VA Medical Centers: VA Should Establish Goals and Measures to Enable Improved Oversight of Facilities' Conditions
Fast Facts
The Veterans Health Administration oversees one of the nation's largest healthcare systems, serving about 9 million veterans at numerous facilities, including 170 medical centers.
To ensure a safe environment for veterans and employees, VHA must keep its facilities clean and well maintained. This can be a challenge given their substantial capital repair and improvement needs.
VHA's Environment of Care Program is an important part of its efforts to ensure its facilities are regularly inspected and meet standards. We recommended VHA develop ways to better measure the program's effectiveness and target areas in need of improvement.
This is a photo of a VA medical center.
Highlights
What GAO Found
Veterans Health Administration's (VHA) medical centers conduct regular inspections of the settings in which patients receive health care services, called the “environment of care”, to identify maintenance and repair needs. These inspections also help ensure compliance with accreditation standards requiring, among other things, that utility systems operate properly and that areas are clean and in good repair. The main three steps in the process associated with these inspections are shown below. In addition to the environment of care inspections, VHA conducts other periodic assessments of facilities' major systems, such as plumbing and air conditioning.
The Three Main Steps of the Environment of Care Inspection Process
VHA inspections routinely identify deficiencies reflective of an aging infrastructure—VHA's buildings are on average 55 years old. This situation in turn is leading to workload and staffing challenges in addressing maintenance and repair needs. For example, according to VHA's 2017 data, medical centers reported conducting approximately 11,000 total inspections for the year that resulted in about 128,000 identified deficiencies. Most of these deficiencies were closed within 14 business days, as required by VHA. However, nearly 30,000 of them were not closed or had been addressed through a plan for future work. Medical center officials added that correcting deficiencies may only be a temporary solution for issues related to aging structures that need extensive repairs and renovations. In addition, VA headquarters and field officials said that staff vacancies are common and can affect the efficiency and speed of maintenance and repairs.
VHA provides guidance and selected oversight to ensure medical centers implement the process for environment of care inspections. However, VHA lacks performance goals, objectives, and measures that would enable it to provide effective oversight, address challenges, and assess how well it is achieving a clean, safe, and functional environment. As part of ensuring compliance with the inspection process, VHA measures whether medical centers meet certain requirements, such as having appropriate staff present for inspections. VHA does not, however, have measures that enable it to assess how well medical centers are achieving desired outcomes. Although it has stated its intent to develop such measures, VHA has not yet committed to a time frame for doing so.
Why GAO Did This Study
VHA oversees one of the largest health care systems, serving approximately 9-million veterans at numerous health care facilities, including 170 medical centers. To ensure a safe environment for veterans and employees, VHA must keep its facilities clean and well maintained.
GAO was asked to examine (1) how VHA medical centers identify maintenance and repair needs and challenges they face in addressing those needs, and (2) to what extent VHA provides oversight to ensure medical centers are providing a safe, clean, and functional environment.
GAO reviewed VHA's procedures and standards related to facility operations and maintenance functions at medical centers and interviewed VHA's administrative office officials regarding oversight of these functions. GAO also interviewed VHA officials from three regional offices and six medical centers selected based on factors such as geographic location and veteran population served, and conducted site visits at four of these medical centers.
Recommendations
GAO recommends that VHA set a timeline for defining goals, objectives, and outcome-oriented performance measures that can address challenges and help achieve a clean and safe care environment. VA concurred with the recommendation and provided general and technical comments, which GAO incorporated as appropriate.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Veterans Health Administration | The Undersecretary for Health should set a timeline for defining goals, objectives, and outcome-oriented performance measures for the Environment of Care Program. (Recommendation 1) |
VHA oversees one of the largest health care systems, serving approximately 9 million veterans at numerous health care facilities, including 170 medical centers. To ensure a safe environment for veterans and employees, VHA must keep its facilities clean and well maintained. VHA medical centers conduct regular inspections of the settings in which patients receive health care services, called the "environment of care," to identify maintenance and repair needs. In 2018, GAO reported that while VHA provides guidance and oversight to ensure medical centers implement the environment of care inspection process, it lacked performance goals, objectives, and measures that would enable it to assess how well it is achieving its policy of a clean, safe, and functional environment. GAO had previously found that results-oriented organizations set performance goals to define desired program outcomes and develop performance measures that are clearly linked to these performance goals and outcomes. VHA's performance measures were not tied to specific performance goals for the Environment of Care Program, as such goals had not yet been created. Nor did these performance measures provide useful information on the actual condition of facilities or desired outcomes. VHA had stated it intended to create goals and objectives for the Environment of Care Program, along with performance measures to assess whether the goals and objectives are being achieved, but it had not yet done so. Absent clear goals, objectives, and performance measures, and a timeline for developing them, VHA would continue to be limited in its ability to assess how effective the program is at ensuring a safe, clean, and functional environment. Therefore, GAO recommended that VHA set a timeline for defining goals, objectives, and outcome-oriented performance measures for the Environment of Care Program. In 2019, GAO confirmed that VHA had developed a timeline for implementing outcome-oriented performance measures for the environment of care program; VHA's timeline indicated that it would propose the performance measures to the Comprehensive Environment of Care Steering Committee in the first quarter of fiscal year 2019, and that it would roll out the performance measures across VHA in the third and fourth quarters of fiscal year 2020. In 2020, GAO confirmed that VHA had implemented these new outcome-oriented performance measures and had defined program goals. According to VHA, the program's primary goal is to provide a safe, clean, and high quality environment for veterans, their families, visitors, and employees in VHA healthcare facilities, and to maintain facilities in accordance with accreditation standards; federal, state, and local regulatory requirements; and Department of Veterans Affairs requirements, directives, and procedures. The program's performance measures are aimed at achieving this overarching goal by ensuring that employees identify and document maintenance and repair needs in a timely manner; providing transparency at the local, regional, and national levels of VHA regarding maintenance and repair needs; and encouraging facilities to take additional steps to address persistent and ongoing maintenance issues. With these goals, objectives and performance measures to guide its actions, VHA will be better positioned to provide oversight and assess how well it is ensuring that its medical facilities are clean, safe, and well maintained.
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