Veterans Health Care: Improvements Needed in Operationalizing Strategic Goals and Objectives
Released: 2016-11-21T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: Veterans' health care needs may change due to changes in veteran demographics and other factors. Strategic planning, including identifying mission, vision, goals, and objectives, and operationalizing strategies to achieve those goals and objectives are essential for VHA to establish its strategic direction to respond to these changing demands and provide care in a dynamic environment.

GAO was asked to review VHA's strategic planning. This report examines (1) VHA's strategic planning process and (2) the extent to which VHA operationalizes its strategic goals and objectives. GAO reviewed VHA strategic planning documents; and interviewed officials from VA and VHA central office, three VISNs selected to provide variation in geographic location, and nine VAMCs within these VISNs selected to provide variation in factors such as geographic location and facility complexity. GAO evaluated VHA's actions against federal standards for internal control and leading practices for strategic planning.

section_title: What GAO Found
paragraphs: The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) uses a multi-step strategic planning process to develop its strategic goals and objectives, which includes two key steps—(1) identifying and assessing factors that may affect health care delivery, which is referred to as environmental scanning, and (2) holding the annual National Leadership Council (NLC) Strategic Planning Summit—according to officials. VHA officials told GAO that they leverage VA's environmental scanning results in making decisions regarding VHA's strategic goals and objectives and that VA's central office has historically had a role in aspects of VHA's strategic planning process—such as participating in the NLC summit.

VHA relies on the VA medical centers (VAMC) that directly provide care to veterans and the Veterans Integrated Service Networks (VISN), regional entities to which the VAMCs report, to operationalize its strategic goals and objectives. However, certain limitations in VHA's processes hinder VISNs' and VAMCs' efforts in operationalizing these goals and objectives. Specifically,

VHA has not specified VAMCs' role and responsibilities in its strategic planning guidance, as it has for VISNs. For example, VHA's directive for VISNs clearly states how VISN directors are to operationalize VHA's operational plans; no such directive exists for VAMC officials. Similarly, VHA provided VISNs a strategic planning guide for operationalizing its current strategic plan, but did not provide a similar guide to the VAMCs.

VHA has not developed detailed strategies for VISNs and VAMCs to use in operationalizing all of its strategic goals and objectives. According to leading practices for strategic planning, strategies should describe how strategic goals and objectives are to be achieved, including a description of the operational processes, staff skills, technology and other resources required. In September 2014, VHA published the Blueprint for Excellence to provide strategies for transforming VHA health care service delivery in response to concerns regarding the VHA wait-time crisis that year. However, it did not develop similar strategy documents for other years or for the other goals and objectives in its strategic plan.

VHA does not have an effective oversight process for ensuring and assessing the progress of VISNs and VAMCs in meeting VHA's strategic goals and objectives. According to VHA officials, VHA relies on two methods for assessing performance towards meeting selected strategic goals and objectives. Specifically, VHA uses VISN and VAMC directors' individual annual performance plans, as well as veteran survey information, to assess VHA's performance towards meeting certain metrics, such as improving veterans' access. However, it is unclear how these specific metrics are linked to assessing overall progress towards VHA's strategic goals and objectives. As a result, VHA may not know to what extent VISNs' and VAMCs' efforts to operationalize its goals and objectives are adequately addressing top management concerns or department-wide strategic goals.

section_title: What GAO Recommends
paragraphs: GAO recommends that VHA (1) specify VAMCs' roles and responsibilities in operationalizing its strategic goals and objectives, (2) develop detailed strategies to operationalize its goals and objectives, and (3) develop an oversight process to assess progress made. VA concurred with GAO's recommendations.

section_title: Letter
paragraphs: The Department of Veterans Affairs’ (VA) Veterans Health Administration  (VHA) operates one of the nation’s largest health care systems through  its 168 VA medical centers (VAMC) and more than 1,000 outpatient  facilities with a total budget of nearly $51 billion in fiscal year (FY) 2015.  VHA provided care to about 6.7 million veterans in FY 2015, and the  demand for its services is expected to grow in the coming years.

Due to changes in the veteran population, including increases in the  number of women and those between the ages of 65 and 84, the health  care needs of veterans may also change. These and other changes, such  as innovations in technology and health care delivery, may affect VHA’s  current strategies for accomplishing its mission to provide care to the  nation’s veterans. Strategic planning—including identifying mission,  vision, goals, and objectives, and operationalizing strategies to achieve  those goals and objectives—is key to VHA’s ability to establish its  strategic direction and can help VHA anticipate and respond to this  demand and provide care in a dynamic environment.

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.  These concerns have contributed to our conclusion that VA health care is  a high-risk area, and we added it to our High-Risk List in 2015. To  improve access to veterans’ health care, among other things, Congress  enacted and the President signed into law the Veterans Access, Choice,  and Accountability Act of 2014 (Choice Act). 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 a disconnect in the  alignment of demand, resources, and authorities, the report includes a  recommendation to develop a governance board to define the strategic  direction for VHA and to ensure accountability for the achievement of  established performance measures.

In addition to requiring the independent assessment, the Choice Act  established the Commission on Care to examine veterans’ access to VA  health care and to examine how best to organize VHA, locate health  resources, and deliver health care to veterans during the next 20 years.  The Commission on Care’s interim report was published on December 4,  2015, and a final report with 18 recommendations was submitted to the  President on June 30, 2016. These reports and their findings have  identified not only the need for VHA to modify a significant number of its  processes and procedures in the short term, but also the need for VHA to  implement long-term system-wide changes to help it meet its mission. For  example, the Commission on Care reported that VHA lacks a long-term  vision and continuity in the development and execution of plans and  programs. To address these issues, the commission recommended  establishing a board of directors to provide VHA overall governance, set  long-term strategy, and direct and oversee the long-term transformation  of VHA.

Based on concerns about VHA’s ability to manage its health care system  and provide timely care, you asked us to conduct a management review  of VHA that encompasses several key organizational components,  including its strategic planning. This report examines  1.  VHA’s strategic planning process and  2.  the extent to which VHA operationalizes its strategic goals and  objectives.

To examine VHA’s strategic planning process, we reviewed relevant  documentation from VHA, such as policies and procedures describing the  process and its alignment with VA’s strategic planning process. We  reviewed external assessments of VHA, such as the independent  assessment report, to identify potential factors that may hinder the  delivery of health care services, including recommendations for  addressing these concerns. We also reviewed documentation and  interviewed officials from three Veterans Integrated Service Networks  (VISN)—VISNs 2, 20, and 23—and nine VAMCs within these VISNs— located in (1) Albany, New York; (2) Anchorage, Alaska; (3) Batavia, New  York; (4) Bath, New York; (5) Boise, Idaho; (6) Fargo, North Dakota; (7)  Hot Springs, South Dakota; (8) Minneapolis, Minnesota; and (9) Portland,  Oregon—to gain insights into the role of VISNs and VAMCs in VHA’s  strategic planning process. We selected the three VISNs to provide  variation in geographic location, including one VISN that was also among  those selected by VHA for realignment. We then selected three VAMCs  within each of these VISNs to reflect a range of geography, such as rural  vs. urban locations, and facility complexity levels, as well as if the VAMC  had any strategic planning best practices as identified by the VISNs.  The information we collected on strategic planning processes at the  VISNs and VAMCs in our review is not generalizable system-wide. We  also interviewed VHA and VA officials to discuss relevant roles and  responsibilities in VHA’s strategic planning process—including officials  from VHA’s Office of the Under Secretary for Health, Office of the  Assistant Deputy Under Secretary for Health for Policy and Planning, and  National Leadership Council (NLC); and VA’s Office of Policy.  Additionally, we received information from the National Cemetery  Administration and interviewed officials from Veterans Benefits  Administration and representatives of veterans service organizations  about VHA’s strategic planning process, including their involvement, if  any, in the process.

To determine the extent to which VHA operationalizes its strategic goals  and objectives, we reviewed relevant documentation from VHA that  describes its processes, including how, if at all, VHA implements,  oversees, communicates, evaluates, and revises its strategic goals and  objectives as needed. We reviewed documents, including VHA’s FY  2013-2018 strategic plan, and other documents, such as VHA directives  and policies, that describe requirements and guidance for operationalizing  VHA’s strategic goals and objectives. We interviewed VHA and VA  officials to discuss relevant roles and responsibilities as they relate to  operationalizing VHA’s strategic goals and objectives, including officials  from VHA’s Office of the Under Secretary for Health, Office of the  Assistant Deputy Under Secretary for Health for Policy and Planning, and  NLC; and VA’s Office of Policy. We also reviewed documentation and  interviewed officials from the three VISNs and nine VAMCs in our review  to discuss their roles and responsibilities, including any challenges and  best practices, in operationalizing VHA’s strategic goals and objectives.  We also interviewed these officials on the extent to which VHA monitors  their efforts.

For both of our reporting objectives, we assessed VHA’s strategic  planning process and its efforts to operationalize its strategic goals and  objectives against relevant federal internal control standards. We also  assessed its efforts against leading practices in federal strategic planning,  including (1) leading practices for planning at lower levels within federal  agencies, including individual programs or initiatives, based on practices  required of federal departments under the Government Performance and  Results Act of 1993 (GPRA), as enhanced by the GPRA Modernization  Act of 2010 (GPRAMA) and (2) related leading practices that our past  work has identified.

We conducted this performance audit from September 2015 through  October 2016 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: In carrying out its mission of providing services to veterans, VA’s  programs are administered through its three major administrations—VHA,  Veterans Benefits Administration, and National Cemetery  Administration—and VA engages all of its administrations in its strategic  planning process. VA’s Office of Policy is responsible for ensuring  integration, collaboration, and cooperation across VA with regard to policy  and strategy development. This office also leads VA’s strategic planning  efforts and is involved with managing VA’s governance process. Within  the Office of Policy, the Policy Analysis Services, the Strategic Studies  Group, and the Strategic Planning Service support this work. In March  2014, VA published its current strategic plan, Department of Veterans  Affairs FY 2014 - 2020 Strategic Plan, which identifies the department’s  mission, values, and three strategic goals.

Within VHA, the Office of the Assistant Deputy Under Secretary for Health  for Policy and Planning supports and advises several VHA offices—the  offices of the Under Secretary for Health, Principal Deputy Under  Secretary for Health, and the Deputy Under Secretary for Health for  Policy and Services—on the development and implementation of VHA  policy, strategic planning, and forecasting. VHA’s Under Secretary for  Health directs all aspects of VHA’s health care system, including its  annual budget and overseeing the delivery of care to veterans, as well as  the health care professionals and support staff that deliver that care.

In December 2012, VHA published its current strategic plan, VHA  Strategic Plan FY 2013 – 2018, which identifies its mission and vision and  guides budgeting, performance management, and service alignment  across VHA, and its plans for how to provide for the health care needs of  veterans. (See app. I.) The plan also outlines VHA’s three goals and 17  objectives that are to be used to guide planning, budgeting, performance  management, and service alignment across VHA; those three goals are  to: (1) provide veterans personalized, proactive, patient-driven health  care, (2) achieve measurable improvements in health outcomes, and (3)  align resources to deliver sustained value to veterans. VHA Directive  1075: Strategic Planning Process is VHA’s most current strategic  planning guidance, and it outlines how VHA will identify its strategic  priorities and establish and execute its strategic plan, as well as identifies  roles and responsibilities in this process.

In recent years, VA and VHA have established several new initiatives,  activities, and priorities in response to changes in internal and external  factors—including VHA leadership changes, congressional concerns  regarding veterans’ access to care, and the placement of VHA on our  High-Risk List. Specifically, VA and VHA have developed the following  new initiatives and priorities in the last 2 years:

MyVA: This VA-wide initiative was launched in July 2015 and is aimed  towards transforming the veterans’ experience. VA has developed five  priorities for this initiative: (1) improving the veteran’s experience, (2)  improving the employee experience, (3) improving internal support  services, (4) establishing a culture of continuous improvement, and  (5) enhancing strategic partnerships.  “The Under Secretary for Health’s Five Priorities:” VHA’s Under  Secretary for Health established these priorities after being appointed  to his position in July 2015. The five priorities are to (1) improve  access, (2) increase employee engagement, (3) establish consistent  best practices, (4) build a high-performing network (which includes VA  and non-VA providers), and (5) rebuild the trust of the American  people.  “The Secretary’s 12 Breakthrough Priorities:” These priorities describe  focus areas for the MyVA initiative and were first presented in a  January 2016 testimony by the Secretary of VA to the Senate  Committee on Veterans’ Affairs. Several of these priorities—such as  improving the veterans experience, increasing access to health care,  and improving community care—are relevant to health care delivery in  VHA.

Additionally, in September 2014, VHA developed the Blueprint for  Excellence, which presents strategies for transforming VHA health care  service delivery in response to concerns regarding the VHA access and  wait-time crisis that year. These strategies, which are linked to the goals  and objectives in VHA’s current strategic plan, include operating a health  care network that anticipates and meets the unique needs of enrolled  veterans, in general, and the service disabled and most vulnerable  veterans, and delivering high-quality, veteran-centered care that  compares favorably to the best of private sector in measured outcomes,  value, access, and patient experience. More recently, VHA developed a  crosswalk for internal discussion documenting how the various VA and  VHA initiatives, activities, and priorities—such as MyVA, Blueprint for  Excellence strategies, the Under Secretary for Health’s Five Priorities,  and the Commission on Care report—relate to each other. See fig. 1 for a  timeline of internal and external factors that have affected or may affect  VHA’s strategic goals and objectives.

section_title: VHA Uses a Multi- Step Strategic Planning Process to Identify Strategic Goals and Objectives
paragraphs: VHA conducts a strategic planning process annually and through this  process also established its current strategic plan. According to officials,  VHA’s current strategic plan was developed through its FY 2012 strategic  planning process. VHA officials told us that they currently do not have  plans to revise VHA’s current strategic plan or develop a new one, but  may, however, develop an operational plan that will cascade from and  operationalize VA’s strategic plan. VHA officials told us that they do plan  to continue to use their current annual strategic planning process to  identify VHA’s future strategic goals and objectives.

According to VHA officials, VHA’s strategic planning process includes two  key steps—(1) assessing the environment, which VHA refers to as  environmental scanning, and (2) holding the annual NLC Strategic  Planning Summit. These steps are consistent with leading practices in  strategic planning. VHA conducts environmental scanning to identify  and assess factors that may affect its future health care delivery.  According to VHA policy, data from VHA’s environmental scan, such as  the projected number of veterans to be served, are to be used by VHA in  developing its goals and objectives. In addition, the results from VHA’s  environmental scanning are to be used by VHA’s Office of Policy and  Planning and VHA program offices, in strategic decision making.

In addition to environmental scanning, the NLC Strategic Planning  Summit is also key to VHA’s strategic planning process, in that it is the  primary forum through which VHA leadership identifies and discusses the  strategic goals and objectives for the next year. The NLC is responsible  for recommending new or revised strategic goals and objectives and for  formulating strategies to achieve them. VHA’s Office of Policy and  Planning coordinates the summit and invites various stakeholders to  attend—such as officials from VHA central office, including program  offices; VA central office; Veterans Benefits Administration; National  Cemetery Administration; VISNs; and representatives of veterans service  organizations. Veterans Benefits Administration and National Cemetery  Administration officials indicated that they have varied levels of  participation. Veterans Benefits Administration officials told us that they  have historically attended several days of the summit, and National  Cemetery Administration officials indicated that they may listen to the  VHA’s general body sessions during the summit. Even though officials  from both administrations indicated they believe their input and  coordination with VHA regarding its strategic planning was sufficient,  Veterans Benefits Administration officials noted that increased  engagement in VHA’s strategic planning process would be beneficial,  given the direct correlation between veterans’ disability compensation  ratings assigned by them and the subsequent care delivered from VHA.

During the course of the summit, the NLC determines if changes to VHA’s  strategic goals and objectives are needed. If there are changes, VHA’s  Office of Policy and Planning drafts a document, gathers additional  stakeholder feedback, and presents the document to VHA’s Under  Secretary for Health for approval.

VHA also obtains and uses information from VA to inform its strategic  planning process. For example, according to VA and VHA officials, VHA’s  environmental scanning process is, and has historically been, health-care  focused, and is adjunct to the broad environmental scanning process  conducted by VA. Officials noted that though distinct processes, VA’s and  VHA’s environmental scanning processes are interrelated. VHA officials  told us that they leverage VA’s environmental scanning results in making  decisions regarding VHA’s strategic goals and objectives. Additionally, VA  officials have historically been invited to participate in VHA’s NLC  Strategic Planning Summit, including the 2016 summit. VA’s draft report  of its environmental scanning identified changes in the veteran  population, including growth in the number of veteran enrollees aged 65  and older, which VA officials reiterated at the 2016 NLC summit.

section_title: VISNs and VAMCs Are Responsible for Operationalizing VHA’s Strategic Goals and Objectives, but VHA Has Not Developed Adequate Strategies or an Effective Oversight Process to Ensure Operationalization
subsections: section_title: VISNs and VAMCs Have Responsibility for Operationalizing VHA’s Strategic Goals and Objectives, but VHA Has Not Defined VAMCs’ Role
paragraphs: VISNs and VAMCs have responsibility for operationalizing VHA’s  strategic goals and objectives, including its strategic plan, according to  VHA officials. Operationalizing involves putting strategic goals and  objectives into use by an organization, and includes developing initiatives,  programs, or actions that will be used to accomplish those goals and  objectives. VISNs and VAMCs must allocate resources, develop day-to- day activities, and create policies as part of that process.

However, we found that VHA provides limited guidance for VAMCs in how  to operationalize VHA’s strategic goals and objectives. First, VHA has not  clearly identified VAMCs’ responsibilities in operationalizing its strategic  goals and objectives as it has for VISNs. For example, VHA Directive  1075 states that VISN directors are to be responsible for: developing  operational plans; annually tracking and reporting accomplishments in  support of the VHA strategic plan; regularly updating plans to address  local issues, such as geographic-specific needs; and providing input to  inform future VHA goals, objectives, and strategies. However, there are  no such stated responsibilities for VAMCs. According to federal internal  control standards, successful organizations should assign responsibility to  discrete units, and delegate authority to achieve organizational objectives.  VHA and VISN officials told us that it is inferred that the VAMCs are part  of the overall process even though there is no specific policy or guidance  for VAMCs. All three VISNs in our review reported developing operational  plans or strategies to operationalize VHA’s goals and objectives at the  VISN level, but two of the nine VAMCs in our review had not developed  such strategies.

Second, in FY 2013, VHA provided VISNs with a strategic planning guide  for operationalizing the current strategic plan, but did not provide a similar  guide for VAMCs. According to the guide, its purpose was to assist VISNs  in outlining a multi-year plan that aligned with VHA’s current strategic plan  and provide relevant information regarding the development of strategies,  the process for conducting a strategic analysis, and the time frame for  providing strategic planning information, such as strategies, to VHA  central office.

The lack of guidance for VAMCs may hinder them from effectively  operationalizing VHA’s strategic goals and objectives, and may lead to  inconsistencies in time frames, documentation, and data used for the  strategic planning process. For those VAMCs in our review that  developed strategies to operationalize VHA’s strategic goals and  objectives, for example, almost all developed local strategies on a fiscal- year cycle, which aligns with VHA’s budgeting and strategic planning  processes, but one VAMC developed strategies on a calendar-year cycle.  Although there is no requirement for VAMCs to conduct strategic planning  on a specific timeline, per leading practices for strategic planning,  organizations should align their activities, core processes, and resources  to ensure achievement of the agency’s objectives. In addition, per  federal internal control standards, management should effectively  communicate information throughout the organization, as the organization  performs key activities in achieving the objectives of the organization.

section_title: VHA Has Not Developed Adequate Strategies or an Effective Oversight Process to Ensure Operationalization of Its Strategic Goals and Objectives
paragraphs: VHA has not developed adequate strategies or an effective oversight  process to ensure VHA’s strategic goals and objectives are effectively  operationalized. Specifically, VISNs and VAMCs lack consistently  developed strategies for operationalizing VHA’s strategic goals and  objectives, and existing performance assessments are limited in  measuring progress towards meeting these goals and objectives.

Lack of consistently developed strategies. VHA has not  consistently developed strategies for VISNs and VAMCs to use in  operationalizing its strategic goals and objectives. Strategies should  describe how a strategic plan’s goals and objectives are to be  achieved, and should include a description of the operational  processes, staff skills, use of technology, as well as the resources— such as, human, capital, and information—required. Among other  things, our previous work has shown that strategies should have  clearly defined milestones, outline how an organization will hold  managers and staff accountable for achieving its goals, and be linked  to the day-to-day activities of the organization. In addition, individual  strategies should be linked to a specific goal or objective. In  September 2014, VHA published the Blueprint for Excellence to  provide strategies for transforming VHA health care service delivery in  response to concerns regarding the VHA wait-time crisis that year.  However, VHA did not develop a similar document for the other  strategic planning years despite the development of multiple strategic  documents, such as the Under Secretary for Health’s five priorities.

Without developing adequate strategies to correspond to all of its  strategic goals and objectives, the VISNs and VAMCs have limited  guidance to help them operationalize VHA’s strategic goals and  objectives. Moreover, the day-to-day activities and initiatives  developed by VISNs and VAMCs may not appropriately align with  those goals and objectives. A direct alignment between strategic  goals and their associated strategies is important in assessing an  organization’s ability to achieve those goals.

No process for ensuring and assessing progress in meeting all  of VHA’s strategic goals and objectives. As our previous work has  shown, assessments can provide feedback to an organization on how  well day-to-day activities and programs developed to operationalize  strategic goals and objectives contribute to the achievement of those  goals and objectives. Specifically, formal assessments are to be  objective and measure the results, impact, or effects of a program or  policy, as well as the implementation and results of programs,  operating policies, and practices; they can also help in determining  the appropriateness of goals or the effectiveness of strategies.   However, VHA does not have effective oversight process for ensuring  that VISNs and VAMCs are meeting all of its strategic goals and  objectives.

According to VHA officials, there are currently two methods for  assessing VHA’s performance towards meeting selected strategic  goals and objectives. One method is VISN and VAMC directors’  individual annual performance plans. For FY 2016, these plans  present VHA’s strategies for providing a successful health care  delivery system, including those outlined in its Blueprint for  Excellence. The directors’ plans include performance metrics, which  VHA, as well as VISNs and VAMCs, can use to measure  demonstrated progress of a VISN or VAMC in meeting these  strategies. However, multiple strategic goals and objectives have  been communicated to the field, such as the Under Secretary for  Health’s five priorities, and it is not clear how these goals align with  the strategies in the current directors’ performance plans or how  progress towards them can be assessed. A VHA official, who is a  member of the workgroup reviewing VHA’s performance metrics, told  us that over the years, performance metrics were added to the  director performance plans as problems or needs arose without  considering the overall purpose of the metric. VHA officials reported  that they have reviewed the current plans and have revised them.  According to a VHA official, the new plans will have fewer metrics,  and will be more strategically focused on VA’s and VHA’s strategic  priorities, such as the Under Secretary for Health’s five priorities.  According to VHA officials, implementation is planned for October 1,  2016. However, it is not clear how these metrics will be linked to the  strategic goals and objectives in VHA’s current strategic plan.

Veterans’ satisfaction with VA’s health care system is the second  method for assessing VHA’s performance towards meeting strategic  goals and objectives, according to VHA officials. VHA currently  collects information from a survey of veterans that addresses two of  VA’s priority goals, including improving access to health care, as  experienced by the veteran. According to VHA officials, for the  veterans’ access goal, there is a large degree of alignment between  the department-wide goal and how VHA measures its progress  towards meeting some of its access goals and objectives in its  strategic plan. However, it is not clear how VAMCs and VISNs are to  use veterans’ satisfaction to assess progress toward meeting other  goals and objectives that have been communicated to them—such as  the Under Secretary for Health’s five priorities that are not focused on  access. VHA officials told us that no additional VHA-level  assessments had been conducted to measure progress towards  meeting strategic goals and objectives. Though VHA has performance  information from VISN and VAMC directors’ performance plans and  veteran satisfaction surveys, the performance of the agency toward  meeting VA’s and VHA’s other strategic goals and objectives may  help provide a more complete picture of overall effectiveness.

In addition to a lack of adequate strategies and an effective oversight  process, a large number of vacant, acting, and interim positions at some  of the VISNs and VAMCs in our review have also created challenges for  VHA in operationalizing its strategic goals and objectives. For example,  officials from one VISN reported that acting and interim senior leadership  positions within a facility in their region have had an effect on the  operations of the VAMC, including the operationalization of VHA’s  strategic goals and objectives. They added that the acting and interim  senior leaders did not feel empowered to make long-term decisions  regarding the operations of the medical center because they did not know  how long they would hold the position. The Under Secretary for Health  told us that one of VHA’s top priorities for 2016 is to fill 90 percent of  VAMC director positions with permanent appointments by the end of the  year. The Under Secretary added that filling these positions would help  address the current gaps in leadership and provide stability for the  VAMCs.

section_title: Conclusions
paragraphs: As the demand for health care by our nation’s veterans increases, and  concerns about VA’s health care system persist, it is essential that VHA  conduct the necessary strategic planning to achieve its goals and  objectives. VHA has established a strategic planning process to identify  strategic goals and objectives for accomplishing its mission, and VISNs  and VAMCs are expected to operationalize these goals and objectives.  However, VHA has not delineated a role for VAMCs in this process as it  has for VISNs. Moreover, the lack of adequate strategies to  operationalize VHA’s strategic goals and objectives, as well as the lack of  an effective oversight process for assessing progress, may hinder the  achievement of VHA’s goals and objectives. Without consistently  developed strategies, the day-to-day activities and initiatives that are  developed to operationalize VHA’s strategic goals and objectives may not  appropriately align with those goals and objectives. This may result in  VHA not being able to determine if it is adequately addressing top  management concerns or department-wide strategic goals. Further,  because VHA does not have an effective process to assess progress in  meeting its strategic goals and objectives, it does not have needed  information on how well the day-to-day activities and programs of VISNs  and VAMCs are contributing to their achievement.

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 three actions:  1.  Define the roles and responsibilities of VAMCs in operationalizing  VHA’s strategic goals and objectives; this could be accomplished by  establishing roles and responsibilities for VAMCs similar to how VHA  defines roles and responsibilities for VISNs in VHA Directive 1075 and  by developing guidance for VAMCs similar to guidance developed for  VISNs.  2.  Consistently develop strategies that can be used by VISNs and  VAMCs to operationalize VHA’s goals and objectives, ensuring that  they clearly link directly to VHA’s goals and objectives.  3.  Develop an oversight process to assess progress made in meeting  VHA’s strategic goals and objectives, including feedback on how well  activities and programs are contributing to achieving these goals and  objectives.

section_title: Agency Comments and Our Evaluation
paragraphs: We provided VA with a draft of this report for its review and comment. In  its written comments, reproduced in appendix II, VA concurred with our  three recommendations, and described the actions it is taking to  implement them by September 2017. VA described the role that  community-based outpatient clinics and health care centers play as  critical health care access points for veterans and commented that our  draft report does not mention these access points as components of  VAMC service delivery systems. While our report draft noted the role of  community-based outpatient clinics and health care centers in VA’s  service delivery system, we clarified that these facilities are components  of VAMCs. VA also commented that our report draft does not mention the  essential role that VHA program offices play in contributing to and  implementing the VHA strategic plan. Our report states that program  offices contribute to VHA’s strategic planning process by developing  some of the programs and actions that VISNs and VAMCs use to provide  health care services to veterans. VA also provided technical comments,  which we incorporated as appropriate.

As agreed with your office, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies of this report to appropriate  congressional committees, the Secretary of Veterans Affairs, the Under  Secretary for Health, and other interested parties. In addition, the report  will be available at no charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made key contributions to this report  are listed in appendix III.

section_title: Appendix I: VHA Strategic Plan FY 2013 – 2018

section_title: Appendix II: Comments from the Department of Veterans Affairs

section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact

section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Janina Austin, Assistant Director;  Kelli A. Jones, Analyst-in-Charge; Jennie Apter; and LaKendra Beard  made key contributions to this report. Also contributing were George  Bogart, Christine Davis, Jacquelyn Hamilton, and Vikki Porter.

Fast facts: How will VHA provide quality health care to veterans?

The Veterans Health Administration provided health care to 6.7 million veterans in fiscal year 2015. However, changes in the veteran population (such as more female veterans) could affect VHA's current strategies to provide quality health care. Effective strategic planning—such as identifying goals and methods to achieve them—can help VHA respond to the changing health care needs of veterans.

We reviewed VHA's strategic planning process and recommended that it clarify the responsibilities of VA's medical centers, and develop an oversight process.

Question-summary annotations: questions: question: What guidance has VHA given for VAMC's role in stragetic planning?
answer: VHA has not specified VAMCs' role and responsibilities in its strategic planning guidance, as it has for VISNs.
child_questions: question: How has VHA clarified the roles of VISN directors regarding operational plans?
answer: For example, VHA's directive for VISNs clearly states how VISN directors are to operationalize VHA's operational plans; no such directive exists for VAMC officials.

question: How has VHA helped the planning work of VISNs?
answer: Similarly, VHA provided VISNs a strategic planning guide for operationalizing its current strategic plan, but did not provide a similar guide to the VAMCs.

questions: question: To what extent has VHA developed strategies for operationalizing its strategic goals?
answer: VHA has not developed detailed strategies for VISNs and VAMCs to use in operationalizing all of its strategic goals and objectives.
child_questions: question: What should well-detailed strategies consist of?
answer: According to leading practices for strategic planning, strategies should describe how strategic goals and objectives are to be achieved, including a description of the operational processes, staff skills, technology and other resources required.

question: What detailed strategies has VHA published?
answer: In September 2014, VHA published the Blueprint for Excellence to provide strategies for transforming VHA health care service delivery in response to concerns regarding the VHA wait-time crisis that year.
child_questions: question: To what extent has VHA followed up with similar strategy documents?
answer: However, it did not develop similar strategy documents for other years or for the other goals and objectives in its strategic plan.

questions: question: What was GAO asked to review?
answer: GAO was asked to review VHA's strategic planning.

question: What did this report examine?
answer: This report examines (1) VHA's strategic planning process and (2) the extent to which VHA operationalizes its strategic goals and objectives.
child_questions: question: What data did GAO review for this report?
answer: GAO reviewed VHA strategic planning documents; and interviewed officials from VA and VHA central office, three VISNs selected to provide variation in geographic location, and nine VAMCs within these VISNs selected to provide variation in factors such as geographic location and facility complexity.
child_questions: question: How did GAO compare these findings to related standards?
answer: GAO evaluated VHA's actions against federal standards for internal control and leading practices for strategic planning.