Federal Health Care Center: VA and DOD Need to Address Ongoing Difficulties and Better Prepare for Future Integrations
GAO-16-280
Published: Feb 29, 2016. Publicly Released: Feb 29, 2016.
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Highlights
What GAO Found
The governance structure for the Captain James A. Lovell Federal Health Care Center (FHCC) demonstration—which includes leadership officials within the Departments of Veterans Affairs (VA) and Defense (DOD)—helped resolve collaboration problems with local leadership, but limitations with the FHCC's leadership selection and evaluation processes may impede future collaboration. For example, VA and DOD did not use—and have not yet developed—FHCC-specific criteria to select individuals for the facility's director (from VA) and deputy director (from the Navy) positions to ensure that they would be well suited for a collaborative environment. As GAO has previously reported, leaders who work successfully in a collaborative environment exhibit certain competencies, such as working well with others and communicating openly. Identifying specific selection criteria that include competencies for leading an integrated facility would help ensure that FHCC leadership have the necessary skills or experience to work well together.
Decisions regarding the integration of the FHCC's civilian and active duty workforce created difficulties with managing staffing across the facility. The FHCC did not initially conduct comprehensive, data-driven staffing analyses, which is not consistent with government best practices for workforce planning. As a result, the FHCC was unable to confirm that its workforce was appropriately aligned to maximize efficiency. According to DOD and Navy officials, this was due to a decision that the FHCC would initially maintain pre-integration staffing levels, and to the difficulty of projecting appropriate staffing levels during demonstration planning. In addition, management's ability to maximize efficiency was further impeded by a lack of data-driven staffing reviews due to data limitations, and a need to focus more intently on other integration requirements. In December 2015, FHCC officials told GAO they had developed an initiative in the interim for reviewing staffing until VA and DOD conduct a more formal, comprehensive, data-driven review of the FHCC's workforce.
The FHCC also faced difficulties integrating certain clinical and administrative operations, including information technology (IT). For example, although the Executive Agreement calls for the FHCC to utilize efficient processes, issues related to the IT infrastructure—which comprises three networks to accommodate differences in VA and DOD's network security standards—initially affected the functioning of some of the FHCC's local IT capabilities and impeded efficiency by limiting the ability of some providers and staff to consistently access VA and DOD's electronic health record systems. Although steps have been taken to improve the functioning of these capabilities, VA officials acknowledged that the FHCC's complex IT infrastructure has created difficulties with managing network connections and providing seamless access to software applications, among other issues. DOD officials said that they continue to work with VA to improve the reliability of the FHCC's IT infrastructure, such as through upgrades and expanding support for data sharing and interoperability. However, VA and DOD officials told GAO that the departments do not plan to resolve differences in network security standards to the extent that the FHCC would be able to have a single-network IT infrastructure. According to VA officials, this is due, at least in part, to the departments' different missions.
Why GAO Did This Study
The National Defense Authorization Act for Fiscal Year 2010 (NDAA 2010) authorized VA and DOD to establish a 5-year demonstration to integrate VA and Navy medical facilities into a first-of-its-kind FHCC in North Chicago, Illinois to provide health care to both VA and DOD beneficiaries. Requirements for the FHCC are outlined in an Executive Agreement.
The NDAA 2010, as amended, included a provision for GAO to review the FHCC demonstration, resulting in prior reports in 2011 and 2012. This third report assesses (1) the extent to which the FHCC governance structure and leadership processes facilitated collaboration, (2) difficulties, if any, that the FHCC faced in integrating the workforce, and (3) difficulties, if any, that the FHCC faced in integrating operations.
To conduct its work, GAO reviewed VA, DOD, and FHCC documents (such as the Executive Agreement), federal standards for internal control, and other sources of related best practices, and interviewed VA, DOD, Navy, and FHCC officials, including former and current leadership and over 100 staff.
Recommendations
GAO is making 8 recommendations, including that VA and DOD collaborate to establish selection criteria for FHCC leadership and that prior to future integration efforts, VA and DOD conduct data-driven strategic workforce planning and resolve differences in IT network security standards to the extent possible. VA and DOD concurred with all of GAO's recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Defense | The Secretaries of Veterans Affairs and Defense should collaborate to establish FHCC-specific selection criteria for the FHCC facility director and deputy director positions that include responsibilities and leadership competencies for effective collaboration. |
The FHCC Advisory Board, which includes VA and DOD/Navy officials, developed preliminary selection criteria for FHCC's Director (VA) and Deputy Director (DOD/Navy) positions and approved the criteria after they were formalized by the relevant Veterans Integrated Service Network (VISN) and Navy office. Specifically, VISN 12 was tasked by the FHCC Advisory Board with formalizing preliminary criteria for the FHCC Director position. The criteria formalized by VISN 12 include (among other things) the demonstration of interpersonal skills, flexibility, adaptability, and experience at a joint venture. According to VA, the criteria can and will be taken into consideration when reviews of applicants are conducted at the VISN level. The Navy Medicine Corps Chiefs Office-the office responsible for oversight and coordination of selection and assignments of Navy Medicine Officers to serve in leadership positions-was tasked by the FHCC Advisory Board with formalizing preliminary criteria for FHCC Deputy Director and Executive Officer positions. The criteria formalized by the office include (among other things) exceptional communication skills, political astuteness, experience with VA, and being a collaborator and consensus builder. The Navy added these criteria to its business rules, which will apply to the assignment of a new Deputy Director in summer 2018 and other assignments moving forward.
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| Department of Veterans Affairs | The Secretaries of Veterans Affairs and Defense should collaborate to establish FHCC-specific selection criteria for the FHCC facility director and deputy director positions that include responsibilities and leadership competencies for effective collaboration. |
The FHCC Advisory Board, which includes VA and DOD/Navy officials, developed preliminary selection criteria for FHCC's Director (VA) and Deputy Director (DOD/Navy) positions and approved the criteria after they were formalized by the relevant Veterans Integrated Service Network (VISN) and Navy office. Specifically, VISN 12 was tasked by the FHCC Advisory Board with formalizing preliminary criteria for the FHCC Director position. The criteria formalized by VISN 12 include (among other things) the demonstration of interpersonal skills, flexibility, adaptability, and experience at a joint venture. According to VA, the criteria can and will be taken into consideration when reviews of applicants are conducted at the VISN level. The Navy Medicine Corps Chiefs Office-the office responsible for oversight and coordination of selection and assignments of Navy Medicine Officers to serve in leadership positions-was tasked by the FHCC Advisory Board with formalizing preliminary criteria for FHCC Deputy Director and Executive Officer positions. The criteria formalized by the office include (among other things) exceptional communication skills, political astuteness, experience with VA, and being a collaborator and consensus builder. The Navy added these criteria to its business rules, which will apply to the assignment of a new Deputy Director in summer 2018 and other assignments moving forward.
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| Department of Defense | The Secretaries of Veterans Affairs and Defense should collaborate to ensure that the evaluation of the leadership performance at the FHCC is carried out jointly between VA and DOD. |
The FHCC Advisory Board, which includes VA and DOD/Navy officials, established processes to ensure each evaluation of the FHCC Director (a VA position) and Deputy Director (a DOD/Navy position) includes input from both VA and DOD/Navy. Specifically, the FHCC Advisory Board approved a process for the FHCC Director's performance evaluation that calls for the Commander for Navy Medicine East (within the Navy's Bureau of Medicine and Surgery) to review the FHCC's Director's self-assessment and provide written comments to the VISN 12 Network Director before the evaluation is finalized. The FHCC Advisory Board also approved a process for reviewing the performance of the FHCC Deputy Director that calls for input from the FHCC's Director, who is a senior VA official. It requires the FHCC Deputy Director to provide the FHCC Director with a copy of the draft fitness report and brag sheet and calls for the FHCC Director to provide written comments to the Commander for Navy Medicine East. The FHCC Director will be invited to participate in a discussion between the FHCC Deputy Director and Commander for Navy Medicine East. In addition, this process calls for the FHCC Director to participate in mid-term counseling between the FHCC Deputy Director and the Commander for Navy Medicine East and allows for the FHCC Director to be consulted for input if at any time the Commander for Navy Medicine East identifies performance concerns with the FHCC Deputy Director.
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| Department of Veterans Affairs | The Secretaries of Veterans Affairs and Defense should collaborate to ensure that the evaluation of the leadership performance at the FHCC is carried out jointly between VA and DOD. |
The FHCC Advisory Board, which includes VA and DOD/Navy officials, established processes to ensure each evaluation of the FHCC Director (a VA position) and Deputy Director (a DOD/Navy position) includes input from both VA and DOD/Navy. Specifically, the FHCC Advisory Board approved a process for the FHCC Director's performance evaluation that calls for the Commander for Navy Medicine East (within the Navy's Bureau of Medicine and Surgery) to review the FHCC's Director's self-assessment and provide written comments to the VISN 12 Network Director before the evaluation is finalized. The FHCC Advisory Board also approved a process for reviewing the performance of the FHCC Deputy Director that calls for input from the FHCC's Director, who is a senior VA official. It requires the FHCC Deputy Director to provide the FHCC Director with a copy of the draft fitness report and brag sheet and calls for the FHCC Director to provide written comments to the Commander for Navy Medicine East. The FHCC Director will be invited to participate in a discussion between the FHCC Deputy Director and Commander for Navy Medicine East. In addition, this process calls for the FHCC Director to participate in mid-term counseling between the FHCC Deputy Director and the Commander for Navy Medicine East and allows for the FHCC Director to be consulted for input if at any time the Commander for Navy Medicine East identifies performance concerns with the FHCC Deputy Director.
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| Department of Defense | The Secretaries of Veterans Affairs and Defense should collaborate to perform data-driven strategic workforce planning prior to implementing any future integration efforts. |
In January 2018, the FHCC Advisory Board, which includes VA and DOD/Navy officials, accepted a report produced by a joint VA and DOD workgroup. This report details a data-driven analysis of integrated FHCC workforce requirements. It identified several areas where the FHCC was potentially overstaffed, such as administrative support and some clinical functions. According to FHCC officials, this analysis will be incorporated into upcoming hiring plans as the FHCC works to implement the report's recommendations through additional study. While this analysis was performed after the FHCC's full integration, it demonstrates an ability for the departments to perform similar data-driven strategic workforce planning efforts prior to the implementation of future integration efforts. In addition, in a 2016 report to Congress, VA and DOD concluded that future integrations should only be considered when data-driven strategic workforce planning is performed.
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| Department of Veterans Affairs | The Secretaries of Veterans Affairs and Defense should collaborate to perform data-driven strategic workforce planning prior to implementing any future integration efforts. |
In January 2018, the FHCC Advisory Board, which includes VA and DOD/Navy officials, accepted a report produced by a joint VA and DOD workgroup. This report details a data-driven analysis of integrated FHCC workforce requirements. It identified several areas where the FHCC was potentially overstaffed, such as administrative support and some clinical functions. According to FHCC officials, this analysis will be incorporated into upcoming hiring plans as the FHCC works to implement the report's recommendations through additional study. While this analysis was performed after the FHCC's full integration, it demonstrates an ability for the departments to perform similar data-driven strategic workforce planning efforts prior to the implementation of future integration efforts. In addition, in a 2016 report to Congress, VA and DOD concluded that future integrations should only be considered when data-driven strategic workforce planning is performed.
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| Department of Defense | The Secretaries of Veterans Affairs and Defense should collaborate to determine how best to fill the FHCC's short-term staffing needs, including any additional statutory authorities that might be necessary to implement the desired approach. |
DOD concurred with this recommendation. VA and DOD coordinated to provide updates on progress toward implementing the recommendation due to the integrated nature of the FHCC. In January 2018, the FHCC Advisory Board, which includes VA and DOD officials, accepted a report detailing an analysis of the FHCC's integrated workforce. In July 2018, VA reported that it had also completed work on a white paper to detail the department's decision to pursue personal service contract (PSC) authority in order to address the FHCC's short-term staffing needs. Personal services contract (PSC) providers work on-site at military treatment facilities (MTFs), are integrated within the clinical departments, and are supervised by government personnel. Certain facilities at the FHCC are not currently designated MTF status, and the PSC authorizing statute currently limits the use of PSCs to support MTFs. The white paper indicates that the FHCC is submitting a legislative proposal requesting PSC authority for the FHCC to use only for deployments or untimely transfers of active duty personnel. FHCC is requesting the authority due to frequent transfers or deployments of active duty providers. In addition, the white paper indicates that the FHCC will utilize the results of the study on FHCC's workforce, received in January 2018, to adjust staffing levels in understaffed areas to address leave coverage and will continue utilizing VA Community Care for high demand services when there are provider shortages. The steps detailed in the white paper represent appropriate action to address this recommendation by detailing the decision to pursue PSC authority and utilize the results of a workforce study. Therefore we are closing the recommendation to reflect implementation.
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| Department of Veterans Affairs | The Secretaries of Veterans Affairs and Defense should collaborate to determine how best to fill the FHCC's short-term staffing needs, including any additional statutory authorities that might be necessary to implement the desired approach. |
VA concurred with this recommendation and provided updates--in coordination with DOD because of the integrated nature of the FHCC--on progress toward implementing it. In January 2018, the FHCC Advisory Board, which includes VA and DOD officials, accepted a report detailing an analysis of the FHCC's integrated workforce. In July 2018, VA reported that it had also completed work on a white paper to detail the department's decision to pursue personal service contract (PSC) authority in order to address the FHCC's short-term staffing needs. Personal services contract (PSC) providers work on-site at military treatment facilities (MTFs), are integrated within the clinical departments, and are supervised by government personnel. Certain facilities at the FHCC are not currently designated MTF status, and the PSC authorizing statute currently limits the use of PSCs to support MTFs. The white paper indicates that the FHCC is submitting a legislative proposal requesting PSC authority for the FHCC to use only for deployments or untimely transfers of active duty personnel. FHCC is requesting the authority due to frequent transfers or deployments of active duty providers. In addition, the white paper indicates that the FHCC will utilize the results of the study on FHCC's workforce, received in January 2018, to adjust staffing levels in understaffed areas to address leave coverage and will continue utilizing VA Community Care for high demand services when there are provider shortages. The steps detailed in the white paper represent appropriate action to address this recommendation by detailing the decision to pursue PSC authority and utilize the results of a workforce study. Therefore we are closing the recommendation to reflect implementation.
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| Department of Defense | The Secretaries of Veterans Affairs and Defense should collaborate to resolve differences in IT network security standards to the extent possible prior to implementing any future integration efforts. |
DOD concurred with this recommendation and has worked with VA to implement it. Most notably, in November 2019, DOD and VA signed an overarching Memorandum of Agreement (MOA) based on both departments' decisions to use the same commercial off-the-shelf electronic health record (EHR) system and ancillary applications. To facilitate interoperability, this agreement included the decision to extend DOD's Medical Community of Interest information technology (IT) network that is currently in deployment to all military treatment facilities to support the connection of VA sites. This network is intended to meet both departments' connectivity security requirements. In addition, the MOA states that the departments shall establish overarching interconnection security agreements as appropriate covering the connections between DOD and VA IT systems needed to fully implement and sustain the Medical Community of Interest network, among other requirements. This MOA, while focused on the joint EHR, supports other sharing use cases, including but not limited to joint facility sharing, such as with the FHCC.
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| Department of Veterans Affairs | The Secretaries of Veterans Affairs and Defense should collaborate to resolve differences in IT network security standards to the extent possible prior to implementing any future integration efforts. |
VA concurred with this recommendation and has worked with DOD to implement it. Most notably, in November 2019, DOD and VA signed an overarching Memorandum of Agreement (MOA) based on both departments' decisions to use the same commercial off-the-shelf electronic health record (EHR) system and ancillary applications. To facilitate interoperability, this agreement included the decision to extend DOD's Medical Community of Interest information technology (IT) network that is currently in deployment to all military treatment facilities to support the connection of VA sites. This network is intended to meet both departments' connectivity security requirements. In addition, the MOA states that the departments shall establish overarching interconnection security agreements as appropriate covering the connections between DOD and VA IT systems needed to fully implement and sustain the Medical Community of Interest network, among other requirements. This MOA, while focused on the joint EHR, supports other sharing use cases, including but not limited to joint facility sharing, such as with the FHCC.
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| Department of Veterans Affairs | The Secretary of Veterans Affairs should take steps to ensure that the FHCC is able to systematically monitor the reasons for referrals to non-VA medical care. |
VA added a new option to the drop down menu in VistA's user interface that allows a provider to indicate that a beneficiary is being referred to non-VA medical care because of the Executive Agreement's patient priority system. The addition of the drop down menu option also enabled the FHCC to search for, and report on, referrals made based on this justification. In July 2016, VA officials reported that the FHCC had successfully monitored providers' utilization of the new drop down menu option, which indicated that some providers made referrals based on the patient priority system from February through June 2016. This monitoring confirmed that two clinics had reached capacity, and as a result, they were prioritizing active duty servicemembers and referring veterans to non-VA medical care, as required by the Executive Agreement's patient priority system. As a result, the FHCC is better equipped to ensure it meets the medical readiness goal for Navy recruits.
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| Department of Defense | The Secretaries of Veterans Affairs and Defense should direct FHCC leadership to provide routine training to civilian managers, who supervise active duty staff on the West Campus, on how to effectively utilize such staff, particularly Navy hospital corpsmen. |
In 2016, FHCC officials developed a mandatory training for all supervisors on the effective utilization of Navy hospital corpsmen. The training covers several objectives, including general hospital corpsmen training, rank structure, chains of command, and typical duties. The training also explains how hospital corpsmen can be utilized within FHCC clinics and clarifies how the corpsman's experience at the FHCC should prepare them for future service duties. According to VA officials, this training was assigned to all FHCC supervisors through VA's Talent Management System and must be taken annually. According to VA officials, as of June 19, 2017, 99 percent of all civilian supervisors had completed the training.
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| Department of Veterans Affairs | The Secretaries of Veterans Affairs and Defense should direct FHCC leadership to provide routine training to civilian managers, who supervise active duty staff on the West Campus, on how to effectively utilize such staff, particularly Navy hospital corpsmen. |
In 2016, FHCC officials developed a mandatory training for all supervisors on the effective utilization of Navy hospital corpsmen. The training covers several objectives, including general hospital corpsmen training, rank structure, chains of command, and typical duties. The training also explains how hospital corpsmen can be utilized within FHCC clinics and clarifies how the corpsman's experience at the FHCC should prepare them for future service duties. According to VA officials, this training was assigned to all FHCC supervisors through VA's Talent Management System and must be taken annually. According to VA officials, as of June 19, 2017, 99 percent of all civilian supervisors had completed the training.
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| Department of Defense | The Secretaries of Veterans Affairs and Defense should direct FHCC leadership to provide additional guidance on the patient priority system to all staff responsible for approving consults and ensure that the monthly capability and capacity reports include information on all categories of FHCC patients defined by the patient priority system. |
In 2016, the FHCC created a scheduling guide for Medical Support Assistants (MSA) responsible for scheduling patient appointments, which included guidance on the patient priority system and provided MSAs with a patient priority desk reference for quick access to the priorities. In addition, required trainings were developed for all FHCC staff that defines the patient priority system, its categories, and how they should be utilized. As of June 19, 2017, 99 percent of all required staff had completed the assigned training. In addition, the monthly capability and capacity reports include information on all categories of FHCC patients as defined by the patient priority system.
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| Department of Veterans Affairs | The Secretaries of Veterans Affairs and Defense should direct FHCC leadership to provide additional guidance on the patient priority system to all staff responsible for approving consults and ensure that the monthly capability and capacity reports include information on all categories of FHCC patients defined by the patient priority system. |
In 2016, the FHCC created a scheduling guide for Medical Support Assistants (MSA) responsible for scheduling patient appointments, which included guidance on the patient priority system and provided MSAs with a patient priority desk reference for quick access to the priorities. In addition, required trainings were developed for all FHCC staff that defines the patient priority system, its categories, and how they should be utilized. As of June 19, 2017, 99 percent of all required staff had completed the assigned training. In addition, the monthly capability and capacity reports include information on all categories of FHCC patients as defined by the patient priority system.
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