VA Health Care: Office of the Medical Inspector Should Strengthen Oversight of Recommendations and Assess Performance
Fast Facts
VA's Office of the Medical Inspector investigates concerns about the quality of health care that the VA provides to veterans, such as reports of understaffing or improper patient scheduling practices in VA facilities. Most of the cases result in recommendations.
But the office relies on one staff person to decide if recommendations have been met—which means it could close recommendations without knowing if the VA fully addressed the underlying problems. Also, the office doesn't have performance goals that define what it expects to achieve or measures that will help assess progress towards these goals.
Our recommendations address these issues.
Highlights
What GAO Found
The Office of the Medical Inspector's mission is to investigate concerns about the quality of health care provided by the Veterans Health Administration (VHA). The office conducts investigations in response to referrals from other Department of Veterans Affairs (VA) and VHA components, and the U.S. Office of Special Counsel, which stem from concerns raised by whistleblowers and others. Such concerns are typically clinical in nature, such as concerns about improper equipment sterilization. The office reported opening between 25 and 74 cases each fiscal year from 2017 through 2022. Its authorized staffing levels were 20 full-time employees in 2022, but three of those positions were unfilled. Nearly all completed cases during the 6-year period resulted in recommendations for corrective action, which were typically made to VHA health care facilities.
For any given case, a clinical program manager within the Office of the Medical Inspector is responsible for determining (1) whether proposed corrective actions adequately address recommendations, and (2) when the actions have been completed, according to officials. However, the office does not conduct supervisory review of these determinations. Doing so would provide greater assurance that the recommendations are implemented to fully address the underlying concerns.
GAO found the Office of the Medical Inspector has not assessed its overall progress toward meeting its mission. Specifically, the office has not taken the three key performance management steps (see figure).
Steps to Assess Progress toward Meeting Mission
Office of the Medical Inspector officials indicated that timeliness and quality are important factors in conducting their work. However, the office has not established goals and performance measures that define the specific results it expects to accomplish—for example, related to timeliness or quality of various aspects of the office's work. As a result, the office does not know to what extent it is meeting its mission. Furthermore, establishing performance information would allow VHA leadership to more fully understand and assess how the office's work complements that of other oversight offices and help better ensure collective oversight and accountability across VHA's vast health care system.
Why GAO Did This Study
VHA operates one of the largest health care systems in the nation, serving about 9 million veterans annually. The Office of the Medical Inspector is one of several oversight offices within VHA and is responsible for investigating quality-of-care concerns at VHA health care facilities.
GAO was asked to review the Office of the Medical Inspector. Among other objectives, this report examines the office's (1) caseload and staffing levels, (2) process for determining whether recommendations have been implemented, and (3) efforts to assess its performance.
GAO examined the Office of the Medical Inspector's documentation, such as policies, and information about its cases, staffing levels, and recommendations from fiscal years 2017 through 2022 (the most recent information available at the time). GAO also interviewed officials from the Office of the Medical Inspector and other relevant VA offices.
Recommendations
GAO is recommending that the Office of the Medical Inspector (1) establish supervisory review for assessing recommendation implementation, (2) establish strategic goals and related performance goals, (3) establish performance measures and collect relevant information to measure progress toward goals, and (4) regularly use such information to assess progress toward goals and inform management decisions. VA concurred with the recommendations and identified steps to implement them.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Veterans Health Administration | The Medical Inspector should establish and document responsibilities for supervisory review as a part of OMI's process for determining (1) whether proposed action plans address the intent of OMI's recommendations, and (2) whether action plans have been successfully completed. (Recommendation 1) |
The VA concurred with this recommendation. In November 2023, OMI updated its standard operating procedures to include supervisory review responsibilities in relation to action plans. Specifically, OMI added language to reflect supervisory review by OMI leadership, stating that OMI leadership is to review proposed action plans and completed action plans to determine if the actions meet the intent of the recommendations and are sustainable. As such, we are closing this recommendation as implemented.
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| Veterans Health Administration | The VHA Under Secretary for Health should ensure that the Office of Medical Inspector establishes strategic goals and related performance goals. Such efforts should be in coordination with stakeholders, including the Under Secretary for Health and other VHA oversight offices. (Recommendation 2) |
VA concurred with this recommendation. In February 2024, OMI completed efforts to establish strategic and performance goals in coordination with stakeholders. Specifically, OMI provided documentation of its development of four strategic goals and four related performance goals. In developing its goals, OMI received input from VHA's Under Secretary for Health; Office for Oversight, Risk, and Ethics; Office of Integrity and Compliance; and VA's Office of the Secretary. As such, we are closing this recommendation as implemented.
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| Veterans Health Administration | The VHA Under Secretary for Health should ensure that the Office of Medical Inspector establishes performance measures and collects relevant information to measure progress toward established performance goals. (Recommendation 3) |
The VA concurred with this recommendation. In February 2024, the VA reported that OMI will develop performance measures once the office completes its ten-step process to establish strategic and performance goals, which includes the Under Secretary for Health's evaluation of these goals (the remaining step to be completed). In May 2024, VA reported that as OMI has established its strategic goals and performance goals, OMI was continuing to work to address the recommendation and updated its target completion date to March 2025. We will continue to monitor the agency's progress addressing the recommendation, including both its progress toward establishing performance measures and collecting relevant information to measure progress toward performance goals.
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| Veterans Health Administration | The VHA Under Secretary for Health should establish a process for regularly using performance information to assess progress toward established goals and inform management decisions. (Recommendation 4) |
The VA concurred with this recommendation. In February 2024, the VA reported that OMI will submit an annual report of its performance to the VHA Under Secretary for Health. The agency stated that OMI has decided to do this annually rather than semi-annually, as originally planned, because similar data has historically been collected on an annual basis. In May 2024, VA stated that the target completion date for OMI's first report, which will include data for fiscal year 2024, is March 2025. We will continue to monitor the agency's progress addressing the recommendation.
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