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. 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. 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. 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. 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. 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. 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. 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.) 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. 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. 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. 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. 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. 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. 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.? 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) 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.

Summary: 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. 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. 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.