Veterans Health Care: Improvements Needed in Operationalizing Strategic Goals and Objectives
Fast Facts
How will VHA provide quality health care to veterans?
The Veterans Health Administration provided health care to 6.7 million veterans in fiscal year 2015. However, changes in the veteran population (such as more female veterans) could affect VHA's current strategies to provide quality health care. Effective strategic planning—such as identifying goals and methods to achieve them—can help VHA respond to the changing health care needs of veterans.
We reviewed VHA's strategic planning process and recommended that it clarify the responsibilities of VA's medical centers, and develop an oversight process.
Timeline of Factors that Have Affected or May Affect the Veterans Health Administration’s Strategic Goals and Objectives, during Fiscal Years 2013 – 2018
Timeline showing 13 reports, events, and strategic plans that may have affected VHA's goals.
Highlights
What GAO Found
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.
Why GAO Did This Study
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.
Recommendations
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.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Veterans Affairs | The Secretary of Veterans Affairs should direct the Under Secretary for Health to 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. |
In June 2017, VHA held its annual National Leadership Council (NLC) Strategic Planning Summit for VISN, Program Office, and VAMC leadership. The focus of the summit was to ensure a clear understanding of the five VA and VHA priorities and the individual components' roles and responsibilities in operationalizing the five priorities. Following this meeting, VHA developed and internally distributed the 2018-2019 VHA Modernization and Operational Planning Worksheet, which was intended to help VHA's organizational components (VAMCs, VISNs, and Program Offices) operationalize each of the strategies supporting the five VA and VHA Priorities. Specifically, VHA's components were instructed to identify strategies, milestones, leads, tactics, requirements, and dependencies that are necessary to operationalize those strategies for which the component has a leading or major supporting role. According to officials, this worksheet was used at VHA's Senior Leader Annual Business Meeting in September 2017, during which Program Office, VISN and VAMC leaders worked together to identify tactics for operationalizing the VA strategies and priorities.
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| Department of Veterans Affairs | The Secretary of Veterans Affairs should direct the Under Secretary for Health to 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. |
In April 2018, VHA published the Veterans Health Administration FY 2018-2019 Operational Plan; this plan outlines the specific strategies, resource requirements, roles and responsibilities, and milestones that will guide how VHA operationalizes VA's five priorities. Per the Department of Veterans Affairs Fiscal Year (FY) 2018-2024 Strategic Plan, the five priorities-(1) greater choice, (2) modernize systems, (3) focus resources, (4) improve timeliness, and (5) suicide prevention-define the operational focus of VA. VHA's process of identifying the specific strategies and tactics for operationalizing VA's five priorities was facilitated by the VHA Office of Policy and Planning, began with the 2017 NLC Strategic Planning Summit, and continued with subsequent NLC meetings and the 2017 Senior Leader Annual Business Meeting. During this process, Program Offices and VISNs were asked to submit individual operational plans that addressed VA's five priorities; the tactics, leads, dependencies, and requirements identified in these plans were synthesized into VHA's FY 2018-2019 Operational Plan.
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| Department of Veterans Affairs | The Secretary of Veterans Affairs should direct the Under Secretary for Health to 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. |
In October 2017, VHA distributed a memorandum, Fiscal Year 2018 Senior Executive Performance Management Guidelines - Responsibilities of Senior Executives and Rating and Reviewing Officials, with guidelines for establishing senior executive performance plans. Per this memorandum, Senior Executive performance plans are to include position-specific performance requirements that focus on measurable results--outputs and outcomes that can be measured in terms of quantity, quality, timeliness, or cost-effectiveness; are clearly aligned to strategic and/or organizational goals and objectives; facilitates Senior Executives in understanding how their performance aligns with organizational goal achievement; and can be cascaded to subordinates, to ensure alignment of performance. In addition to mid-year performance reviews, Senior Executives (and their rating officials) are also encouraged to engage in frequent two-way feedback that include conversations regarding progress; indicators of success and areas for improvement; obstacles that may impede progress towards achieving identified goals; and the need to revise the plan to account for changing objectives, priorities, and other factors that may affect performance.
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