VA Health Care: Actions Needed to Improve Administration of the Provider Performance Pay and Award Systems
Released: 2013-08-23T00:00:00

Letter

Background

Performance Pay

Most VA providers—including full- and part-time providers—are eligible for performance pay, but they may choose not to participate. Performance pay is given annually in a lump sum and may not exceed the lesser amount of $15,000 or 7.5 percent of a provider’s combined base and market pay, under the statute that defines the elements of provider pay. However, according to VHA officials, VA headquarters and each network and medical center have discretion to set a lower annual cap for their providers, and the amounts awarded may also depend on VA’s budget. Under the statute, performance pay is given on the basis of a provider’s achievement of specific goals and performance objectives, referred to in this report as goals. According to policy, performance pay goals can be established by medical center and network officials. As a result, the goals may be the same for all providers in the network, at a particular medical center, or within a particular specialty, or they may vary by individual provider. The amount of performance pay depends on the extent to which it is determined that a provider met his or her performance pay goals. Performance pay goals may include, for example, achieving a specific patient panel size, and are required by VA policy to be established within 90 days of the beginning of each fiscal year. VA’s performance pay policy requires medical centers to use form 10-0432 for each provider to document the goals and the provider’s achievement of them. When completed, the form is given to the medical centers’ respective human resources offices, which process the performance pay.

Performance Awards

Most providers are eligible for performance awards, although these awards are not required. The awards are lump-sum payments that are made annually and are based on providers’ annual performance reviews. VA policy requires that all providers—including full- and part-time providers—who have worked at VA medical centers receive annual performance reviews. For nonsupervisory providers, the reviews consist of a standard set of measures, including clinical, educational, and administrative competence; research and development; and personal qualities, such as dependability. A provider can receive an overall rating of unsatisfactory, low satisfactory, satisfactory, high satisfactory, or outstanding on an annual performance review. Service chiefs and chiefs of staff at VA medical centers, and providers at headquarters and networks who are in supervisory positions, also receive annual performance reviews based on measures outlined in VHA’s managerial performance plan. For nonsupervisory providers, the policy specifies that performance award amounts should not exceed $7,500. However, as with performance pay, VA headquarters, networks, and medical centers have discretion to determine the level of performance that would merit an award and the award amount within the $7,500 limit. For example, one medical center may grant performance awards to all providers who receive an overall performance rating of satisfactory or higher, while another medical center may only grant performance awards for an overall rating of outstanding, or not give them at all.

Performance-Related Personnel Actions

VA policy states that VA medical centers may take actions, such as major adverse and disciplinary actions, against providers to address and correct deficiencies related to providers’ clinical performance. These actions range in severity from admonishment to termination of employment. In addition, VHA also has the option of taking privileging action—that is, reducing, revoking, denying, or failing to renew a provider’s clinical privileges—against medical center providers to address performance deficiencies.

Medical centers have discretion in determining the type of action appropriate for each provider’s performance issue. Performance- related personnel actions may serve as an indication that the provider has not delivered high-quality, safe health care.

VA’s Performance Pay Policy Has Gaps in Information Needed to Administer Performance Pay

VA’s Policy Allows Discretion in the Establishment of Performance Pay Goals, but Lacks an Overarching Purpose That the Goals Should Support

VA’s performance pay policy gives VA’s 21 networks and 152 medical centers discretion in the establishment of performance pay goals for providers. The policy, issued in 2005 and revised in 2008, states that providers who meet established goals should receive performance pay. However, the policy does not provide an overarching purpose that the goals should support. VA’s Under Secretary for Health at the time the performance pay law was being considered stated in a congressional hearing that this pay would recognize providers’ achievements in quality, productivity, and support of the overall goals of the department. The Senate committee report and statements by members of Congress at the time the bill was passed provided that performance pay would recognize outstanding contributions to the medical center, to the care of veterans, or to the practice of medicine or dentistry, and it would motivate providers and ensure quality of care through the achievement of specific goals or objectives set for providers in advance.responsible for writing the performance pay policy also told us that the In addition, VA officials purpose of performance pay is to improve health care outcomes and quality; however, these goals are not documented in the policy.

Officials at the four medical centers we visited differed in their views of what constituted appropriate goals for performance pay. The following are examples of the factors these officials thought should be considered when establishing performance pay goals. According to these officials, the goals should be objective and measurable, measure only clinical achievements, recognize performance that is above and beyond expectations, or be measured at the individual provider level to ensure that the provider has direct control over the achievement of the goals.

As a result of these differing views, our review of the goals established for a mental health provider at each of four medical centers we visited found similarities as well as differences in the fiscal year 2011 goals. For example, one medical center used clinical goals exclusively, while others used a combination of goal types, such as clinical, patient satisfaction, and research.

Table 1 includes examples of the types of goals established for a mental health provider at each of the four medical centers we visited.

VHA officials told us that they have not formally reviewed the various goals that have been established by individual medical centers and networks to determine the purpose or purposes these goals support. In 2009, the Principal Deputy Under Secretary for Health asked that a group be convened to solicit and compile performance pay goals in order to review the types of goals being developed for each physician specialty and dental service across VA’s health care system. VHA officials told us at the time of our review that they had not yet done this, but planned to begin compiling and discussing a list of useful goals sometime in 2013. Because VHA has not reviewed the goals that have been set across medical centers and networks, it cannot have reasonable assurance that the goals established make a clear link between performance pay and providers’ performance. This condition is inconsistent with federal standards for internal control activities, which includes management of human capital.

Of the eight providers who were the subject of performance-related personnel actions in fiscal year 2010 or 2011 at the four medical centers visited, three providers were not eligible for performance pay during the same fiscal year. Two of the three providers were not eligible because they were terminated or resigned before the end of the fiscal year, and the third was not eligible because the provider was placed on indefinite suspension without pay and was not practicing as of the end of the fiscal year. $7,663 in performance pay, 67 percent of the amount for which the provider was eligible.

Another provider was reprimanded for refusing to see assigned patients waiting in the emergency department because the provider believed that patients had been triaged inappropriately. As a result, wait times increased. Documentation provided by the medical center indicated that, of the 98 patients who were triaged to the emergency department that day, 15 patients waited for over 6 hours to be seen and 9 patients left without being seen. That same fiscal year, this provider received $7,500 out of a maximum of $15,000 in performance pay. Specifically, this provider had 13 performance pay goals, which included becoming a member of a committee, attending staff meetings, and ensuring that all provider notes were signed in accordance with medical center policy. The provider met 1 of the 13 goals, which was assigned a weight of 50 percent. This goal was not specific to the individual provider, but instead was based on the achievements of all emergency department providers; it included meeting performance measures, such as maintaining productivity despite reduced resources, and adhering to the medical center policy for length of stay for patients in the emergency room. Since the medical center determined that the emergency department providers, which included this provider, met this goal, the provider received 50 percent of the maximum amount of performance pay. The service chief told us that his preference would have been to deny performance pay to this provider altogether, but he was told that the provider was entitled to the pay.

In contrast to the performance pay policy, VA’s performance award policy clearly states the purpose of these awards—specifically, that they are to recognize sustained performance of providers beyond normal job requirements as reflected in the provider’s most recent performance rating. VA policy also lists the measures supervisors are to use to determine the performance rating for providers in nonsupervisory positions, such as clinical competence.

VA’s Policy Is Unclear about Documenting Certain Requirements and Silent about Documenting Performance Pay Decisions for Providers Who Had Performance- Related Personnel Actions

VA’s performance pay policy is unclear about how to document compliance with two requirements—the goal-setting discussion between the supervisor and provider and the approval of the performance pay amount. For the documentation of goal-setting discussions, the policy states that supervisors are to discuss established goals with individual providers within 90 days of the beginning of the fiscal year, but it does not specify how medical centers are to demonstrate compliance with this requirement. VA’s policy specifies that form 10-0432 is to be used for documenting performance pay. The form has space at the top for listing the goals that a provider must meet to receive performance pay. The form includes a signature and date box for the supervisor and for the provider, respectively. (See fig. 1, section A.) The VA officials who wrote the policy, and VHA officials who are responsible for helping medical centers implement it, told us they expect that provider and supervisor signatures on the top of the form would indicate that goals have been discussed and the date would indicate when this discussion took place. The officials told us that this date is to verify that the 90-day requirement was met, but they have not documented or provided this guidance to the medical centers.

Because the policy does not specify how compliance with the 90-day requirement should be documented, one of the four medical centers we visited did not interpret the policy the way VA and VHA officials did, and therefore, did not document compliance with the 90-day requirement when administering performance pay. Officials responsible for processing the performance pay form at this medical center told us that VA does not have a requirement for documenting compliance with the 90-day requirement and they do not believe form 10-0432 should be used for this purpose. At this medical center, we found that none of the forms we reviewed were signed by the supervisor and provider within 90 days of the beginning of the fiscal year, and instead all the forms were signed after the end of the fiscal year. Officials from the other three medical centers said that the form should be signed by the provider and supervisor within 90 days, or as soon as possible after the beginning of the fiscal year to indicate that the goals have been communicated. However, our review of the documentation from these three medical centers indicates that their forms were not always signed within 90 days.

For the second documentation requirement, the policy states that the performance pay amount must be approved and that performance payments for the fiscal year must be disbursed no later than March 31 of the following fiscal year, but does not state that the approving official must sign form 10-0432 by that date. VA’s policy also states that the supervisor should forward form 10-0432 to the designated approving official for action. The bottom of form 10-0432 includes a signature and date box for an approving official, who is to sign and date the form. (See fig. 1, section B.) VA and VHA officials told us they expect that medical centers will not disburse performance pay, which they are required to do by March 31 or earlier, unless the approving official’s signature and date are on the form. However, VA’s policy does not state that the approving official’s signature must be dated before March 31.

Because the policy does not specify when the approving official should sign the form 10-0432, officials at the four medical centers had not all interpreted and implemented the policy the way VA and VHA officials did, and the medical centers differed in how they documented approval when administering performance pay. For example, one medical center official who became responsible for processing these forms in 2011 told us that he does not look for the approving official’s signature to be dated by March 31. At this medical center, all of the fiscal year 2011 forms 10-0432 we reviewed were signed by the approving official after March 31, which indicates that the payments were made after the required disbursement date or that payments were made before they were approved. For fiscal year 2010, when a different official at this medical center was responsible for processing the performance pay forms, we found that nearly all of the forms were signed by the approving official by March 31. At the other three medical centers, we found that some forms were signed by the approving officials after March 31 or not at all, even though officials at these medical centers told us they strive to meet this date.

Further, VA’s policy lacks a requirement for documenting whether performance-related personnel actions had an impact on providers’ achievement of performance pay goals, and as a result, how these actions affected performance pay decisions, such as reducing or denying this pay. Some VHA headquarters officials we interviewed said that situations involving providers who had a performance-related personnel action would need to be reviewed case by case to determine if the action had an impact on whether the provider met established goals, since not all performance-related personnel actions would merit reducing or denying a provider’s performance pay. These officials told us they expected medical center officials to document their review of these actions when determining whether to give performance pay to these providers. However, these expectations are not explicit in VA’s performance pay policy. The documents provided by the four medical centers for five providers who had performance-related personnel actions did not include documentation that the actions were considered. Some medical center officials told us that they did not consider the performance- related personnel actions when making performance pay determinations, while others told us that they did but that they did not document it.

Without a performance pay policy that clearly specifies how to document decisions or compliance with requirements, VHA does not have reasonable assurance that documentation includes all necessary information, a condition that is inconsistent with federal standards for internal control activities. In addition, medical centers will likely continue to vary in their interpretation of the policy for documenting goal-setting within 90 days of the beginning of the fiscal year, and subsequent approval of performance pay and the extent to which they document compliance with it. As a result, VHA does not have reasonable assurance that medical centers are complying with requirements.without documentation of whether performance-related personnel actions affected performance pay decisions, VHA lacks information about how these decisions were made and whether these decisions appropriately reflected providers’ performance.

VHA’s Oversight Is Inadequate to Ensure Compliance with Performance Pay and Award Requirements

VHA does not provide adequate oversight to ensure that its medical centers are in compliance and remain in compliance with performance pay and award requirements. VHA’s Workforce Management and Consulting Office conducts annual Consult, Assist, Review, Develop, and Sustain (CARDS) reviews, which are consultative reviews that were initiated in 2011 to assist medical centers in complying with human resources requirements, including performance award requirements.According to VHA officials, the results of these reviews are provided to the medical centers. However, these reviews have limitations and, as a result, do not always ensure that medical centers comply and remain in compliance with human resources requirements.

The five CARDS reviewers take turns in the lead CARDS reviewer role on a yearly basis. This individual was the lead CARDS reviewer during our review, and as such can speak for all of the reviewers. centers. CARDS reviews use a standard list of elements to review other human resources requirements, including performance awards.

In addition, the CARDS reviewers do not have the authority to require medical centers to resolve compliance problems they identify, and VHA has not formally assigned responsibility to an organizational component with the knowledge and expertise of human resources issues to do this, a condition that is inconsistent with internal control standards for control environment. currently indicate that network human resources managers, who typically accompany CARDS reviewers on reviews, are to follow up with medical centers’ human resources offices to ensure identified problems are resolved. However, this reviewer said CARDS reviewers do not have the authority to require that this follow-up be done. Further, network human resources managers lack the authority to require medical center human resources managers to correct identified problems because medical center directors, not network human resources managers, typically have oversight authority over medical center human resources managers, according to VHA officials. Figure 2 shows the organization of VHA offices that are involved in performance pay and awards for providers at medical centers.

GAO/AIMD-00-21.3.1. network director reports directly to the Deputy Under Secretary for Health for Operations and Management.

Generally, the applicable network human resources official attends the CARDS review.

As a result of the limitations with CARDS reviews—the lack of a standard list of performance pay elements, as well as the lack of an organizational component assigned to follow up on noncompliance and ensure it is corrected—VHA is unable to ensure that medical centers correct the problems found by the reviews and that problems do not recur, a condition that is inconsistent with internal control standards for monitoring. We found that two of the four VA medical centers we visited did not always correct problems identified through CARDS reviews. For example, a May 2011 CARDS review of one of these two medical centers found that the medical center did not conduct a formal evaluation of its awards program, as required. A CARDS review of this same medical center about a year later found the identical problem. An October 2011 CARDS review of the second medical center found that the facility was not using the required form 4659 for performance awards, and we found that the same medical center did not use form 4659 for performance awards in fiscal years 2010 and 2011. We also found that another medical center was not using form 4659 for performance awards in fiscal years 2010 and 2011. Additionally, we found other instances of noncompliance at two of the four medical centers. For example, we found that one of the medical centers we visited used form 4659 for performance awards, but was unable to provide the form for two of the five providers who received awards in fiscal year 2011. Further, we found that another medical center was unable to provide the required form 10- 0432 for performance pay for six of the providers we reviewed in fiscal years 2010 or 2011. Also, for the providers’ forms that were available in fiscal year 2010, two forms did not indicate whether the goals were met to justify the performance pay amounts, as required by VA policy.

Conclusions

Part of VHA’s responsibility for administering performance pay and awards is ensuring that providers understand the link between this compensation and their performance, according to federal internal control standards. However, VA’s performance pay policy does not state a purpose for this pay, and VHA, which administers this pay, has not reviewed the performance pay goals that have been established across VA medical centers and networks. Without stating a purpose for the pay and reviewing the goals, VHA cannot determine the purposes these goals support, and the relationship between performance pay and providers’ performance is unclear. All of the providers we reviewed who were eligible for performance pay in fiscal year 2010 or 2011 received this pay, including providers who had performance-related personnel actions taken against them. Because VA’s policy is silent on documenting whether performance-related personnel actions affected performance pay, none of the medical centers provided documentation that these actions were considered in making performance pay decisions. As a result, VHA lacks information about how these decisions were made and whether these decisions reflect providers’ performance. Moreover, because VA’s policy does not specify how compliance should be documented for certain performance pay requirements, such as discussion of goals and approval of amounts, VHA cannot ensure consistent compliance across its medical centers.

In addition, oversight of medical centers’ management of performance pay and awards is not adequate for VHA to have reasonable assurance that medical centers fully comply with requirements. VHA has not assigned responsibility to an organizational component to follow up on identified problems at medical centers, including problems identified during CARDS reviews, to ensure that they are corrected and remain corrected. Oversight that does not ensure that identified problems are resolved and remain so is inconsistent with federal standards for internal control, and may allow compliance problems to persist or worsen.

Recommendations for Executive Action

To clarify VA’s performance pay policy, we recommend that the Secretary of Veterans Affairs direct the Assistant Secretary for Human Resources and Administration to take the following four actions to specify in policy: the overarching purpose of performance pay; how medical centers should document that supervisors have discussed performance pay goals with providers within the first 90 days of the fiscal year; that medical centers should document approval of performance pay amounts and that the approval occurred before the required March 31 disbursement date; and how medical center officials should document whether performance- related personnel actions had an impact on providers’ achievement of performance pay goals, and as a result, affected performance pay decisions.

To ensure that performance pay goals are consistent with the overarching purpose that VA specifies for this pay, we recommend that the Secretary of Veterans Affairs direct the Under Secretary for Health to review existing performance pay goals across VA’s health care system.

To strengthen oversight of medical centers’ compliance with VA policy requirements for performance pay and awards, we recommend that the Secretary of Veterans Affairs direct the Under Secretary for Health to take the following two actions: ensure medical centers are in compliance with the requirements in the performance pay and award policies and assign responsibility to a VHA organizational component with the knowledge and expertise to ensure correction of medical centers’ noncompliance with VA’s performance pay and award policy requirements, including problems identified during CARDS reviews, and ensure that medical centers maintain compliance with these requirements.

Agency Comments and Our Evaluation

VA provided written comments on a draft of this report, which we have reprinted in appendix II.conclusions and recommendations.

In its comments, VA generally agreed with our In response to our recommendations to clarify the performance pay policy, VA stated that it concurred with three of them and concurred in principle with the fourth. Regarding the overarching purpose of performance pay, VA stated that it will coordinate with VHA to develop a policy change that will clearly articulate the purpose of performance pay, which is to ensure and improve the quality of care through the achievement of specific goals and objectives. In response to our recommendations that VA specify how medical centers should document the goal-setting discussion between the supervisor and provider, and the approval of the performance pay amount, VA stated that it would revise the performance pay policy to include more detailed instructions for documenting compliance with these two requirements. In addition, VA said it would revise form 10-0432 to include sections for documenting compliance with these two requirements.

VA stated that it agreed in principle with our recommendation that medical centers should document whether performance-related personnel actions had an impact on providers’ achievement of performance pay goals, and affected performance pay decisions. VA agreed that medical center officials should consider whether a performance-related personnel action had an impact on the provider’s achievement of the goals and objectives associated with performance pay, but stated that it is inappropriate to require the documentation of the decision on form 10-0432. We appreciate VA’s commitment to clarify in policy that medical center officials should consider performance-related personnel actions when making performance pay decisions. We support VA’s flexibility as to where to document these considerations, which is why we did not specify in our recommendation that form 10-0432 should be used for this purpose. However, we continue to believe that if such considerations are not documented, VHA lacks information about how these decisions were made and whether these decisions appropriately reflected providers’ performance, which is inconsistent with federal internal control standards for documentation.

To address our recommendation that the Under Secretary for Health review the existing performance pay goals across VA’s health care system to ensure that performance pay goals are consistent with the purpose specified in policy, VA stated that the Under Secretary for Health directed a committee on February 11, 2013, to conduct a review of policies and controls associated with the administration of performance pay, including evaluating challenges associated with establishing performance pay goals, inconsistent application of performance pay, and the overall perceived value of performance pay. In June 2013, the Under Secretary for Health directed a new task force to build upon the work of that committee and make recommendations for ensuring a consistent and system-wide process for setting and evaluating performance pay goals and granting performance pay, including making recommendations for reviewing and setting uniform performance pay goals across the system that are aligned to help VHA achieve its goals.

To address our recommendations to strengthen oversight of medical centers’ compliance with VA policy requirements for performance pay and awards, VA stated that the Under Secretary for Health established in May 2013 a task force to develop and provide guidance and methodology for performance pay. In addition, VA stated that VHA’s Office of the Deputy Under Secretary for Health for Operations and Management will assign responsibility to the network directors, in coordination with the network human resources managers, network chief medical officers, medical center directors, medical center chiefs of staff, and medical center human resources managers, for monitoring and enforcing VA’s performance pay and award policies, and communicate that responsibility in a memorandum. Additionally, the Office of the Deputy Under Secretary for Health for Operations and Management will communicate in a memorandum to the network directors and human resources managers that they should monitor and track CARDS reviews and coordinate with the medical center directors and human resources managers to ensure proper corrective actions are taken for compliance.

VA also provided a general comment that it considered our definition of performance-related personnel actions, defined in footnote 5 of the report, to be too broad. Specifically, VA stated that performance actions are taken when an employee lacks the skill and ability to perform assigned duties, and that in such situations providers are given assistance and an opportunity period to perform at an acceptable level of competence. VA also stated that if the provider fails to perform at an acceptable level during this period, the resulting performance action will be either a reduction of privileges or termination. However, VA’s policy on employee/management relations states that disciplinary actions—which include admonishments and reprimands—and major adverse actions— which include suspension, transfer, reduction in grade, and reduction in basic pay, in addition to termination—can be taken to address performance or conduct. In addition, VA stated that four of the five scenarios listed in appendix I of the report were conduct actions, not performance actions. As stated in footnote 5 of the report, we created the term performance-related personnel actions to include any action taken to address clinical performance—that is, an action that medical centers’ documentation indicated was related to patient safety or quality. Documentation provided by the medical centers for each of the five cases listed in appendix I clearly stated that the actions that were taken against the providers were related to patient safety or quality.

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If you or your staffs 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 major contributions to this report are listed in appendix III.

Appendix I: Performance-Related Personnel Actions and Performance Pay Amounts

Appendix I: Performance-Related Personnel Actions and Performance Pay Amounts A reprimand is an official letter of censure to a provider for deficiencies in competence. Reprimands can also be issued for acts of misconduct. A reprimand is a more severe disciplinary action than an admonishment, which is an official letter of censure to a provider for minor deficiencies in competence or conduct.

VA officials did not provide documentation of the letter of alternative discipline but indicated that it was probably a reprimand. We included this case in our sample based on documentation provided by the medical center, which indicated that the action was closed in fiscal year 2010.

Appendix II: Comments from the Department of Veterans Affairs

Appendix III: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

In addition to the contact named above, Mary Ann Curran, Assistant Director; Elizabeth Conklin; Kaitlin McConnell; Elizabeth T. Morrison; Lisa Motley; and Christina Castillo Serna made key contributions to this report.