which their participation  was solicited as part of recent organizational structure changes and to  obtain their perspectives on organizational structure changes, such as the  VISN realignment. The six VAMCs were selected to provide variation in  (1) whether the VAMC was affected by the realignment; (2) whether the  associated VISN was affected by the realignment; (3) geographic  location; (4) tenure of the VAMC director; (5) tenure of the VISN director;  and (6) facility complexity level. The six selected VAMCs were  Huntington VAMC (Huntington, W.V.); Jerry L. Pettis Memorial Veterans’  Hospital (Loma Linda, Calif.); John D. Dingell VAMC (Detroit, Mich.);  Jonathan M. Wainwright Memorial VAMC (Walla Walla, Wash.); Nashville  VAMC (Nashville, Tenn.); and Togus VAMC (Togus, Maine). The  information from our VAMC interviews is not generalizable to all VAMCs.  We evaluated the monitoring and guidance provided by VHA against  federal internal control standards related to risk assessment and  monitoring.
We conducted this performance audit from September 2015 to  September 2016 in accordance with generally accepted government  auditing standards. Those standards require that we plan and perform the  audit to obtain sufficient, appropriate evidence to provide a reasonable  basis for our findings and conclusions based on our audit objectives. We  believe that the evidence obtained provides a reasonable basis for our  findings and conclusions based on our audit objectives.
subsections: section_title: Background
subsections: section_title: VHA Organizational Structure
paragraphs: The Under Secretary for Health is the head of VHA and is supported by  the Principal Deputy Under Secretary for Health, four Deputy Under  Secretaries for Health (DUSH), and nine Assistant Deputy Under  Secretaries for Health (ADUSH). Five of these senior leadership positions  have been added since 2015. (See fig. 1.)
The four DUSH-level positions are
Operations and Management: This official oversees VHA’s field  operations. All VISN directors report to the DUSH for Operations and  Management; VISNs manage the day-to-day functions of VAMCs and  outpatient facilities within their network. The Office of the DUSH for  Operations and Management supports the VISNs by providing  guidance and individual assistance to address operational challenges  (such as personnel issues, adverse events at facilities, and  implementation of legislation), and supporting the management of  access to care (through the ADUSH for Access to Care position,  added in 2016). The office also serves as the focal point for the flow of  information and guidance between VHA central office and the VISNs  and VAMCs.
Policy and Services: This official oversees VHA offices focused on  health care policy, information management, and research. The Office  of the DUSH for Policy and Services is responsible for developing and  promulgating VHA policies, employing information and informatics  tools to improve patient outcomes, and measuring results to ensure  continuous learning.
Organizational Excellence: This official oversees program offices  focused on assessing and improving quality and safety, providing  VHA leadership with analytics to assess how VHA is performing as an  organization, and addressing issues related to public trust and  integrity. For example, the ADUSH for Integrity reports to the DUSH  for Organizational Excellence and is responsible for the day-to-day  management of offices focused on internal and external audits,  compliance, and ethics. The Office of the DUSH for Organizational  Excellence—created in 2015—serves as a hub to enable VHA to  achieve the five priorities the Under Secretary of Health established in  2015, and to respond to our High Risk List designation.
Community Care: This official oversees all VHA community care  programs and business processes, such as determining veterans’  eligibility to receive health care benefits and purchasing care from  non-VA providers. The Office of the DUSH for Community Care was  created in 2015 to implement provisions in the Choice Act that  expanded veterans’ access to non-VA health care services and  directed VHA to consolidate the administration of payment for care  from non-VA providers. Prior to the creation of this office, the  administration of such care to veterans had been spread across VHA.
section_title: Internal and External Reviews of VHA Organizational Structure
paragraphs: Recent internal and external reviews of VHA operations have identified  deficiencies in VHA’s organizational structure and recommended changes  that require significant restructuring to address, including eliminating and  consolidating program offices and reducing VHA central office staff. For  example, the Choice Act required VA to contract with a private entity to  conduct an independent assessment of 12 areas of its health care  delivery system and management processes, including VHA’s  leadership. The Independent Assessment report, which VHA reported  cost $68 million, was released in September 2015. It made  recommendations across each of the 12 areas that support the report’s  four systemic findings of (1) a disconnect in the alignment of demand,  resources, and authorities; (2) uneven bureaucratic operations and  processes; (3) non-integrated variations in clinical and business data and  tools; and (4) leaders not fully empowered due to a lack of clear authority,  priorities, and goals. For example, to address the finding of uneven  bureaucratic business operations and processes, the report includes a  recommendation for VHA to develop a patient-centered operations model  that balances local autonomy with appropriate standardization and  employs best practices for high-quality health care. To accomplish this,  the report states that, among other things, VHA should reorient its central  office to better support field operations in its delivery of care to veterans.
Pub. L. No. 113-146, § 202(g), 128 Stat. 1776.
On September 1, 2016, the President concurred with 15 of the 18 recommendations and  directed VA to implement any of the 15 recommendations that the department was not  already working to implement. assessment of the Commission on Care’s recommendations and a  description of the recommendations VHA is directed to implement.
In addition to the reviews required by the Choice Act, VHA initiated  internal task forces to examine organizational structure changes and  make recommendations. For example, VHA chartered its governance  task force in December 2014, with the goal of making recommendations  to improve operational effectiveness and efficiency, and to align the  agency to strengthen business processes. According to the task force’s  charter, VHA needed to modify its governance structure to help address  recent issues with substandard and inconsistent care delivery. The  governance task force submitted a report in February 2015 with 21  recommendations. For example, the task force recommended  reorganizing VHA’s central office around functional areas and  establishing processes for regular review and revision of the VISN and  VHA central office structures.
A governance task force recommendation to examine VISN staffing  resulted in VHA chartering another task force, the VISN Staffing Task  Force, in February 2015. In July 2015, this task force submitted a report  to the DUSH for Operations and Management with recommendations for  a new VISN staffing model. It included an option for reorganized VISN organizational structures; new positions focused on special populations (e.g., women’s health,  rural health), nursing, and communications; and  staffing limits that would result in 95 fewer VISN full-time-equivalent  staff nationally in fiscal year 2016 compared to fiscal year 2012.
In addition, VHA chartered a task force—the Integrated Project Team—in  September 2015 to develop a detailed, time-limited, and organization- specific plan for, and initiate implementation of, selected  recommendations from the Independent Assessment required by the  Choice Act. According to the task force’s charter, it was formed because,  in a climate of intense public and congressional scrutiny, VHA needed to  act quickly and could not afford to wait for the Commission on Care to  publish its recommendations, which were to incorporate the results of the  Independent Assessment.
section_title: VHA Does Not Have a Process That Ensures Recommended Organizational Structure Changes Are Evaluated and Implemented
paragraphs: Despite several critical internal and external reviews, VHA does not have  a process that ensures that recommendations resulting from these  reviews are evaluated to determine appropriate actions and that any such  appropriate actions are implemented. (See app. I for a table of recent  internal and external reviews that examined VHA’s organizational  structure.) The lack of such processes is inconsistent with federal  standards for internal control, which state that management should  remediate identified internal control deficiencies on a timely basis. This  remediation may include evaluating the results of reviews to determine  appropriate actions, and, once decisions are made, completing and  documenting corrective actions on a timely basis.
We found instances where VHA task force actions in response to recent  recommendations for organizational structure changes were incomplete,  not documented, or not timely:  Governance task force. A senior VHA official on the task force— one of 10 senior officials who worked on the February 2015  report—told us that the Under Secretary for Health did not  approve 13 of the 21 recommendations, so they would not be  implemented. Additionally, VHA officials stated that there was no  documentation of the Under Secretary for Health’s decisions on  the recommendations because they were communicated verbally.  Some of these 13 unimplemented recommendations focused on  organizational structure changes that were later repeated in the  Independent Assessment’s recommendations. For example, the  Independent Assessment and the VHA governance task force  reports both noted that VHA central office programs and staff had  increased dramatically in recent years, resulting in a fragmented  and “silo-ed” organization without any discernible improvement in  business or health outcomes, and recommended restructuring and  downsizing VHA central office. The Under Secretary for Health  told us that his immediate priorities were to focus on improving  access to care and hiring officials for vacant senior-level positions,  and as a result he did not want to make significant changes to  VHA’s organizational structure. Recommendations the Under  Secretary for Health approved included those on improving the  coordination and oversight of non-VA community care,  restructuring the monthly meetings of VHA’s National Leadership  Council, and establishing processes to develop and improve  health care performance measures.
VISN Staffing Task Force. VHA officials told us that the DUSH  for Operations and Management verbally communicated approval  of the task force’s recommendations to change VISN staffing,  which were developed over a week-long work session and  incorporated input from all VISN directors. VHA officials provided  us a VISN organizational chart with revised VISN staffing limits as  documentation of the DUSH’s approval, but did not provide  documentation of the decision made on each task force  recommendation. For example, the documentation did not include  the DUSH’s decisions on the task force’s recommendations on  whether larger VISNs should be allowed to establish deputy  network director positions, or if certain staff positions could be  shared across VISNs. It also did not include information on why  one staffing model was chosen over another. Officials stated that  the DUSH was responsible for implementing the new VISN  staffing model, but had not developed a timeline for its  implementation. VHA officials were not able to provide us with any  updates on implementation and told us in May 2016 that the task  force had been disbanded.
Integrated Project Team. The task force, made up of 18 senior  VA and VHA officials, conducted its work over about 6 months but  did not produce the detailed implementation plan of the  Independent Assessment recommendations it was chartered to  create, according to VHA officials. A senior VHA official on the  task force told us that the team planned to have a completed  implementation plan in March 2016, and had identified senior-level  VHA officials who would be responsible for ensuring  implementation of the recommendations. The official also noted  that the task force’s work would be included in VHA’s strategic  planning summit in April 2016, at which point the task force would  disband. VHA officials later told us that although the Integrated  Project Team developed eight topic areas that applied to the  Independent Assessment’s recommendations, and presented  them at the strategic planning summit, they would not be moving  forward with further work to develop and approve an  implementation plan. In August 2016, VHA officials told us that  since the strategic planning summit, they have been focused on  addressing other priorities such as the Commission on Care  report, proposed legislation that could affect VHA operations, and  the Under Secretary for Health’s five priorities for VHA.
VHA devoted significant time and effort to these different task forces, but  then either did not act or acted slowly to implement recommendations.  For example, all three task forces included senior officials from VHA’s  central office and VISNs, whose participation on the task forces created  additional responsibilities beyond those related to their positions. In  addition, all three sets of recommendations were available to VHA  officials in 2015, but decisions on these recommendations were delayed  by 6 months to 1 year after the report’s completion, and in the case of the  Integrated Project Team’s work, decisions have not been made at all.  One attribute of the federal internal control standard for timely  remediation for identified deficiencies is assigning responsibility and  authority for carrying out corrective actions. The three task force charters  did not require senior leadership to make decisions on the results of  reviews within a certain time frame, or ensure implementation of agreed- upon recommendations. As a result, when officials retired (as did the  chairs for all three task forces) or resumed their regular duties, there were  no other individuals or offices responsible for ensuring that  recommendations were acted on, or any documentation available to track  progress made. VHA officials expressed frustration and confusion at the  lack of response from central office to the findings and recommendations  resulting from task forces. Without a process for ensuring that the  recommendations resulting from internal and external reviews are  evaluated, decisions documented, and promptly acted on, VHA will not be  able to ensure that officials are accountable for taking actions that will  resolve deficiencies. VHA also cannot ensure that it is making efficient  use of internal resources allocated to developing and implementing  recommendations.
section_title: VHA Central Office Has Provided Little Monitoring and Did Not Anticipate Challenges for a Recent and Significant Organizational Structure Change, the VISN Realignment
paragraphs: The VISN realignment is a significant change to VHA’s organizational  structure; it is the first large-scale reorganization of VISN boundaries  since the VISNs were created in 1995. However, VISNs have been  implementing this change with little monitoring from VHA’s central office.  In addition, VHA did not proactively identify and provide guidance to  address challenges VISNs and VAMCs have encountered. These actions  are inconsistent with federal standards for internal control concerning  monitoring and risk assessment. Specifically, these controls state that  management should establish monitoring activities, evaluate the results,  and remediate identified deficiencies in a timely manner. This monitoring  may include ongoing activities that are built into operations, as well as  evaluations that provide feedback on the effectiveness of the monitoring  and identify possible deficiencies that require corrective actions. In  addition, these controls state management should identify, analyze, and  respond to changes that could affect the system.
In October 2015, VHA began to implement a realignment of its VISN  boundaries, with the goal of aligning them with MyVA regional  boundaries. This involved decreasing the number of VISNs from 21 to 18  and reassigning some VAMCs to different VISNs. The governance task  force evaluated several options for aligning VISN boundaries with MyVA  regions and for aligning VISN boundaries better with state lines, and  proposed an 18-VISN configuration. For example, the governance task  force proposed reassigning West Virginia VAMCs so that they would all  report to one VISN instead of four different VISNs. (See app. II for pre-  and post-realignment VISN maps, and a table that shows the extent that  each VISN is affected by the realignment.) VHA officials anticipate that  the realignment will be completed, at the earliest, by the end of fiscal year  2018. Directors from the 15 VISNs affected by the realignment described  a range of actions that needed to be completed as part of the  realignment, including setting up new VISN governance structures;  merging clinical and administrative functions; and assessing the  operations in VAMCs that have been reassigned to a VISN to ensure they  are in alignment with the VISN’s practices, such as VAMCs’ use of  service contracts. According to VHA, the realignment is not expected to  impact veterans’ access to health care. For example, officials told us that  the VISNs are expected to continue to honor historical geographical  referral patterns for veterans—that is, to continue to refer veterans to the  same VAMC or outpatient facility they were referred to prior to the  realignment even if that VAMC or facility is part of a different VISN post- realignment.
VHA has provided little monitoring of VISNs’ implementation efforts, and it  has not provided adequate guidance in anticipation of implementation  challenges. VHA chartered a task force—the VISN Realignment  Workgroup—to implement the realignment across the VISNs. According  to its charter, the task force is responsible for developing an  implementation plan and timeline for the realignment, as well as  identifying barriers and solutions to mitigate them. The task force is made  up of VHA central office and VISN officials and led by the DUSH for  Operations and Management and a VISN director. It meets monthly with  VISNs affected by the realignment. Although these meetings provide a  structure for VISN directors to share actions taken and challenges  encountered in the realignment process, VHA has not taken an active role  in implementing the realignment. VISN Realignment Workgroup officials  told us that at the beginning of the realignment, the workgroup provided  guidance in the form of a communication plan that answered frequently  asked questions about the realignment’s purpose, and made decisions  about how the VISNs would be numbered. However, officials added that  they wanted to be facilitators, rather than directors or implementers, for  the realignment, and that VISN directors were capable of implementing  the realignment independently without the need for a close level of  monitoring.
Directors from several VISNs affected by the realignment told us that they  have made decisions independently about how to implement the  realignment in their VISNs, and many also noted that they continue to  face challenges with implementation, including services and budgets. Directors from 12 of the 15 VISNs affected by  the realignment told us they continue to face challenges in managing  services and budgets. The director of a VISN that gained a VAMC  with after-hours call center services on site told us he faced an  unexpected task of consolidating his VISN’s existing call center  services with those being provided at the VAMC. In addition, a VAMC  director expressed concern about potentially having to re-start a VISN  strategic planning exercise that the VAMC had participated in for 18  months because the VISN to which it had been reassigned had not  done similar planning work. Finally, several VISN directors expressed  concerns about how the realignment would affect their budgets,  including one director who was concerned about losing a large VAMC  that supplemented budget losses for other, smaller VAMCs in the  VISN.  “double-encumbered” positions. Six of the 15 VISNs affected by  the realignment are in the process of merging, which has resulted in  double-encumbered positions—two officials serving in the same  position, such as two Chief Financial Officers. For example, one VISN  director told us at the time of our interview (February 2016) that there  were about 30 double-encumbered positions between two merging  VISNs, which represented about one-third of their total staff.  According to VHA, 23 positions remained double-encumbered in the  merged VISN as of August 2016. Several VISN directors described  challenges in resolving double-encumbered positions. For example,  without authorization to offer Voluntary Separation Incentive  Payments—also known as buyout authority—or specific instructions  from central office, directors told us they were concerned that any  actions they took (such as having officials compete for the position)  would be inconsistent with other VISNs. VHA officials told us that they  have been involved in helping VISNs address double-encumbered  positions, such as assisting in finding staff new positions within VHA,  but not all such situations had been resolved. Further, according to  VHA, one merged VISN received central office approval to pursue  buyout authority, and two other merged VISNs were awaiting approval  as of August 2016. VISN directors with double-encumbered staff  expressed frustration at the lack of resolution of this issue and told us  it has contributed to low staff morale. Double-encumbered positions  were a VISN realignment challenge that VHA could have anticipated  and made plans to address before the realignment started, but  according to senior task force officials, the task force did not establish  a subgroup on human resources until after the realignment began. As  of August 2016, VHA reported there were 37 double-encumbered  positions across the three merged VISNs.  information technology. Six of the 15 directors from VISNs affected  by the realignment told us that they continue to face information  technology challenges, including having to manually reconstruct  datasets to add or delete VAMCs that are still electronically  associated with their former VISNs. One VISN director described  difficulties in obtaining access rights to data from VAMCs that were  reassigned to the VISN. Similarly, a VAMC director told us that the  facility was no longer able to access its own data after changing  VISNs because the data were located on their former VISN’s server,  requiring workarounds to gain access because there was no  guidebook or plan for how to transfer VAMC data from one VISN to  another.
VISN Realignment Workgroup officials told us they were aware of  continued realignment challenges, but had no plans in place at the time of  our review to expand their monitoring efforts to include an evaluation of  the implementation of the realignment. Officials said that if they  conducted an evaluation, the best time frame would be after the  realignment is mostly complete because realignment actions are still in  the process of being implemented. However, an evaluation may be useful  to correct any identified implementation deficiencies. It can also help  inform future organizational structure changes by offering VHA the  opportunity to anticipate challenges and proactively provide guidance to  address them. For example, the Under Secretary for Health told us he  would be open to other VHA organizational structure changes in the  future once he completes the process of filling vacant leadership positions  within VHA. In addition, the implementation of the Commission on Care  report recommendations could result in large-scale organizational  structure changes. VISN Realignment Workgroup officials told us they  thought that an evaluation could also be useful for identifying any  unintended consequences resulting from the realignment that bear  examination.
section_title: Conclusions
paragraphs: VHA is aware that it is providing health care services to veterans in a time  of significant scrutiny from us and others. This scrutiny comes in the wake  of VHA’s inability to provide timely health care services to veterans, which  contributed to the placement of VA health care on our High Risk List.  Although VHA has spent considerable resources—staff time and funds— on reviews and task forces that recommended improvements in its  organizational structure, VHA lacks the processes needed to ensure that  officials can evaluate those recommendations, document decisions,  monitor and evaluate implementation, and hold staff accountable. In  addition, without adequate monitoring, including a plan for evaluation,  VHA cannot be certain it is effectively implementing the ongoing VISN  realignment. VHA would also miss the opportunity to apply lessons  learned from such an evaluation to future organizational structure  changes, such as those it makes in response to the Commission on Care  report’s recommendations. Without processes for evaluating and  implementing recommendations and actively monitoring major  organizational structure changes, there is little assurance that VHA’s  delivery of health care to the nation’s veterans will improve.
section_title: Recommendations for Executive Action
paragraphs: We recommend that the Secretary of Veterans Affairs direct the Under  Secretary for Health to take the following two actions:  1.  Develop a process to ensure that organizational structure  recommendations resulting from internal and external reviews of VHA  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.  2.  Conduct an evaluation of the implementation of the VISN realignment  to determine whether deficiencies exist that need corrective actions,  and apply lessons learned from the evaluation to future organizational  structure changes, such as possible changes to VISN staffing models  or actions to implement Commission on Care recommendations.
section_title: Agency Comments
paragraphs: We provided a draft of this report to VA for comment. In its written  comments, reproduced in appendix III, VA agreed with our conclusions  and concurred with our recommendations. In its comments, VA stated  that VHA plans to develop processes to ensure organizational structure  changes are evaluated and implemented appropriately and to evaluate  the implementation of the VISN realignment, with estimated completion  dates for the development of these processes by March 2017 and  September 2017, respectively. VA also stated that as the VISN  realignment continues, VHA will strive to ensure a seamless flow of  communication and execution of VHA’s mission at all levels.
As agreed with your offices, unless you publicly announce its contents  earlier, we plan no further distribution of this report until 30 days from its  issue date. At that time, we will send copies of this report to the  appropriate congressional committees, the Secretary of Veterans Affairs,  the Under Secretary for Health, and other interested parties. In addition,  the report will be available at no charge on the GAO Web site at  http://www.gao.gov.
If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or at draperd@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix IV.
section_title: Appendix I: Recent External and Internal Reviews That Include an Examination of Veterans Health Administration’s (VHA) Organizational Structure
paragraphs: Appendix I: Recent External and Internal  Reviews That Include an Examination of  Veterans Health Administration’s (VHA)  Organizational Structure VHA contracted with the Centers for Medicare & Medicaid Services’ Alliance to Modernize  Healthcare (operated by MITRE Corporation, a private entity) and the Institute of Medicine to conduct  the assessment. Parts of the evaluation were subcontracted to other organizations, including  McKinsey & Company and the RAND Corporation.
section_title: Appendix II: Department of Veterans Affairs’ (VA) MyVA Regions and the Veterans Health Administration’s (VHA) Veterans Integrated Service Network (VISN) Realignment
paragraphs: VA announced a major organizational initiative in September 2014 called  MyVA. As part of this initiative, the department established a single  regional framework for its three administrations—VHA, the Veterans  Benefits Administration, and the National Cemetery Administration— dividing the United States into five regions based on state boundaries.  (See fig. 2.)
Following the MyVA initiative’s implementation, VHA announced plans to  realign, and in some cases, merge its VISNs—regional offices that  oversee networks of VA medical centers (VAMC) and outpatient  facilities—so that they geographically aligned with MyVA regional  boundaries. (See figs. 3 and 4 for pre- and post-realignment VISN maps,  respectively; and table 2 for information on the extent that each VISN is  affected by the realignment.) The VISN realignment began in October  2015 and VHA officials anticipate it will be completed, at the earliest, by  the end of fiscal year 2018.
Some VISN borders will cross state lines and MyVA regional boundaries  once the realignment is complete. VHA officials told us this reflects  geographical referral patterns and the locations of outpatient clinics,  which can be across state lines from their associated VAMCs. VHA  officials told us that the VISNs are expected to continue to honor historical  geographical referral patterns for veterans—that is, to continue to refer  veterans to the same VAMC or outpatient facility they were referred to  prior to the realignment even if that VAMC or facility is part of a different  VISN post-realignment.
section_title: Appendix III: Comments from the Department of Veterans Affairs
section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
paragraphs: Debra A. Draper, (202) 512-7114 or draperd@gao.gov.
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Janina Austin, Assistant Director;  Malissa G. Winograd, Analyst-in-Charge; Amanda Cherrin; and Amanda  Pusey made key contributions to this report. Also contributing were  Jennie F. Apter, George Bogart, Muriel Brown, and Jacquelyn Hamilton.