In carrying out its mission of providing services to veterans, VA’s programs are administered through its three major administrations—VHA, Veterans Benefits Administration, and National Cemetery Administration—and VA engages all of its administrations in its strategic planning process. VA’s Office of Policy is responsible for ensuring integration, collaboration, and cooperation across VA with regard to policy and strategy development. This office also leads VA’s strategic planning efforts and is involved with managing VA’s governance process. Within the Office of Policy, the Policy Analysis Services, the Strategic Studies Group, and the Strategic Planning Service support this work. In March 2014, VA published its current strategic plan, Department of Veterans Affairs FY 2014 - 2020 Strategic Plan, which identifies the department’s mission, values, and three strategic goals. Within VHA, the Office of the Assistant Deputy Under Secretary for Health for Policy and Planning supports and advises several VHA offices—the offices of the Under Secretary for Health, Principal Deputy Under Secretary for Health, and the Deputy Under Secretary for Health for Policy and Services—on the development and implementation of VHA policy, strategic planning, and forecasting. VHA’s Under Secretary for Health directs all aspects of VHA’s health care system, including its annual budget and overseeing the delivery of care to veterans, as well as the health care professionals and support staff that deliver that care. In December 2012, VHA published its current strategic plan, VHA Strategic Plan FY 2013 – 2018, which identifies its mission and vision and guides budgeting, performance management, and service alignment across VHA, and its plans for how to provide for the health care needs of veterans. (See app. I.) The plan also outlines VHA’s three goals and 17 objectives that are to be used to guide planning, budgeting, performance management, and service alignment across VHA; those three goals are to: (1) provide veterans personalized, proactive, patient-driven health care, (2) achieve measurable improvements in health outcomes, and (3) align resources to deliver sustained value to veterans. VHA Directive 1075: Strategic Planning Process is VHA’s most current strategic planning guidance, and it outlines how VHA will identify its strategic priorities and establish and execute its strategic plan, as well as identifies roles and responsibilities in this process. In recent years, VA and VHA have established several new initiatives, activities, and priorities in response to changes in internal and external factors—including VHA leadership changes, congressional concerns regarding veterans’ access to care, and the placement of VHA on our High-Risk List. Specifically, VA and VHA have developed the following new initiatives and priorities in the last 2 years: MyVA: This VA-wide initiative was launched in July 2015 and is aimed towards transforming the veterans’ experience. VA has developed five priorities for this initiative: (1) improving the veteran’s experience, (2) improving the employee experience, (3) improving internal support services, (4) establishing a culture of continuous improvement, and (5) enhancing strategic partnerships. “The Under Secretary for Health’s Five Priorities:” VHA’s Under Secretary for Health established these priorities after being appointed to his position in July 2015. The five priorities are to (1) improve access, (2) increase employee engagement, (3) establish consistent best practices, (4) build a high-performing network (which includes VA and non-VA providers), and (5) rebuild the trust of the American people. “The Secretary’s 12 Breakthrough Priorities:” These priorities describe focus areas for the MyVA initiative and were first presented in a January 2016 testimony by the Secretary of VA to the Senate Committee on Veterans’ Affairs. Several of these priorities—such as improving the veterans experience, increasing access to health care, and improving community care—are relevant to health care delivery in VHA. Additionally, in September 2014, VHA developed the Blueprint for Excellence, which presents strategies for transforming VHA health care service delivery in response to concerns regarding the VHA access and wait-time crisis that year. These strategies, which are linked to the goals and objectives in VHA’s current strategic plan, include operating a health care network that anticipates and meets the unique needs of enrolled veterans, in general, and the service disabled and most vulnerable veterans, and delivering high-quality, veteran-centered care that compares favorably to the best of private sector in measured outcomes, value, access, and patient experience. More recently, VHA developed a crosswalk for internal discussion documenting how the various VA and VHA initiatives, activities, and priorities—such as MyVA, Blueprint for Excellence strategies, the Under Secretary for Health’s Five Priorities, and the Commission on Care report—relate to each other. See fig. 1 for a timeline of internal and external factors that have affected or may affect VHA’s strategic goals and objectives. VHA conducts a strategic planning process annually and through this process also established its current strategic plan. According to officials, VHA’s current strategic plan was developed through its FY 2012 strategic planning process. VHA officials told us that they currently do not have plans to revise VHA’s current strategic plan or develop a new one, but may, however, develop an operational plan that will cascade from and operationalize VA’s strategic plan. VHA officials told us that they do plan to continue to use their current annual strategic planning process to identify VHA’s future strategic goals and objectives. According to VHA officials, VHA’s strategic planning process includes two key steps—(1) assessing the environment, which VHA refers to as environmental scanning, and (2) holding the annual NLC Strategic Planning Summit. These steps are consistent with leading practices in strategic planning. VHA conducts environmental scanning to identify and assess factors that may affect its future health care delivery. According to VHA policy, data from VHA’s environmental scan, such as the projected number of veterans to be served, are to be used by VHA in developing its goals and objectives. In addition, the results from VHA’s environmental scanning are to be used by VHA’s Office of Policy and Planning and VHA program offices, in strategic decision making. In addition to environmental scanning, the NLC Strategic Planning Summit is also key to VHA’s strategic planning process, in that it is the primary forum through which VHA leadership identifies and discusses the strategic goals and objectives for the next year. The NLC is responsible for recommending new or revised strategic goals and objectives and for formulating strategies to achieve them. VHA’s Office of Policy and Planning coordinates the summit and invites various stakeholders to attend—such as officials from VHA central office, including program offices; VA central office; Veterans Benefits Administration; National Cemetery Administration; VISNs; and representatives of veterans service organizations. Veterans Benefits Administration and National Cemetery Administration officials indicated that they have varied levels of participation. Veterans Benefits Administration officials told us that they have historically attended several days of the summit, and National Cemetery Administration officials indicated that they may listen to the VHA’s general body sessions during the summit. Even though officials from both administrations indicated they believe their input and coordination with VHA regarding its strategic planning was sufficient, Veterans Benefits Administration officials noted that increased engagement in VHA’s strategic planning process would be beneficial, given the direct correlation between veterans’ disability compensation ratings assigned by them and the subsequent care delivered from VHA. During the course of the summit, the NLC determines if changes to VHA’s strategic goals and objectives are needed. If there are changes, VHA’s Office of Policy and Planning drafts a document, gathers additional stakeholder feedback, and presents the document to VHA’s Under Secretary for Health for approval. VHA also obtains and uses information from VA to inform its strategic planning process. For example, according to VA and VHA officials, VHA’s environmental scanning process is, and has historically been, health-care focused, and is adjunct to the broad environmental scanning process conducted by VA. Officials noted that though distinct processes, VA’s and VHA’s environmental scanning processes are interrelated. VHA officials told us that they leverage VA’s environmental scanning results in making decisions regarding VHA’s strategic goals and objectives. Additionally, VA officials have historically been invited to participate in VHA’s NLC Strategic Planning Summit, including the 2016 summit. VA’s draft report of its environmental scanning identified changes in the veteran population, including growth in the number of veteran enrollees aged 65 and older, which VA officials reiterated at the 2016 NLC summit. VISNs and VAMCs have responsibility for operationalizing VHA’s strategic goals and objectives, including its strategic plan, according to VHA officials. Operationalizing involves putting strategic goals and objectives into use by an organization, and includes developing initiatives, programs, or actions that will be used to accomplish those goals and objectives. VISNs and VAMCs must allocate resources, develop day-to- day activities, and create policies as part of that process. However, we found that VHA provides limited guidance for VAMCs in how to operationalize VHA’s strategic goals and objectives. First, VHA has not clearly identified VAMCs’ responsibilities in operationalizing its strategic goals and objectives as it has for VISNs. For example, VHA Directive 1075 states that VISN directors are to be responsible for: developing operational plans; annually tracking and reporting accomplishments in support of the VHA strategic plan; regularly updating plans to address local issues, such as geographic-specific needs; and providing input to inform future VHA goals, objectives, and strategies. However, there are no such stated responsibilities for VAMCs. According to federal internal control standards, successful organizations should assign responsibility to discrete units, and delegate authority to achieve organizational objectives. VHA and VISN officials told us that it is inferred that the VAMCs are part of the overall process even though there is no specific policy or guidance for VAMCs. All three VISNs in our review reported developing operational plans or strategies to operationalize VHA’s goals and objectives at the VISN level, but two of the nine VAMCs in our review had not developed such strategies. Second, in FY 2013, VHA provided VISNs with a strategic planning guide for operationalizing the current strategic plan, but did not provide a similar guide for VAMCs. According to the guide, its purpose was to assist VISNs in outlining a multi-year plan that aligned with VHA’s current strategic plan and provide relevant information regarding the development of strategies, the process for conducting a strategic analysis, and the time frame for providing strategic planning information, such as strategies, to VHA central office. The lack of guidance for VAMCs may hinder them from effectively operationalizing VHA’s strategic goals and objectives, and may lead to inconsistencies in time frames, documentation, and data used for the strategic planning process. For those VAMCs in our review that developed strategies to operationalize VHA’s strategic goals and objectives, for example, almost all developed local strategies on a fiscal- year cycle, which aligns with VHA’s budgeting and strategic planning processes, but one VAMC developed strategies on a calendar-year cycle. Although there is no requirement for VAMCs to conduct strategic planning on a specific timeline, per leading practices for strategic planning, organizations should align their activities, core processes, and resources to ensure achievement of the agency’s objectives. In addition, per federal internal control standards, management should effectively communicate information throughout the organization, as the organization performs key activities in achieving the objectives of the organization. VHA has not developed adequate strategies or an effective oversight process to ensure VHA’s strategic goals and objectives are effectively operationalized. Specifically, VISNs and VAMCs lack consistently developed strategies for operationalizing VHA’s strategic goals and objectives, and existing performance assessments are limited in measuring progress towards meeting these goals and objectives. Lack of consistently developed strategies. VHA has not consistently developed strategies for VISNs and VAMCs to use in operationalizing its strategic goals and objectives. Strategies should describe how a strategic plan’s goals and objectives are to be achieved, and should include a description of the operational processes, staff skills, use of technology, as well as the resources— such as, human, capital, and information—required. Among other things, our previous work has shown that strategies should have clearly defined milestones, outline how an organization will hold managers and staff accountable for achieving its goals, and be linked to the day-to-day activities of the organization. In addition, individual strategies should be linked to a specific goal or objective. In September 2014, VHA published the Blueprint for Excellence to provide strategies for transforming VHA health care service delivery in response to concerns regarding the VHA wait-time crisis that year. However, VHA did not develop a similar document for the other strategic planning years despite the development of multiple strategic documents, such as the Under Secretary for Health’s five priorities. Without developing adequate strategies to correspond to all of its strategic goals and objectives, the VISNs and VAMCs have limited guidance to help them operationalize VHA’s strategic goals and objectives. Moreover, the day-to-day activities and initiatives developed by VISNs and VAMCs may not appropriately align with those goals and objectives. A direct alignment between strategic goals and their associated strategies is important in assessing an organization’s ability to achieve those goals. No process for ensuring and assessing progress in meeting all of VHA’s strategic goals and objectives. As our previous work has shown, assessments can provide feedback to an organization on how well day-to-day activities and programs developed to operationalize strategic goals and objectives contribute to the achievement of those goals and objectives. Specifically, formal assessments are to be objective and measure the results, impact, or effects of a program or policy, as well as the implementation and results of programs, operating policies, and practices; they can also help in determining the appropriateness of goals or the effectiveness of strategies. However, VHA does not have effective oversight process for ensuring that VISNs and VAMCs are meeting all of its strategic goals and objectives. According to VHA officials, there are currently two methods for assessing VHA’s performance towards meeting selected strategic goals and objectives. One method is VISN and VAMC directors’ individual annual performance plans. For FY 2016, these plans present VHA’s strategies for providing a successful health care delivery system, including those outlined in its Blueprint for Excellence. The directors’ plans include performance metrics, which VHA, as well as VISNs and VAMCs, can use to measure demonstrated progress of a VISN or VAMC in meeting these strategies. However, multiple strategic goals and objectives have been communicated to the field, such as the Under Secretary for Health’s five priorities, and it is not clear how these goals align with the strategies in the current directors’ performance plans or how progress towards them can be assessed. A VHA official, who is a member of the workgroup reviewing VHA’s performance metrics, told us that over the years, performance metrics were added to the director performance plans as problems or needs arose without considering the overall purpose of the metric. VHA officials reported that they have reviewed the current plans and have revised them. According to a VHA official, the new plans will have fewer metrics, and will be more strategically focused on VA’s and VHA’s strategic priorities, such as the Under Secretary for Health’s five priorities. According to VHA officials, implementation is planned for October 1, 2016. However, it is not clear how these metrics will be linked to the strategic goals and objectives in VHA’s current strategic plan. Veterans’ satisfaction with VA’s health care system is the second method for assessing VHA’s performance towards meeting strategic goals and objectives, according to VHA officials. VHA currently collects information from a survey of veterans that addresses two of VA’s priority goals, including improving access to health care, as experienced by the veteran. According to VHA officials, for the veterans’ access goal, there is a large degree of alignment between the department-wide goal and how VHA measures its progress towards meeting some of its access goals and objectives in its strategic plan. However, it is not clear how VAMCs and VISNs are to use veterans’ satisfaction to assess progress toward meeting other goals and objectives that have been communicated to them—such as the Under Secretary for Health’s five priorities that are not focused on access. VHA officials told us that no additional VHA-level assessments had been conducted to measure progress towards meeting strategic goals and objectives. Though VHA has performance information from VISN and VAMC directors’ performance plans and veteran satisfaction surveys, the performance of the agency toward meeting VA’s and VHA’s other strategic goals and objectives may help provide a more complete picture of overall effectiveness. In addition to a lack of adequate strategies and an effective oversight process, a large number of vacant, acting, and interim positions at some of the VISNs and VAMCs in our review have also created challenges for VHA in operationalizing its strategic goals and objectives. For example, officials from one VISN reported that acting and interim senior leadership positions within a facility in their region have had an effect on the operations of the VAMC, including the operationalization of VHA’s strategic goals and objectives. They added that the acting and interim senior leaders did not feel empowered to make long-term decisions regarding the operations of the medical center because they did not know how long they would hold the position. The Under Secretary for Health told us that one of VHA’s top priorities for 2016 is to fill 90 percent of VAMC director positions with permanent appointments by the end of the year. The Under Secretary added that filling these positions would help address the current gaps in leadership and provide stability for the VAMCs. As the demand for health care by our nation’s veterans increases, and concerns about VA’s health care system persist, it is essential that VHA conduct the necessary strategic planning to achieve its goals and objectives. VHA has established a strategic planning process to identify strategic goals and objectives for accomplishing its mission, and VISNs and VAMCs are expected to operationalize these goals and objectives. However, VHA has not delineated a role for VAMCs in this process as it has for VISNs. Moreover, the lack of adequate strategies to operationalize VHA’s strategic goals and objectives, as well as the lack of an effective oversight process for assessing progress, may hinder the achievement of VHA’s goals and objectives. Without consistently developed strategies, the day-to-day activities and initiatives that are developed to operationalize VHA’s strategic goals and objectives may not appropriately align with those goals and objectives. This may result in VHA not being able to determine if it is adequately addressing top management concerns or department-wide strategic goals. Further, because VHA does not have an effective process to assess progress in meeting its strategic goals and objectives, it does not have needed information on how well the day-to-day activities and programs of VISNs and VAMCs are contributing to their achievement. We recommend that the Secretary of Veterans Affairs direct the Under Secretary for Health to take the following three actions: 1. Define the roles and responsibilities of VAMCs in operationalizing VHA’s strategic goals and objectives; this could be accomplished by establishing roles and responsibilities for VAMCs similar to how VHA defines roles and responsibilities for VISNs in VHA Directive 1075 and by developing guidance for VAMCs similar to guidance developed for VISNs. 2. Consistently develop strategies that can be used by VISNs and VAMCs to operationalize VHA’s goals and objectives, ensuring that they clearly link directly to VHA’s goals and objectives. 3. Develop an oversight process to assess progress made in meeting VHA’s strategic goals and objectives, including feedback on how well activities and programs are contributing to achieving these goals and objectives. We provided VA with a draft of this report for its review and comment. In its written comments, reproduced in appendix II, VA concurred with our three recommendations, and described the actions it is taking to implement them by September 2017. VA described the role that community-based outpatient clinics and health care centers play as critical health care access points for veterans and commented that our draft report does not mention these access points as components of VAMC service delivery systems. While our report draft noted the role of community-based outpatient clinics and health care centers in VA’s service delivery system, we clarified that these facilities are components of VAMCs. VA also commented that our report draft does not mention the essential role that VHA program offices play in contributing to and implementing the VHA strategic plan. Our report states that program offices contribute to VHA’s strategic planning process by developing some of the programs and actions that VISNs and VAMCs use to provide health care services to veterans. VA also provided technical comments, which we incorporated as appropriate. As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies of this report to appropriate congressional committees, the Secretary of Veterans Affairs, the Under Secretary for Health, and other interested parties. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix III. In addition to the contact named above, Janina Austin, Assistant Director; Kelli A. Jones, Analyst-in-Charge; Jennie Apter; and LaKendra Beard made key contributions to this report. Also contributing were George Bogart, Christine Davis, Jacquelyn Hamilton, and Vikki Porter.

Summary: Veterans' health care needs may change due to changes in veteran demographics and other factors. Strategic planning, including identifying mission, vision, goals, and objectives, and operationalizing strategies to achieve those goals and objectives are essential for VHA to establish its strategic direction to respond to these changing demands and provide care in a dynamic environment. GAO was asked to review VHA's strategic planning. This report examines (1) VHA's strategic planning process and (2) the extent to which VHA operationalizes its strategic goals and objectives. GAO reviewed VHA strategic planning documents; and interviewed officials from VA and VHA central office, three VISNs selected to provide variation in geographic location, and nine VAMCs within these VISNs selected to provide variation in factors such as geographic location and facility complexity. GAO evaluated VHA's actions against federal standards for internal control and leading practices for strategic planning. The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) uses a multi-step strategic planning process to develop its strategic goals and objectives, which includes two key steps—(1) identifying and assessing factors that may affect health care delivery, which is referred to as environmental scanning, and (2) holding the annual National Leadership Council (NLC) Strategic Planning Summit—according to officials. VHA officials told GAO that they leverage VA's environmental scanning results in making decisions regarding VHA's strategic goals and objectives and that VA's central office has historically had a role in aspects of VHA's strategic planning process—such as participating in the NLC summit. VHA relies on the VA medical centers (VAMC) that directly provide care to veterans and the Veterans Integrated Service Networks (VISN), regional entities to which the VAMCs report, to operationalize its strategic goals and objectives. However, certain limitations in VHA's processes hinder VISNs' and VAMCs' efforts in operationalizing these goals and objectives. Specifically, VHA has not specified VAMCs' role and responsibilities in its strategic planning guidance, as it has for VISNs. For example, VHA's directive for VISNs clearly states how VISN directors are to operationalize VHA's operational plans; no such directive exists for VAMC officials. Similarly, VHA provided VISNs a strategic planning guide for operationalizing its current strategic plan, but did not provide a similar guide to the VAMCs. VHA has not developed detailed strategies for VISNs and VAMCs to use in operationalizing all of its strategic goals and objectives. According to leading practices for strategic planning, strategies should describe how strategic goals and objectives are to be achieved, including a description of the operational processes, staff skills, technology and other resources required. In September 2014, VHA published the Blueprint for Excellence to provide strategies for transforming VHA health care service delivery in response to concerns regarding the VHA wait-time crisis that year. However, it did not develop similar strategy documents for other years or for the other goals and objectives in its strategic plan. VHA does not have an effective oversight process for ensuring and assessing the progress of VISNs and VAMCs in meeting VHA's strategic goals and objectives. According to VHA officials, VHA relies on two methods for assessing performance towards meeting selected strategic goals and objectives. Specifically, VHA uses VISN and VAMC directors' individual annual performance plans, as well as veteran survey information, to assess VHA's performance towards meeting certain metrics, such as improving veterans' access. However, it is unclear how these specific metrics are linked to assessing overall progress towards VHA's strategic goals and objectives. As a result, VHA may not know to what extent VISNs' and VAMCs' efforts to operationalize its goals and objectives are adequately addressing top management concerns or department-wide strategic goals. GAO recommends that VHA (1) specify VAMCs' roles and responsibilities in operationalizing its strategic goals and objectives, (2) develop detailed strategies to operationalize its goals and objectives, and (3) develop an oversight process to assess progress made. VA concurred with GAO's recommendations.