VA Health Care: Improved Monitoring Needed for Effective Oversight of Care for Women Veterans
Released: 2016-12-02T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: In 2010, GAO found a number of weaknesses related to care for women veterans at VA medical facilities. GAO was asked to update that study. This report examines (1) the extent that VA medical centers complied with requirements related to the environment of care for women veterans and VHA's oversight of that compliance; (2) what is known about the availability of VHA medical providers who can provide sex-specific care for women veterans at VA facilities; and (3) VHA's efforts to provide and monitor access to sex-specific care for women veterans through Choice. To do this work, GAO reviewed VHA data on environment of care deficiencies; the number, location, and availability of VHA and Choice medical providers; women veteran enrollment; and Choice access-related performance measures. In addition, GAO inspected the environment of care for compliance with VHA policy at a nongeneralizable sample of six VA medical centers, which were selected to achieve variation in different care models, the size of the women veterans' population, and geographical locations. GAO also interviewed VHA Central Office and VA medical center officials.

section_title: What GAO Found
paragraphs: The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) does not have accurate and complete data on the extent to which its medical centers comply with environment of care standards for women veterans. VHA policy requires its medical facilities, including VA medical centers, to meet environment of care standards related to the privacy, safety, and dignity of women veterans. VHA Central Office relies on medical centers to conduct regular inspections and to report instances of noncompliance, which are compiled in a VHA database. However, almost all the noncompliance GAO identified through inspections at six VA medical centers it visited had not been reported or recorded in the VHA database, and compliance rates ranged from 65 percent to 81 percent. For example, GAO found a lack of auditory privacy at check-in clerk stations and a lack of privacy curtains in examination rooms, as required by VHA policy. GAO also found weaknesses in VHA's oversight of the environment of care for women, including a lack of thorough inspections and limited verification of facility-reported data which results in inaccurate and incomplete data. As a result, the privacy, safety, and dignity of women veterans may not be guaranteed when they receive care at VA facilities. Federal internal control standards for monitoring call for management to establish activities to monitor the quality of performance over time and promptly resolve any identified issues.

GAO's analysis of VHA data shows that nationally the number of VHA full-time-employee equivalent gynecologists and the number of women's health primary care providers—VHA primary care providers specially trained in women's health care services, such as breast exams—increased by 3 percent and 15 percent respectively, from fiscal year 2014 through fiscal year 2015, and those percentages exceeded the 1 percent growth in women veteran enrollment during the same period. However, about 27 percent of VA medical centers and health care systems lacked an onsite gynecologist and about 18 percent of VA facilities providing primary care lacked a women's health primary care provider, according to VHA data. VHA officials said not all facilities require onsite gynecologists and facilities may authorize gynecological services from non-VA providers. They acknowledged a shortage of at least 675 women's health primary care providers and have a plan to train at least 535 providers by the end of fiscal year 2016.

The Veterans Choice Program (Choice) is a primary option for veterans to receive care from non-VA providers in the community if care cannot be provided at VA facilities. While the number of obstetricians and gynecologists under Choice has increased, some areas lack these providers, according to a VHA analysis. While VHA monitors access-related Choice performance measures (such as timely appointment scheduling) for all veterans, it does not have such measures for women veterans' sex-specific care, such as mammography, maternity care, or gynecology. VHA's data show poor performance on access-related performance measures for all veterans, and GAO found cases where women veterans' maternity care was significantly delayed, suggesting that veterans, including women, face challenges receiving timely access to care. Federal internal control standards for monitoring call for management to establish activities to monitor the quality of performance over time and promptly resolve any identified issues.

section_title: What GAO Recommends
paragraphs: GAO recommends that VA (1) strengthen the policies and guidance for its environment of care inspection process and (2) monitor women veterans' access to sex-specific care under current and future community care contracts. VA concurred with GAO's recommendations.

section_title: Letter
paragraphs: According to the Department of Veterans Affairs (VA), women are the  fastest growing subpopulation of veterans. According to VA officials, in  2016, almost 10 percent of the total veteran population is female—over 2  million women—and by 2020, VA estimates that this proportion will rise to  almost 11 percent. Women veterans seeking care through VA’s national  health care system, which is operated by the Veterans Health  Administration (VHA), are eligible to receive a full range of health care  services—including services specific to their sex, such as breast  examinations, cervical cancer screenings and treatment, and obstetric  care. When these and other services are not available at VA medical  facilities—including health care systems, VA medical centers (VAMC),  and community-based outpatient clinics—or within required driving  distances or time frames, VA may purchase care from non-VA providers  through its care in the community programs, such as the Veterans Choice  Program (Choice).

Given the growth in the number of women veterans, in 2010 we examined  the availability of VHA health care services for women. We found  variation in the types of sex-specific health care services available to  women veterans at VA medical facilities. We also found that none of the  19 VA medical facilities we visited were in compliance with VHA’s policies  that govern the environment of care for women veterans. These VHA  policies require all VA medical facilities to adhere to certain standards  intended to ensure women’s privacy, safety, and dignity when they  receive care. The standards relate to, for example, ensuring auditory  privacy at check-in and in interview areas, the location of exam rooms,  and the presence of privacy curtains in exam and inpatient rooms.

In our 2010 report, we recommended that VA take several steps to  strengthen VHA’s provision and oversight of services for women  veterans. VA agreed with our recommendations and has made progress  in addressing issues raised. For example, VHA introduced a policy in  2010 requiring that all women veterans treated at VA medical facilities  have access to a primary care provider specially trained in women’s  health care services, known as a women’s health primary care provider.  However, there are still concerns that VHA may not be fully meeting the  health care needs of women veterans. For example, a Congressional  hearing in April 2015 raised concerns about gaps in the services available  for women veterans in VA medical facilities. In addition, we and others  have expressed significant concerns about VHA’s management of its  health care system, including VHA’s ability to effectively provide timely  access to health care for veterans. In 2014, a series of events called into  question the ability of veterans to gain timely access to care from VHA  medical facilities. As a result of these and other systemic problems, we  concluded that VA health care is a high-risk area and added it to our High  Risk List in 2015.

We were asked to follow-up on our 2010 report and assess VA’s progress  in providing a full range of health care services for women veterans. This  report examines:  1.  the extent to which VAMCs complied with requirements related to the  environment of care for women veterans, and VHA’s oversight of  medical facilities’ compliance with these requirements;  2.  what is known about the availability of VHA medical providers who  can provide sex-specific care for women veterans at VA medical  facilities; and,  3.  VHA’s efforts to provide and monitor access to sex-specific care for  women veterans through Choice.

To examine the extent to which VAMCs comply with requirements related  to the environment of care for women veterans, we reviewed VHA Central  Office’s database of VAMC self-reported instances of noncompliance in  the environment of care for six selected VAMCs for fiscal years 2015 and  2016. We selected VAMCs located in Baltimore and Perry Point,  Maryland; Gainesville and Lake City, Florida; Cincinnati, Ohio; and  Cheyenne, Wyoming. We chose these sites to represent different  models of care for women veterans, diverse regions of the country, urban  and rural locations, and a range in the percentage of the state population  made up by women veterans. For these selected VAMCs, we  conducted site visits to inspect the environment of care in waiting areas  as well as in procedure and examination areas across various outpatient,  inpatient, and residential treatment units where women veterans can  receive health care services. We developed a standardized data  collection instrument containing the VHA environment of care  requirements we reviewed during our inspections to determine whether  each requirement in every applicable setting was in compliance. The  findings of our site visits cannot be generalized to other VAMCs. To  examine VHA’s oversight of medical facilities’ compliance with  requirements related to the environment of care for women veterans, we  reviewed VHA policies on the environment of care rounds process and  related internal inspections. We also reviewed the findings from  contracted evaluations of women’s health programs at VA medical  facilities. Finally, we interviewed officials from the VHA administrative  office that oversees compliance in the environment of care at VA medical  facilities and from the selected VAMCs about VHA oversight and the  implementation of environment of care policies. We examined this  evidence in the context of federal internal control standards for monitoring  and control environment.

To examine what is known about the availability of VHA medical providers  who can provide sex-specific care for women veterans, we analyzed  available VHA data on the number, location, and the availability of  women’s health primary care providers and gynecologists in fiscal years  2014 and 2015. We also reviewed VHA data on women veteran  enrollment and the number of completed VA women’s health and  gynecology appointments for fiscal years 2014 and 2015. We assessed  the reliability of the data sources by reviewing relevant documentation,  interviewing knowledgeable agency officials, or reviewing the data for  missing values and outliers. Through these steps, we determined that the  data were sufficiently reliable for the purposes of this reporting objective.  In addition, we interviewed VHA Central Office and medical facility  officials involved in coordinating and providing health care to women  veterans, including women veterans program managers and clinicians at  the six VAMCs we visited.

To examine VHA’s efforts to provide and monitor access to sex-specific  care for women veterans through Choice, we reviewed VHA data on the  number of obstetricians and gynecologists in Choice networks from May  2015 through May 2016. We also reviewed the results of a 2016 VHA  study analyzing the number and location of Choice obstetricians and  gynecologists in Veterans Integrated Service Networks (VISN) 10 and 19  as of May 2016 and the VA medical facilities where gynecology is  available in those VISNs. For these two VISNs, we compared the  reported number and location of Choice obstetricians and gynecologists  in May 2016 with the number of non-VA community providers that VA  medical facilities in these VISNs sent women veterans to for obstetrics or  gynecology services in fiscal year 2014, prior to the introduction of Choice  in November 2014. We focused on VISNs 10 and 19 because, as a part  of this study, we conducted site visits to VAMCs in these VISNs, located  in Cincinnati, Ohio and Cheyenne, Wyoming. In addition, these VISNs  allow for comparisons of urban and rural areas. We also reviewed VHA  data on women veteran enrollment in 2014 and 2016 and third-party  administrator (TPA) performance data on Choice access to care and  network adequacy from August 2015 through May 2016. In addition, for  illustrative purposes, we identified three examples of sex-specific care  obtained by women veterans under Choice from a review of veteran  medical records associated with an ongoing GAO study examining the  implementation of Choice. We assessed the reliability of these data  sources by reviewing relevant documentation, interviewing  knowledgeable agency officials or reviewing the data for missing values  and outliers. Through these steps, we determined that the data were  sufficiently reliable for the purposes of this reporting objective. We also  interviewed VHA officials responsible for monitoring Choice and officials  from the TPAs. We examined this evidence in the context of federal  internal control standards for monitoring.

We conducted our performance audit from October 2015 to December  2016 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: VA’s national health care system is one of the largest in the United States  and provides enrolled veterans—including women veterans—with a full  range of services including primary care, mental health care, inpatient  care, and residential treatment. VA’s national health care system is organized into regionally organized VISNs containing individual VAMCs  and health care systems made up of multiple VAMCs. In addition, VAMCs  operate VA community-based outpatient clinics that provide basic primary  care services on site. VHA is responsible for oversight of the provision of  health care at all VA medical facilities.
subsections: section_title: Women’s Health Care at VA Medical Facilities
paragraphs: Through its medical facilities, VA provides a wide range of sex-specific  health care services to women veterans. Basic women’s primary care  services are typically provided by women’s health primary care providers  who are trained in providing sex-specific primary care to women  veterans. Women’s health primary care providers must maintain clinical  competency through ongoing education and training and by having a  certain percentage of women veterans on their patient panel. Sex- specific primary care for women veterans includes breast examinations,  cervical cancer screenings, management of contraceptive medications,  and menopause management. More specialized sex-specific care for  women is typically provided by a gynecologist. Services provided by a  VHA gynecologist include treatment of menstrual disorders, fertility  assessments, treatment of gynecological malignancies, and performance  of gynecological procedures such as colposcopy.

section_title: Environment of Care at VA Medical Facilities
paragraphs: VHA requires all facilities to follow certain standards related to the  environment of care in accordance with agency policy and Joint  Commission standards. VHA policies specify privacy, dignity, sense of  security, and safety considerations that all clinical spaces in VA medical  facilities must meet.

To ensure compliance with environment of care standards, VHA directs  VAMCs to conduct weekly inspections of the facility (known as  environment of care rounds), and all patient care areas must be inspected  twice every fiscal year. An environment of care rounds team made up of  representatives from various facility departments—such as nursing, police  service, and environmental management—is responsible for identifying  any instances of noncompliance. The women veterans program  manager—a staff person at each VAMC or health care system who is  responsible for helping to coordinate services for women veterans—is a  member of the environment of care rounds team and is responsible for  ensuring compliance with requirements related to women veterans. The  environment of care rounds coordinator is responsible for examining  rounds data and closing the inspection on an online tool, which then  automatically sends a notification to the appropriate medical facility  departments to address instances of noncompliance; this data then also  becomes available to officials at VHA Central Office. According to VHA  policy, noncompliance must be addressed within 14 days, including  developing an action plan, if necessary. VHA Central Office maintains a  database that contains all noncompliance reports and periodically follows  up with facilities to check on the status of open reports.

section_title: VA Care in the Community Programs
paragraphs: If veterans cannot receive timely care within VA or need care that a VA  medical facility cannot provide, VHA is authorized to purchase care for  veterans from non-VA providers, known as VA care in the community.  Non-VA care is frequently used for women veterans because some VA medical facilities do not offer certain types of sex-specific health care,  such as mammography or maternity care. According to VHA, based on  fiscal year 2014 data—the latest available data at the time of our review— women utilize more non-VA outpatient care than men. Veterans may be  referred to a care in the community program by a VHA clinician, but VA  medical facility staff must determine the veteran’s eligibility before  authorization for care is granted. Current VA care in the community  options include:

Veterans Choice Program. Choice was established in November  2014 under the Veterans Access, Choice, and Accountability Act of  2014. According to VHA policy, it typically must be the first option  considered for providing care in the community to veterans. According  to VHA data from March 2016, the majority of care in the community  authorizations are for Choice. After a veteran is authorized for  Choice, the TPA that administers the relevant Choice network is  responsible for (1) contacting the veteran to determine whether she  would like to receive Choice care, (2) identifying community providers  in the TPA’s network who can meet the veteran’s needs and asking  the veteran if she wants to see a specific provider, (3) scheduling an  appointment, and (4) ensuring that the veteran’s appointment is within  specified time frames. Specifically, after the TPAs have confirmed  veterans would like to receive Choice care, the TPAs are contractually  required to, among other things:  schedule appointments within 5 business days (for routine care)  from the time the veteran agrees to participate in Choice or within  2 business days (for urgent care) of accepting the authorization  from the referring VA medical facility; ensure that veterans receive care within 30 days of scheduling an  appointment for routine care or within 2 business days (for urgent  care) of accepting the authorization from the referring VA medical  facility;  return authorizations to the referring VA medical facility when  appointments cannot be scheduled within required time frames;  and  track the number of authorizations for which they did not schedule  appointments for veterans and the reasons why.

Patient-Centered Community Care (PC3). In September 2013, VHA  awarded contracts to two TPAs to develop regional networks of  community providers of specialty care, mental health care, limited  emergency care, and maternity and limited newborn care when such  care is not feasibly available from a VA medical facility. VHA and the  TPAs began implementing the PC3 program in October 2013, and it  was fully implemented nationwide as of April 2014. In August 2014,  VHA expanded the PC3 program to allow community providers of  primary care to join the networks. PC3 is a program VHA created  under existing statutory authorities, not a program specifically enacted  by law, like Choice. Currently, the two TPAs that administer PC3 also  administer Choice. The regional networks built for PC3 provided a  basis upon which the Choice networks were established.

Individually authorized care. VA medical facilities may approve  individual authorizations for care in the community from providers who  agree to see VA patients. Historically, individually authorized care was  the primary means by which VHA provided care in the community to  veterans.

Choice is scheduled to expire in August 2017, or when appropriations for  the program are expended, whichever occurs first. The upcoming  expiration of Choice does not extend to VHA’s other care in the  community programs, which VHA has proposed to consolidate into a  single program.

section_title: VHA Lacks Complete and Accurate Data on VAMC Compliance with Environment of Care Requirements for Women Veterans and Does Not Consistently Identify or Address Noncompliance
paragraphs: VHA Central Office lacks complete and accurate data on the extent to  which VAMCs are in compliance with environment of care requirements.  VHA relies on VAMC staff to self-report their facilities’ level of compliance  with environment of care requirements; however, almost all of the  noncompliance that we identified at the six VAMCs we visited was not  reported to VHA Central Office. In addition, during site visits, we found  that levels of compliance with VHA’s environment of care requirements  for women veterans varied.
subsections: section_title: VHA Lacks Complete and Accurate Data on VAMC Compliance with Environment of Care Requirements for Women Veterans
paragraphs: VHA Central Office does not have complete and accurate information on  VAMCs’ compliance with the environment of care requirements for  women veterans and, as discussed later, does not verify the data it  receives from facilities. Based on our inspections, we observed 155  instances of noncompliance at six VAMCs we visited, and almost all (152)  of these instances had not been reported to VHA Central Office and  entered into its database, according to our analysis of VHA data. For four  of the VAMCs we visited, none of the instances of noncompliance we  observed had been reported to VHA Central Office. Because VHA Central  Office uses this database to track facility compliance, the accuracy of the  data is vital for the agency to perform its oversight duties effectively.

Among the six VAMCs we visited, based on our inspections, we observed  varying levels of compliance with selected VHA requirements related to  the environment of care for women veterans, ranging from 65 percent to  81 percent. Across all six VAMCs, outpatient clinics had lower rates of  compliance than inpatient units and residential treatment programs.  Specifically, outpatient clinics complied with 74 percent of selected VHA  requirements related to the environment of care for women veterans; in  comparison, inpatient units and residential programs across the six  VAMCs each complied with 96 percent of selected VHA requirements.  (See table 1.) The number of instances where requirements were  applicable varies by facility, due to facility size and types of services  available. In addition, at the time of our inspections, circumstances may  have precluded us from observing each requirement in every instance; for  example, some exam rooms may have been occupied or some clinics  were not open. VHA requires VAMCs to comply with its environment of  care requirements in all instances where they are applicable. (See  appendix III for VAMC compliance rates by each individual requirement  we inspected.)

Outpatient setting. Across the six selected VAMCs, rates of  compliance with the selected outpatient environment of care  requirements varied. Figure 1 shows how frequently each of the  VAMCs was in compliance with the applicable environment of care  requirements in the outpatient areas we reviewed.

Some common areas of noncompliance that we observed in outpatient  clinics included the following:

Lack of auditory privacy at check-in clerk station. VHA policy  requires that check-in clerk stations must be positioned in a way  that protects the privacy of patients who are checking in. However,  over one-third (14 out of 40) of all check-in stations we observed  across the selected VAMCs were located in such close proximity  to the waiting room area that conversations between the patient  and the check-in clerk could be heard by other patients. Only one  of the six VAMCs we visited ensured adequate auditory privacy at  the check-in clerk station in all outpatient clinical settings.

Lack of auditory privacy in procedure and testing areas. VHA  policy requires that patients be assured auditory privacy while they  are in procedure and testing areas to help protect the  confidentiality of their health conditions and treatments. However,  in over one-third (11 out of 32) of all outpatient clinics in the  selected VAMCs, we observed at least one examination room  from which conversations between a patient and provider could be  heard from the hallway despite a closed door. Only one of the six  VAMCs that we visited was fully compliant with VA’s requirement  of auditory privacy in all procedure and testing areas.

Privacy curtains not present in all examination rooms. VHA  policy requires that all examination rooms be equipped with a  privacy curtain. However, in over one-quarter (8 out of 28) of all  outpatient clinics that we observed where this requirement was  applicable, at least one examination room where women veterans  could be asked to disrobe was missing a privacy curtain.  Additionally, in many exam rooms where privacy curtains were  present, the curtains were positioned in a way that did not  adequately shield adjustable exam tables. Figure 2 (right) shows  an example of an examination room we inspected that was  missing a privacy curtain. In addition, the examination room  featured an adjustable exam table placed with the foot facing the  door. Both of these are inconsistent with VHA policy.

Sanitary products not available in all women’s restrooms.

According to VHA policy, sanitary napkins and tampons must be  made available in all women’s restrooms. However, in over half  (40 out of 69) of all women’s restrooms that we inspected across  the six selected VAMCs, there were no sanitary napkins or  tampons provided. One facility official stated that she places  sanitary products only in the restrooms that are most frequently  used by women, but this is inconsistent with VHA policy.

Unrestricted access to examination and procedure areas.

According to VHA policy, access to clinic examination and  procedure areas must be limited only to authorized clinic staff and  patients with appointments. However, 38 percent (15 out of 39) of  the examination and procedure areas that we observed across the  selected VAMCs either had unlocked doors that allowed for  unrestricted access or were adjacent to other unrestricted clinic  hallways, potentially allowing non-clinic staff or individuals that are  not patients into the exam area.

Inpatient setting. The only instances of noncompliance that we  observed in inpatient units were the following:

Two out of the 12 units we visited did not have privacy curtains  available in every examination room.

While visiting one unit, we observed a staff member entering a  patient room without knocking.

Residential treatment programs. The only instances of  noncompliance that we observed in residential treatment programs  were the following:

One out of the seven programs we visited did not have  appropriate private space for women veterans to visit with  children.

While visiting one program, we observed a staff member entering  a patient room without knocking.

section_title: VHA’s Oversight Processes Do Not Consistently Identify or Address Noncompliance Due to Weaknesses in Environment of Care Rounds and Related Policies
paragraphs: We found weaknesses in VHA’s oversight processes of the environment  of care rounds and related policies. Specifically, we identified the  following weaknesses:

Environment of care rounds not always conducted in a thorough  manner. VHA requires all patient care areas in a medical facility to be  inspected twice per fiscal year. According to an official at one facility,  when environment of care rounds are conducted at a time of day  when care is being provided, the rounds team will not inspect  examination rooms and other areas that are being used. As a result,  the environment of care rounds team may not inspect every room in a  facility twice per fiscal year, as required. Additionally, we found that  the checklist—which was developed by an environment of care field  advisory committee and is used across VAMCs to conduct the  environment of care rounds—lists only 22 requirements for the  environment of care, while VHA’s women’s health handbook contains  46 requirements. For example, the checklist does not require  inspection teams to examine whether clinical procedure and testing  areas have auditory privacy. In our review of the six selected VAMCs,  we found that all six exhibited noncompliance with women’s health  handbook requirements that are not included on the environment of  care rounds checklist.

Responsibility for addressing noncompliance not always clear.

At three of the selected VAMCs we visited, facility staff were unable to  identify the medical center department, such as engineering or  building maintenance, responsible for correcting identified instances  of noncompliance with certain environment of care policies. Without  clearly delineated roles and responsibilities, instances of  noncompliance are not addressed in a timely manner. For example, at  one selected VAMC, we observed a privacy curtain missing from a  primary care exam room. The provider who uses this room explained  that she reported this noncompliance to the facility’s maintenance  department but was told that the replacement of the curtain was not  the responsibility of the maintenance department. When we spoke  with the provider, it had been 6 months since she had reported the  noncompliance, and the issue had still not been addressed.  Furthermore, this instance of noncompliance was also among those  that the VAMC had not reported to VHA Central Office.

No systematic process to verify that medical facilities conduct  thorough reviews and fully report noncompliance issues. VHA  Central Office does not have a systematic process to independently  verify the compliance information it receives from VAMCs. According  to an agency official, VHA is largely dependent on the environment of  care rounds coordinator at each facility to report information on  instances of noncompliance to VHA by entering this information into  VHA’s data system. However, VHA does not verify the accuracy and  completeness of this information. VHA Central Office officials told us  that they do conduct periodic site visits to VAMCs to review the work  done by facilities’ maintenance departments, and that one component  of these reviews is examining the VAMCs’ compliance with  environment of care standards. According to VHA officials, only 4 of  these visits were conducted in fiscal year 2015, and 9 of the 12 visits  scheduled for fiscal year 2016 were conducted by June 2016. In  addition, the sites to be reviewed are not selected randomly but  instead are selected based on a request from VAMC or VISN  leadership.

In our 2010 report, we found similar problems with data accuracy and a  lack of clarity in delegated responsibilities. Specifically, none of the  medical facilities we visited had fully reported their noncompliance, and  we recommended that the agency establish a process to independently  validate facilities’ self-reported compliance with environment of care  requirements for women veterans. At the time, VA agreed with our  recommendation, and agency officials told us that VHA Central Office  directed VAMCs to report, on a quarterly basis, information on their  noncompliance with the environment of care standards. Agency officials  also told us that VHA Central Office directed VISNs to verify this  information by conducting separate environment of care rounds as part of  the VISNs’ oversight of VAMCs. However, our current findings suggest  that there are weaknesses in the operational effectiveness of these  actions. Additionally, according to VHA Central Office officials, as of July  2016, VISNs are not conducting these rounds and verifying the extent of  compliance among VAMCs. We have previously expressed significant  concerns about inadequate oversight and accountability within VA,  including that VHA’s oversight efforts have been impeded by the agency’s  reliance on facilities’ self-reported data, which lack independent validation  and are often inaccurate or incomplete.

This failure to verify reported information is inconsistent with federal  internal control standards for monitoring, which call for management to  establish activities to monitor the quality of performance over time and  promptly resolve the findings of audits and other reviews. Additionally,  the lack of thorough inspections and of clearly delegated responsibilities  is also inconsistent with federal internal control standards for control  environment, which require management to establish an organizational  structure, assign responsibility, and delegate authority to achieve agency  objectives and to evaluate performance and hold individuals accountable  for their internal control responsibilities. By not acting in accordance with  federal internal control standards, VHA does not have reasonable  assurance that its facilities are meeting the agency’s standards when  delivering care to women veterans.

section_title: While the Number of VHA Gynecologists and Women’s Health Primary Care Providers Has Increased Overall, Availability Was Limited in Some Locations
subsections: section_title: The Number of VA Gynecologists Has Increased Over Time, but More than a Quarter of VAMCs and VA Health Care Systems Did Not Have an Onsite Gynecologist
paragraphs: Our analysis of VHA data shows that the number of VHA gynecologists  increased about 3 percent nationally from fiscal year 2014 to fiscal year  2015. Specifically, in fiscal year 2014, there was the equivalent of about  75 full-time gynecologists, and in fiscal year 2015, the number increased  to the equivalent of about 77 full-time gynecologists. While the increase  in gynecologists exceeded the rate at which women veterans enrolled in  VA’s national health care system for the same time period, it remains  unclear whether the number of current VHA gynecologists is sufficient to  meet demand and whether the distribution of these gynecologists across  VA medical facilities is optimal. Thirty-nine of 145 VAMCs or VA health  care systems in fiscal year 2015 (about 27 percent) did not have an  onsite gynecologist. VHA Central Office officials said that, based on  workload, not all VA medical facilities need an onsite gynecologist, and  women veterans may receive necessary gynecological services through a  care in the community program.

At facilities where onsite gynecology was available, the number of VHA  gynecologists available to treat women veterans varied. In fiscal year  2015, the number of full-time equivalent gynecologists (for VAMCs or VA  health care systems that had them) ranged from 3.18 (Gainesville,  Florida) to 0.02 (Dayton, Ohio), which corresponds to less than 1 hour per  week. VA data also show that the number of completed gynecology  appointments increased across VA, from about 81,000 in fiscal year 2014  to about 85,000 in fiscal year 2015—an increase of about 5 percent. The  increase in completed gynecology appointments suggests a greater  overall utilization of gynecology services in VA medical facilities. (See  appendix IV for more information on the number of full-time equivalent  gynecologists by VISN and the number of completed gynecology  appointments by VISN.)

section_title: The Number of VHA Women’s Health Primary Care Providers Has Increased Over Time, but Almost One-Fifth of VA Clinics Offering Primary Care Lacked Such a Provider
paragraphs: Our analysis of VHA data indicates that the number of women’s health  primary care providers increased by almost 15 percent from fiscal year  2014 through fiscal year 2015. Specifically, in fiscal year 2014, there were  2,130 providers, and in fiscal year 2015, there were 2,439 providers.  The increase in providers significantly outpaced the increase in women  veteran enrollment (1 percent) during the same time period. In addition,  VHA data show that the number of completed women’s health  appointments increased across VHA, from about 304,000 in fiscal year  2014 to about 331,000 in fiscal year 2015—an increase of about 9  percent.

VHA data show that a women’s health primary care provider was  available to see veterans about 31 clinical hours per week, on average, at  the end of fiscal year 2015. However, that availability included any  clinical time women’s health primary care providers spent seeing male  veterans. Because women’s health primary care providers see both  men and women, according to VHA, it is highly likely that a typical  women’s health primary care provider was available for less than 31  hours per week to see women veterans. When VHA adjusted clinical  availability data by the proportion of women veterans seen for primary  care at each VA medical facility, the data show that a women’s health  primary care provider’s availability was estimated at about 6 hours per  week, on average, at the end of fiscal year 2015. Fiscal year 2015 was  the first year for which VHA collected and validated data on the clinical  availability of women’s health primary care providers, and according to  VHA officials, the data are considered preliminary and not yet robust  enough to compare with the demand for services.

Despite the increase in providers nationally, VHA data show that 17  percent of VA community-based outpatient clinics that provide primary  care and 3 percent of VAMCs or VA health care systems lacked a  women’s health primary care provider at the end of fiscal year 2015.  Specifically, 151 out of 881 outpatient clinics that provide primary care  and 4 out of 155 VAMCs lacked a women’s health primary care provider  at the end of fiscal year 2015. (See appendix V for more information on  the number of outpatient clinics that provide primary care lacking a  women’s health primary care provider.) At least 1 of the 4 VAMCs lacking  a women’s health primary care provider also lacked an onsite  gynecologist based on VHA fiscal year 2015 data.

The fact that nearly 18 percent of VAMCs and outpatient clinics providing  primary care lacked a women’s health primary care provider in fiscal year  2015 suggests that VHA may face challenges ensuring that all women  veterans have timely access to these providers, as required under VHA  policy. Specifically, each VA medical facility must ensure that eligible  women veterans have access to comprehensive medical care that is  comparable to care provided to male veterans, and veterans should not  wait more than 30 days from either the date an appointment is deemed  clinically appropriate by a VA provider or, if no such clinical determination  has been made, the date a veteran prefers to be seen for care. A VHA  official told us that if a women’s health primary care provider is not  available at a veteran’s local facility, women veterans can seek sex- specific care at other VA medical facilities, though in these cases women  veterans may face longer wait times and potentially longer driving  distances. Eligible women veterans may also receive care through  Choice or another care in the community program.

In our interviews with VHA officials, they acknowledged a shortage of  women’s health primary care providers at VA medical facilities. A VHA  official told us that facilities have difficulty recruiting and retaining primary  care providers who are interested and proficient in caring for women  veterans, particularly in rural areas. According to an agency memo, VHA  needs at least 675 additional women’s health primary care providers,  under a guiding principle that each VA medical facility—VAMCs and  community-based outpatient clinics—should have, at a minimum, two  women’s health primary care providers. In addition, according to the  agency memo, VA medical facilities with 2,000 or more women veteran  enrollees should have the equivalent of an additional one full-time  women’s health primary care provider for every 1,000 women veteran  enrollees or fraction thereof. According to the memo, these providers do  not all have to be new hires, but could be drawn from VHA’s existing pool  of primary care providers and trained to provide sex-specific care.  According to VHA, existing providers may participate in a VHA-sponsored  women’s health training to become women’s health primary care  providers, unless providers already possess the necessary training and  experience.

While VHA has taken steps to hire and train additional women’s health  primary care providers, these efforts have not yet yielded a sufficient  number of such providers. According to VHA, as of August 2016, using  funding from the Veterans Access, Choice, and Accountability Act of  2014, VHA had hired 45 women’s health-specific providers, including 11  gynecologists, since September 30, 2015. However, due to subsequent  turnover in staff as well as growth in the demand for services, VHA  reported that the number of women’s health primary care providers  needed to meet VHA’s criteria of a minimum of two per VA medical facility  has remained approximately the same. A VHA official told us that the  agency has a plan to train existing VHA providers so that there will be at  least 500 additional women’s health primary care providers in fiscal year  2016. According to VHA documents, 305 providers attended the agency’s  national training program in the spring and summer of 2016, and a VHA  official said an additional 230 providers will be trained by the end of fiscal  year 2016 at nine different VA locations across the country.

section_title: While the Number of Obstetricians and Gynecologists Participating in Choice Networks Has Increased, VHA Does Not Have Performance Measures for Monitoring Access to Sex-Specific Care under Choice
subsections: section_title: Obstetricians and Gynecologists Participating in Choice Networks Have Increased Nationally, though Some Geographic Areas Lack These Types of Providers
paragraphs: Our analysis of VHA data show that the number of obstetricians and  gynecologists participating in Choice networks nationally increased  significantly from about 6,200 in May 2015 to 10,100 in May 2016, an  increase of about 64 percent. While the number of obstetricians and  gynecologists increased, some geographic areas lacked these types of  providers, which provided access challenges for women veterans seeking  care. For example, our analysis of VHA data for VISN 19 indicated that as of May 2016,  there were almost 33 percent more community obstetricians and  gynecologists participating in Choice (615) compared to the number of these providers (464) who delivered care to women veterans through  individually authorized care prior to the implementation of Choice in  fiscal year 2014. However, according to a VHA analysis of VISN 19  based on May 2016 data, certain areas within VISN 19 lacked these  providers. (See fig. 3). Specifically, VHA’s analysis found that two  VA medical facilities in Montana offered gynecology services, and  there were no VHA or Choice obstetricians and gynecologists located  north and east of Billings, Montana. Parts of central Utah also  lacked VHA or Choice obstetricians and gynecologists. The Salt Lake  City/Provo/Ogden area was the only area in Utah that offered VHA  gynecology services, and Choice providers were also concentrated in  this area. According to the analysis, the areas lacking Choice  obstetricians and gynecologists generally had fewer veterans (male  and female) relative to other areas of these states.

Our analysis of VA data for VISN 10 showed that there were 4 percent  fewer non-VA community obstetricians and gynecologists participating  in Choice as of May 2016 (431) than there were providers who  delivered care to women veterans through individually-authorized care  prior to the implementation of Choice (451). According to a VHA  analysis of VISN 10 based on May 2016 data, 15 percent of Choice  obstetricians and gynecologists in VISN 10 are located outside of  VHA’s gynecology service areas—the roughly 40 miles surrounding a  VA medical facility—suggesting that most Choice obstetricians and  gynecologists in VISN 10 are not extending significant access to  veterans living outside of VHA’s gynecology service areas.

section_title: VHA Does Not Have Performance Measures for Monitoring Access to Sex- Specific Care under Choice
paragraphs: VHA lacks performance measures for the availability under Choice of sex- specific care, such as mammograms, maternity care, or gynecology. In  contrast, for another VA care in the community program, PC3—a program  that the Choice TPAs also administer—VHA has performance measures  to evaluate women veterans’ access to mammography and maternity  care, sex-specific services that are not routinely provided at most VA  medical facilities. Specifically, as part of PC3, VHA monitors women  veterans’ driving distances to obtain mammograms and maternity care  services as a measure of network adequacy. One VHA official  responsible for monitoring the TPAs’ performance on Choice contract  requirements told us that the PC3 performance measures specific to sex- specific care were simply overlooked in the haste to implement Choice.  VHA could monitor driving distances for women veterans to receive  mammograms and maternity care services delivered through Choice, as  the TPAs currently collect these data as part of PC3, according to VHA  officials.

While VHA doesn’t have performance standards for sex-specific care  under Choice, it does have performance standards for all care delivered  through Choice. For example, VHA’s contracts with the two TPAs require  the timely scheduling and completion of appointments, and VHA also  monitors the rates at which the TPAs return Choice authorizations to VHA  medical facilities without appointments. However, VHA data show that the  TPAs did not meet VHA’s performance standards for providing timely  access for veterans, including women veterans. See table 2 for TPA  average monthly performance under Choice for certain access-related  performance measures.

If VHA monitored access to sex-specific Choice care for women veterans,  it is possible that delays in care would be identified and actions could be  taken to minimize future occurrence. For example, if VHA were  monitoring sex-specific Choice care, it might have identified the three  cases of delayed maternity care through Choice we found as part of an  ongoing review of 196 Choice authorizations for care (of both men and  women) from early calendar year 2016. In one case, almost a month and  a half elapsed from the time of the veteran’s initial pregnancy confirmation  appointment at VA (when she was 6 weeks pregnant) to when the Choice  authorization was sent by the VA facility to the TPA for scheduling. It then  took two additional weeks for the TPA to attempt to schedule a prenatal  appointment; by that point, she was almost 15 weeks pregnant. At 18  weeks pregnant, she finally scheduled her initial prenatal appointment  herself, almost 3 months after her pregnancy was confirmed at VHA. In  another case, about a week and a half elapsed from the time the  veteran’s Choice authorization was created (when she was 6 to 7 weeks  pregnant) to when the VA facility sent it to the TPA for scheduling. It then  took the TPA nearly a month to reach the veteran and determine if she  wanted to participate in Choice. After the veteran agreed to participate in  Choice, it took more than 2 weeks for the TPA to schedule an  appointment. The veteran was about 14 weeks pregnant by the time her  first appointment was scheduled.

Federal standards of internal control for monitoring call for management  to establish activities to monitor the quality of performance over time and  promptly resolve the findings of audits and other reviews. VHA does not  currently have performance measures for sex-specific care under Choice.  While VA does monitor access to Choice care for all veterans, the past  performance of TPAs on access-related measures highly suggests that  veterans have problems obtaining timely access to these services as  required under Choice. Since women are more likely to use non-VA care  than male veterans, according to VHA, the lack of timely access to  Choice care may affect women veterans more so than male veterans. In  addition, we found instances where women veterans’ care under Choice  was significantly delayed and we found a lack of participating  obstetricians and gynecologists in some areas, both of which further  underscore the importance of VHA’s ability to monitor access to sex- specific care for women veterans. Without performance measures, VHA  does not have reasonable assurance that women veterans can obtain  timely access to sex-specific care.

section_title: Conclusions
paragraphs: Our review shows that, despite some progress since 2010, VHA still has  a significant problem ensuring that its medical facilities are complying with  VHA’s environment of care requirements, which are intended to protect  the privacy, safety, and dignity of women veterans when they receive  care. This lack of oversight reflects long-standing weaknesses in the  policies and guidance for the environment of care rounds inspections  process, including how data is collected by facility staff and what  information is reported to VHA Central Office. For example, facility staff  do not inspect all applicable areas within the facility and the list of  requirements they inspect does not include all requirements in the VHA  women’s health handbook. In addition, responsibilities for addressing  noncompliance are not clearly delegated, and VHA does not verify the  noncompliance information it receives from its facilities. These  weaknesses are similar to those we identified in our 2010 report, and the  problems have persisted even though VHA agreed with our previous  recommendations to strengthen oversight of its environment of care  standards. These findings further underscore the agency’s continued lack  of adequate oversight and accountability, which resulted in our adding VA  health care to our High Risk List in 2015. If VHA does not strengthen its  environment of care inspections policies, it will remain unable to provide  reasonable assurance that it is protecting the privacy, safety, and dignity  of women veterans who receive care at VA medical facilities.

Our review also suggests that VHA faces challenges ensuring that  women veterans have access to sex-specific care at its own medical  facilities and through community providers participating in Choice. VHA  has acknowledged that there are an insufficient number of women’s  health primary care providers across the national health system, and  some services, such as mammography, maternity care, and gynecology,  are not offered at many VA medical facilities. To the extent that VA  medical facilities cannot deliver sex-specific services, women veterans  will need to receive these services through Choice or other care in the  community programs. However, VHA does not monitor access for women  to sex-specific care through Choice. Unless VHA establishes  performance measures that monitor access to sex-specific services, VHA  will not have reasonable assurance that women veterans have adequate  access to these services.

section_title: Recommendations for Executive Action
paragraphs: To improve care for women veterans, we recommend that the Secretary  of Veterans Affairs direct the Under Secretary for Health to take the  following two actions:

Strengthen the environment of care inspections process and VHA’s  oversight of this process by expanding the list of requirements that  facility staff inspect for compliance to align with VHA’s women’s health  handbook, ensuring that all patient care areas of the medical facility  are inspected as required, clarifying the roles and responsibilities of  VA medical facility staff responsible for identifying and addressing  compliance, and establishing a process to verify that noncompliance  information reported by facilities to VHA Central Office is accurate and  complete.

Monitor women veterans’ access to key sex-specific care services— mammography, maternity care, and gynecology—under current and  future community care contracts. For those key services, monitoring  should include an examination of appointment scheduling and  completion times, driving times to appointments, and reasons  appointments could not be scheduled with community providers.

section_title: Agency Comments
paragraphs: We provided a draft of this report to VA for review and comment. While  VA was reviewing a draft of this report, the agency requested further  clarification on the scope of our second recommendation; as a result, we  revised the recommendation to be more clear and specific. In its written  comments, which are reproduced in appendix I, VA concurred with our  recommendations. VA stated it will charter a workgroup to examine  issues related to VA facility compliance with environment of care  requirements for women veterans. VA also said it is focused on providing  community care to all eligible veterans and will ensure that future  community care contracts incorporate areas for improvement based on  lessons learned. VA also provided technical comments, which we  incorporated as appropriate.

We are sending copies of this report to the appropriate congressional  committees, the Secretary of Veterans Affairs, the Under Secretary for  Health, and other interested parties. In addition, the report is available at  no charge on the GAO website at http://www.gao.gov.

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

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

section_title: Appendix II: Veterans Health Administration (VHA) Environment of Care Requirements Inspected by GAO
paragraphs: Appendix II: Veterans Health Administration  (VHA) Environment of Care Requirements  Inspected by GAO Inpatient Units  Is patient-identifiable information not visible  in hallways?

Residential Programs  Are client records not left unattended?

Are patient names not posted in public areas?  Are patient records not left unattended?

Are female bathrooms either private  or lockable if accessible from unit  hallways or other public spaces?

Are patient names not called out loudly?

When doors are closed, do staff knock and  wait until they are invited to enter?

Are female bedrooms located in a  separate and secured area of the unit  or located near main staff offices or  nursing stations?

Are sanitary napkin and tampon dispensers  available in the women’s public restrooms  nearest to this clinic or unit?

Are privacy curtains present in all rooms  (mental health units are exempt)?

Is there appropriate private space  available for female veterans to visit  with children?

Are disposal bins available in the women’s  public restrooms nearest to this clinic or unit?

Are rooms assigned either to only one client  or to same-sex clients (except in facilities  where spouses share rooms)?

When doors are closed, do staff  knock and wait until they are invited to  enter?

Are baby changing tables available in women’s  public restrooms nearest to this clinic or unit?

Do women patients have access to women- only toilet and shower facilities in close  proximity to the patients’ rooms?

Are rooms assigned either to only one  client or to same-sex clients (except in  facilities where spouses share  rooms)?

Does the interview/intake area have auditory  privacy?

Do women have door locks, access  bar codes, or controlled access ID  card scanners?

Is the access to hallways restricted for  patients/staff not using or working in that clinic  area?

Is patient-identifiable information not visible in  hallways?

When doors are closed, do staff knock and wait  until they are invited to enter?

Do restrooms not open into a public waiting  room or high traffic corridor?

Are privacy curtains present in all examination  rooms?

Are examination tables placed with the foot  facing away from the door?

Do procedure and testing areas have auditory  privacy?

Is a women’s restroom available within or in  close proximity to this clinic?

Are sanitary napkin and tampon dispensers  available in the women’s restroom nearest to  this clinic?

Are disposal bins available in the women’s  restroom nearest to this clinic?

Outpatient Clinics  Is special consideration given to privacy and  dignity in gynecology?

Is special consideration given to privacy and  dignity in radiology dressing areas (e.g.,  mammography)?

Is special consideration given to privacy and  dignity in ultrasound, transvaginal ultrasound  testing, etc.?

section_title: Appendix IV: Veterans Health Administration (VHA) Gynecologist Availability

section_title: Appendix V: Veterans Affairs (VA) Clinics Without a Women’s Health Primary Care Provider
paragraphs: Number (percentage) of clinics without a  women’s health primary care provider   7 (16)  6 (18)  4 (14)  10 (20)  4 (24)  2 (7)  9 (20)  10 (18)  15 (28)  3 (9)  2 (6)  0 (0)  12 (20)  5 (8)  5 (14)  8 (18)  5 (12)   13 (30)  11 (26)  4 (13)   16 (26)  151 (17)

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

section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Marcia A. Mann (Assistant  Director), Stella Chiang (Analyst-in-Charge), Carolyn Fitzgerald, Arushi  Kumar, and Alexis MacDonald made key contributions to this report. Also  contributing were Krister Friday, Jacquelyn Hamilton, Emily Wilson, and  Vikki Porter.

Fast facts: Are women veterans getting the medical care they need?

The Department of Veterans Affairs has policies in place to help ensure the privacy, safety, and dignity of women veterans when they receive care at its medical facilities. For example, exam rooms must have privacy curtains and exam tables must face away from doors.

However, we found many instances of noncompliance with these policies. We also found that 27 percent of VA medical facilities lacked an onsite gynecologist.

We recommended that VA improve its oversight of care for women veterans, including monitoring access to services such as gynecology and maternity care.

Question-summary annotations: questions: question: What data is missing or incomplete?
answer: The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) does not have accurate and complete data on the extent to which its medical centers comply with environment of care standards for women veterans.
child_questions: question: What does the policy require, in regards to women veterans?
answer: VHA policy requires its medical facilities, including VA medical centers, to meet environment of care standards related to the privacy, safety, and dignity of women veterans.

question: What is required by the VHA Central Office?
answer: VHA Central Office relies on medical centers to conduct regular inspections and to report instances of noncompliance, which are compiled in a VHA database.
child_questions: question: What was the evidence of the inspection conducted via the GAO?
answer: However, almost all the noncompliance GAO identified through inspections at six VA medical centers it visited had not been reported or recorded in the VHA database, and compliance rates ranged from 65 percent to 81 percent.

question: What examples demonstrated this lack of reporting?
answer: For example, GAO found a lack of auditory privacy at check-in clerk stations and a lack of privacy curtains in examination rooms, as required by VHA policy. GAO also found weaknesses in VHA's oversight of the environment of care for women, including a lack of thorough inspections and limited verification of facility-reported data which results in inaccurate and incomplete data.
child_questions: question: Due to these shortcomings, what may not be guaranteed for women veterans?
answer: As a result, the privacy, safety, and dignity of women veterans may not be guaranteed when they receive care at VA facilities.

question: What is the purpose of the federal internal control standards for monitoring call for management?
answer: Federal internal control standards for monitoring call for management to establish activities to monitor the quality of performance over time and promptly resolve any identified issues.

questions: question: What role does the Veterans Choice Program play for veterans who need to receive care?
answer: The Veterans Choice Program (Choice) is a primary option for veterans to receive care from non-VA providers in the community if care cannot be provided at VA facilities.

question: What limitations do the Choice facilities have, regarding access to care?
answer: While the number of obstetricians and gynecologists under Choice has increased, some areas lack these providers, according to a VHA analysis. While VHA monitors access-related Choice performance measures (such as timely appointment scheduling) for all veterans, it does not have such measures for women veterans' sex-specific care, such as mammography, maternity care, or gynecology.

question: In what areas do the VHA's data show poor performance?
answer: VHA's data show poor performance on access-related performance measures for all veterans, and GAO found cases where women veterans' maternity care was significantly delayed, suggesting that veterans, including women, face challenges receiving timely access to care.
child_questions: question: What was the response of the federal government?
answer: Federal internal control standards for monitoring call for management to establish activities to monitor the quality of performance over time and promptly resolve any identified issues.

questions: question: What did the GAO discover in 2010?
answer: In 2010, GAO found a number of weaknesses related to care for women veterans at VA medical facilities.
child_questions: question: What was the GAO asked to do?
answer: GAO was asked to update that study.

question: What does the report examine?
answer: This report examines (1) the extent that VA medical centers complied with requirements related to the environment of care for women veterans and VHA's oversight of that compliance; (2) what is known about the availability of VHA medical providers who can provide sex-specific care for women veterans at VA facilities; and (3) VHA's efforts to provide and monitor access to sex-specific care for women veterans through Choice.

question: What information needed to be reviewed by the GAO?
answer: To do this work, GAO reviewed VHA data on environment of care deficiencies; the number, location, and availability of VHA and Choice medical providers; women veteran enrollment; and Choice access-related performance measures.
child_questions: question: What other aspects were investigated by GAO?
answer: In addition, GAO inspected the environment of care for compliance with VHA policy at a nongeneralizable sample of six VA medical centers, which were selected to achieve variation in different care models, the size of the women veterans' population, and geographical locations. GAO also interviewed VHA Central Office and VA medical center officials.