VA Health Care: Actions Needed to Improve Oversight of Community-Based Outpatient Clinics
Fast Facts
Community-based outpatient clinics are an increasingly important part of the Department of Veterans Affairs’ health care system, providing millions of veterans with services like primary and mental health care. Most of them are operated by VA, but others are operated by contractors.
We found weaknesses in VA's oversight of community-based outpatient clinics, leading us to make four recommendations to help ensure veterans receive the same standard of care regardless of whether a clinic is operated by VA or by a contractor.
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Highlights
What GAO Found
Community-based outpatient clinics (CBOC) are an important part of the Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) health care delivery system. These clinics are geographically separate from VA medical centers (VAMC) and provide outpatient services, including primary care and mental health care. GAO found weaknesses in VHA's oversight of CBOCs:
Incomplete policy implementation. VHA has not implemented certain CBOC oversight requirements as outlined in its policy. Specifically, VHA has not developed guidelines for monitoring the quality and comprehensiveness of care in CBOCs and officials said they have no plans to do so. Officials told GAO they believe the requirement was met as part of their regular oversight of Veterans Integrated Service Networks (VISN)—regional networks responsible for oversight of VAMCs and CBOCs. However, VHA may miss CBOC performance problems that are not identifiable in VISN-level data. Further, although policy requires VHA central office officials to review CBOC performance as part of quarterly VISN performance reviews, officials said they do not specifically do so unless the VISN identifies a problem. Officials from three of the four VISNs in GAO's review said they largely delegate CBOC oversight to VAMCs, and do not separately review clinic performance unless a VAMC identifies a problem.
An inaccurate and incomplete CBOC Report. VHA's CBOC Report is prepared by VHA central office and distributed to VISNs and VAMCs quarterly and at year-end. The CBOC Report could be useful to compare clinical quality of care between VHA-operated and contracted CBOCs, but it is inaccurate and incomplete. Specifically, VHA officials have used their judgment to classify certain sites as CBOCs in the report, rather than use the official classifications in policy. GAO found that 22 percent of sites were incorrectly classified as CBOCs when they were other types of sites, including VAMCs. As a result, the report is of limited usefulness to VHA as an oversight tool.
Lack of guidance or training on the CBOC Report. VHA central office officials do not provide guidance or training specific to understanding the CBOC Report to assist VISNs and VAMCs in their oversight of CBOCs. GAO found that in several places in the report, shorthand text and acronyms were used, but not defined. In addition, several VISN and VAMC officials stated that guidance or training would be helpful.
No requirement to use the CBOC Report. VHA officials told GAO that VAMCs and VISNs are expected to use the CBOC Report as an oversight tool, but GAO found that VHA lacks a requirement that they do so. Officials from three of the four VISNs and three of the four VAMCs in GAO's review were not using the report.
These weaknesses potentially lead to inconsistent oversight and create a risk that VHA is not providing one standard of care that is of high quality to veterans across VHA-operated and contracted CBOCs.
Why GAO Did This Study
In fiscal year 2016, VHA's 733 CBOCs provided care to more than 3 million veterans at a cost of $5.3 billion. Although most of these clinics are VHA-owned and -operated, 101 are operated through contracts with non-VHA organizations. VHA policy states that CBOCs, whether VHA-operated or contracted, must provide one standard of care that is of high quality.
GAO was asked to review VHA's use of contracts to carry out core functions. This report examines, among other issues, the extent to which VHA oversees CBOC operations.
To conduct this work, GAO reviewed VHA's policies and CBOC Report. GAO also interviewed officials from VHA's central office and from a nongeneralizable sample of eight CBOCs and their four respective VAMCs and VISNs. The CBOCs were selected for variation in factors such as contract status and geographic area.
Recommendations
GAO recommends that VHA (1) implement oversight requirements that align with existing policy; (2) establish a process to ensure the CBOC Report is accurate and complete; (3) provide guidance or training to VISNs and VAMCs on how to use the CBOC Report; and (4) require use of the CBOC Report as an oversight tool. VA concurred with all of GAO's recommendations and identified actions it is taking to implement them.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Office of the Under Secretary for Health | The VHA Undersecretary for Health should implement oversight requirements that align with VHA's existing policy, including developing guidelines for monitoring quality of care in CBOCs. (Recommendation 1) |
VA concurred with this recommendation. In November 2018, the Veterans Health Administration (VHA) issued a memorandum to all Veterans Integrated Service Network (VISN) Directors and Chief Medical Officers that required VISN and VA Medical Center directors to consistently use the Community-Based Outpatient Clinics (CBOC) Report (which was developed to monitor quality of care in CBOCs), including incorporating reviews of the CBOC Report as a standing item in quality committee meetings. The memo also required designating a local official as responsible for monitoring the CBOC report, as well as regular VISN monitoring to ensure that medical centers take corrective actions when non-adherence to the use of the report is identified. VHA also provided evidence in July 2019 that all VISNs had attested to their compliance with the requirements of the memo. As a result, we consider this recommendation implemented.
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| Office of the Under Secretary for Health | The VHA Undersecretary for Health should establish a process for regularly updating the CBOC Report to ensure it contains an accurate and complete list of CBOCs that is consistent with VHA's established site classifications. (Recommendation 2) |
VA concurred with this recommendation. In February 2019, the Veterans Health Administration (VHA) reported that it had changed the methodology for the Community-Based Outpatient Clinics (CBOC) Report (which was developed to monitor quality of care in CBOCs) to pull outpatient site classifications from the VAST system, which is VHA's authoritative source for site classifications. The CBOC Report was also renamed as the "Outpatient Quality of Care in the Department of Veterans Affairs Sites of Care" report, and now reports data on CBOCs as well as Other Outpatient Sites and VA Mobile clinics. Officials confirmed these sites will be included as long as they have reported data for the quality of care measures included in the report. In addition, VA officials stated that annual updates to the VAST classification model will ensure accurate site classification so that the outpatient sites of care report will reflect an accurate and complete list of CBOCs. As a result of these actions, we consider this recommendation closed.
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| Office of the Under Secretary for Health | The VHA Undersecretary for Health should ensure that VISNs and VAMCs receive guidance or training on how to use the CBOC Report. (Recommendation 3) |
VA concurred with this recommendation and in June 2018 reported its actions to implement it. Specifically, the VHA Office of Performance Measurement's Office of Reporting, Analytics, Performance, Improvement, and Deployment (RAPID) provided guidance regarding the availability and use of the CBOC Report during its monthly Performance Measurement Office Hours National Call on May 9, 2018. Officials could not confirm exact VISN/VAMC attendance, but believe the call included good representation from VISNs and VAMCs as officials at those levels are invited to the calls. In addition, the Assistant Deputy Under Secretary for Health for Clinical Operations, supported by Performance Measurement, provided guidance and training on the use of the CBOC Report during a quarterly Face to Face Conference on May 17-18, 2018 for national and VISN-level clinical leadership. Finally, officials noted that information on RAPID's calls and presentations are accessible on internal webpages. We also found that in the updated CBOC Report VHA sent, RAPID had updated the documentation of the CBOC Report's methodology to include more details about the sources used. We stated in our report that the methodology previously did not make it clear that the measures in the report are derived from a standardized dataset that officials could receive training on. There are now links to provide more information about these data sources in the methodology section. Because of these actions, we consider this recommendation implemented.
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| Office of the Under Secretary for Health | The VHA Undersecretary for Health should require the use of the CBOC Report as an oversight tool for ensuring one standard of care that is of high quality across VHA-operated and contracted CBOCs. (Recommendation 4) |
VA concurred with this recommendation. In November 2018, the Veterans Health Administration (VHA) issued a memorandum to all Veterans Integrated Service Network (VISN) Directors and Chief Medical Officers that required VISN and VA Medical Center directors to consistently use the Community-Based Outpatient Clinics (CBOC) Report (which was developed to monitor quality of care in CBOCs) as an oversight tool. This memo included requirements such as incorporating reviews of the CBOC Report as a standing item in quality committee meetings, as well as incorporating the CBOC report into all VISN quarterly performance reviews with medical centers. It also required regular VISN monitoring to ensure that medical centers take corrective actions when non-adherence to the use of the report is identified. VHA also provided evidence in July 2019 from all VISNs attesting to their compliance with the requirements of the memo. As a result, we consider this recommendation implemented.
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