VA Real Property: Improvements in Facility Planning Needed to Ensure VA Meets Changes in Veterans' Needs and Expectations
Fast Facts
VA provides medical services to a veteran population that is growing older and more diverse. These demographic shifts will drive changes in veterans’ needs and expectations, and require adjustments to VA medical facilities. We looked at how VA is incorporating these changes into its planning efforts.
We found that:
VA is not fully assessing veterans' changing expectations
Local VA planners do not fully trust or use VA estimates on future space needs for their medical facilities
We recommended that VA work to better incorporate veterans' changing needs and expectations into its facilities planning efforts.
One of 172 VA Medical Centers
A VA Medical Center
Highlights
What GAO Found
The Department of Veterans Affairs (VA) analyzes demographic trends to assess veterans' future health-care needs, such as the need for more long-term care or women's health care services. VA does not, however, systematically collect data concerning whether demographic groups differ in their expectations for how they will receive care, such as whether some groups expect different levels of privacy. VA officials said they gauge expectations by surveying veterans and talking to veterans service organizations. GAO's review, however, found the amount of information VA collected through these methods is limited. Without robust data about veterans' expectations and assessing how changes would affect facilities' space needs, VA cannot readily anticipate and adapt to meet veterans' changing expectations—a goal in its FY 2018–2024 Strategic Plan .
In addition to identifying meeting veterans' changing needs and expectations as a national strategic goal, VA defined a national set of VA-delivered core medical services called “foundational health services” to, in part, meet veterans' expectations of consistent care offerings across VA medical centers (VAMC) and also to focus VA's resources on its highest priority services. However, based on GAO's survey of VAMCs and discussions with selected facility-planning officials, GAO found that VA did not clearly instruct VAMCs in how to apply VA's strategic goal or foundational health services to facility planning. Accordingly, more than three quarters of VAMC facility-planning officials responding to GAO's survey indicated additional instruction from VA for the strategic goal and foundational health services would be useful. Without providing clear instruction, VA increases its risk that its strategic goal and foundational health services are not meeting their objective to incorporate veterans' changing needs and expectations.
Most facility-planning officials had concerns with using estimated space needs derived from VA's Strategic Capital Investment Planning (SCIP) process, which converts estimated needs for veterans' health care into future space needs for the VAMCs. Specifically, the officials (1) did not understand how the SCIP process converts health care needs into physical space and (2) questioned how accurately the space estimates reflected the future health-care needs for local facilities. For example, 72 percent of facility-planning officials responding to GAO's survey reported that at least one of SCIP's 12 space category estimates was “generally inaccurate” at reflecting projected space needs for their facility. As a result, instead of relying on SCIP's space estimates as a starting point to incorporate veterans' changing needs into facility planning, VAMC facility planners told GAO that they may instead use locally identified health care needs and priorities to determine space needs. Without a process for VA to understand and address concerns about the SCIP process, VAMCs may spend time and resources on capital projects that do not necessarily meet veterans' future needs as VA intended. This approach may therefore impede VA's ability to respond to veterans needs as this population changes.
Why GAO Did This Study
VA provides for care to over 9-million veterans in its health care system, including 172 VAMCs. As veterans' demographics shift, such as by age or gender, their needs for health care and their expectations for how they receive that care may also change. Along with the VA MISSION Act of 2018, which requires VA to assess its facilities for realignment and modernization, these changes could have implications for VA's capital-planning efforts.
GAO was asked to review how VA incorporates veterans' changing needs and expectations into facility planning. This report examines: (1) VA's efforts to assess trends in veterans' future needs and expectations; (2) VA's efforts to help VAMCs address these changes through facility planning; and (3) how VAMCs use VA's process for identifying facilities' future space needs.
GAO surveyed all VAMCs, visited nine VAMCs, reviewed VA's planning documents and data, and interviewed officials from VA and veterans service organizations. GAO's survey response rate was 99 percent.
Recommendations
GAO recommends VA: (1) assess changes in veterans' expectations; (2) instruct facility planners on how to incorporate veterans' changing needs and expectations; (3) clarify foundational health services implementation; and (4) assess concerns with the SCIP process and make needed adjustments. VA agreed with GAO's recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Veterans Affairs | To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations develop and implement a process to assess veterans' changing expectations and disseminate this information to VAMCs. (Recommendation 1) |
The Department of Veterans Affairs (VA) provides for care to over 9 million veterans in its health care system, including 172 VA medical centers (VAMC). As veterans' demographics shift, such as by age or gender, their needs for health care and their expectations for how they receive that care may also change. Such a change will have implications for VA's capital-planning efforts that are primarily undertaken by the VAMCs. GAO visited nine VAMCs. In 2019, GAO reported that VA analyzes information about the needs of different veterans' groups and their demographic data to assess veterans' future needs for care. While VA uses information about the needs of different groups in combination with demographic data to assess trends in veterans' future needs, it does not systematically collect data concerning how, if at all, demographic groups differ in their expectations for how they would like to receive care. VA officials told GAO that they learn about veterans' changing expectations through surveys and conversations with veterans service organizations (VSO). GAO found, however, that the information VA collects through these efforts may be limited based on its review of VA's surveys and our discussions with five VSOs. VA's FY 2018-2024 Strategic Plan noted the requirement for VA to solicit veteran feedback and to continuously adapt benefits and care offerings to meet their changing needs and expectations but did not offer clear definitions or instructions on how to meet the changing expectations portion. In addition, federal standards for internal control state that agencies should use quality information to achieve their objectives. Absent clear definitions and instructions, VA told GAO it uses surveys and interactions with VSOs to obtain information about veterans' satisfaction with aspects of their care. GAO's review of VA's surveys, however, found that VA may be limited in its ability to systematically assess trends in veterans' expectations due to the lack of explicit questions and measures of expectations for many types of VA health-care services-based on the definition of expectations provided by VA. VA also lacks a process for assessing veterans changing expectations. Without robust data about veterans' expectations and assessing how changes would affect facilities' space needs, VA cannot readily anticipate and adapt to meet veterans' changing expectations. Therefore, GAO recommended that VA develop and implement a process to assess veterans' changing expectations and disseminate this information to VAMCs. However, at the time of our review, VA officials said that VA could provide better clarity to VAMCs by either better defining what it meant by "meeting veterans' changing expectations" or by removing the requirement as a strategic goal. In 2023, we determined that VA had removed the requirement in its strategic plan. Specifically, VA's previous strategic goal for VAMCs was to "meet veterans needs and changing expectations," but its FY 2022-28 Strategic Plan updated its strategic objective by removing the element of the goal to "meet veterans' changing expectations." While this change did not create a process for assessing veteran expectations or communicate it to VAMCs, it addressed the underlying condition which caused uncertainty at VAMCs in a way that implemented the spirit of our recommendation. Removing the need to "meet veterans' changing expectations" as a goal will help VAMCs better know how to manage their facilities by clarifying VA's goals for delivering timely, accessible, high-quality benefits to meet the unique needs of veterans.
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| Department of Veterans Affairs |
Priority Rec.
To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations instruct VAMCs on how to meet VA's strategic goal of incorporating veterans' changing needs and expectations into facility planning, such as by identifying certain resources or tools and directing VAMCs to use them. (Recommendation 2) |
VA provides for care to over 9 million veterans in its health care system, including 172 VA medical centers (VAMC). As veterans' demographics shift, their needs for health care and their expectations for how they receive that care may also change. Such a change will have implications for VA's capital-planning efforts that are primarily undertaken by the VAMCs. GAO surveyed facility-planning officials from all VAMCs and visited nine VAMCs. In 2019, GAO reported that VA made soliciting and using veterans' changing needs and expectations a strategic goal. However, VA had not provided instruction to VAMC facility-planning officials on how to incorporate veterans' needs and expectations into their facility planning. For example, VA could identify certain resources or tools and direct VAMCs to use them. Federal standards for internal control state that management should internally communicate the necessary quality information to achieve the entity's objectives, i.e., implementing its strategic goal. Based on GAO's survey of VAMCs and discussions with selected facility-planning officials, GAO found that VA did not clearly instruct VAMCs in how to apply VA's strategic goal to facility planning. Accordingly, 87 percent of VAMC facility-planning officials responding to GAO's survey indicated additional instruction from VA for the strategic goal would be useful. Without clear, internal communication explaining how it expects its stated goals to be achieved, VA cannot reasonably ensure that VAMCs' future facility plans are designed to meet veterans' changing needs and expectations. Therefore, GAO recommended that VA ensure the appropriate offices and administrations instruct VAMCs on how to meet VA's strategic goal of incorporating veterans' changing needs and expectations into facility planning. In 2023, GAO concluded that VA took two actions that implemented this recommendation. First, in January 2020, VA issued guidance to VAMCs, which instructed them to use VA's Health Systems Planning Application as a resource to ensure that facility planning is consistent with veterans' changing needs. This application provides the VAMCs a source for obtaining information on VA's assessment of veterans' changing needs, which the VAMCs have been instructed to use in their facility planning. Second, in April 2022, VA released its Fiscal Year 2022-28 Strategic Plan which, among other things, modified its strategic goals. These modifications included removing references to "changing expectations" from the goal related to anticipating veterans' needs to improve their health care experiences, thus eliminating the need for VA to instruct VAMCs on how to incorporate veterans' changing expectations into facility planning. This simplification of the goal provides more clarity to VAMCs regarding how VA expects the modified goal to be achieved. As a result, VA is better positioned to ensure its VAMCs are incorporating veterans' changing needs into future facility plans.
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| Department of Veterans Affairs | To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations provide additional instruction to VAMCs on how to incorporate the concept of foundational health services into facility planning. (Recommendation 3) |
The Department of Veterans Affairs (VA) provides for care to over 9 million veterans in its health care system, including 172 VA medical centers (VAMC). GAO surveyed facility-planning officials at all VAMCs across the country. In 2019, GAO reported that at the national level, VA selected a set of core medical services called "foundational health services," in part, according to VA officials, to meet veterans' expectations of consistent care offerings across VAMCs, and also to focus its resources on its highest priority services. Based on its survey of VAMCs and discussions with selected facility-planning officials, GAO found that VA did not provide clear instruction to facility-planning officials on how to incorporate foundational and non-foundational-those services not defined as foundational-health services into their facility planning. Without this instruction, VAMC facility-planning officials said they were unsure how foundational services fit into facility planning or even if foundational services would continue to be a priority under the then-current leadership-a concern that VA officials also shared. Specifically, GAO found that some facility-planning officials were unsure if they should plan to provide all foundational services or if they should propose facility projects for spaces that provided services that were not included on the list of foundational services identified in VA's instructions. Therefore, GAO recommended that VA ensure the appropriate offices and administrations provide additional instruction to VAMCs on how to incorporate the concept of foundational health services into facility planning. In 2021, GAO confirmed that VA took sufficient action to address the intent of this recommendation. Specifically, in 2019, VA reported that its Office of the Deputy Under Secretary for Health for Operations and Management had evaluated the instructions on foundational services and determined it would rescind the whole concept of foundational services. In 2020, VA rescinded the concept, which included the associated instructions, and directed VAMCs not to incorporate the foundational services concept in facility planning. By rescinding the concept, VA also eliminated the uncertainty of facility-planning officials regarding how foundational services fit into facility planning. This action gives facility-planning officials the clarity they need to focus on understanding their local veterans' needs and expectations and incorporating them into VAMC facility planning.
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| Department of Veterans Affairs |
Priority Rec.
To improve VA's ability to plan for and align its facilities with estimated changes to veterans' needs and expectations, we recommend that the Secretary of Veterans Affairs ensure the appropriate offices and administrations systematically gather feedback from facility planners and address (as necessary) their concerns with the reliability of the SCIP process, including providing additional information on how SCIP's space estimates are derived. (Recommendation 4) |
The Department of Veterans Affairs (VA) provides for care to over 9 million veterans in its health care system, including 172 VA medical centers (VAMC). GAO surveyed facility-planning officials at all VAMCs across the country. In 2019, GAO reported that VA uses its Strategic Capital Investment Planning (SCIP) process-which converts estimated needs for veterans' health care into future space needs for the VAMCs-to identify facilities' future needs for space, but VAMC facility-planning officials have concerns about the SCIP estimates. In speaking to and surveying facility-planning officials at VAMCs, GAO found most do not fully understand the calculation of the SCIP space estimates, and to some extent questioned their reliability and usefulness. Further, VAMC facility-planning officials believe that some SCIP space estimates do not accurately reflect the projected needs for their facilities, and some have reported large annual variations in the estimates. As a result, instead of using SCIP space estimates as a starting point to incorporate veterans' changing needs, VAMC facility planners may instead rely on local priorities, such as those identified by VAMC management or through feedback from local veterans, including VA's national level satisfaction surveys of veterans. VAMC facility planners' concerns can result in inconsistent use of SCIP estimates across the VAMCs and diminish the ability to equitably and systematically assess needs. Unless VA officials work with the VAMC facility-planning officials to understand and address their concerns with the SCIP process, VA may not have all the necessary information and the facility-planning officials may continue to miss out on an opportunity to incorporate veterans' changing needs. Therefore, GAO recommended that VA ensure the appropriate offices and administrations systematically gather feedback from facility planners and address (as necessary) their concerns with the reliability of the SCIP process. In 2020, GAO confirmed that VA provided information to VAMC facility-planning officials to address their concerns with the reliability of the SCIP process by adding an explanation of how SCIP space estimates are derived for both clinical and non-clinical space, as well as what was expected for gap closure for these spaces. Furthermore, VA issued and completed a field survey to ensure that users understood key concepts, including gauging whether they wanted more training. Using the result of this survey, VA's Office of Asset Enterprise Management created an online training video that will be hosted on a VA server that describes how space gaps are calculated. Through these actions, VA is better positioned to help VAMC facility-planning officials understand SCIP estimates and address their related concerns.
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