At the local level, VHA’s delivery system is organized into 18 VISNs, each responsible for overseeing VAMCs within a defined geographic area. VISN directors report to the Deputy Under Secretary for Health (USH) for Operations and Management who oversees VHA’s field operations. The Deputy USH for Operations and Management also serves as the focal point between VHA’s central office and the VISNs and VAMCs. Within VHA’s central office, policy management roles are divided between multiple offices. VHA’s central office is responsible for national policies developed by individual program offices—approximately 145 program offices as of May 2017. These program offices may have clinical or administrative functions and vary in the number of policies that they develop and manage. To help standardize national policy processes and reduce the burden on program office subject matter experts, VHA’s Office of Regulatory and Administrative Affairs (ORAA) manages the national policy development and review process. As of June 2017, ORAA had about four full-time- equivalent staff assigned to national policy management. These staff are primarily responsible for shepherding documents through the policy review process, providing policy-writing expertise, and working with relevant VHA subject matter experts within individual program offices to develop or update policies. Through its policy-development process, ORAA aims to reduce variability, simplify the process, and ensure any issues are identified and vetted prior to final approval. ORAA advises responsible program offices about their policies, but does not have the authority to require their compliance to complete policy-related tasks. ORAA also tracks and reports policy, procedural, and timeliness requirements, and is responsible for ongoing process improvement. It collaborates with the Office of Policy and Services on policy management activities and with the Office of Organizational Excellence on high-risk areas of concern. See figure 1 for VHA’s key leadership positions related to policy management. VHA Directive 6330 governs the organization’s policy management; the June 2016 revisions established clearer definitions for national policy and guidance documents. It also updated VHA’s policy drafting and submission processes, as well as its requirements for policy issuance and recertification. Specifically, the revised directive defines national policy as a document that “establishes a definite course of action for VHA and assigns responsibilities for executing that course to identifiable individuals or groups.” The directive stipulates that two primary document types are to be used for national policy—directives and notices: Directives are to be used to establish national policy and contain certain types of information, such as the roles and responsibilities for each component of the organization. Notices are to be used to communicate information about a one-time event (e.g., rescinding a current national policy) or to establish interim policy until a directive can be developed. The directive also states that a memo signed by the USH can be used to establish policy for VHA’s central office, but not for VISNs and VAMCs. Additionally, VHA Directive 6330 states that guidance is not national policy and defines guidance as “recommendations that inform strong practices within the organization and are supported by evidence, legal requirements, national policy, or organizational priorities.” It states that guidance includes recommendations for implementing statutes, regulations, or national policy. Guidance documents include program office memos, standard operating procedures, and other such documents that are not signed by the USH. VHA Directive 6330 establishes a 5-year recertification date for directives, while notices have an automatic 1-year expiration period. VHA has not established recertification time frames for guidance documents. We found that VHA is in the process of reviewing existing national policy documents to align with its new policy definitions as outlined in Directive 6330. It began reviewing documents in October 2015 in response to our high-risk concerns related to policy management, and this effort has evolved over time. Specifically, ORAA initiated a process of reviewing 788 documents previously issued as national policy—directives, handbooks, manuals, and information letters—the majority of which were outdated. However, existing guidance documents, such as program office memos, have not been included in this review because there is no central repository that would facilitate their identification, and the number of these documents is unknown. In addition, ORAA officials told us that they do not have enough staff to review these additional documents. (See figure 2.) Through its review process, ORAA intends to streamline the number and types of policy documents used by the organization. (See table 1.) ORAA is eliminating handbooks, manuals, and information letters, although they will continue to function as national policy until rescinded. As part of this effort, ORAA plans to move any relevant content to other policy and guidance documents as appropriate. For example, ORAA is incorporating handbooks into their related directives. VHA noted that this consolidation should help reduce any redundancy and inconsistency when multiple documents articulate different aspects of a single policy. This will also help VHA ensure that when national policy is updated, the update will also include a review of relevant information currently found in other policy documents. Officials from many of the VISNs and VAMCs in our review agreed that a single document source for policy information would be helpful. ORAA officials noted that the definitions for what constitutes national policy and guidance documents are still evolving. According to our review of ORAA information, almost 60 percent of the 788 policy documents identified for transition under the new definitions were outdated in October 2015. As part of its transition, ORAA is taking outdated documents and either rescinding them or recertifying the ones that are still relevant. VHA’s recertification process involves assessing whether a national policy document still serves a purpose and should be updated accordingly, or is no longer needed and should be rescinded or combined with another policy. Officials from most VISNs and VAMCs in our review told us that unless a policy has been rescinded, they continue to follow it, even if past its recertification date. This practice is consistent with requirements in the revised VHA Directive 6330 and a memo signed by the USH in June 2016. ORAA officials expect that transitioning VHA’s existing policy documents will take about 5 years. As of June 2017, ORAA reduced the total number of documents identified for transition by 193 (from 788 to 595), and 43 percent of these remaining documents (256 of 595) are outdated. (See figure 3.) Much of the reduction has been driven by rescinding manuals and information letters. The number of directives and handbooks has not changed substantially; this is due, in part, to the continuation of policies reaching their recertification dates and the publication of new or changed policies. ORAA officials said that its limited progress is also due to resource constraints, such as insufficient staffing, funding, and inadequate information technology capability. Because ORAA does not own the policies, officials noted that they must rely on the responsible program offices to comply with policy-related tasks. Contrary to the new national policy definitions in VHA Directive 6330, program offices continue to issue policy using memos—an issue we also noted in our high-risk update in 2017. Officials from every program office in our review told us that they have continued to use memos to issue policy quickly. ORAA officials stated this may be due to the lengthy national policy review process, which they said took an average of 317 days in fiscal year 2016. Program offices use memos for a variety of purposes, including clarifications or updates to issued directives, data collection requests, information about policies or procedures while a directive is under development, and the provision of training information. Memos signed by the Deputy USH for Operations and Management— referred to as “10N” memos—are the most common type of program office memo we identified in our review. Historically, VHA has primarily used 10N memos to communicate with VISNs and VAMCs because the Deputy USH for Operations and Management oversees local operations. ORAA officials stated that program office memos were never intended to serve as national policy. Specifically, VHA Directive 6330 states that a notice should be used to establish interim policy until a directive can be developed. However, VHA has mostly used notices to issue rescissions of previous policy documents, and memos continue to be used to establish policy. For example, we identified a 10N memo that instructed VAMCs to immediately implement changes to ongoing professional practice evaluations and peer review requirements for VAMC chiefs of staff. In another instance, officials at one VAMC noted that, at the time of our visit, they had already received 32 changes to the Veterans Choice Program since 2014 through non-policy documents, including memos. Using program office memos—instead of the appropriate policy vehicle— to issue policy is problematic in light of VHA’s new policy and guidance document definitions. Additionally, unlike national policy, program office memos are not internally vetted and are not subject to recertification, as described below. Lack of internal vetting. Memos are not subject to a formal review process and can be issued quickly once signed. VHA noted in its high-risk action plan that 10N memos are the predominant source of guidance documents, and have been used to create policy without being vetted by other agency offices or VA’s labor management relations group. Without such a vetting process, VHA leadership and other officials in the organization do not always have input on or even awareness of the potential impact of policy issued through these memos. Further, some of the VISNs and VAMCs in our review cited concerns about contradictory information among related program office memos. Not subject to recertification. Unlike national policy documents, memos are not subject to recertification and are therefore typically not rescinded.