Major Management Challenges at the Department of Veterans Affairs

Overall, the Department of Veterans Affairs (VA) has made progress in addressing the five key management challenges GAO identified in 2003, though GAO has not reported on VA's role in preventing and responding to biological and chemical acts of terrorism since 2003. However, VA continues to be challenged to improve access to health care to its enrolled population, including a growing elderly veteran population and a population of new veterans from the conflicts in Iraq and Afghanistan. While VA has continued to make progress in improving disability claims processing, modernizing federal disability programs remains on GAO's high-risk list due to the use of outmoded criteria and remaining challenges in VA's claims processing. Additional actions are needed for VA to successfully overcome financial management weaknesses and information technology management challenges.

VA is challenged to ensure that its enrolled veteran population has access to quality health care that is both timely and convenient. While VA continues to open community- based outpatient clinics, VA identified a large number of geographic areas where veterans face long travel times to access VA outpatient care in its recently completed study conducted as part of its efforts to realign resources. To improve access, VA needs to strategically plan how best to use its resources and funding to provide equitable access to veterans needing acute care services, while also providing a growing elderly veteran population with institutional and noninstitutional long-term care services. VA also faces challenges in making blind rehabilitation and mental health care services, including those for post-traumatic stress disorder, more widely available to its enrolled veteran population. GAO made and VA concurred with recommendations to ensure more complete data for program monitoring and the availability of a range of long-term care, blind rehabilitation, and mental health programs services to veterans. In addition, VA must also ensure the safety of veterans in two ways. First, GAO recommended that VA conduct more thorough screening of the personal and professional backgrounds of health care providers to minimize the chance of patients receiving care from providers who may be incompetent or who may intentionally harm them. Second, VA needs to strengthen its human subject protections program by addressing continuing weaknesses in the program. VA created a task force to review its screening policies for health care employees, and its research offices have updated VA's human subject protections policies.

VA confronts an accelerating need to manage resources and workload by finding more efficient ways to meet veterans' increasing demand for health care. Through its Capital Asset for Realignment for Enhanced Services (CARES) process, VA is working toward realigning its capital assets, primarily buildings, to better serve veterans' needs. VA has completed a market-based plan for restructuring its delivery of health care. As a result of CARES, VA will increase the number of community-based clinics, improve access to inpatient care, and modernize outdated facilities. However, VA has many obstacles to overcome before the restructuring of its health care delivery system is a reality. In addition, VA must continually assess the demand for its services so that it can adequately plan for the number of eligible veterans seeking care. In response to GAO's recommendations, VA has taken steps to better allocate comparable resources for comparable workloads by expanding the number of allocation categories in its Veterans Equitable Resource Allocation System and by incorporating into the allocation system better workload measures. While VA is becoming more efficient, it must continue its efforts to streamline and improve service delivery. In particular, VA and the Department of Defense (DOD) need to find additional efficiencies through increased sharing of resources and joint purchasing of drugs and medical supplies. VA and DOD are continuing to work together to identify opportunities for increased efficiency in service delivery.

While GAO has not reported on this issue since January 2003, VA has taken a number of steps to help ensure that its facilities and staff are prepared to respond to emergency situations, including biological and chemical acts of terrorism . In addition, VA's broader role as a support agency in the event of a national emergency depends upon a larger governmentwide discussion of homeland security issues.

VA faces continuing challenges in improving its veterans' disability program. Although some progress has been made, VA is still far from meeting its timeliness goal. GAO made, and VA concurred with, recommendations on ways to improve the timeliness and accuracy of disability claims decisions and compensation. VA needs to address concerns about possible inconsistencies in disability claims decisions made by its 57 regional offices and better report and use the data on the accuracy of its decisions. In addition, VA needs to provide more transparency in its justification for staffing levels in the disability compensation and pension program and use better staff attrition data and analysis in its workforce planning. VA concurred with GAO's recommendations to improve various aspects of its workforce planning. Overall, VA will need to continue seeking solutions to providing meaningful and timely support to veterans with disabilities, including balancing its cash assistance with vocational rehabilitation and employment services. Additional information on modernizing federal disability programs can be found in High-Risk Series: An Update ( GAO-05-207 ).

VA continues to face challenges in developing departmentwide management strategies to build a high-performing organization. VA continues to address two long-standing financial management weaknesses in the areas of information systems security and financial management system integration. Inadequate information security controls continue to place VA's sensitive financial and veteran medical information at risk of inadvertent or deliberate misuse or fraudulent use. The lack of an integrated financial management system continues to impede VA's ability to prepare, process, and analyze financial information to support the timely preparation of its financial statements. These material internal control weaknesses also contribute to VA's lack of substantial compliance with federal financial management systems requirements under the Federal Financial Management Improvement Act of 1996. While VA is making progress in improving its security posture, significant actions are still needed, including certifying and accrediting more than half of its 871 systems, improving configuration management, and implementing an intrusion detection system. Additionally, after unsuccessfully piloting a new integrated financial system, VA is reevaluating its current plans for the new system. In the interim, task groups will investigate the feasibility of developing tools to support the effective and efficient preparation of financial statements. GAO made recommendations to improve VA's internal controls over selected operational areas, and VA is planning to implement most of these recommendations.

VA's commitment to addressing critical information technology (IT) management weaknesses has been evident, although challenges to improving key areas of IT performance remain. The department continues to define products and processes essential to the development of an integrated, departmentwide enterprise architecture—a blueprint for systematically and completely defining its current and desired IT environment—and it is taking steps to improve effective management of its IT investments. However, key documentation critical to effectively implementing and managing the architecture needs to be finalized, and policies and guidance for ensuring sound management of VA's investment portfolio need to be completed. VA also faces the challenge of establishing performance measures that show how well its IT initiatives support veterans' benefits programs. Additionally, in conjunction with DOD, VA is proceeding with efforts to share electronic health information for veterans and active-duty service members, but faces the challenge of clearly defining its strategy and technological approach to realize this exchange of information. GAO made recommendations to help ensure progress in achieving the health information exchange, which the two departments agreed with and have planned or undertaken actions to address.

Related GAO Products

Ensure Access to Quality Health Care

VA Long-Term Care: Oversight of Nursing Home Program Impeded by Data Gaps . GAO-05-65 . Washington, D.C.: November 10, 2004.

VA Long-Term Care: More Accurate Measure of Home-Based Primary Care Workload Is Needed . GAO-04-913 . Washington, D.C.: September 8, 2004.

VA Health Care: VA Needs to Improve Accuracy of Reported Wait Times for Blind Rehabilitation Services . GAO-04-949 . Washington, D.C.: July 22, 2004.

VA Health Care: More Outpatient Rehabilitation Services for Blind Veterans Could Better Meet Their Needs . GAO-04-996T . Washington, D.C.: July 22, 2004.

Department of Veterans Affairs: Federal Gulf War Illnesses Research Strategy Needs Reassessment . GAO-04-767 . Washington, D.C.: June 1, 2004.

VA Health Care: Improved Screening of Practitioners Would Reduce Risk to Veterans. GAO-04-566 . Washington, D.C.: March 31, 2004.

VA Health Care: Veterans at Risk from Inconsistent Screening of Practitioners. GAO-04-625T . Washington, D.C.: March 31, 2004.

VA Health Care: Access for Chattanooga-Area Veterans Needs Improvement . GAO-04-162 . Washington, D.C.: January 30, 2004.

VA Long-Term Care: Changes In Service Delivery Raise Important Questions . GAO-04-425T . Washington, D.C.: January 28, 2004.

VA Health Care: Further Efforts Needed to Improve Hepatitis C Testing for At-Risk Veterans . GAO-04-106 . Washington, D.C.: December 12, 2003.

VA Health Care: Adequacy of Resident Supervision Is Not Assured, but Plans Could Improve Oversight . GAO-03-625 . Washington, D.C.: July 2, 2003.

VA Research: Actions Insufficient to Further Strengthen Human Subject Protections . GAO-03-917T . Washington, D.C.: June 18, 2003.

VA Long-Term Care: Veterans' Access to Noninstitutional Care is Limited by Service Gaps and Facility Restrictions . GAO-03-815T . Washington, D.C.: May 22, 2003.

VA Long-Term Care: Service Gaps and Facility Restrictions Limit Veterans' Access to Noninstitutional Care . GAO-03-487 . Washington, D.C.: May 9, 2003.

Department of Veterans Affairs: Key Management Challenges in Health and Disability Programs . GAO-03-756T . Washington, D.C.: May 8, 2003.

VA Health Care: Improvements Needed in Hepatitis C Disease Management Practices . GAO-03-136 . Washington, D.C.: January 31, 2003.

Manage Resources and Workload to Enhance Health Care Delivery

VA and DOD Health Care: Efforts to Coordinate a Single Physical Exam Process for Servicemembers Leaving the Military . GAO-05-64 . Washington, D.C.: November 12, 2004.

Veterans Health Administration-Appropriations for CARES Cost Comparison Studies. B-302973 . Washington, D.C.: October 6, 2004.

VA and Defense Health Care: More Information Needed to Determine If VA Can Meet an Increase in Demand for Post-Traumatic Stress Disorder Services. GAO-04-1069 . Washington, D.C.: September 20, 2004.

VA and DOD Health Care: Resource Sharing at Selected Sites. GAO-04-792 . Washington, D.C.: July 21, 2004.

VA Health Care: Guidance Needed for Determining the Cost to Collect from Veterans and Private Health Insurers. GAO-04-938 . Washington, D.C.: July 21, 2004.

VA Health Care: Resource Allocations to Medical Centers in the Mid South Healthcare Network . GAO-04-444 . Washington, D.C.: April 21, 2004.

DOD and VA Health Care: Incentives Program for Sharing Resources. GAO-04-495R . Washington, D.C.: February 27, 2004.

Veterans Affairs: Posthearing Questions Regarding the Departments of Defense and Veterans Affairs Providing Seamless Health Care Coverage to Transitioning Veterans . GAO-04-294R . Washington, D.C.: November 25, 2003.

Veterans Affairs: Posthearing Questions Concerning the Departments of Defense and Veterans Affairs Providing Seamless Health Care Coverage to Transitioning Veterans . GAO-04-292R . Washington, D.C.: November 24, 2003.

VA Health Care: Framework for Analyzing Capital Asset Realignment for Enhanced Services Decisions . GAO-03-1103R . Washington, D.C.: August 18, 2003.

VA Health Care: Contract Labor Cost Analysis in RAND Study . GAO-03-579R . Washington, D.C.: June 30, 2003.

DOD and VA Health Care: Access for Dual Eligible Beneficiaries. GAO-03-904R . Washington, D.C.: June 13, 2003.

VA Health Care: VA Increases Third-Party Collections as It Addresses Problems in Its Collections Operations. GAO-03-740T . Washington, D.C.: May 7, 2003.

Whether Department of Veterans Affairs Memorandum is a Rule Under the Congressional Review Act. B-291906 . Washington, D.C.: February 28, 2003.

VA Health Care: Third-Party Collections Rising as VA Continues to Address Problems in Its Collections Operations. GAO-03-145 . Washington, D.C.: January 31, 2003.

Improving Veterans' Disability Program

Veterans Benefits: VA Needs Plan for Assessing Consistency of Decisions . GAO-05-99 . Washington, D.C.: November 19, 2004.

Veterans' Benefits: More Transparency Needed to Improve Oversight of VBA's Compensation and Pension Staffing Levels. GAO-05-47 . Washington, D.C.: November 15, 2004.

VA Vocational Rehabilitation and Employment Program: GAO Comments on Key Task Force Findings and Recommendations . GAO-04-853 . Washington, D.C.: June 15, 2004.

Veterans' Benefits: Improvements Needed in the Reporting and Use of Data on the Accuracy of Disability Claims Decisions. GAO-03-1045 . Washington, D.C.: September 30, 2003.

VA Benefits: Fundamental Changes to VA's Disability Criteria Need Careful Consideration. GAO-03-1172T . Washington, D.C.: September 23, 2003.

Veterans Benefits Administration: Process for Preventing Improper Payments to Deceased Veterans Can Be Improved. GAO-03-906 . Washington, D.C.: July 24, 2003.

Department of Veterans Affairs: Key Management Challenges in Health and Disability Programs . GAO-03-756T . Washington, D.C.: May 8, 2003.

Veterans Benefits Administration: Better Collection and Analysis of Attrition Data Needed to Enhance Workforce Planning. GAO-03-491 . Washington, D.C.: April 28, 2003.

Veterans Benefits Administration: Better Staff Attrition Data and Analysis Needed. GAO-03-452T . Washington, D.C.: February 11, 2003.

Developing Sound Departmentwide Management Strategies to Build a High-Performing Organization

VA Medical Centers: Internal Controls over Selected Operating Functions Needs Improvement . GAO-04-755 . Washington, D.C.: July 21, 2004.

VA Medical Centers: Internal Control Weaknesses Impair Third-Party Collections. GAO-04-967T . Washington, D.C.: July 21, 2004.

VA Medical Centers: Further Operational Improvements Could Enhance Third-Party Collections . GAO-04-739 . Washington, D.C.: July 19, 2004.

Health Care: National Strategy Needed to Accelerate the Implementation of Information Technology . GAO-04-947T . Washington, D.C.: July 14, 2004.

Contract Management: Further Efforts Needed to Sustain VA's Progress in Purchasing Medical Products and Services . GAO-04-718 . Washington, D.C.: June 22, 2004.

Veterans Health Administration: Inadequate Controls over the Purchase Card Program Resulted in Improper and Questionable Purchases . GAO-04-857T . Washington, D.C.: June 17, 2004.

Computer-Based Patient Records: VA and DOD Efforts to Exchange Health Data Could Benefit from Improved Planning and Project Management . GAO-04-687 . Washington, D.C.: June 7, 2004.

VHA Purchase Cards: Internal Controls Over the Purchase Card Program Need Improvement . GAO-04-737. Washington, D.C.: June 7, 2004.

Computer-Based Patient Records: Improved Planning and Project Management Are Critical to Achieving Two-Way VA-DOD Health Data Exchange . GAO-04-811T . Washington, D.C.: May 19, 2004.

Computer-Based Patient Records: Subcommittee Questions Concerning VA and DOD Efforts to Achieve a Two-Way Exchange of Health Data . GAO-04-691R . Washington, D.C.: May 14, 2004.

Computer-Based Patient Records: Sound Planning and Project Management Are Needed to Achieve a Two-Way Exchange of VA and DOD Health Data. GAO-04-402T . Washington, D.C.: March 17, 2004.

Information Technology Management: Governmentwide Strategic Planning, Performance Measurement, and Investment Management Can Be Further Improved. GAO-04-49 . Washington, D.C.: January 12, 2004.

Computer-Based Patient Records: Short-Term Progress Made, but Much Work Remains to Achieve a Two-Way Data Exchange Between VA and DOD Health Systems. GAO-04-271T . Washington, D.C.: November 19, 2003.