[Senate Hearing 115-323]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 115-323

      GAO'S HIGH-RISK LIST AND THE VETERANS HEALTH ADMINISTRATION

=======================================================================

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 15, 2017

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
                               __________
                               

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         Available via the World Wide Web: http://www.fdsys.gov
                     COMMITTEE ON VETERANS' AFFAIRS

                   Johnny Isakson, Georgia, Chairman

Jerry Moran, Kansas                  Jon Tester, Montana, Ranking 
John Boozman, Arkansas                   Member
Dean Heller, Nevada                  Patty Murray, Washington
Bill Cassidy, Louisiana              Bernard Sanders, (I) Vermont
Mike Rounds, South Dakota            Sherrod Brown, Ohio
Thom Tillis, North Carolina          Richard Blumenthal, Connecticut
Dan Sullivan, Alaska                 Mazie K. Hirono, Hawaii
                                     Joe Manchin III, West Virginia

                  Thomas G. Bowman, Staff Director \1\
                  Robert J. Henke, Staff Director \2\
                Tony McClain, Democratic Staff Director

                      Majority Professional Staff
                            Amanda Meredith
                             Gretchan Blum
                            Leslie Campbell
                            Maureen O'Neill
                               Adam Reece
                             David Shearman
                            Jillian Workman

                      Minority Professional Staff
                            Dahlia Melendrez
                            Cassandra Byerly
                                Jon Coen
                              Steve Colley
                               Simon Coon
                           Michelle Dominguez
                             Eric Gardener
                               Carla Lott
                              Jorge Rueda


\1\ Thomas G. Bowman served as Committee majority Staff Director 
through September 5, 2017, after being confirmed as Deputy Secretary of 
Veterans Affairs on August 3, 2017.
\2\ Robert J. Henke became the Committee majority Staff Director on 
September 6, 2017.
                            
                            
                            C O N T E N T S

                              ----------                              

                             March 15, 2017
                                SENATORS

                                                                   Page
Tillis, Hon. Thom, U.S. Senator from North Carolina..............     1
Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana......     1
Rounds, Hon. Mike, U.S. Senator from South Dakota................    29
Murray, Hon. Patty, U.S. Senator from Washington.................    31
Boozman, Hon. John, U.S. Senator from Arkansas...................    33

                               WITNESSES

Draper, Debra A., Ph.D., Director, Health Care Team, Government 
  Accountability Office..........................................     2
    Prepared statement...........................................     5
    Response to posthearing questions submitted by:
      Hon. Jon Tester............................................    37
      Hon. Mazie K. Hirono.......................................    39
      Hon. Sherrod Brown.........................................    40
Missal, Michael J., Inspector General, U.S. Department of 
  Veterans Affairs; accompanied by John D. Daigh, Jr., M.D., CPA, 
  Assistant Inspector General for Healthcare Inspections, Office 
  of Inspector General...........................................    14
    Prepared statement...........................................    15
    Response to posthearing questions submitted by:
      Hon. Jon Tester............................................    43
      Hon. Mazie K. Hirono.......................................    44
      Hon. Joe Manchin III.......................................    44
      Hon. Sherrod Brown.........................................    45
Clancy, Carolyn M., M.D., Deputy Under Secretary for Health for 
  Organizational Excellence, Veterans Health Administration, U.S. 
  Department of Veterans Affairs; accompanied by Jennifer Lee, 
  M.D., Deputy Under Secretary for Health for Policy and 
  Services; and Amy Parker, Executive Director of Operations, 
  Office of Management...........................................    21
    Prepared statement...........................................    22
    Response to request arising during the hearing by:
      Hon. Thom Tillis...........................................    27
      Hon. Jon Tester............................................    28
      Hon. Patty Murray..........................................    32
    Response to posthearing questions submitted by:
      Hon. Jon Tester............................................    46
      Hon. Richard Blumenthal....................................    49
      Hon. Mazie K. Hirono.......................................    50
      Hon. Joe Manchin III.......................................    51
      Hon. Sherrod Brown.........................................    53

 
      GAO'S HIGH-RISK LIST AND THE VETERANS HEALTH ADMINISTRATION

                              ----------                              


                       WEDNESDAY, MARCH 15, 2017

                                       U.S. Senate,
                           Committees on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:30 p.m. in room 
418, Russell Senate Office Building, Hon. Thom Tillis, 
presiding.
    Present: Senators Boozman, Rounds, Tillis, Tester, Murray, 
and Brown.

            OPENING STATEMENT OF HON. THOM TILLIS, 
                U.S. SENATOR FROM NORTH CAROLINA

    Senator Tillis. I call the hearing to order. Thank you all 
for being here. Senator Isakson is out today and I will be 
standing in. Senator Boozman is at a meeting where he should be 
joining us and taking the gavel shortly.
    We all continue to wish the very best for Senator Isakson 
who is recovering from back surgery. He submitted a statement 
in a prior meeting. Although the reality is I am wearing this 
bow tie, which is a University of Georgia bow tie, because I am 
repaying a bet that I lost, but since I am sitting in his chair 
for a little bit today I am going to say I am doing it in honor 
of Senator Isakson.
    I would like to welcome the witnesses. Then, we are going 
to defer to Senator Tester to allow him to make his opening 
statement. He has a meeting outside, in the anteroom, which we 
will let him move to. I want to thank the witnesses on the 
panel today.
    Senator Tester, I will wait until after your opening 
statement, in the interest of time, to introduce the witnesses.

             OPENING STATEMENT OF HON. JON TESTER, 
           RANKING MEMBER, U.S. SENATOR FROM MONTANA

    Senator Tester. Thank you, Chairman Tillis. I very much 
appreciate the hospitality, and thank you all for being here 
today.
    As many of you know, we had a hearing on GAO's High-Risk 
List a few weeks ago at the Homeland Security and Government 
Affairs Committee. During the questioning of the Comptroller, 
Gene Dodaro, who is a guy that I like a lot, who works really 
tirelessly to help agencies work more effectively and save 
taxpayer dollars, he told me that he was very concerned about 
the VA's reaction to its inclusion on the list.
    Chief among his concerns is that the VA did not seem to 
move--did not seem overly interested in doing what it takes to 
be removed from that High-Risk List. Now that is something that 
should concern the panelists and something that should concern 
everybody. Dr. Clancy, I would love to hear from you whether 
the VA is being productive in addressing those GAO concerns and 
whether there is an appropriate sense of urgency, because, I 
want to tell you, the fact that the VA has not fully met the 
action plan for getting off the list is worrisome in and of 
itself.
    Meanwhile, recent reports from the VA Inspector General, 
including one about VA in Montana that was released late last 
week, indicate that the problems that caused GAO to add it to 
this list are still occurring. According to that report--and 
the IG is here--according to that report, the IG found that 
steps have been taken to improve consult time, in addition, and 
address factors that contribute to future delays at Fort 
Harrison in Montana, but that is little solace to the four 
veterans who are identified in that report as being potentially 
harmed by the consult backlog.
    On behalf of them and the veterans seeking care at 
facilities across this country, we need to do better, the VA 
has to do better. I think you guys realize that, but I want you 
to know.
    I will hold everybody at the VA accountable for this. 
Secretary Shulkin knows this, and he also knows we will hold 
everybody in the leadership team accountable too, including the 
team at Fort Harrison.
    If done right, VA's action and response to the GAO concerns 
can leave that agency and, more importantly, the veterans of 
this country in a better place, which is what we want. We want 
the best services and care for our veterans.
    I want to thank you again for calling this hearing. It is 
always good to work with the good Senator from North Carolina. 
This is an important topic and I think it has bipartisan 
support.
    Senator Tillis. Thank you, Senator Tester.
    We are welcoming to the panel today Debra Draper, Ph.D., 
Director, Health Care Team, Government Accountability Office; 
Michael Missal, Inspector General, Department of Veterans 
Affairs. I think that he is accompanied by Dr. John Daigh--did 
I pronounce that correctly?--Assistant Inspector General for 
Healthcare Inspections, Office of the Inspector General; 
Carolyn M. Clancy, M.D., Deputy Under Secretary for Health for 
Organizational Excellence, Department of Veterans Affairs; 
Jennifer Lee, M.D., Deputy Under Secretary for Health for 
Policy and Services, Department of Veterans Affairs; and Amy 
Parker, Executive Director of Operations, Office of Management, 
Department of Veterans Affairs.
    If you all would like to begin with your opening 
statements; we will just go from left to right. If we can keep 
those tight so we can get to questions I would appreciate it.

  STATEMENT OF DEBRA A. DRAPER, Ph.D., DIRECTOR, HEALTH CARE 
          TEAM, U.S. GOVERNMENT ACCOUNTABILITY OFFICE

    Ms. Draper. Chairman Tillis, Ranking Member Tester, and 
Members of the Committee. I appreciate the opportunity to be 
here today to discuss the status of veterans' health care as a 
high-risk area. In my testimony today, I will focus on the 
concerns that led to this designation, what actions VA has 
taken in response, and what additional actions are needed to 
ensure progress and eventual removal from the list.
    Veterans' health care was added to GAO's High-Risk List for 
the first time in 2015, because of concerns about VA's ability 
to ensure the timeliness, cost-effectiveness, quality, and 
safety of the care provided to veterans. In designating 
veterans' health care as high risk, we categorize our specific 
concerns into five categories: (1) ambiguous policies and 
inconsistent processes; (2) inadequate oversight and 
accountability: (3) information technology challenges; (4) 
inadequate training for VA staff; and (5) unclear resource 
needs and allocation priorities.
    At the time, we were also concerned that VA had not 
implemented more than 100 GAO recommendations related to 
veterans' health care, and many had been open for three or more 
years.
    Last month, as we do every 2 years, at the start of each 
new Congress, we updated our High-Risk List and reported on 
progress made by each area on our list, including veterans' 
health care. We assess progress and potential for removal from 
the list based on five criteria: leadership commitment; 
capacity, in terms of people and resources; an action plan; 
monitoring; and demonstrated progress.
    Our assessment is that VA has taken some, albeit 
exceedingly limited actions, to address the concerns that led 
to its high-risk designation. For example, some leadership 
actions have been taken, including the establishment of a task 
force, working groups, and a governance structure to address 
the concerns. Additionally, VA leadership provided us with an 
action plan in August, in which they acknowledged the deep-
rooted nature of the concerns and stated that addressing these 
would require substantial time and work.
    Based on these actions, we concluded that VA had partially 
met the high-risk removal criteria of leadership commitment and 
an action plan, and had made no progress with regard to the 
other three criteria: capacity; monitoring; and demonstrated 
progress.
    I want to be very clear that even in the areas where VA has 
made some progress, there is a long path toward fully meeting 
the criteria. For example, the action plan submitted to us 
lacked many critical elements, including an analysis of the 
root causes for each of the categories of concern, a critical 
step to better understanding why the problem exists, and what 
specifically needs to be addressed; reasonable timelines, given 
the significant scope of the efforts needed; clear metrics 
necessary for measuring and monitoring progress; and finally, 
the plan lacked an assessment of the resources needed for 
implementation.
    We also continue to be concerned about the large number of 
open recommendations, and while VA has taken actions to address 
some of these, considerable work remains. As I noted at the 
time of its high-risk designation in 2015, VA had more than 100 
open GAO recommendations related to veterans' health care. 
Seventy-four new recommendations have been added since then. 
Currently, there are still more than 100 open recommendations 
and about a quarter of these have been open for three or more 
years.
    It is critical that VA resolve our recommendations in a 
timely manner, not only to remedy the specific weaknesses 
identified but because they may be symptomatic of larger 
underlying problems that also need to be addressed.
    There are a number of actions that VA needs to immediately 
take to move forward. The most important of these are ensuring 
strong, department-level leadership support; developing a 
robust action plan that provides a clear roadmap for what needs 
to be done, when it will be done, how progress will be 
measured, and what resources are needed to ensure successful 
implementation; integrating VA's response to its high-risk 
designation with other initiatives such as the Secretary's 10-
point plan; and resolving open recommendations in a timely 
manner.
    We are very concerned about VA's exceedingly slow pace of 
progress. Unfortunately, as of today, VA is not much further 
ahead at addressing the concerns that led to its high risk 
designation than it was 2 years ago. The lack of progress 
raises several important questions, including how seriously VA 
is taking this, whether the right people with the right skills 
are being tasked to address the high risk concerns, and whether 
the overall responsibility for achieving removal from the High-
Risk List is at the right organizational level within VA.
    Mr. Chairman, this concludes my opening remarks. I would be 
happy to answer any questions.
    [The prepared statement of Ms. Draper follows:]
     Prepared Statement of Debra A. Draper, Director, Health Care, 
                 U.S. Government Accountability Office



    Chairman Isakson, Ranking Member Tester, and Members of the 
Committee: I am pleased to be here today to discuss the status of the 
Department of Veterans Affairs' (VA) actions to address the concerns 
that led to the high-risk designation we made related to VA health 
care. We added managing risks and improving VA health care to our High 
Risk List in 2015 due to our concern about VA's ability to ensure the 
cost-effective and efficient use of resources to improve the 
timeliness, quality, and safety of health care for veterans.\1\ We 
expressed continued concerns about VA health care in our 2017 high-risk 
report.\2\
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    \1\ GAO, High Risk Series: An Update, GAO 15 290 (Washington, DC: 
Feb. 11, 2015).
    \2\ GAO, High Risk Series: Progress on Many High-Risk Areas, While 
Substantial Efforts Needed on Others, GAO 17 317 (Washington, DC: Feb. 
15, 2017).
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    VA's Veterans Health Administration (VHA) operates one of the 
largest health care delivery systems in the Nation, with 168 medical 
centers and more than 1,000 outpatient facilities organized into 
regional networks. VA has faced a growing demand by veterans for its 
health care services--due, in part, to servicemembers returning from 
military operations in Afghanistan and Iraq and the needs of an aging 
veteran population--and that trend is expected to continue. The total 
number of veteran enrollees in VA's health care system rose from 7.9 
million to almost 9 million from fiscal year 2006 through fiscal year 
2016. Over that same period, VHA's total budgetary resources have 
increased substantially, from $37.8 billion in fiscal year 2006 to 
$91.2 billion in fiscal year 2016.
    Although VA's budget and enrollees have substantially increased for 
at least a decade, there have been numerous reports during this same 
period--by us, VA's Office of the Inspector General, and others--of VA 
facilities failing to provide timely health care.\3\ In some cases, the 
delays in care or VA's failure to provide care at all reportedly have 
resulted in harm to veterans. In response to these serious and 
longstanding problems with access to VA health care, the Veterans 
Access, Choice, and Accountability Act of 2014 was enacted, which 
provided temporary authority and $10 billion in funding through 
August 7, 2017 (or sooner, if those funds are exhausted) for veterans 
to obtain health care services from community (non-VA) providers to 
address long wait times, lengthy travel distances, or other challenges 
they may face accessing VA health care.\4\ Under this authority, VA 
introduced the Veterans Choice Program in November 2014, which offers 
veterans the option to receive hospital care and medical services from 
a non-VA provider when a VA facility cannot provide an appointment 
within 30 days, or when veterans reside more than 40 miles from the 
nearest VA facility.\5\
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    \3\ See, for example, GAO, VA Health Care: Actions Needed to 
Improve Newly Enrolled Veterans' Access to Primary Care, GAO 16 328 
(Washington, DC: Mar. 18, 2016) and GAO, VA Mental Health: Clearer 
Guidance on Access Policies and Wait-Time Data Needed, GAO 16 24 
(Washington, DC: Oct. 28, 2015). See also, for example, Department of 
Veterans Affairs, Office of Inspector General, Veterans Health 
Administration, Review of Alleged Patient Deaths, Patient Wait Times, 
and Scheduling Practices at the Phoenix VA Health Care System, Report 
No. 14-02603-267 (Washington, DC: Aug. 26, 2014) and VA, Department of 
Veterans Affairs Access Audit, System-Wide Review of Access, Results of 
Access Audit Conducted May 12, 2014, through June 3, 2014.
    \4\ Pub. L. No. 113-146, 128 Stat. 1754. The $10 billion is meant 
to supplement VA's medical services budget and is funded through a 
separate appropriations account, the Veterans Choice Fund. The 2014 law 
also appropriated $5 billion to expand VA's capacity to deliver care to 
veterans by hiring additional clinicians and improving the physical 
infrastructure of VA's medical facilities.
    \5\ VA has purchased care from non-VA community providers through 
its care in the community programs since as early as 1945. VHA has 
numerous programs, including the Veterans Choice Program, through which 
it purchases VA care in the community services.
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    In addition to concerns about timely access to care, VA faces 
challenges regarding the reliability, transparency, and consistency of 
its budget estimates for medical services, as well as weaknesses in 
tracking obligations for medical services and estimating budgetary 
needs for future years. These challenges were evident in June 2015, 
when VA requested additional funds from Congress because agency 
officials projected a fiscal year 2015 funding gap of about $3 billion 
in its medical services appropriation account.\6\ The projected funding 
gap was largely due to administrative weaknesses that slowed the 
utilization of the Veterans Choice Program in fiscal year 2015 and 
resulted in higher-than-expected demand for VA's previously established 
VA community care programs.\7\ To address the projected funding gap in 
fiscal year 2015, the VA Budget and Choice Improvement Act provided VA 
temporary authority to use up to $3.3 billion from the Veterans Choice 
Program appropriation for obligations incurred for other specified 
medical services.\8\ In our June 2016 report on VA's health care 
budget, we reported that VA officials anticipated requesting another 
increase in funding for health care services in the budget request for 
fiscal year 2018.\9\ Over the course of fiscal year 2016, utilization 
of the Veterans Choice Program increased considerably, and the Veterans 
Choice Fund had a $4.5 billion remaining balance at the start of fiscal 
year 2017 to cover community care services.\10\ However, in 
February 2017, a VA official told us that VA would need an estimated $2 
billion in addition to its fiscal year 2018 advance appropriation of 
about $70 billion to continue providing services.\11\
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    \6\ See GAO, VA's Health Care Budget: In Response to a Projected 
Funding Gap in Fiscal Year 2015, VA Has Made Efforts to Better Manage 
Future Budgets, GAO 16 584 (Washington, DC: Jun. 3, 2016). In our 2016 
report, the projected funding gap refers to the period in fiscal year 
2015 when VA's obligations for medical services were projected to 
exceed its available budget authority for that purpose for that year. 
The Antideficiency Act prohibits agencies from incurring obligations in 
excess of available budget authority. 31 U.S.C. Sec. 1341(a). An 
evaluation of whether an Antideficiency Act violation occurred in 
fiscal year 2015 was outside the scope of our work.
    \7\ In particular, VA officials expected that the Veterans Choice 
Program would absorb much of the increased demand from veterans for 
health care services delivered by non-VA providers, but instead the 
slow utilization resulted in veterans continuing to receive care 
through previously established VA community care programs that drew 
funds from VA's medical services appropriation account.
    \8\ Pub. L. No. 114-41, Tit. IV, Sec. 4004, 129 Stat. 443, 463-464 
(2015). Specifically, VA was authorized to use the Veterans Choice 
Program appropriation to cover obligations incurred for the other 
specified medical services starting May 1, 2015, until October 1, 2015.
    \9\ See GAO 16 584.
    \10\ At the start of fiscal year 2016, VA issued a policy 
memorandum to its VAMCs requiring them to offer eligible veterans 
referrals to the Veterans Choice Program before they authorize care 
through VA's previously established community care programs.
    \11\ Each year, Congress provides funding for VA health care 
through the appropriations process. Specifically, Congress provides 
appropriations for the coming fiscal year (which begins October 1 of 
that year), as well as an advance appropriation for the following 
fiscal year. VA's advance appropriation for fiscal year 2018 was 
enacted on September 29, 2016. Pub. L. No. 114-223, 130 Stat. 857, 869 
(2016).
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    My statement today, which is based on our February 2017 High-Risk 
Series: Progress on Many High-Risk Areas, While Substantial Efforts 
Needed on Others, will address (1) actions VA has taken over the past 2 
years to address the areas of concern that led us to place VA health 
care on our High-Risk List in 2015, (2) the number of open GAO 
recommendations related to VA health care, and (3) additional actions 
VA needs to take to address the concerns that led to the high-risk 
designation. We conducted the work on which this statement is based in 
accordance with generally accepted government auditing standards.
    Those standards require that we plan and perform the audit to 
obtain sufficient, appropriate evidence to provide a reasonable basis 
for our findings and conclusions based on our audit objectives. We 
believe that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives.
                               background
    Since 1990, we have regularly reported on government operations 
that we have identified as high risk due to their vulnerability to 
fraud, waste, abuse, and mismanagement, or the need for transformation 
to address economy, efficiency, or effectiveness challenges. Our high-
risk program--which is intended to help inform the congressional 
oversight agenda and to guide efforts of the administration and 
agencies to improve government performance--has brought much-needed 
focus to problems impeding effective government and costing billions of 
dollars. In 1990, we designated 14 high-risk areas. Since then, 
generally coinciding with the start of each new Congress, we have 
reported on the status of progress to address previously designated 
high-risk areas, determined whether any areas could be removed or 
consolidated, and identified new high-risk areas.
    Since 1990, a total of 60 different areas have appeared on the 
High-Risk List, 24 areas have been removed, and 2 areas have been 
consolidated. On average, high-risk areas that have been removed from 
the list remained on it for 9 years after they were initially added. 
Our experience has shown that the key elements needed to make progress 
in high-risk areas are top-level attention by the administration and 
agency leaders grounded in the five criteria for removal from the High-
Risk List, as well as any needed congressional action. The five 
criteria for removal that we issued in November 2000 are as 
follows:\12\
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    \12\ GAO, Determining Performance and Accountability Challenges and 
High Risks, GAO 01 159SP (Washington, DC: November 2000).

     Leadership Commitment. The agency demonstrates strong 
commitment and top leadership support.
     Capacity. The agency has the capacity (i.e., people and 
resources) to resolve the risk(s).
     Action Plan. A corrective action plan exists that defines 
the root cause and solutions, and provides for substantially completing 
corrective measures, including steps necessary to implement solutions 
we recommended.
     Monitoring. A program has been instituted to monitor and 
independently validate the effectiveness and sustainability of 
corrective measures.
     Demonstrated Progress. The agency is able to demonstrate 
progress in implementing corrective measures and in resolving the high-
risk area.
    These five criteria form a road map for efforts to improve and 
ultimately address high-risk issues. Addressing some of the criteria 
leads to progress, while satisfying all of the criteria is central to 
removal from the list. In our April 2016 report, we provided additional 
information on how agencies had made progress addressing high-risk 
issues.\13\ Figure 1 shows the five criteria for removal for a 
designated high-risk area and examples of actions taken by agencies as 
cited in that report.
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    \13\ GAO, High-Risk Series: Key Actions to Make Progress Addressing 
High-Risk Issues, GAO 16 480R (Washington, DC: Apr. 25, 2016).

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]


    Importantly, the actions listed are not ``stand alone'' efforts 
taken in isolation from other actions to address high-risk issues. That 
is, actions taken under one criterion may also be important in meeting 
other criteria. For example, top leadership can demonstrate its 
commitment by establishing a corrective action plan including long-term 
priorities and goals to address the high-risk issue and using data to 
gauge progress--actions which are also vital to monitoring criteria.
va has made limited progress in addressing the concerns that led to the 
               2015 va health care high-risk designation
    VA officials have expressed their commitment to addressing the 
concerns that led to the high-risk designation for VA health care. As 
part of our work for the 2017 high-risk report, we identified actions 
VA had taken, such as establishing a task force, working groups, and a 
governance structure for addressing the five areas of concern 
contributing to the designation: (1) ambiguous policies and 
inconsistent processes; (2) inadequate oversight and accountability; 
(3) information technology (IT) challenges; (4) inadequate training for 
VA staff; and (5) unclear resource needs and allocation priorities. For 
example, in July 2016, VA chartered the GAO High Risk List Area Task 
Force for Managing Risk and Improving VA Health Care to develop and 
oversee implementation of VA's plan to address the root causes of the 
five areas of concern we identified in 2015.
    VA's task force and associated working groups are responsible for 
developing and executing the department's high-risk mitigation plan for 
each of the five areas of concern we identified. VA also executed two 
contracts with a total value of $7.8 million to support its actions to 
address the concerns behind the high-risk designation. These 
contracts--with the MITRE Corporation and Atlas Research, LLC--are 
intended to provide additional support for actions such as developing 
and executing an action plan, creating a plan to enhance VA's capacity 
to manage the five areas, and assisting with establishing the 
management functions necessary to oversee the five high-risk-area 
working groups.
    On August 18, 2016, VA provided us with an action plan that 
acknowledged the deep-rooted nature of the areas of concern, and stated 
that these concerns would require substantial time and work to address. 
Although the action plan outlined some steps VA plans to take over the 
next several years to address the concerns that led to its high-risk 
designation, several sections were missing critical actions that would 
support our criteria for removal from the High-Risk List, such as 
analyzing the root causes of the issues and measuring progress with 
clear metrics. In our feedback to VHA on drafts of its action plan, we 
highlighted these missing actions and also stressed the need for 
specific timelines and an assessment of needed resources for 
implementation. For example, VA plans to use staff from various 
sources, including contractors and temporarily detailed employees, to 
support its high-risk-area working groups, so it is important for VA to 
ensure that these efforts are sufficiently resourced.
Overall Rating for Managing Risks and Improving VA Health Care
    As we reported in the February 2017 high-risk report, when we 
applied the five criteria for High-Risk List removal to each of the 
areas of concern, we determined that VA has partially met two of the 
five criteria: leadership commitment and an action plan. VA has not met 
the other three criteria for removal: capacity to address the areas of 
concern, monitoring implementation of corrective actions, and 
demonstrating progress. It is worth noting that although both criteria 
were rated as partially met, the department made significantly less 
progress in developing a viable action plan than it has in 
demonstrating leadership commitment. Specifically, VA partially met the 
action plan criterion for only one of the five areas of concern--
ambiguous policies and inconsistent processes--whereas VA partially met 
the leadership commitment criterion for four out of five areas of 
concern.
    The following is a summary of the progress VA has made in 
addressing the five criteria for removal from the High-Risk List for 
each of the five areas of concern we identified.\14\
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    \14\ For more detailed analysis of VA's actions in each of the five 
areas of concern, see GAO 17 317.
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Ambiguous Policies and Inconsistent Processes
    Summary of concern. When we designated VA health care as a high-
risk area in 2015, we reported that ambiguous VA policies led to 
inconsistent processes at local VA medical facilities, which may have 
posed risks for veterans' access to VA health care. Since then, we 
highlighted the inconsistent application of policies in two recent 
reports examining mental health and primary care access at VA medical 
facilities in 2015 and 2016, respectively.\15\ In both reports, we 
found wide variation in the time that veterans waited for primary and 
mental health care, which was in part caused by a lack of clear, 
updated policies for appointment scheduling; therefore, we recommended 
that VA update these policies. These ambiguous policies contributed to 
errors made by appointment schedulers, which led to inconsistent and 
unreliable wait-time data. For mental health, we also found that two 
policies conflicted, leading to confusion among VA medical center staff 
as to which wait-time policy to follow. In 2015, VA resolved this 
policy conflict by revising its mental health handbook, but other 
inconsistent applications of mental health policy have not yet been 
addressed, such as our recommendation to issue guidance about the 
definitions used to calculate veteran appointment wait times, and 
communicate any changes to those definitions within and outside VHA.
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    \15\ See GAO, VA Health Care: Actions Needed to Improve Newly 
Enrolled Veterans' Access to Primary Care, GAO 16 328 (Washington, DC: 
Mar. 18, 2016); and GAO, VA Mental Health: Clearer Guidance on Access 
Policies and Wait-Time Data Needed, GAO 16 24 (Washington, DC: Oct. 28, 
2015).
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    2017 assessment of VA's progress. Based on actions taken since 
2015, VA has partially met our criteria for removal from the High-Risk 
List for this area of concern for leadership commitment and action 
plan. VA has partially met the leadership commitment criterion because 
it established a framework for developing and reviewing policies--with 
the goal of ensuring greater consistency and clarity--and set goals for 
making the policy-development process more efficient. VA has partially 
met the action plan criterion for this high-risk area of concern 
because its action plan described an analysis of the root causes of 
problems related to ambiguous policies and inconsistent processes, an 
important aspect of an action plan. However, VA has not met our 
criteria for removal from the High-Risk List for capacity, monitoring, 
and demonstrated progress for this area of concern because it has not 
addressed gaps that exist between its stated goals and available 
resources, addressed inconsistent application of policies at the local 
level, or demonstrated that its actions are linked to identified root 
causes.
Inadequate Oversight and Accountability
    Summary of concern. In our 2015 high-risk report, we found that VA 
had problems holding its facilities accountable for their performance 
because it relied on self-reported data from facilities, its oversight 
activities were not sufficiently focused on compliance, and it did not 
routinely assess policy implementation. We continued to find a lack of 
oversight in our October 2015 review of the efficiency and timeliness 
of VA's primary care. For example, we found inaccuracies in VA's data 
on primary care panel sizes, which are used to help medical centers 
manage their workload and ensure that veterans receive timely and 
efficient care.\16\ We found that while VA's primary care panel 
management policy required facilities to ensure the reliability of 
their panel size data, it did not assign responsibility for verifying 
data reliability to regional- or national-level officials or require 
them to use the data for monitoring purposes. As a result, VA could not 
be assured that local panel size data were reliable, or know whether 
its medical centers had met VA's goals for efficient, timely, and 
quality care. We recommended that VA incorporate an oversight process 
in its primary care panel management policy that assigns 
responsibility, as appropriate, to regional networks and to VA's 
central office for verifying and monitoring panel sizes.
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    \16\ GAO, VA Primary Care: Improved Oversight Needed to Better 
Ensure Timely Access and Efficient Delivery of Care, GAO 16 83 
(Washington, DC: Oct. 8, 2015).
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    2017 assessment of VA's progress. VA has partially met the 
leadership commitment criterion for this area of concern because it 
established a high-level governance structure and adopted a new model 
to guide the department's oversight and accountability activities. 
However, VA has not met our criteria for removal from the High-Risk 
List for capacity, action plan, monitoring, or demonstrated progress 
for this area of concern because the department continues to rely on 
existing processes that contribute to inadequate oversight and 
accountability.
Information Technology Challenges
    Summary of concern. In our 2015 high-risk report, we identified 
limitations in the capacity of VA's existing IT systems, including the 
outdated, inefficient nature of certain systems and a lack of system 
interoperability as contributors to VA's IT challenges related to VA 
health care. We have continued to report on the importance of VA 
working with the Department of Defense to achieve electronic health 
record interoperability. In August 2015, we reported on the status of 
these interoperability efforts and noted that the departments had 
engaged in several near-term efforts focused on expanding 
interoperability between their existing electronic health record 
systems. However, we were concerned by the lack of outcome-oriented 
goals and metrics that would more clearly define what VA and the 
Department of Defense aim to achieve from their interoperability 
efforts. Accordingly, we recommended that the departments establish a 
timeframe for identifying outcome-oriented metrics and define related 
goals for achieving interoperability. In February 2017, we reported 
that VA has begun to define an approach for identifying outcome-
oriented metrics focused on health outcomes in selected clinical areas, 
and it also has begun to establish baseline measurements.\17\ We intend 
to continue monitoring the departments' efforts to determine how these 
metrics define and measure the results achieved by interoperability 
between the departments.
---------------------------------------------------------------------------
    \17\ GAO, Veterans Affairs Information Technology: Management 
Attention Needed to Improve Critical System Modernizations, Consolidate 
Data Centers, and Retire Legacy Systems, GAO 17 408T (Washington, DC: 
Feb. 7, 2017).
---------------------------------------------------------------------------
    2017 assessment of VA's progress. VA has partially met our 
leadership commitment criterion by involving top leadership from VA's 
Office of Information & Technology in this area of concern, but it has 
not met our four remaining criteria for removing IT challenges from the 
High-Risk List. For example, VA has not demonstrated improvement in 
several capacity actions, such as establishing specific 
responsibilities for its new functions, improving collaboration between 
internal and external stakeholders, and addressing skill gaps. VA also 
needs to conduct a root cause analysis that would help identify and 
prioritize critical actions and outcomes to address IT challenges.
Inadequate Training for VA Staff
    Summary of concern. When identifying this area of concern in our 
2015 high-risk report, we described several gaps in VA's training, as 
well as burdensome training requirements. We have continued to find 
these issues in our subsequent work. For example, in our December 2016 
report on VHA's human resources (HR) capacity, we found that VA's 
competency assessment tool did not address two of the three personnel 
systems under which VHA staff may be hired.\18\ We recommended that VHA 
(1) develop a comprehensive competency assessment tool for H.R. staff 
that evaluates knowledge of all three of VHA's personnel systems and 
(2) ensure that all VHA H.R. staff complete it so that VHA may use the 
data to identify and address competency gaps among H.R. staff. Without 
such a tool, VHA will have limited insights into the abilities of its 
H.R. staff and will be ill-positioned to provide necessary support and 
training.
---------------------------------------------------------------------------
    \18\ GAO, Veterans Health Administration: Management Attention Is 
Needed to Address Systemic, Long-standing Human Capital Challenges, GAO 
17 30 (Washington, DC: Dec. 23, 2016).
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    2017 assessment of VA's progress. VA has not met any of our 
criteria for removing this area of concern from the High-Risk List. VA 
intends to establish a comprehensive health care training management 
policy and a mandatory annual training process; however, as of 
December 2016, VA officials said they had not begun drafting a new 
policy to replace an outdated document from 2002 that contains training 
requirements that are no longer relevant. The high-level nature of the 
descriptions in the action plan and lack of action to update outdated 
policies and set goals for improving training shows that VA lacks 
leadership commitment to address the concerns that led to our inclusion 
of this area in the 2015 high-risk report.
Unclear Resource Needs and Allocation Priorities
    Summary of concern. In our 2015 high-risk report, we described gaps 
in the availability of data needed for VA to identify the resources it 
needs and ensure they are effectively allocated across VA's health care 
system as contributors to our concern about unclear resource needs and 
allocation priorities. We have continued to report on this concern. For 
example, in our September 2016 report on VHA's organizational 
structure, we found that VA devoted significant time, effort, and funds 
to generate recommendations for organizational structure changes 
intended to improve the efficiency of VHA operations.\19\ However, the 
department then either did not act or acted slowly to implement the 
recommendations. Without robust processes for evaluating and 
implementing recommendations, there was little assurance that VHA's 
delivery of health care to the Nation's veterans would improve. We 
recommended that VA develop a process to ensure that it evaluates 
organizational structure recommendations resulting from internal and 
external reviews of VHA. This process should include documenting 
decisions and assigning officials or offices responsibility for 
ensuring that approved recommendations are implemented. We concluded 
that such a process would help VA ensure that it is using resources 
efficiently, monitoring and evaluating implementation, and holding 
officials accountable.
---------------------------------------------------------------------------
    \19\ GAO, VA Health Care: Processes to Evaluate, Implement, and 
Monitor Organizational Structure Changes Needed, GAO 16 803 
(Washington, DC: Sept. 27, 2016).
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    2017 assessment of VA's progress. VA's actions have partially met 
our criterion for leadership commitment but not met the other four 
criteria for removing this area of concern from the High Risk List. 
VA's planned actions do not make clear how VHA, as the agency managing 
VA health care, is or will be incorporated into VA's new framework for 
the strategic planning and budgeting process.\20\ It is also not clear 
how the framework will be communicated and reflected at the regional 
network and medical center levels. VA also has not identified what 
resources may be necessary to establish and maintain new functions at 
the national and local levels, or established performance measures 
based on a root cause analysis of its unclear resource needs and 
allocation priorities.
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    \20\ In its action plan, VA reported adopting a framework in 2016 
called ``Managing for Results'' to better connect VA's requirements 
setting process (that forecasts veterans' needs) with its process for 
developing the department's budget. VA stated that full implementation 
of the framework will take place over several budget cycles.
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            more than 100 gao recommendations for improving 
                       va health care remain open
    Since we added VA health care to our High-Risk List in 2015, VA's 
leadership has increased its focus on implementing our prior 
recommendations, but additional work is still needed. Between 
January 2010 and February 2015 (when we first designated VA health care 
as a high-risk area), we made 178 recommendations to VA related to VA 
health care. When we made our designation in 2015, the department only 
had implemented about 22 percent of them.\21\ Since February 2015, we 
have made 74 new recommendations to VA related to VA health care, for a 
total of 252 recommendations from January 1, 2010 through February 15, 
2017 (when we issued the 2017 high-risk report).\22\ VA has implemented 
about 50 percent of these recommendations. However, there continue to 
be more than 100 open recommendations related to VA health care, almost 
a quarter of which have remained open for 3 or more years.\23\ We 
believe that it is critical that VA implement our recommendations not 
only to remedy the specific weaknesses we previously identified, but 
because they may be symptomatic of larger underlying problems that also 
need to be addressed. Since the 2015 high-risk report, we have made new 
recommendations to VA relating to each of the five areas of concern. 
(See table 1.)
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    \21\ Of the 178 recommendations, 134 were open because VA had not 
yet implemented them. Additionally, 39 had been closed because VA 
implemented them, and 5 had been closed without VA implementing them. 
We close recommendations without agencies having implemented them 
primarily if the recommendation is no longer valid because 
circumstances have changed.
    \22\ See GAO 17 317.
    \23\ Specifically, 112 recommendations are open because VA has not 
yet implemented them, 25 of which have been open for 3 or more years. 
In addition, 127 recommendations were closed because VA implemented 
them, and 13 were closed without VA implementing them.

 Table 1: GAO Recommendations to the Department of Veterans Affairs (VA) Related to VA Health Care from January
                              1, 2010 through February 15, 2017, by Area of Concern
----------------------------------------------------------------------------------------------------------------
                                                                                                    Cumulative
                                                 Number of        Number of                       percentage of
                                              recommendations  recommendations     Cumulative          GAO
                                                prior to GAO   added since GAO   number of GAO   recommendations
       VA health care area of concern            high-risk        high-risk     recommendations       VA has
                                                designation      designation      Jan. 1, 2010     implemented,
                                               (Jan. 1, 2010    (Feb. 11, 2015    through Feb.     Jan. 1, 2010
                                                through Feb.     through Feb.      15, 2017*       through Feb.
                                                 11, 2015)*       15, 2017)*                         15, 2017
----------------------------------------------------------------------------------------------------------------
Ambiguous policies and inconsistent                   42               21               63               52%
 processes..................................
Inadequate oversight and accountability.....          63               36               99               51
Information technology challenges...........          11                2               13               44
Inadequate training for VA staff............           6                8               14               43
Unclear resource needs and allocation                 48                6               54               66
 priorities.................................
Not assigned to an area of concern..........           8                1                9               44
                                             -------------------------------------------------------------------
  Total.....................................         178               74              252               50%
----------------------------------------------------------------------------------------------------------------
Source: GAO. GAO 17 473T.
* Recommendation counts listed include both implemented and not implemented recommendations as of the dates
  indicated.

      sustained leadership support and strategic focus needed to 
                    meet high-risk removal criteria
    VA has taken an important step toward addressing our criteria for 
removal from the High-Risk List by establishing the leadership 
structure necessary to ensure that actions related to the High-Risk 
List are prioritized within the department. It is imperative, however, 
that VA demonstrate strong leadership support as it continues its 
transition under a new administration, address weaknesses in its action 
plan, and continue to implement our open recommendations.
    As a new administration sets its priorities, VA will need to 
integrate those priorities with its high-risk-related actions, and 
facilitate their implementation at the local level through strategies 
that link strategic goals to actions and guidance. In its action plan, 
VA separated its discussion of department-wide initiatives, like MyVA, 
from its description of High-Risk List mitigation strategies.\24\ We do 
not view high-risk mitigation strategies as separate from other 
department initiatives; actions to address the High-Risk List can, and 
should be, integrated in VA's existing activities.
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    \24\ According to VA, MyVA intends to make changes to VA's systems 
and structures to (1) improve the veteran experience, (2) improve the 
employee experience, (3) achieve support services excellence, (4) 
establish a culture of continuous performance improvement, and (5) 
enhance strategic partnerships.
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    VA's action plan did not adequately address the concerns that led 
to the high-risk designation because it lacked root cause analyses for 
most areas of concern, as well as clear metrics and identified 
resources needed for achieving VA's stated outcomes. This is especially 
evident in VA's plans to address the IT and training areas of concern. 
In addition, with the increased use of community care programs, it is 
imperative that VA's action plan include a discussion of the role of 
community care in decisions related to policies, oversight, IT, 
training, and resource needs. VA will also need to demonstrate that it 
has the capacity to sustain efforts by devoting appropriate resources--
including people, training, and funds--to address the high-risk 
challenges we identified. Until VA addresses these serious underlying 
weaknesses, it will be difficult for the department to effectively and 
efficiently implement improvements addressing the five areas of concern 
that led to the high-risk designation.
    We will continue to monitor VA's institutional capacity to fully 
implement an action plan and sustain needed changes in all five of our 
areas of concern. To the extent we can, we will continue to provide 
feedback to VA officials on VA's action plan and areas where they need 
to focus their attention. Additionally, we have ongoing work focusing 
on VA health care that will provide important insights on progress, 
including the policy development and dissemination process, 
implementation and monitoring of VA's opioid safety, Veterans Choice 
Program implementation, physician recruitment and retention, and 
processes for enrolling veterans in VA health care.
    Finally, we plan to also continue to monitor VA's efforts to 
implement our recommendations and recommendations from other reviews 
such as the Commission on Care.\25\ To this end, we believe that the 
following GAO recommendations require VA's immediate attention:

    \25\ The Veterans Access, Choice, and Accountability Act of 2014 
established the Commission on Care to examine, assess, and report on 
veterans' access to VA health care and to strategically examine how 
best to organize VHA, locate health resources, and deliver health care 
to veterans during the next 20 years. The Commission's June 2016 report 
to the President included 18 recommendations to improve veterans' 
access to care and, more broadly, to improve the quality and 
comprehensiveness of that care. On September 1, 2016, the President 
concurred with 15 of the 18 recommendations and directed VA to 
implement them.

     improving oversight of access to timely medical 
appointments, including the development of wait-time measures that are 
more reliable and not prone to user error or manipulation, as well as 
ensuring that medical centers consistently and accurately implement 
VHA's scheduling policy.
     improving oversight of VA community care to ensure--among 
other things--timely payment to community providers.
     improving planning, deployment, and oversight of VA/VHA IT 
systems, including identifying outcome-oriented metrics and defining 
goals for interoperability with DOD.
     ensuring that recommendations resulting from internal and 
external reviews of VHA's organizational structure are evaluated for 
implementation. This process should include the documentation of 
decisions and assigning officials or offices responsibility for 
ensuring that approved recommendations are implemented.

    Moreover, it is critical that Congress maintain its focus on 
oversight of VA health care to help address this high-risk area. 
Congressional committees responsible for authorizing and overseeing VA 
health care programs held more than 70 hearings in 2015 and 2016 to 
examine and address VA health care challenges. As VA continues to 
change its health care service delivery in the coming years, some 
changes may require congressional action--such as VA's planned 
consolidation of community care programs after the Veterans Choice 
Program expires. Sustained congressional attention to these issues will 
help ensure that VA continues to improve its management and delivery of 
health care services to veterans.

    Chairman Isakson, Ranking Member Tester, and Members of the 
Committee, this concludes my statement. I would be pleased to respond 
to any questions you may have.

    Senator Tillis. Thank you.
    Mr. Missal.

    STATEMENT OF MICHAEL J. MISSAL, INSPECTOR GENERAL, U.S. 
 DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY JOHN D. DAIGH, 
  JR., M.D., CPA, ASSISTANT INSPECTOR GENERAL FOR HEALTHCARE 
            INSPECTIONS, OFFICE OF INSPECTOR GENERAL

    Mr. Missal. Senator Tillis and Members of the Committee, 
thank you for the opportunity to discuss the work of the VA 
Office of Inspector General and how we provide effective 
oversight of VA programs and operations through independent 
audits, inspections, and investigations. I am accompanied by 
Dr. David Daigh, the Assistant Inspector General for Healthcare 
Inspections.
    The OIG seeks to prevent and detect fraud, waste, and abuse 
and make meaningful recommendations to drive economy, 
efficiency, and effectiveness throughout VA's programs and 
operations. Our goal is to undertake impactful work that will 
assist VA in providing the appropriate and timely services and 
benefits that veterans so deservedly earned and ensuring the 
proper expenditure of taxpayer funds.
    I have had the great privilege of serving as the Inspector 
General since May 2, 2016. Since that time, I have fully 
immersed myself in the work, priorities, and policies of the 
OIG. We have made a number of enhancements since I started, in 
an effort to do more impactful work in a timelier manner.
    The OIG shares a similar mission with GAO. It is important 
that we have a strong relationship with GAO, to ensure we avoid 
duplication of effort as much as possible. To that end, one of 
the first things I did when I started was to meet with 
Comptroller General Dodaro, Dr. Draper, and his other senior 
staff. Our offices have had a number of communications since 
that time to promote coordination and more effective oversight 
of VA.
    GAO added VA health care to its biannual High-Risk List in 
2015, and it remains on the High-Risk List that was just issued 
in 2017. GAO focused its concern in five broad areas. While our 
work is determined by what we believe is the most effective 
oversight of VA, a number of our reports addressed concerns in 
these same five areas. My written statement includes examples 
of OIG work in each of the areas that resulted in GAO placing 
VA health care on its High-Risk List. It should be noted that 
many of the OIG's reports could fit into more than one area. I 
will highlight a few of those reports now.
    We have issued a number of reports in the past few years 
that include VA's ambiguous policies and inconsistent 
processes. For example, our review of the Health Eligibility 
Center determined that VA had not effectively managed its 
business processes to ensure the consistent creation and 
maintenance of essential health care eligibility data.
    Proper oversight by management would ensure that programs 
and operations would work effectively and efficiently. Our 
September 2016 report on the Denver replacement medical center 
is an extremely costly example of the result of inadequate 
oversight. Through all phases of the project, we identified 
various factors that significantly contributed to delays and 
rising costs. This occurred due to a series of questionable 
business decisions and mismanagement by VA senior officials, 
resulting in a project years behind schedule and costing more 
than twice the initial budget of $800 million.
    We have frequently identified VA struggles to design, 
procure, and/or implement functional IT systems. IT security is 
continually reported as a material weakness in VA's 
consolidated financial statements. Moreover, VA has a high 
number of legacy IT systems needing replacement. Furthermore, 
after years of effort focused on replacement of VA's legacy 
scheduling software, a new scheduling system is still not in 
place. VA's issues with scheduling software are related to the 
inability to define its requirements and determine if a 
commercial solution is available or if it must design the 
system.
    One prevailing theme of the OIG's work related to wait 
times and scheduling issues was the inadequate, lack of, or 
incorrect training provided to VA staff responsible for 
scheduling appointments. As we have stated in reports that have 
been issued since the allegations at the Phoenix VA health care 
system surfaced in April 2014, the lack of training for 
schedulers, the lack of understanding of the process by their 
managers, and, in some cases, the disregard of VA scheduling 
policies created a system where services have not been provided 
timely, and in some situations, wait times were not accurately 
portrayed. VA needs to accurately forecast the demand for 
health care services in both the near term and the long term.
    In conclusion, the OIG is committed to providing effective 
oversight of the programs and operations of VA. We will 
continue to produce reports that provide VA, Congress, and the 
public with recommendations that we believe will help VA 
operate its programs and services in a manner that will 
effectively and timely deliver services and benefits to 
veterans and spend taxpayer money appropriately.
    Senator Tillis, this concludes my statement. Dr. Daigh and 
I would be happy to answer questions that you or other Members 
of the Committee may have.
    [The prepared statement of Mr. Missal follows:]
      Prepared Statement of Michael J. Missal, Inspector General, 
                  U.S. Department of Veterans Affairs
    Mr. Chairman, Ranking Member Tester, and Members of the Committee, 
Thank you for the opportunity to discuss the work of the VA Office of 
Inspector General (OIG) and how the OIG provides effective oversight of 
VA programs and operations through independent audits, inspections, and 
investigations. The OIG seeks to prevent and detect fraud, waste, and 
abuse, and make meaningful recommendations to drive economy, 
efficiency, and effectiveness throughout VA programs and operations. 
Our goal is to undertake impactful work that will assist VA in 
providing the appropriate and timely services and benefits that 
veterans so deservedly earned, and ensuring the proper expenditure of 
taxpayer funds. I am accompanied by John D. Daigh, Jr., M.D., CPA, 
Assistant Inspector General for Healthcare Inspections.
    I have had the great privilege of serving as the Inspector General 
since May 2, 2016. Since that time, I have fully immersed myself in the 
work, priorities, and policies of the OIG. We have made a number of 
enhancements since I started, including issuing a Mission, Vision, and 
Values statement; increasing transparency; creating a Rapid Response 
team in our Healthcare Inspections directorate; expanding our data 
analytics capabilities; and being more proactive in our review areas. I 
believe that these changes, as well as other enhancements we will make, 
will enable us to do additional impactful work in a more timely manner.
    The OIG shares an analogous mission with the Government 
Accountability Office (GAO). It is important that the VA OIG has a 
strong relationship with GAO to ensure that we avoid duplication of 
effort as much as possible. To that end, one of the first things I did 
when I started was to meet with Comptroller General Dodaro and some of 
his senior staff. Our offices have communicated regularly since that 
time to promote coordination and more effective oversight of VA.
    In February 2015, GAO added Managing Risks and Improving VA Health 
Care to its biannual High Risk list. It focused its concerns in five 
broad areas:

     Ambiguous policies and inconsistent processes,
     Inadequate oversight and accountability,
     Information technology challenges,
     Inadequate training for VA staff, and
     Unclear resource needs and allocation priorities.

    While our work is determined by what we believe is the most 
effective oversight of VA, a number of our reports address concerns in 
these same five areas. I will highlight a sampling of OIG work in each 
of the areas that resulted in GAO placing VA Health Care on its High 
Risk list. However, it should be noted that many of the OIG's reports 
could fit in more than one area.
             ambiguous policies and inconsistent processes
    We have issued a number of reports in the past few years that 
include VA's ambiguous policies and inconsistent processes. Our recent 
report \1\ on wait time in one specific Veteran Integrated Service 
Network (VISN), we assessed the reliability of wait time data and 
timely access within VISN 6 which includes VHA facilities in North 
Carolina and Virginia. The objective of the audit was to determine 
whether VISN 6 facilities provided new patients timely access to health 
care within its medical facilities and through Choice, as well as to 
determine whether VISN 6 facilities appropriately managed consults. We 
reported that veterans who were authorized Choice care in VISN 6 did 
not consistently receive the authorized health care within 30 days as 
required by Health Net's contract with VA.
---------------------------------------------------------------------------
    \1\ Audit of Veteran Wait Time Data, Choice Access, and Consult 
Management in VISN 6, March 2, 2017
---------------------------------------------------------------------------
    We reviewed a statistical sample of 389 Choice authorizations 
provided to Health Net by VISN 6 medical facility staff during the 
first quarter of Fiscal Year (FY) 2016. Based on our sample results, we 
estimated that for the approximately 34,200 veterans who were 
authorized Choice care in VISN 6, approximately 22,500 veterans who 
received Choice care waited an average of 84 days to get their care 
through Health Net providers. We estimated it took VA medical facility 
staff an average of 42 days to provide the authorization to Health Net 
to begin the Choice process and an additional 42 days for veterans to 
receive the medical service through Health Net providers. We identified 
delays related to authorizations for primary care, mental health care, 
and specialty care. VHA's Chief Business Officer addressed a potential 
cause for delay in creating appointments by executing a contract 
modification effective November 1, 2015. This change allowed Health Net 
to initiate phone contact with a veteran to arrange a Choice 
appointment, rather than require the veteran to contact Health Net as 
previous required. Our analysis showed that, while still untimely, this 
change lowered the percentage of veterans who waited more than 5 days 
for Health Net to create an appointment from 86 percent to 69 percent.
    The Under Secretary for Health concurred with our 10 
recommendations and provided a responsive action plan and milestones to 
address the recommendations regarding monitoring controls over 
scheduling requirements, wait time data, and access to health care and 
consult management. Our recommendations will help ensure staff use 
clinically indicated and preferred appointment dates consistently, 
medical facilities conduct required scheduler audits, and staffing 
resources are adequate to ensure timely access to health care. The 
report's recommendations remain open.
    Another example, in September 2015, we reported in Review of 
Alleged Mismanagement at the Health Eligibility Center that VA's Chief 
Business Office (CBO) had not effectively managed its business 
processes to ensure the consistent creation and maintenance of 
essential health care eligibility data. Due to the amount and age of 
the Enrollment System (ES) data, as well as lead times required to 
develop and implement software solutions, a multiyear project 
management plan was needed to address the accuracy of pending ES 
records and improve the usefulness of ES data. We offered 13 
recommendations in the report including one focused on controls to 
ensure that future enrollment data are accurate and reliable before 
being entered into the Enrollment System. VA concurred with the 
recommendations and provided sufficient information to close all 
recommendations in October 2016. We have an ongoing review of the 
Health Eligibility Center focusing on the alleged lack of effective 
governance over the Veterans Health Administration's (VHA) execution of 
the health care enrollment program at its medical facilities. We expect 
to issue our report in late spring 2017.
    Another program that operates nationwide also had issues related to 
inconsistent implementation of policies is the Homeless Grant Per Diem 
Program. In a June 2015 report, Audit of Homeless Providers Grant and 
Per Diem Case Management Oversight, we determined VA needed to clarify 
eligibility requirements across the program to ensure that all homeless 
veterans have equal access to case management services. Historically, 
homeless veterans ineligible for VA health care have not been excluded 
from the program. However, we questioned the application of the 
program's eligibility criteria, and found the criteria were unclear and 
inconsistently applied. This was confirmed in our interviews of VA's 
Office of General Counsel, program directors, network homeless 
coordinators, and liaisons, which revealed confusion occurred at all 
program levels. We made five recommendations, three of which involved 
establishing a definitive legal standard on program eligibility and 
ensuring that policies and controls matched that standard and were 
applied across the program. The recommendations dealing with policies 
and controls remain open.
                inadequate oversight and accountability
    Proper oversight by management ensures that programs and operations 
would work effectively and efficiently. Our September 2016 report, 
Review of the Replacement of the Denver Medical Center, Eastern 
Colorado Health Care System, on the management of the construction of a 
new VA medical center in the Denver area, is an extremely costly 
example of the result of inadequate oversight. We confirmed the project 
to build a new medical center in the Denver area has experienced 
significant and unnecessary cost overruns and schedule slippages. 
Originally estimated for 2013 completion, it will not be ready before 
mid-to-late 2018, about 20 years after its need was identified.
    Through all phases of the project, we identified various factors 
that significantly contributed to delays and rising costs, including:

     Inadequate planning and design,
     Initiation of the construction phase without adequate 
design plans,
     Changing the acquisition strategy mid-stream, and
     Untimely change request processing.

    This occurred due to a series of questionable business decisions 
and mismanagement by VA senior officials. The report summarizes the 
significant management decisions and factors that resulted in a project 
years behind schedule and costing more than twice the initial budget of 
$800 million. We made five recommendations and VA management concurred 
with all recommendations. We recently requested information from VA on 
the implementation status of the recommendations and will keep them 
open until VA provides satisfactory evidence of implementation.
    In June 2016, we issued a report on allegations related to 
appointment cancellations at the Houston VA Medical Center, titled 
Review of Alleged Manipulation of Appointment Cancellations at VA 
Medical Center, Houston, Texas. We substantiated that two previous 
scheduling supervisors and a current director of two outpatient clinics 
instructed staff to input clinic cancellations incorrectly as canceled 
by the patient. We also confirmed that a current director of two CBOCs 
instructed staff, as recently as February 2016, to record an 
appointment as canceled by the patient if clinic staff at one CBOC 
offered to reschedule a veteran's appointment at a different CBOC 
situated about 17 miles away and the veteran declined the appointment. 
The CBOC Director noted this was appropriate since the CBOC was still 
offering the patient an appointment. However, when interviewed 
regarding these cancellations, the CBOC Director acknowledged she 
instructed staff to cancel appointments by the patient if the veteran 
declined an appointment in the alternate location. We made six 
recommendations, including referring the matter to VA's Office of 
Accountability Review (OAR), to determine what, if any, administrative 
actions should be taken based on the factual circumstances developed in 
our report.
    In December 2014, we released an audit related to VA's National 
Call Center for homeless veterans, titled Audit of The National Call 
Center for Homeless Veterans. We reported that homeless and at-risk 
veterans who contacted the Call Center often experienced problems 
accessing a counselor and/or receiving a referral after completing the 
Call Center's intake process. We reported:

     Veterans could leave a message on an answering machine 
only 27 percent of the time period reviewed,
     Veteran messages were not referred to VA medical 
facilities due to inaudible messages or no contact information in 16 
percent of the time period reviewed,
     Veterans were not referred to VA medical facilities 
despite providing all the necessary information in 4 percent of the 
time period we reviewed.

    Moreover, the Call Center closed approximately 47 percent of 
referrals even though the VA medical facilities had not provided the 
Homeless veterans any support services. These missed opportunities 
occurred due to lapses in the Call Center's management and oversight. 
We made seven recommendations, including implementing effective 
performance metrics to ensure homeless veterans receive needed 
services. We closed our report in September 2015 based on information 
received that all recommendations had been implemented.
                   information technology challenges
    As we reported in our list of VA's Major Management Challenges 
within VA's Annual Financial Report, we have frequently identified VA's 
struggles to design, procure, and/or implement functional information 
technology (IT) systems. IT security is continually reported as a 
material weakness in the Consolidated Financial Statement audits that 
are conducted annually by the OIG's independent auditing firm, 
CliftonLarsonAllen (CLA).
    VA has a high number of legacy systems needing replacement 
including the Financial Management System; Integrated Funds 
Distribution, Control Point Activity, Accounting and Procurement 
system; Veterans Health Information Systems and Technology 
Architecture, and the Benefits Delivery Network; After years of effort 
focused on replacement of VA's legacy scheduling software, a new 
scheduling system is still not in place. VA's issues with scheduling 
appointments are related to the inability to define its requirements 
and determine if a commercial solution is available or if it must 
design a system. Replacing systems has been a major challenge across 
the government and is not unique to VA. We have issued a number of 
reports outlining access issues and our work in this area is 
continuing.
    While the difficulties between VA's electronic health record (EHR) 
and the Department of Defense's EHR are well documented, the increased 
utilization of care in the community will present further IT 
challenges. To ensure that medical providers both inside and outside VA 
have the most complete and up-to-date information, VA needs to find a 
more effective method for sharing patients' EHRs. We reported on the 
possibility of delays in care because of the difficulties in sharing 
medical records in the Urology Clinic at the Phoenix VA Health Care 
System in our October 2015 report, titled Healthcare Inspection, Access 
to Urology Service, Phoenix VA Health Care System, Phoenix, Arizona. 
Specifically, we identified approved authorizations for non-VA care 
coordination (NVCC) urological care and a notation that an 
authorization was sent to the non-VA provider. A scheduled date and 
time of an appointment with the non-VA urologist was often documented. 
However, we were unable to locate scanned documents from non-VA 
providers in these patients' EHRs verifying that the patients had been 
seen for evaluations, and if seen, what the evaluations might have 
revealed. This finding suggested that the Phoenix VA Health Care System 
(PVAHCS) did not have accurate data on the clinical status of the 
patients who were referred for the specialty care.
    Further, with respect to scanning and reviewing outside clinical 
documents (for example, clinic notes, labs, or imaging results), when 
the services were provided by TriWest Health Care Alliance (TriWest), 
the treating providers' office submitted this data to the TriWest 
Portal. To access that information, an NVCC staff member was required 
to log into the TriWest Portal to print and scan these records into the 
patients EHRs. This process was delayed because of the NVCC staffing 
shortages, which could have resulted in important clinical information 
not being reviewed for several months. We made three recommendations, 
including one specifically related to ensuring that non-VA care 
providers' clinical documentation is available in the EHRs in a timely 
manner for PVAHCS providers to review. We closed our report in 
June 2016 after VA provided information that addressed the 
recommendations.
    In the area of IT security, VA uses personally identifiable 
information (PII), protected health information (PHI), and other 
sensitive information to deliver benefits to veterans and their 
dependents. Employees and contractors must safeguard this information. 
As we reported in our September 2015 report, Review of Alleged Data 
Sharing Violations at VA's Palo Alto Health Care System, the VA Palo 
Alto Health Care System (VAPAHCS) did not ensure that contract staff 
had the appropriate background investigations or proper security and 
privacy awareness training before being granted access to VA patient 
information. Additionally, facility Information Security Officers were 
not involved prior to the contractor placing its software on a VA 
server. We made three recommendations to VAPAHCS management and a 
fourth recommendation that VA's Office of Information Technology 
implement controls to ensure that unauthorized software is not procured 
or installed on VA networks without a formal risk assessment and 
approval to operate. We closed our report based on information provided 
that the recommendations were implemented.
                    inadequate training for va staff
    One prevailing theme of the OIG's work related to wait times and 
scheduling issues was the inadequate, lack of, or incorrect training 
provided to VA staff responsible for scheduling appointments. We 
conducted extensive work related to allegations of wait time 
manipulation through FY 2015 and FY 2016 after the allegations at the 
PVAHCS surfaced in April 2014. As we have reported in more than 90 
Administrative Summaries of Investigation and other reports that have 
been issued, the lack of training for schedulers and the lack of 
understanding of the process by their managers created a system in 
which long wait times were not accurately portrayed to management.
    In October 2016, we reported again that some confusion persists 
regarding appointments. The focus for this report was on consult 
management. In our report, Review of Alleged Consult Mismanagement at 
the Phoenix VA Health Care System, we substantiated that in 2015, 
PVAHCS staff inappropriately discontinued consults. We determined that 
staff inappropriately discontinued 24 percent of specialty care 
consults we reviewed. This occurred because staff were generally 
unclear about specific consult management procedures, and services 
varied in their procedures and consult management responsibilities. As 
a result, patients did not receive the requested care or they 
encountered delays in care. This report offered 14 recommendations 
including ensuring that staff are hired and trained appropriately. We 
are tracking VA's progress on implementing all the recommendations.
    In January 2016, we determined that VHA did not provide medical 
facilities with adequate tools to reasonably estimate non-VA care (NVC) 
obligations in our report, Audit of Non-VA Medical Care Obligations. 
The facilities we visited used a combination of methods that were 
ineffective at ensuring NVC cost estimates were reasonable. The methods 
used to calculate estimated costs included Medicare or contract rates, 
historical costs, and the optional cost estimation tools provided by 
CBO. The accuracy of estimates varied widely among these methodologies. 
We made five recommendations including for VA to improve the cost 
estimate tools so that NVC cost estimates are produced consistently. 
The recommendations related to cost estimate tools remain open.
           unclear resource needs and allocations priorities
    In March 2017, we published Consult Delays and Management Concerns, 
VA Montana Healthcare System, Fort Harrison, MT. We assessed the extent 
that patients experienced delays in obtaining consults, and the impact 
of any delays on patient outcomes. We reported that, for system 
consults ordered through VA Montana Healthcare System in FY 2015, there 
were apparent delays \2\ for:

    \2\ We considered delayed consults to be those that were not 
completed, canceled or discontinued within the expected timeframe.
---------------------------------------------------------------------------
     11,073 of 26,293 patients (42 percent) with at least one 
in-house consult;
     11,863 of 21,221 patients (56 percent) with at least one 
non-VA care consult; and
     2,683 of 4,427 patients (61 percent) with at least one 
Choice consult.

    We found that delays among consults ordered in FY 2015 may have 
harmed four patients. Beginning in July 2015, system leadership 
initiated a focused effort to identify and resolve factors that 
contributed to consult delays, including hiring additional support 
staff to process consults. Despite this effort, we found evidence of 
persistent issues with completing consults timely in FY 2016 (through 
late August 2016). We also noted that system leadership initiated 
ongoing reviews to determine if patient harm occurred due to delays in 
care.
    We made two recommendations to the VA Montana Director to ensure 
that an external (non-system) source review the care of patients we 
identified who were potentially harmed by consult delays and that VA 
staff provide institutional disclosures, as appropriate. We also made a 
recommendation regarding ongoing efforts to improve consult timeliness. 
The VA Montana Director and the VISN 19 Director concurred with our 
three recommendations and provided a responsive action plan and 
milestones to address the recommendations.
    The OIG has repeatedly reported on VA's legacy systems and how they 
impair VA operations. A key element to accurate planning is a financial 
system that provides timely information to VA leadership. As was 
reported in Audit of VA's Financial Statements for Fiscal Years 2016 
and 2015, VA's complex, disjointed, and legacy financial management 
system architecture continues to deteriorate over time and no longer 
meets the increasingly stringent and demanding financial management and 
reporting requirements mandated by the Department of the Treasury and 
the Office of Management Budget. VA continues to be challenged in its 
efforts to apply consistent and proactive enforcement of established 
policies and procedures throughout its geographically dispersed 
portfolio of legacy applications and systems. VA announced in 
October 2016 that it selected the Department of Agriculture as its 
Federal shared service provider to deliver a modern financial 
management solution to replace its existing core financial management 
system. When completed, this will be a major and critical effort for VA 
in modernizing its system architecture for financial management.
    The audit of VA's FY 2016 Consolidated Financial Statements also 
identified Community Care obligations, reconciliations, and accrued 
expenses as a material weakness. Lack of tools to estimate non-VA Care 
costs, lack of controls to ensure timely deobligations, and the 
difficulty in reconciling non-VA Care authorizations to obligations in 
VA's Financial Management System, make the accurate and timely 
management of purchased care funds challenging. In addition, the Office 
of Community Care (OCC) did not have adequate policies and procedures 
for its own monitoring activities. OCC's activities were not integrated 
with VA and VHA Chief Financial Officer (CFO) responsibilities under 
Public Law (P.L.) 101-576, the Chief Financial Officers Act of 1990, to 
develop and maintain integrated accounting and financial management 
systems and provide policy guidance and oversight of all Community Care 
financial management personnel, activities, and operations.
    To address the difficulties in estimating costs, VA requested 
legislation that would allow VA to record an obligation at the time of 
payment rather than when care is authorized. In its consolidation plan, 
VA said this would likely reduce the potential for large deobligation 
amounts after the funds have expired. We recognize that the current 
process and system infrastructure are complex and do not provide for 
effective funds management. We caution that such a change alone--i.e., 
obligating funds at the time of payment--would not necessarily remove 
all of VA's challenges in this area. VA would still need adequate 
controls to monitor accounting, reconciliation, and management 
information processes to ensure they effectively manage funds 
appropriated by Congress.
    VA needs to accurately forecast the demand for health care services 
in both the near term and the long term. The OIG is required by Section 
301 of Public Law 113-146, the Veterans Access, Choice, and 
Accountability Act of 2014, to review VHA occupations with the largest 
staffing shortages. We have issued three reports at this time and under 
the statute we will report for another two years. In our most recent 
report issued in September 2016,\3\ we identified (i) medical officer; 
(ii) nurse; (iii) psychologist; (iv) physician assistant; and (v) 
physical therapist/medical technician as five critical occupations with 
the largest staffing shortages. In our initial review \4\ and our 
subsequent reviews,\5\ we continue to recommend VHA create a staffing 
model that considers demand and complexity, and matches that to budget 
requests and allocations. While VHA has continually concurred with the 
recommendation, their planned completion date is September 2017. 
Further delay will potentially result in missed opportunities to 
request appropriate funding when planning for the FY 2019 budget.
---------------------------------------------------------------------------
    \3\ https://www.va.gov/oig/pubs/VAOIG-16-00351-453.pdf, 
September 28, 2016
    \4\ OIG Determination of Veterans Health Administration's 
Occupational Staffing Shortages, January 30, 2015
    \5\ OIG Determination of Veterans Health Administration's 
Occupational Staffing Shortages, September 1, 2015
---------------------------------------------------------------------------
                               conclusion
    The OIG is committed to providing effective oversight of the 
programs and operations of VA. A number of our reports address the five 
broad areas noted by GAO in placing VA Health Care on its High Risk 
list. We will continue to produce reports that provide VA, Congress, 
and the public with recommendations that we believe will help VA 
operate its programs and services in a manner that will effectively and 
timely deliver services and benefits to veterans and spend taxpayer 
money appropriately.

    Mr. Chairman, this concludes my statement and we would be happy to 
answer any questions that you or other Members of the Committee may 
have.

    Senator Tillis. Thank you, Mr. Missal.
    Dr. Clancy.

 STATEMENT OF CAROLYN M. CLANCY, M.D., DEPUTY UNDER SECRETARY 
   FOR HEALTH AND ORGANIZATIONAL EXCELLENCE, VETERANS HEALTH 
     ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
 ACCOMPANIED BY JENNIFER LEE, M.D., DEPUTY UNDER SECRETARY FOR 
   HEALTH FOR POLICY AND SERVICES; AND AMY PARKER, EXECUTIVE 
          DIRECTOR OF OPERATIONS, OFFICE OF MANAGEMENT

    Dr. Clancy. Good afternoon, Senator Tillis, Members of the 
Committee. Thank you for the opportunity to discuss VA's 
efforts to improve the issues identified by the GAO when they 
placed VA health care on the High-Risk List in 2015. As you 
noted, I am accompanied by Dr. Jennifer Lee and Amy Parker.
    In its High-Risk List update, GAO identified managing risks 
and improving VA health care as a high-risk area and noted five 
associated issues, which we have detailed in our written 
statement, and Debra Draper just reiterated.
    On March 3, 2017, Secretary Shulkin met with Comptroller 
General Dodaro to convey VA leadership's commitment to 
accelerating the changes required to meet all of GAO's criteria 
for removal from the High-Risk List. Secretary Shulkin 
acknowledged the significant scope of the work that remains and 
committed to better integrate its high risk-related actions 
with the President's priorities and ongoing VA transformation 
efforts.
    We immediately began working with GAO to follow through on 
Secretary Shulkin's commitments and to ensure continued VA 
collaboration with our GAO colleagues. We take GAO's work and 
the Inspector General's very seriously and appreciate the 
advice and feedback we have received from them. We are pleased 
to have the opportunity to report on our progress to date and 
our plan to ultimately be removed from the list.
    Addressing these risks will provide a sustainable 
foundation for continued transformation of the Veterans Health 
Administration. We have made progress since being placed on the 
High-Risk List. Two years ago, VHA had over 800 policies and 
over half of these had expired. On average, it took about 340 
days to produce national policy, and VHA lacked a consistent 
process for their development. Since that time, we have 
established a workgroup of all outcome executives, meeting 
every 2 weeks, tracking all policies and development, examining 
every step of the process, addressing barriers, and piloted and 
established a new lean process that would be completed within 
120 days.
    There are now approximately 650 active policies. New 
policies are created and reviewed promptly, and essential 
policies on access, scheduling, and consultations have been 
completed, published, and widely disseminated. We have 
committed to completing GAO's recommendations to ensure medical 
facility controlled substance inspection programs meet our 
requirements by October of this year.
    VHA also instituted a significant organizational 
transformation that aligned key offices, including offices of 
compliance and business integrity, medical audit, a new 
internal audit function, the management review service, and 
ethics, under a single combined Office of Integrity, led by a 
new leader, Assistant Deputy Under Secretary for Health, Dr. 
Gerard Cox, who reports to me.
    The newly established Office of Internal Audit and Risk 
Assessment uses reports from VA's Office of Inspector General, 
GAO, and the Office of Special Counsel to conduct further 
assessments into potential weaknesses in VA health care 
programs or care quality.
    During the past 2 years, in partnership with GAO, we 
conducted a comprehensive inventory of open recommendations and 
instituted a regular process for adjudicating closure based on 
documentation of completed actions, and linked them quite 
specifically to the risk areas identified by the GAO. Now, more 
than 45 percent of open recommendations were made, just in a 
year or less, and we have requested closure on 18 percent of 
the open recommendations.
    We have learned that integrating with or updating our 
veterans health information systems and technology 
architecture, known as VistA, is difficult and costly. We must 
be able to consistently access veteran information to succeed. 
We certified our interoperability with the Department of 
Defense on April 8, 2016. Today the Joint Legacy Viewer is 
available to all clinicians in every one of our facilities 
across the country, and we are also actively onboarding private 
sector partners into our health information exchange, because 
that is absolutely imperative for community care to work well.
    Mr. Chairman, transformation is a marathon, not a sprint. 
It takes several years to turn any organization around and we 
are acutely aware that most of the candidates on GAO's High-
Risk List have taken multiple years to meet that requirement. 
Secretary Shulkin is absolutely dedicated that we do this as 
rapidly as possible.
    While I am proud of the progress we have made in a short 
time, I am also acutely aware that we have much more work to 
do. I am grateful for the subject matter advice and 
consultation provided by Dr. Draper and her colleagues, and 
reiterate my commitment to working more closely with them.
    We look forward to working with you and Members of this 
Committee and to better serve our veterans, and to have 
committed to quarterly briefings to your staff.
    Thank you for the opportunity to testify and I look forward 
to your questions.
    [The prepared statement of Dr. Clancy follows:]
 Prepared Statement of Carolyn M. Clancy, M.D., Deputy Under Secretary 
       for Health for Organizational Excellence, Veterans Health 
          Administration, U.S. Department of Veterans Affairs
    Good afternoon, Chairman Isakson, Ranking Member Tester, and 
Members of the Committee. Thank you for the opportunity to discuss the 
Department of Veterans Affairs' (VA) efforts to improve the issues 
identified by the Government Accountability Office (GAO) that placed VA 
health care on the 2015 GAO High Risk List. I am accompanied today by 
Dr. Jennifer Lee, Deputy Under Secretary for Health for Policy and 
Services, and Amy Parker, Executive Director of Operations, Office of 
Management.
                              introduction
    In its 2015 High Risk List Update, GAO identified ``Managing Risks 
and Improving VA Health Care'' as a high-risk area and noted five 
associated high-risk issues:

     Ambiguous policies and inconsistent processes;
     Inadequate oversight and accountability;
     Information technology (IT) challenges;
     Inadequate training for VA staff; and,
     Unclear resources needs and allocation priorities.

    We take GAO's work seriously and appreciate the advice and feedback 
we have received from our colleagues. We are pleased to have the 
opportunity to report on our progress to date and our plan to be 
removed from the list. Addressing these risks will provide a 
sustainable foundation for continued transformation of the Veterans 
Health Administration (VHA).
                     progress to date by risk area
Ambiguous Policies
     Two years ago, VHA had over 800 policies, and more than 
half had expired. On average, it took over 340 days to produce national 
policy, and VHA lacked a consistent process for policy development. 
Since that time, we have established a workgroup comprised of all 
outcome executives that meets every two weeks and tracks all policies 
in development. We examined every step of the process, addressed 
barriers, and piloted and established a new, lean process with an 
aspirational timeline of 120 days. Our new process incorporated review 
and comments from medical centers and administrative offices--something 
that had never been formally required in the past, and which addressed 
many of the gaps identified by GAO. We funded seven full-time 
contractors to support transformation. We identified and rescinded 112 
expired policies and 20 additional policies that were no longer 
relevant. We completed work updating many policies imperative to 
addressing then-Under Secretary for Health Dr. David Shulkin's five 
priorities, and are eliminating handbooks and manuals in an effort to 
simplify and streamline national policy. There are now approximately 
650 active policies, including essential policies on access, 
scheduling, and consultations that were completed, published, and 
widely disseminated. We are also beginning to experience the 
unquantifiable benefits of culture change, as people in VA Central 
Office and the field become aware of these new processes, and the 
response has been overwhelmingly positive.
Inadequate Oversight and Accountability
     VHA instituted a significant organizational transformation 
that aligned several key offices including the Office of Compliance and 
Business Integrity, the Office of the Medical Inspector, the Office of 
Internal Audit and Risk Assessment, the Management Review Service, and 
the National Center for Ethics in Health Care. These offices are led by 
a newly established Assistant Deputy Under Secretary for Health for 
Integrity, Dr. Gerard Cox, who reports to the Deputy Under Secretary 
for Organizational Excellence. VHA also established a new Office of 
Internal Audit and Risk Assessment that uses reports from VA's Office 
of Inspector General (OIG), GAO, and the U.S. Office of Special Counsel 
to conduct further assessments into potential weaknesses in VA health 
care programs or care quality. The expected outcomes from VHA's 
integration of oversight and accountability activities are that: 1) VHA 
program offices, Veterans Integrated Service Networks (VISN), and 
facilities will possess a common understanding of how their oversight 
authorities, roles, and responsibilities align, 2) VHA will have a 
workforce well trained in oversight standards, 3) program offices, 
VISNs, and facilities will uniformly oversee policy implementation, and 
4) VHA will have a culture that incorporates both values and process to 
solve policy concerns.
     During the past two years VA, in partnership with GAO, 
conducted a comprehensive inventory of open recommendations and 
instituted a regular process for adjudicating closure based on 
documentation of completed actions. This adjudication process resulted 
in closure of 91 recommendations, and we have requested closure on 18 
percent of open recommendations. We have systematically cleared out the 
backlog of old recommendations so that currently over 45 percent of our 
open recommendations were made during the past 12 months. An additional 
30 percent of open recommendations are between 1- and 3-years old.
                   information technology challenges
     VA has learned that integrating with or updating the 
Veterans Health Information Systems and Technology Architecture (VistA) 
is difficult and costly. VistA Evolution is a joint VHA and Office of 
Information and Technology project intended to improve the efficiency 
and quality of Veterans' health care by modernizing VA's health 
information systems, increase data interoperability with the Department 
of Defense (DOD) and network care partners, and reduce the time it 
takes to deploy new health information management capabilities. VistA 
Evolution funds have enabled critical investments in systems and 
infrastructure; supported interoperability, networking and 
infrastructure sustainment; continuation of legacy systems; and other 
efforts that are critical to maintenance and deployment. These 
investments will deliver value for Veterans and VA providers regardless 
of whether our path forward is to continue with VistA, shift to a 
commercial Electronic Health Record (EHR) as DOD is doing, or some 
combination of both.
     Access to accurate Veteran information is one of our core 
responsibilities, and today the Joint Legacy Viewer (JLV) is available 
to all clinicians in every VA facility in the country. VA certified VA/
DOD interoperability on April 8, 2016, in accordance with section 
713(b)(1) of the National Defense Authorization Act for Fiscal Year 
2014 (Public Law 113-66). However, JLV is a read-only application. 
Leveraging this JLV interoperability infrastructure, the Enterprise 
Health Management Platform (eHMP) will ultimately replace JLV. eHMP is 
a cornerstone of the VistA Evolution Program, building on the 
capability for clinically actionable, patient-centric data pioneered by 
JLV. eHMP will fill clinical gaps in VA's current tools, bridge the EHR 
modernization effort, and simplify VHA's overall clinical user 
experience. Upon completion, eHMP will offer robust support for 
Veteran-centric health care, team-based health care, and quality driven 
health care while improving access based on clinical need.
Inadequate Training for VA Staff
     Training is vital to maintain a competent workforce and 
ensure that Veterans consistently receive timely, safe, high quality 
care. Training also requires a substantial investment of time and 
resources. From March to June 2016, then-Under Secretary for Health Dr. 
Shulkin directed a temporary moratorium on all Talent Management System 
(TMS) assignments not assigned by law or Executive Order. A detailed 
listing of previous training requirements was built to review all 
assignments, and comprehensive recommendations from across the 
organization were collected on existing training assignments. The VHA 
training policy was revised based on the results of this training 
review and is currently under evaluation.
     As a result, all 32,326 VHA employee TMS assignments were 
reviewed, and more than 700,000 hours of training were targeted for 
potential removal along with possible savings of over $38.7 million in 
hourly equivalent staff salary. To continue this improvement, VHA's new 
Mandatory Training Policy will be implemented this year in a phased 
rollout, with additional steps for review of content and comment from 
field-based experts.
Unclear Resource Needs and Allocation Priorities
     Key accomplishments for connecting strategy, requirements, 
programming, budgeting, and execution (since June 2015) include:

     Completion of the Quadrennial Strategic Planning Process 
(QSPP)--Strategic Options and Alternative of Analysis Phases. Outputs 
from the QSPP informed our planning guidance.
     Selection of the U.S. Department of Agriculture as a 
Federal Shared Service Provider to support the migration of a new 
financial management system (FMS). VA established a Financial 
Management Business Transformation program office and an Executive 
Steering Committee to manage the multi-year effort to improve VA's 
financial management accuracy and transparency.
     Issuance of FY 2019-2023 Programming Guidance as the 
disciplined framework to develop, assess, and prioritize multi-year 
requirements. VA successfully implemented two Managing for Results 
Programming cycles, which enhanced the connection of requirements and 
resources to support more defensible budget justifications. This 
included conducting Program Review Boards with senior leadership to 
assess gaps, impacts, and mitigations in advance of budget formulation.
     Publication of the FY 2018-2022 Programming Decision 
Memorandum (PDM) to capture decisions from the Program Review Boards 
and inform budget formulation guidance. The PDM included senior 
leadership decisions for resource prioritization and enterprise-wide 
mitigations to garner efficiencies and optimize strategic outcomes.
     Publication of a VA Cost Estimating Guide as a new 
financial policy outlining procedures for developing lifecycle 
estimates for programs that meet requirement thresholds.
                              path forward
    On March 3, 2017, Secretary Shulkin met with Comptroller General 
Gene Dodaro to convey VA leadership's commitment to accelerating the 
changes required to meet all of GAO's criteria for removal from the 
High-Risk List. Secretary Shulkin acknowledged the significant scope of 
the work that remains and committed to better integrate its high-risk 
related actions with the President's priorities and ongoing performance 
improvement initiatives.
    VA immediately began working with GAO to follow through on 
Secretary Shulkin's commitments to Comptroller General Dodaro and to 
ensure continued VA collaboration with our GAO colleagues.
    As we did in 2016, we will continue to place priority on 
implementing GAO's and VA OIG's recommendations using our new 
adjudication process. We have committed to completing GAO's 
recommendations to ensure medical facility controlled substance 
inspection programs meet VA requirements by October 2017. VHA's new 
office of Internal Audit and Risk Assessment will lead this work and 
will harmonize the policy, its implementation, training, and internal 
controls for required corrective actions to ensure consistent 
enterprise-wide management of controlled substances.
    We will buildupon our accomplishments for same-day access for 
Veterans with urgent problems in primary care or mental health, develop 
and disseminate a policy that builds on current guidance to the field, 
further improve our oversight of access to ensure all VA medical 
facilities consistently prioritize the needs of Veterans with urgent 
problems today, and transition to rely on Veterans' reports in how we 
display information to the public on wait times.
    VA will work with GAO and Congress to redesign the Veterans Choice 
Program so it works for Veterans and community providers, improve 
oversight of VA community care to ensure Veterans receive the care they 
deserve, and ensure our community partners are paid in a timely 
fashion.
    VA needs Congressional action to extend the current Choice Program 
beyond August 7, 2017. VA also needs new legislation to: (1) provide 
standardized, clear eligibility criteria for Veterans to get care 
closer to home; (2) facilitate building a high-performing network of 
community care providers, which includes our DOD, other Federal, and 
academic affiliate partners as the foundation and reimburses for care 
using contemporary payment models; and (3) better coordinate benefits 
for Veterans, allowing VA to work directly with third-party insurers. 
We look to Congress and our stakeholders to help enact these changes 
for Veterans within six months so that once all the Choice funds are 
depleted, there will be a plan in place for Veterans to continue 
receiving uninterrupted community care.
    As described above, VA's patient scheduling and EHR system requires 
significant improvement, and VA will take steps this year to address 
these needs. In addition, VA will improve oversight of the systems, to 
include establishing outcome-oriented metrics. VA's relationship with 
DOD and our community providers is complex and evolving. We will work 
closely with DOD to improve interoperability of VA and DOD record 
systems, and with our community providers to ensure continuity of care 
for Veterans. VA will implement a process to develop, document, 
implement, and oversee organizational structure recommendations to 
ensure approved recommendations are implemented, outcomes are measured, 
and plans are adjusted as necessary.
    VA is a complex ``system of systems,'' and this is reflected in the 
root cause analysis work we have accomplished thus far. We will 
complete this analysis in 2017, integrating the health care high-risk 
area actions with the President's priorities, the Secretary's 10-Point 
Plan, and with VA's ongoing performance improvement initiatives. We 
will use the results of the analysis to fine tune and speed up VA's 
progress in managing its health care high-risks.
    VA efforts will buildupon each other across a period of years to 
develop a sustainable solution to each high-risk issue, as well as to 
put in place systems that dramatically reduce the chance that high-risk 
issues will reemerge.
                               conclusion
    Mr. Chairman, transformation is a marathon, not a sprint. It takes 
several years to turn any organization around, and VA is no exception. 
While I am proud of the transformation VA has undergone in response to 
being placed on the High-Risk List, and the progress we have made, I am 
also acutely aware we have much more work to do to meet all five of 
GAO's criteria for removal. I am grateful for the subject matter expert 
advice and consultation provided by Dr. Debra Draper and the GAO 
medical team; it has proved invaluable in helping VA achieve the 
progress we've made since 2015. We look forward to working with 
Congress and GAO to better serve our Veterans. Thank you for the 
opportunity to testify before the Committee. I look forward to your 
questions.

    Senator Tillis. Thank you, Dr. Clancy.
    Are any of the other witnesses present intending to offer 
an opening statement? Here to answer questions?
    [No audible response.]
    Senator Tillis. OK. Thank you.
    Mr. Missal, I want to start with you. I want to get into 
some of your specific observations, and, Dr. Draper, this may 
relate to your lanes as well.
    When we do these evaluations, do we do it purely from the 
perspective of the regulatory, statutory construct as it exists 
today? Is there ever a focus on the possible root cause of some 
of the problems that need to be addressed being exacerbated by 
current rules or regulations, or do you accept that as the 
norm?
    Mr. Missal. No, we do not accept that as the norm. When we 
go into a project and we publish a report, I would like the 
reports to answer at least four questions. One, why we are 
doing this--and that may get to your question: is it a 
regulatory issue; is there something to put it in perspective? 
Two, what happened? Again, we should be accurate and fair as to 
what happened. Third, why something happened, and that really 
gets to the root cause of the problem. If a report is going to 
be a learning experience, helping VA improve, we really have to 
be pretty descriptive on why something happened. Then, fourth, 
who was responsible, so that if somebody did not perform as 
expected, that they could be held accountable.
    Senator Tillis. Thank you for that.
    Dr. Clancy, I think you know that the Ranking Member and I 
worked together for the last couple of years, with Secretary 
McDonald, to take a look at the transformation effort, the 
breakthrough priorities, and getting updated on activities and 
actions there. I think that there is some progress to be made.
    One question that I have, with the transition now of Dr. 
Shulkin to the role of Secretary, are any of those priorities 
changing? Are there any efforts being made to try to 
accelerate? Are we still on the same path, and can you give us 
some update on where either those breakthrough policies or 
specific remediation measures in reaction to the Inspector 
General's report are actually--are we making progress? In other 
words, where are we making traction?
    Dr. Clancy. We have made a great deal of traction to the 
transformation known as MyVA, in terms of the fact that all of 
our facilities achieved same-day access. These are the major 
medical centers for urgent problems and primary care and mental 
health at the end of calendar year 2016.
    Senator Tillis. How are we measuring that? I mean, how are 
we measuring things so that I can go back and get a review of 
the 100 or so recommendations, I think a quarter of which are 3 
years old.
    You referred in your opening comment to lean process. I 
like that, because I have done lean process design in the 
private sector. All those efforts are driven by metrics--
current State metrics, future metrics, any of the metrics you 
are making positive progress along the way.
    Are there specific things that you can speak to or submit 
for the Committee's purposes to look at quantitative, 
measurable changes that are in place, addressing the problems 
that are in the report?
    Dr. Clancy. We have a great deal of information on 
quantifiable improvements in access, both in terms of wait 
times and veterans' experience. There are reports of how often 
can they get care when they needed it right away, and so forth, 
and also plans in terms of future audits, because right at the 
end of calendar year 2016 is when we achieved that addition of 
same-day access.
    Many of the priorities in the MyVA transformation are 
continuing. I expect, as Dr. Shulkin's team comes together, 
that some may just simply move to become organizational efforts 
and not at that very high priority level, because they are 
underway. You would expect that in any transformation. I would 
imagine that has been part of your background prior to joining 
the U.S. Senate as well, but certainly we would be happy to 
take that for the record for a more complete picture.

    [Responses were not received within the Committee's 
timeframe for publication.]

    Senator Tillis. Thank you. Mr. Missal, I also appreciate 
the work that was done, looking specifically at VISN 6. That is 
a little bit closer to home, since that covers my geography. 
But, has there been any work done, in terms of even 
rethinking--in my estimation, a lot of the problems that exist 
with VA as a whole is how we are organized and the duplicative 
technology processes that we see out there, inconsistent 
experiences from VISN to VISN, and actually even within a VISN.
    Are there other things that we can do to really put the 
pressure on, and prioritizing in the right order? One of the 
concerns that I have with the number of recommendations for 
improvement, it is a target-rich environment for change. That 
is the good news. The bad news is if you are shooting at every 
target at the same time you are not going to hit any one of 
them.
    What is your view of the remedial measures that have gone 
into place, and whether or not the department is organizing 
properly to address the problems, and ultimately, over some 
period of time, get off the High-Risk List?
    Mr. Missal. We have looked at access to care in a number of 
different ways. Before the VISN 6 report, we had been looking 
at it facility by facility and it was hard to really get a 
sense of whether there are any themes, or is there a wider-
spread problem other than at a particular facility. We 
obviously found significant problems at VISN 6. We are looking 
at another VISN, again, just to compare to see if it is a 
leadership issue at the VISN. Is it higher? Is it lower than 
that?
    We try to make recommendations that are meaningful, that 
hopefully you do not see the same mistake happen again. We are 
going to continue to do that, and we are also going to be 
looking at the whole governance structure as well, because I 
agree, that could be an issue that could help a lot by 
addressing it.
    Senator Tillis. It just speaks to some of the impediments 
that are a part of the root cause of the problem.
    Ranking Member Tester.
    Senator Tester. Thank you, Mr. Chairman. Mr. Missal, I 
appreciate your work at Fort Harrison. Since you have been 
confirmed I think you have done some very good work and I want 
to thank you for that.
    Dr. Clancy, I spoke with Secretary Shulkin about this 
already and I need to make it clear. The findings in the 
report, as I said in my opening statement, unacceptable. Debra, 
as you may remember, the GAO issued a report in September 2014 
on consult management. You made six recommendations that are 
all still open, per your website. In one, the VHA promised to 
complete the first round of VAMC consult audits by September 
2016. Debra, was that completed?
    Ms. Draper. They have started the audit process. They 
provided us documentation in August, but we felt like the 
information provided was not complete. They did not provide all 
the documentation that we needed to assess the recommendations 
for closure, so we sent it back to them. Just recently they 
provided additional documentation; we are currently looking at 
what they provided so that we can assess whether the 
recommendation should be closed.
    But, in the information they provided to us, 75 percent of 
the VAMCs had done at least one audit--one consult. So, there 
is work to be done.
    Senator Tester. Was Fort Harrison included in any of those 
results?
    Ms. Draper. They did not provide us detail. It was 75 
percent of the VA medical centers. I think this is being done, 
spearheaded, through Dr. Clancy's office. She may be able to 
tell you that.
    Senator Tester. Go ahead, Dr. Clancy.
    Dr. Clancy. Sure. I spoke with leadership from the facility 
and the network yesterday, and they have made substantial 
progress, about which I would be happy to provide specific 
details. What I heard that was more important was: in addition 
to the fact that they have already contacted three of the four 
veterans--the fourth they are having some difficulty reaching 
but will continue----
    Senator Tester. Right.
    Dr. Clancy [continuing]. And had disclosed to them and 
their families what had happened, that they have not only made 
progress but are looking upstream now at how did we get here. 
Right? How might we use electronic consults to specialists, 
noting a shortage of some specialists across the State, in 
Montana, not just in VA.
    Senator Tester. Yes, there are.
    Dr. Clancy. And also looking at, are there ways that we 
might be training primary care clinicians? Are they referring 
to specialists too often, right, that they might be able to get 
extra expertise----
    Senator Tester. Got it.
    Dr. Clancy [continuing]. If you have got a scarce resource.
    I do not hear that very often. You are aware that the 
entire leadership team has turned over there.
    Senator Tester. I am.
    Dr. Clancy. It was a very different tone then when I have 
spoken to leadership at that facility before. We will certainly 
keep you updated, as I know it is very high on Dr. Shulkin's 
screen.
    Senator Tester. That is good, and I do think we have 
upgraded the leadership team in a big, big way--you guys have, 
I should say, at Fort Harrison.
    Another VHA started calls to share best practices with 
respect to consults. Dr. Clancy, was Fort Harrison--did they 
participate in those calls too?
    Dr. Clancy. I would have to double-check to be concrete 
about that, and I will take it for the record. Thanks.

    [Responses were not received within the Committee's 
timeframe for publication.]

    Senator Tester. OK. All right.
    Mike, your report on Fort Harrison indicated that steps had 
been taken to improve consult timeliness. Are you confident 
that these steps are sufficient?
    Mr. Missal. You know, we have got recommendations. They 
have an opportunity to prove to us that the steps that they 
have agreed to take will be implemented. We look at all 
recommendations very closely, and if we believe additional work 
needs to be done we will do so.
    Senator Tester. OK. All right. OK, that is fine.
    The High-Risk Report describes deficiencies in the action 
plan VHA submitted to address the high-risk status. Debra, can 
you articulate the impact these deficiencies are having on 
patient care within the VA?
    Ms. Draper. Yes. Well, basically, our high-risk work is a 
culmination of our work since 2010, so it reflects work in 
areas like access, which includes wait time and scheduling, the 
Choice Program, quality. So, in some of our work we have found 
that delays in care have put patients at risk, or veterans at 
risk for bad outcomes. I mean, I think there is sufficient 
evidence to suggest that when care is delayed or care is not 
received at all, for certain conditions, that the conditions 
worsen and then it becomes much more complex and costly to then 
treat that particular condition.
    I can give you a couple of examples in our mental health 
access report that we did in 2016. We found that for some 
veterans, when their mental health care was delayed, they 
decompensated and then their conditions became urgent and they 
then required urgent care, which sometimes resulted in 
hospitalization. We had other cases; for example, in the 
reprocessing of reusable medical equipment, if not cleaned 
properly or sterilized, it exposed many veterans to infectious 
diseases such as hepatitis.
    We have numerous examples, from the five areas that we have 
identified as the areas of concern in our high risk report, 
that are the underlying underpinnings that really, if not 
addressed sufficiently, raise the risk of harm for veterans.
    Senator Tester. Thank you, Mr. Chairman.
    Senator Tillis. Senator Rounds.

        HON. MIKE ROUNDS, U.S. SENATOR FROM SOUTH DAKOTA

    Senator Rounds. Thank you, Mr. Chairman. Mr. Missal, I 
would just like to start by asking a question about the 
hospital in Aurora, CO. It originally was set up with $600 and 
$700 million, as an estimate. Last time we checked, the 
estimated overrun was $1 billion. That has been more than a 
year ago. In your most recent review, is it still about $1 
billion overrun or have we increased it since then?
    Mr. Missal. We have not done any additional work. There is 
going to be an additional cost once the facility is done to 
essentially move into the facility, so that amount has to be on 
top of the building costs as well.
    Senator Rounds. So, how much, in addition to the $1 billion 
overrun, are you estimating at this time, or are you 
anticipating, and how will they come up with the resources to 
pick up that cost?
    Mr. Missal. I think it is going to be another--it was in 
our report, and my recollection it was somewhere around another 
$315 million, but these are not construction funds.
    Senator Rounds. Did you look at--on another matter, have 
you looked at the Choice Program and the operation of the 
Choice Program?
    Mr. Missal. Yes. We have done a number of reports on 
Choice.
    Senator Rounds. When you did the review of Choice, did you 
look at the cost analysis of the administrative costs of Choice 
versus non-Choice activity?
    Mr. Missal. We did not examine it that closely. We looked 
at, certainly, the administrative burdens of Choice and whether 
or not it operated as a barrier for veterans, but we did not 
actually look at the cost of each.
    Senator Rounds. It seemed that--and the reason why I bring 
it up, it seems as though there may be a duplication of 
activity there, and I did not know whether or not you had found 
that or had addressed it at all. My understanding is that there 
is a third party which had been hired to actually do the 
administration of the Choice to begin with, in terms of the 
appointments, and then also for the billings on behalf of the 
physicians, and that same third party is the same organization 
that--like in our part of the country it is HealthNet, but 
HealthNet handles not only VA Choice but they also do TRICARE 
as well.
    They seem to work very well within TRICARE but when it 
comes to working with the VA, my understanding is that they 
have a substantially higher cost, not because HealthNet charges 
more but because they are required to work through additional 
layers. In fact, every single time a veteran goes to a facility 
or to a physician or to a provider, it is a review and a 
reauthorization as opposed to a continuation of an existing 
approval method. Is that correct?
    Mr. Missal. I believe that is correct. When we looked at 
Choice, we first looked at the implementation of Choice, which 
took it from the beginning of the program until September 30, 
2015. We found a lot of administrative burdens and that the 
administration by VA caused significant delays.
    We then looked at it again, as part of our VISN 6 report, 
which went to the end of the calendar year, meaning December 
31, 2015. Again, we saw some changes. It got a little better 
but there are still burdens.
    Senator Rounds. Just to continue along that same line, my 
understanding, also, is that although they are perfectly 
capable of making the review, delivering the requested payments 
through providers and so forth--we have had delays of up to 9 
months for providers--it seems as though HealthNet is not the 
case where the problem is at. It actually goes into the VA and 
the VA then farms it back out for a second review, to be put 
back into their system, thus increasing the cost on a per claim 
basis by perhaps a tenfold factor. Were you able to look at 
that at all?
    Mr. Missal. We understand that they have changed the 
payments, where now they are doing bulk payments with the two 
third-party administrators, HealthNet and TriWest. So, they are 
constantly making changes to try to facilitate the payments.
    Senator Rounds. Do you know if they are still duplicating 
the efforts that those two third parties are expected to do?
    Mr. Missal. I do not know precisely. I know they constantly 
are looking at it. We have not--we are taking a hard look now 
at it, but we----
    Senator Rounds. Could I ask that in your next review you 
look to see, because it appears to me that Choice, one way or 
another, is going to continue on, and that we are going to 
continue to use third parties somewhere along the line. If that 
is the case, it seems inappropriate to have a duplication of 
efforts within the VA, simply to get things paid. Number 1, it 
seems to be a cost that we do not need, and second of all, it 
most certainly delays the payment to providers, which there is 
some reason why providers are not getting paid in a timely 
fashion.
    Mr. Missal. Right. We have an audit ongoing on the 
payments. We can add that in.
    Senator Rounds. OK. Thank you, sir. Thank you, Mr. 
Chairman.
    Senator Tillis. Senator Murray.

        HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON

    Senator Murray. Mr. Chairman, thank you very much. Thank 
you to all of our panelists for being here today.
    Let me just say, veterans have really benefited from 
expanded access to affordable health insurance and the expanded 
Medicaid, in particular, under ACA. That progress is really in 
jeopardy as the American Health Care Act would effectively end 
the Medicaid expansion and eliminate the coverage that is 
helping so many of our veterans. This is more important now 
than ever, as the VA continues to struggle with wait times, and 
as we work to reform the way veterans receive care both in and 
outside the VA.
    Dr. Clancy, I wanted to ask you, what would happen to the 
workload on VA and veterans' access to care if Congress repeals 
the Affordable Care Act?
    Dr. Clancy. We will be looking at that very closely, 
Senator. What I can tell you is that we did a policy analysis 
that compared States that had expanded Medicaid under the ACA, 
compared with those that had not, and saw that that increased 
demand for our services, somewhere between 6 and 18 percent--
the broad range just refers to type of services. I believe 18 
percent is outpatient care and 6 is inpatient. So, we would 
expect to see increased demand for our services for those 
veterans who had benefited----
    Senator Murray. So, what you are saying is that States that 
expanded Medicaid, that it is now at threat of being taken 
away, those families would--how many people would that be that 
would increase the demand at the VA?
    Dr. Clancy. I would actually have to track it back to get 
you some good numbers, but could do that. This was an analysis 
done by some policy researchers working with academic 
colleagues, because I was wondering about the differential 
impact.
    Senator Murray. Mm-hmm. Can you get us any studies you have 
done on the effects of the ACA on veterans' care or on the VA 
workload, for the record?
    Dr. Clancy. Mm-hmm.

    [Responses were not received within the Committee's 
timeframe for publication.]

    Senator Murray. Because I think that would be really 
important to know.
    OK. Dr. Clancy, I did note that at the end of your 
testimony you state that the VA will address the GAO 
recommendations in conjunction with implementing the 
Secretary's 10-point plan and implementing the President's 
priorities.
    I have been watching, because I believe that actions speak 
louder than words, the President's actions, and I have seen 
him, at the VA, leave almost every senior position in the 
department without a permanent official in place. He is 
refusing to personally meet with major veterans' organizations. 
He has implemented a hiring freeze that prevents VBA from 
hiring the staff needed to process veterans' claims. We know he 
has raised money, allegedly, for veterans' charities and then 
avoided giving to those groups until questioned. Those actions 
I am deeply concerned about.
    I did listen to him at the Joint Session of Congress a few 
weeks back, when he said his budget, which is not out yet, 
would somehow increase funding for veterans.
    So, I wanted to ask you, is fixing the VA simply a matter 
of more money to the VA, regardless of any policy or 
leadership?
    Dr. Clancy. I think that we need both the necessary 
resources, the right strategy, and the right leadership. To 
that end, I think your confirmation of Secretary Shulkin was a 
really terrific move, because as he said to you at the time of 
his hearing, he would not have a learning curve. I did not 
realize just how much he meant that, but, you know, he has been 
able to move very, very swiftly, in my experience in 
transitions, which I think is going to be good for veterans.
    I think you also heard him say ``not on my watch,'' in 
terms of privatizing, and I have full confidence that he will 
let you know if we need more resources to get the job done 
right.
    Senator Murray. I just think that that really matters.
    Dr. Clancy. Yes.
    Senator Murray. Obviously, we all love to say we are 
getting more money. We would love to see that, but we need 
leadership too, from the top on this----
    Dr. Clancy. Yes.
    Senator Murray [continuing]. And I do not know what that is 
yet, and I am not talking about the Secretary.
    Dr. Clancy. Yeah.
    Senator Murray. So, I am concerned and I just wanted to 
register that.
    Dr. Draper, good to see you again. Thank you for all the 
work you and GAO put into making sure we provide the best care 
for our veterans.
    Your testimony is very concerning, particularly the 
apparent lack of urgency in VA's steps to get off the High-Risk 
List. Not one of the five criteria in any of the areas of 
concern GAO identified has been fully met by the VA. Can you 
tell us how far along the VA should be now that it has been 2 
years since it was first put on that High-Risk List?
    Ms. Draper. Well, we are very concerned that 2 years later 
we are not much further ahead, or the VA is not much further 
ahead in addressing the issues. Let me just tell you a little 
bit about what we have done in the past couple of years to 
really express the need for urgency.
    The Comptroller General met with the then Secretary 
McDonald three times in the past couple of years. First was to 
tell him they were being put on the High-Risk List, the second 
time was that they were not making progress, the third time was 
that they were not making progress and that he offered the 
availability or access to subject matter experts within GAO 
that could help them with some of their initiatives, like 
contracting. We had a meeting in August between VA leadership 
and GAO subject matter experts, and unfortunately, to date, 
they really have not taken us up on accessing our subject 
matter experts that could really help point them, in terms of 
best practices. You know, we look across governments so we know 
what works well, what does not.
    Senator Murray. So, which agencies would you point them to, 
to tell them to look at?
    Ms. Draper. Well, it would really depend on what the issue 
was, but we had pointed the high risk--the group--Dr. Clancy's 
group to the Department of Homeland Security, which we feel has 
done a nice job addressing the high-risk concerns. I think they 
have a copy of their action plan and contact information 
related to that particular area.
    As I think Dr. Clancy said, the Comptroller General and 
Secretary Shulkin did meet on March 3, to talk about the lack 
of progress and concerns, and what they needed to do. The most 
immediate thing to do was to have a viable action plan that 
really provides a roadmap and lays out what they need to do and 
how they are going to do it.
    Senator Murray. OK. Thank you very much. Thank you, Mr. 
Chairman.

                STATEMENT OF HON. JOHN BOOZMAN, 
                   U.S. SENATOR FROM ARKANSAS

    Senator Boozman [presiding]. Thank you all so much for 
being here, and I apologize for being late. I had to give a 
little talk, and we had votes, and it was during the period 
when the votes took up. You all know how these things are. We 
do appreciate all of your hard work, and for coming over and 
talking to us about these things that are so very important.
    One of the areas that I really am concerned about, I think 
all of us are concerned about, is the management of information 
technology, which has been something that lots of people have 
been working on. I have been here since 2001, on the VA 
Committee in the House and now in the Senate, and this is just 
something that has been difficult.
    We talked about before, that, you know, there are 
proprietary ways of doing this. I was pleased that recently, I 
believe Dr. Shulkin said that we were going to be looking at 
commercial applications. Is that correct?
    Dr. Clancy. [No audible response.]
    Senator Boozman. Dr. Clancy, in your testimony you 
mentioned that the VA will take steps this year to address 
patient scheduling and electronic health record systems. Again, 
Secretary Shulkin has mentioned the VA was pursuing VSE as a 
scheduling solution, as well as MASS, another scheduling tool. 
It was my understanding that a go or no-go has been reached 
regarding VSE. Can you talk to us a little bit about that?
    Dr. Clancy. I am going to hand this to my partner, Dr. Lee, 
who knows all of the details much more than I do. Thanks.
    Senator Boozman. Very good. I have partners just like that.
    Dr. Lee. Thank you, Senator, for the question. We are 
currently moving ahead to implement a commercial scheduling 
solution called MASS, the Medical Appointment Scheduling 
System. We are currently piloting it right now at our site in 
Boise.
    I had the opportunity to see a demo of MASS a few weeks 
ago, and I was really impressed. It is state-of-the-art, it is 
so far advanced from where we are right now, and it will build 
in all kinds of functionality for our patients that we do not 
have right now, including rules and the ability to see what 
services individual patients qualify for, inside the system.
    Because it is so far advanced, it will take some time to 
fully implement across the entire system, on the order of 
probably several years, and because our current system is so 
primitive--as you know it is from the '80s and it is a DOS-
based system with--just very difficult to use. In fact, I saw 
our schedulers--I spent a day at a site watching some of our 
primary care clinic schedulers use our system, and it is 
cumbersome.
    We needed an interim solution that we could quickly roll 
out in the meantime, and that is the VistA Scheduling 
Enhancement, VSE. A few weeks--last month, actually, we did 
approve the national rollout of VSE as an interim scheduling 
solution, and we are planning to have that be implemented 
throughout the system through the summer.
    Senator Boozman. Very good. That is a great step in the 
right direction. That is encouraging.
    Dr. Clancy, you also, in your testimony, you highlighted 
the progress of the Joint Legacy Viewer. I believe that that is 
available now to clinicians throughout the system, you know, 
which is a good thing. Can you talk a little bit about how many 
people are--how many clinicians are actually using it, and our 
progress in that regard, or Dr. Lee?
    Dr. Lee. Currently we have over 200,000 authorized users 
for the Joint Legacy Viewer. This allows interoperability 
between VA and DOD health records. We are exchanging daily, on 
a daily basis, over 1.5 million data elements between VA and 
DOD.
    Just to speak about this from my own personal experience, I 
am an ER doctor and I see patients at the DCVA in the ER there, 
on the weekends. I have used Joint Legacy Viewer myself to find 
records from DOD when I am seeing patients there. You can also 
see records from the community. So, as more of our care is 
provided in the community, we need to have that 
interoperability with our community partners. You can also see 
the records from the community, as long as they are 
participating in our health information exchange.
    Senator Boozman. Along with that, can you talk a little bit 
about the enterprise Health Management Platform and how that is 
going to become a major cog?
    Dr. Lee. Yes, enterprise Health Management Platform, or 
eHMP, allows us to have even better interoperability by adding 
search, and also writes that functionality. JLV, the Joint 
Legacy Viewer, currently is in read-only state. The eHMP, 
brings all of the information together in one place. I have 
also used this myself. It allows providers on the same care 
team to communicate with each other. It can allow for clinical 
decision support to be added to the system, where you have many 
more tools in one place. This platform is really critical for 
us, as the clinical users and providers, to take care of our 
patients.
    Senator Boozman. Very good. Well, we look forward to 
hearing the progress, you know, as these things go forward. And 
it certainly seems like a big step in the right direction.
    Dr. Clancy. We could, if you were interested, I think 
arrange a demonstration locally, for you or your staff.
    Senator Boozman. Yeah, that would be great. Sure. Very 
much.
    Senator Tester.
    Senator Tester. Thank you, Mr. Chairman. Real quick, the 
incidences with servicemembers being sexually harassed on 
Facebook and other websites, it is critically important that we 
pay attention to what the heck is going on there, both from a 
DOD perspective and a VA perspective. The DOD, I believe, will 
bring the offenders to justice.
    Dr. Clancy, as you know, the VA has the authority to 
provide counseling services at med centers to active duty 
servicemembers who have experienced military sexual trauma, 
which would seem to include this type of abuse and harassment. 
Is the VA taking any actions to make sure these servicemembers 
can seek help from the VA?
    Dr. Lee. I can say, Senator, that it is our policy to--
currently, to provide care for any servicemember or veteran who 
has experienced military sexual trauma----
    Senator Tester. OK.
    Dr. Lee [continuing]. No matter where they enter our 
system.
    Senator Tester. OK. All right. Well, I would hope that you 
would take the necessary steps to let people know that if they 
have--we will call them challenges--that we are there, you are 
there. OK?
    I notice there are three docs on this panel. Are we all 
medical doctors?
    Ms. Parker. I am not.
    Senator Tester. OK. So are there four docs? I did not see 
her. Do we have four docs on the panel?
    Ms. Parker. I am a Ph.D.
    Senator Tester. Oh. OK. All right. Sounds good. The others 
are medical doctors. OK.
    One of the reasons--and correct me if I am wrong--that the 
VA was put on the High-Risk List is because of improper 
sterilization of equipment. Is that correct? [No audible 
response.]
    To me, as not a doctor, but as a patient, it is pretty 
fundamental to good health care, and it seems to me it is 
something that kind of takes me aback, to be quite frank with 
you. I mean, if I was looking at a hospital that had these 
kinds of problems, I would not step foot in the door.
    So, the question is, does this still exist? I am talking 
about improper sterilization.
    Dr. Clancy. We have made enormous improvements in sterile 
processing, while recognizing, at the same time, that it is an 
area that needs careful attention at all times. Part of the 
reason it needs careful attention is that what they are 
sterilizing changes a lot. Scopes, for example, for 
gastrointestinal procedures, keep changing and becoming more 
sophisticated; each time those change the instructions that go 
with it do too, and so forth.
    Quite recently, the people in sterile processing actually 
pointed out a problem, which we had to bring back to a device 
manufacturer, and they were very, very appreciative. This had 
to do with probes used for ultrasounds in sensitive areas, for 
men and women. Because of what someone in sterile processing 
had picked up, and noticed as part of their cleaning, they were 
worried about a concern of increased contamination. They 
flagged that right up through their supervisory chain, and we 
ultimately got a call from the CEO of the company, saying thank 
you. They have since changed their instructions for customers 
in this country and around the world.
    So, we have made dramatic improvements. When you talked 
about seeing it when you walked in, you would not. It is an 
area where----
    Senator Tester. You are exactly right on that.
    Dr. Clancy. Yeah.
    Senator Tester. I mean, you would not see it, but if you 
read about it?
    Dr. Clancy. Yes. No, I would be very, very worried. It is 
absolutely vital. It is not an area where we need innovation; 
we need constant attention to detail. But, we also need for 
those folks to be able to share their concerns, and I was quite 
thrilled that recently they did that.
    Senator Tester. No, that is good. It is very foundational 
to good health care. I mean, you just cannot have one without 
the other.
    I am just going to close it out with this. Oftentimes, it 
does not matter what business you are in; you want to do what 
you have been doing because it is just moving right along and 
you have got other things to think about.
    Mike Missal, we spent a long time getting you confirmed as 
IG, which is bad on us, by the way. You should have been 
confirmed a long time ago. But, now that you are in there, I 
would hope that the VA treats you with the highest respect and 
integrity, because I believe you are a man of those qualities.
    It is the same thing with the GAO. Gene Dodaro, your boss, 
Ms. Draper, is a fine, fine man, and has incredible respect 
within the Senate. I would just say that when they come forward 
with the recommendations, even if you do not like them, then 
tell this Committee that you think they are wrong. Then, we can 
bring him in and talk to him some more, and if you think they 
are right, fix it. OK?
    That is it.
    Dr. Clancy. That is fair.
    Senator Tester. That is the best preaching job I have got 
for today. Thank you for being here.
    Senator Boozman. We appreciate your preaching job for 
today, and we appreciate all of you for being here. Again, I 
know you are busy but it is so, so very important that we 
understand what is going on. So, thank you for being here.
    The record will be open for the next 5 days. With that we 
adjourn.
    [Whereupon, at 3:32 p.m., the Committee was adjourned.]

                                ------                                

Response to Posthearing Questions Submitted by Hon. Jon Tester to Debra 
A. Draper, Ph.D., Director, Health Care Team, Government Accountability 
                                 Office
                          fort harrison report
    Question 1.  In one open recommendation from the September 2014 GAO 
report on consults, VHA promised to complete a first round of VAMC 
consult audits by September 2016. Was Fort Harrison included and what 
were the results?
    Response. While VHA has begun conducting its audits of consult 
management activities, it has not yet finalized a report summarizing 
the findings. Since the audits include all VAMCs, Fort Harrison should 
be included, but we have not yet received a copy of the audit results, 
which are expected to be finalized at the end of April 2017.
    When VHA updated its national directive on consult processes and 
procedures in August 2016, it required VAMCs to engage in twice yearly 
audits of consult management activities and to report audit data to 
their Veterans Integrated Service Networks (VISN).\1\ Specifically, 
compliance and business integrity officers at each VAMC are responsible 
for reviewing a statistically valid random sample of closed consults 
(i.e., consults that have been completed, discontinued, or canceled).
---------------------------------------------------------------------------
    \1\ See VHA Directive 1232(1), Consult Processes and Procedures 
(Aug. 24, 2016, as amended on Sept. 23, 2016).
---------------------------------------------------------------------------
    Compliance and business integrity officers from each VISN are 
responsible for validating the data VAMCs report to VHA's Office of 
Compliance and Business Integrity. Officials from VHA's Office of 
Compliance and Business Integrity are responsible for examining audit 
results to determine systemic causes and circumstances related to 
delays in consults and the accuracy of consult documentation. They also 
are responsible for identifying systemic trends, educational 
opportunities, and recommending consult process improvements as 
necessary.
    In December 2016, VHA officials confirmed that VHA's Office of 
Compliance and Business Integrity had completed data collection for its 
initial audit of VAMC consult management activities in September 2016, 
and at that time, they expected to finalize a baseline report detailing 
the results of the audit in January 2017. VHA officials also told us in 
December 2016 that they began the data collection for the second 
national consult audit cycle in November 2016 and that they planned to 
finalize a second national consult audit report in February 2017. We 
received an update on the status of the consult audits in April 2017. 
When we requested copies of the initial consult audit reports, VHA 
officials told us that the analysis was not yet complete. They now 
estimate that their first national consult audit report--which will 
summarize the results of data collected during the first two audits--
will be finalized at the end of April 2017. They agreed to provide us a 
copy of the report when it is ready. We will continue to meet with VHA 
officials to discuss how they are using the results of nationwide 
consult audits to inform their oversight of consult processes and 
procedures across VHA, as well as to obtain documentation of these 
efforts.
                      implementing recommendations
    Question 2.  As of the date of the hearing, how many open 
recommendations does VA have?

    Question 3.  What progress is being made by VA in addressing these 
recommendations, and do you believe that they have been cooperative in 
this process?

    Question 4.  When VA and GAO agree on root problems but disagree on 
the path to address those problems, how is that resolved?
    Response. We are providing a combined response to questions 2, 3, 
and 4, as all three relate to VA's progress in implementing GAO 
recommendations related to veterans' health care.
    As of the date of the hearing (March 15, 2017), there were 113 GAO 
recommendations related to veterans' health care that VA had not yet 
implemented. See the following table for additional information about 
the status of the 255 recommendations related to veterans' health care 
that were included in products we issued between January 1, 2010 and 
March 15, 2017.

 Status of GAO Recommendations Related to Department of Veterans Affairs
      (VA) Health Care from January 1, 2010 through March 15, 2017
------------------------------------------------------------------------
                                                        Number of GAO
                                                      recommendations,
             Status of recommendations              Jan. 1, 2010 through
                                                        March 15, 2017
------------------------------------------------------------------------
Open because VA has not yet implemented them......        a 113
Closed because VA implemented them................          128
Closed without VA implementing them b.............           14
                                                   ---------------------
    Total.........................................          255
------------------------------------------------------------------------
Source: GAO.
a Of these 113 recommendations, 32 have been open for 3 or more years.
b We close recommendations without agencies having implemented them
  primarily if the recommendation is no longer valid because
  circumstances have changed.

    Since February 2015, when we designated VA health care as a high-
risk area, VA has increased its focus on implementing our 
recommendations. At the time we added this issue to our High-Risk List 
in 2015, VA had only implemented about 22 percent of our 
recommendations related to VA health care. The rate at which VA has 
implemented our recommendations has increased steadily since then, and 
at the time of our February 2017 High Risk Update, VA had implemented 
about 50 percent of our recommendations related to VA health care.
    Since 2015, GAO staff have been routinely meeting about every 4 to 
6 weeks with staff from VHA's Management Review Service (MRS) to 
discuss the status of open GAO recommendations, and these meetings have 
been cooperative and productive. MRS staff have prioritized for closure 
GAO recommendations that have been open for 3 or more years, and they 
are working to identify and support the actions VHA program offices 
need to take to implement those recommendations. MRS staff have also 
facilitated meetings between GAO teams and VHA subject matter experts. 
The meetings help clarify actions VHA is taking, and allow for 
discussions of documentation VHA should provide to GAO to support 
closing a recommendation as implemented, as well as any ideas VA may 
have for addressing the intent of the recommendation even if it does 
not exactly match our recommendation wording.
    In general, VA concurs with recommendations we have made, and it 
has been rare for VA officials and GAO staff to disagree about how our 
recommendations related to VA health care should be addressed. 
Sometimes, we need VA to provide us additional evidence showing that 
actions have actually been taken to address our recommendations (rather 
than just planned). In a few instances, the actions VA took were too 
late to meet the intent of our recommendation.
                         information technology
    Question 5.  The GAO report lays out a number of outdated IT 
systems operating at VA right now. What do you think is the most 
critical IT system for Secretary Shulkin to address immediately from 
the perspective of risk to veterans?
    Response. The use of IT is crucial to helping VA effectively serve 
the Nation's veterans. Each year, the department spends more than $4 
billion on IT and operates approximately 240 information systems. Many 
of VA's unmet IT needs have a direct relationship to the quality and 
safety of veterans' health care. However, GAO has not done work to 
prioritize VA's IT needs and therefore has no basis to identify which 
unmet IT needs are the most critical to address.
    As we have reported for many years, VA has had difficulty managing 
its information systems, raising questions about the effectiveness of 
its operations and its ability to deliver intended outcomes needed to 
help advance the department's mission. We have published a number of 
reports about VA's need to address aging information technology (IT) 
systems, including those related to delivering health care services to 
veterans. For example, in addition to the VA IT systems we discussed in 
the High Risk report, we also recently reported that VA is still using 
two of the Federal Government's oldest legacy IT systems--both of which 
have been in use for more than 50 years.\2\
---------------------------------------------------------------------------
    \2\ One of these systems is the Personnel and Accounting Integrated 
Data system, which automates time and attendance for employees, 
timekeepers, payroll and supervisors. The other is the Benefits 
Delivery Network, which tracks claims filed by veterans for benefits, 
eligibility, and dates of death. See GAO, Information Technology: 
Federal Agencies Need to Address Aging Legacy Systems, GAO-16-468 
(Washington, DC: May 25, 2016).
---------------------------------------------------------------------------
    VA's Office of Information and Technology (OI&T) has the important 
responsibility of providing IT services across VA and managing the 
department's IT assets and resources. VA has taken some steps to 
mitigate IT management weaknesses we have identified in past reports, 
such as transitioning oversight and accountability for IT projects to a 
new project management process.
    In addition to considering whether an IT improvement could help 
mitigate risks to patient safety or quality of care, there are other 
key factors for OI&T to take into account. According to Federal IT 
investment best practices we have identified, OI&T should assess VA's 
IT needs in light of criteria such as investment size, project 
longevity, technical difficulty, project risk, business impact, 
customer needs, cost-benefit analysis, organizational impact, and 
expected improvement.\3\ As new VA leaders transition into roles at 
OI&T, sustained management attention and organizational commitment will 
be essential to ensuring VA's progress in the area of IT management.
---------------------------------------------------------------------------
    \3\ See GAO, Information Technology Investment Management: A 
Framework for Assessing and Improving Process Maturity, GAO-04-394G 
(Washington, DC: Mar 1, 2004).
---------------------------------------------------------------------------
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to 
    Debra A. Draper, Ph.D., Director, Health Care Team, Government 
                         Accountability Office
                           mental health care
    Question 6.  Dr. Draper, the GAO highlights mental health care as 
one area where inconsistent application of policies has created access 
issues for veterans. Secretary Shulkin recently indicated the VA would 
be offering urgent mental health care for former servicemembers with 
less than honorable discharges: is the VA even equipped to expand into 
providing such services? Do you have a general sense of whether or not 
this will further exacerbate the problem of access for veterans to 
mental health services?
    Response. VA estimates that there are currently about 500,000 
former servicemembers with other-than-honorable (OTH) discharges, and 
according to DOD data, approximately 117,000 of these servicemembers 
separated from active duty between fiscal years 2001 and 2014.\4\ 
However, it is difficult to determine whether offering urgent mental 
health services to individuals with OTH discharges will negatively 
affect veterans' access to VA mental health care because of continued 
limitations of VA's appointment wait-time data. Without complete, 
reliable data on the extent to which veterans who are already receiving 
VA care are waiting for mental health care appointments, VHA lacks 
assurance that it has sufficient capacity to expand services to 
individuals with OTH discharges--even if it only offers urgent mental 
health care to these individuals.
---------------------------------------------------------------------------
    \4\ These 117,000 servicemembers with OTH discharges separated from 
the Army, Navy, Marine Corps, or Air Force between fiscal years 2001 
and 2014 (fiscal year 2014 data is as of June 2014). This data was 
accessed from HTTP://WWW.DOD.MIL/PUBS/FOI/READING_ROOM/ 
STATISTICAL_DATA/14-F-0775_FY2001-2014_ACTIVE_ENLISTED_SEPARATIONS.XLSX 
on January 29, 2016. This figure does not include servicemembers who 
separated from the National Guard or Reserve.
---------------------------------------------------------------------------
    For example, VHA has yet to implement our December 2012 
recommendation to improve the reliability of its wait time measures 
either by clarifying its scheduling policy to better define the desired 
date (which at the time, was the name for the starting date that was 
used to calculate wait times), or by identifying clearer wait time 
measures that are not subject to interpretation and prone to scheduler 
error.\5\ In July 2016, VA published a revised VHA outpatient 
scheduling directive, which provided new instructions for scheduling 
appointments. However, the new instructions, which form the basis for 
measuring wait times, are still prone to scheduler interpretation, 
making training vital to consistent and accurate implementation of the 
policy. As of November 2016, VHA reported that the majority of staff 
responsible for scheduling appointments had been trained on the new 
directive and that separate training on a new scheduling system 
enhancement was scheduled to begin in February 2017. We cannot assess 
whether VHA scheduling staff are accurately implementing the new 
scheduling policy until all relevant staff are trained on the new 
system.
---------------------------------------------------------------------------
    \5\ See GAO, VA Health Care: Reliability of Reported Outpatient 
Medical Appointment Wait Times and Scheduling Oversight Need 
Improvement, GAO-13-130 (Washington, DC: Dec 21, 2012).
---------------------------------------------------------------------------
    In addition, in October 2015, we reported that the way that VHA 
calculates veterans' wait times for full mental health evaluations 
(using veterans' preferred dates instead of the dates veterans 
initially request a referral to mental health care) may not reflect the 
overall amount of time a veteran waits for care.\6\ Further, we found 
that VHA's mental health wait time data may not be comparable over time 
(due to definitional changes), or comparable between VAMCs, making it 
difficult for VHA to provide effective oversight of access to mental 
health care.
---------------------------------------------------------------------------
    \6\ See GAO, VA Mental Health: Clearer Guidance on Access Policies 
and Wait-Time Data Needed, GAO-16-24 (Washington, DC: October 28, 
2015).
---------------------------------------------------------------------------
    While there is uncertainty about the extent to which veterans are 
experiencing wait times for mental health care, VA has engaged in 
recent hiring initiatives to improve access to health care services. 
For example, the Veterans Access, Choice, and Accountability Act of 
2014 appropriated $5 billion to expand VA's capacity to deliver care to 
veterans by hiring additional clinicians and improving the physical 
infrastructure of VA's medical facilities.\7\ In addition, in our 
October 2015 report on VA's mental health access, we reported that VA 
was able to hire about 5,300 new clinical and non-clinical mental 
health staff as a result of a two-part hiring initiative from June 2012 
through December 2013. While about 1,600 of these hires were for newly 
created mental health positions, about 2,300 filled existing vacancies 
(or vacancies that opened during the hiring initiative).\8\ Officials 
at the five VAMCs we visited as part of this review reported local 
improvements in access to mental health services as a result of the 
additional hiring, such as the ability to offer mental health services 
in new locations.
---------------------------------------------------------------------------
    \7\ Pub. L. No. 113-146, Sec. 801, 128 Stat. 1754 (2014).
    \8\ The remaining staff hired as part of this initiative were 
either non-clinical support staff or peer specialists (veterans with 
mental health conditions who are in recovery and have been trained to 
help others with mental health conditions).
---------------------------------------------------------------------------
    VA exempted certain positions, including mental health providers, 
from the January 2017 hiring freeze on executive branch employees in 
order to meet the department's public safety responsibilities. This 
exemption allowed VA to continue to recruit mental health providers, 
although officials at VAMCs we visited for our October 2015 report told 
us they faced several challenges in hiring and placing mental health 
providers. These challenges included: (1) pay disparity with the 
private sector; (2) competition among VAMCs for staff; (3) the lengthy 
VHA hiring process; (4) a nationwide shortage of mental health 
professionals; (5) a lack of space to provide care; and (6) a lack of 
non-clinical support staff to relieve providers' administrative burden 
and increase providers' clinical availability. Officials at four of the 
five VAMCs we reviewed also stated that they were still unable to meet 
overall demand for mental health care despite VHA's recent hiring 
initiative.
                                 ______
                                 
 Response to Posthearing Questions Submitted by Hon. Sherrod Brown to 
    Debra A. Draper, Ph.D., Director, Health Care Team, Government 
                         Accountability Office
                      oversight and accountability
    Question 7.  Dr. Draper, in your testimony you raise concerns 
regarding self-reported data from facilities and whether that data 
could be independently corroborated. What steps would GAO recommend VA 
take to ensure that the data collected and report to VACO can be 
independently corroborated? There are concerns that the data reported 
through SPOT and other systems do not properly reflect the day-to-day 
safety, quality, and access concerns that have been raised by GAO over 
the years.
    Response. There are several actions VA can take to independently 
corroborate self-reported data, including on-site inspections, pulling 
samples of patient records for independent review, ensuring that 
Veterans Integrated Service Networks (VISN) review reports generated by 
VA medical centers, and assigning responsibility to appropriate levels 
in the organization to verify data. When we added VA health care to the 
High Risk List in 2015, we noted that reliance on self-reported data 
contributed to weaknesses in VA's ability to hold its health care 
facilities accountable and ensure that identified problems are resolved 
in a timely and appropriate manner. We reiterated that concern in our 
2017 high-risk report. Ensuring that self-reported data are reliable 
can inform oversight decisions and help VA ensure that its corrective 
actions are addressing the root causes of the problem, which is part of 
our criteria for removal from the High-Risk List.
    We have several open recommendations for actions VHA can take to 
address our concern about reliance on self-reported data from VAMCs. 
Addressing these open recommendations can not only serve to correct the 
specific deficiency identified, but also help address the underlying 
problem of inadequate oversight and accountability.
    Descriptions of selected findings and open recommendations from 
recent GAO reports are provided in the table below.

    Summaries of Findings and Open Recommendations (as of April 7, 2017) from Selected GAO reports Addressing
    Concerns with Reliance on Self-Reported Data at the Department of Veterans Affairs' (VA) Veterans Health
                                              Administration (VHA)
----------------------------------------------------------------------------------------------------------------
               Report                            Finding Summary                     Open Recommendation
----------------------------------------------------------------------------------------------------------------
GAO-17-242, VA Health Care: Actions   We found that two of the four         To help VHA achieve its objective of
 Needed to Ensure Medical Facility     selected Veterans Integrated          reducing the risk of diversion
 Controlled Substance Inspection       Service Networks (VISN) in our        through effective implementation
 Programs Meet Agency Requirements     review did not review their           and oversight of the controlled
                                       facilities' quarterly trend reports   substance inspection program, the
                                       of controlled substance               Secretary of Veterans Affairs
                                       inspections, as required by VHA.      should direct the Under Secretary
                                       Such reports identify inspection      for Health to ensure that networks
                                       program trends such as missed         review their facilities' quarterly
                                       inspections and areas for             trend reports and ensure facilities
                                       improvement. We found that one        take corrective actions when
                                       network that had reviewed the trend   nonadherence is identified.
                                       reports failed to follow up with a
                                       facility to ensure it had submitted
                                       missed trend reports.
----------------------------------------------------------------------------------------------------------------
GAO-17-52, VA Health Care: Improved   We found VHA's lack of reliable data  To improve care for women veterans,
 Monitoring Needed for Effective       meant that it could not ensure        the Secretary of Veterans Affairs
 Oversight of Care for Women           medical center compliance with        should direct the Under Secretary
 Veterans                              requirements related to the           for Health to strengthen the
                                       environment of care for women         environment of care inspections
                                       veterans. These requirements          process and VHA's oversight of this
                                       include standards for privacy at      process by expanding the list of
                                       check-in and interview areas,         requirements that facility staff
                                       location of exam rooms, and the       inspect for compliance to align
                                       presence of privacy curtains in       with VHA's women's health handbook,
                                       exam and inpatient rooms. We found    ensuring that all patient care
                                       that only 3 of the 155 instances of   areas of the medical facility are
                                       noncompliance we observed during on-  inspected as required, clarifying
                                       site inspections of waiting,          the roles and responsibilities of
                                       procedure, and examination areas at   VA medical facility staff
                                       six VA medical centers were           responsible for identifying and
                                       reported to VA central office.        addressing compliance, and
                                       Because VA uses these data to track   establishing a process to verify
                                       facility compliance, their accuracy   that noncompliance information
                                       is vital for effective oversight.     reported by facilities to VHA
                                                                             Central Office is accurate and
                                                                             complete.
----------------------------------------------------------------------------------------------------------------
GAO-14-808, VA Health Care:           We found that VHA's limited           To improve VHA's ability to
 Management and Oversight of Consult   oversight of consults impedes its     effectively oversee the consult
 Process Need Improvement to Help      ability to ensure VA medical          process, and help ensure VAMCs are
 Ensure Veterans Receive Timely        centers provide timely access to      providing veterans with timely
 Outpatient Specialty Care             specialty care. For example, as       access to outpatient specialty
                                       part of its consult initiative, VHA   care, the Secretary of Veterans
                                       required VAMCs to review a backlog    Affairs should direct the Interim
                                       of thousands of unresolved            Under Secretary for Health to
                                       consults--those open more than 90     enhance oversight of VAMCs by
                                       days--and if warranted to close       routinely conducting independent
                                       them. However, VHA did not require    assessments of how VAMCs are
                                       VAMCs to document their rationales    managing the consult process,
                                       for closing them. As a result,        including whether they are
                                       questions remain about whether        appropriately resolving consults.
                                       VAMCs appropriately closed these      This oversight could be
                                       consults and if VHA's consult data    accomplished, for example, by VISN
                                       accurately reflect whether veterans   officials periodically conducting
                                       received the care needed in a         reviews of a random sample of
                                       timely manner, if at all.             consults as we did in the review we
                                                                             conducted.
----------------------------------------------------------------------------------------------------------------
Source: GAO.

    VHA has also taken some actions to implement recommendations that 
will help address the concern about the reliability of self-reported 
data. For example:

     In 2015, as part of our review of VA's primary care 
oversight, we found inaccuracies in VA's data on primary care panel 
sizes, which are used to help medical centers manage their workload and 
ensure that veterans receive timely and efficient care.\9\ We found 
that while VA's primary care panel management policy required 
facilities to ensure the reliability of their panel size data, it did 
not assign responsibility for verifying data reliability to regional- 
or national-level officials or require them to use the data for 
monitoring purposes. As a result, VA could not be assured that local 
panel size data were reliable, or whether its medical centers had met 
VA's goals for efficient, timely, and quality care. We recommended that 
VA incorporate an oversight process in its primary care panel 
management policy that assigned responsibility, as appropriate, to 
regional networks and central office for verifying and monitoring panel 
sizes. In October 2016, VA reported that it had completed nationwide 
deployment of new software for managing panel sizes, called Primary 
Care Management Module (PCMM) Web, which is designed to enable better 
management and monitoring of primary care panel sizes. In addition, in 
September 2015 and December 2016, VA required all facilities to 
validate their data on primary care panel sizes, as well as the number 
of support staff and exam rooms. In February 2017, all but one VA 
facilities certified that they had validated their data (the remaining 
facility was still in the process of completing data validation 
efforts), and we closed this recommendation as implemented.
---------------------------------------------------------------------------
    \9\ See GAO, VA Primary Care: Improved Oversight Needed to Better 
Ensure Timely Access and Efficient Delivery of Care, GAO-16-83 
(Washington, DC: Oct. 8, 2015).
---------------------------------------------------------------------------
     In our July 2015 report examining VHA's root cause 
analysis (RCA) program for adverse events, officials from VHA's 
National Center for Patient Safety (NCPS) told us that VAMCs sometimes 
chose alternative processes, such as those based on Lean methods, to 
address adverse events when an RCA was not required.\10\ NCPS officials 
told us they supported VAMCs' use of these alternative processes when 
appropriate, but acknowledged loss of information as the results of 
these processes were not required to be entered into WebSPOT (VHA's 
centralized RCA reporting system), or otherwise shared with NCPS. 
However, VHA was unaware how many VAMCs used these alternative 
processes. We recommended that VHA determine the extent to which VAMCs 
are using alternative processes to address the root causes of adverse 
events when an RCA is not required, and collect information from VAMCs 
on the number and results of those alternative processes. In 
September 2015, NCPS developed and fielded a survey to all medical 
centers to assess what degree they were utilizing alternative processes 
to address root causes of adverse events when a root cause analysis is 
not required. NCPS was able to obtain data from 86 percent of medical 
centers that demonstrated the types of alternative processes used and 
how medical centers were using them. As a result, we closed this 
recommendation as implemented.
---------------------------------------------------------------------------
    \10\ See GAO, VA Health Care: Actions Needed to Assess Decrease in 
Root Cause Analyses of Adverse Events, GAO-15-643 (Washington, DC: Jul. 
29, 2015).
---------------------------------------------------------------------------
                                 ______
                                 
   Response to Posthearing Questions Submitted by Hon. Jon Tester to 
   Michael J. Missal, Inspector General, U.S. Department of Veterans 
                                Affairs
                          fort harrison report
    Question 1.  The recent report on Ft. Harrison indicated that steps 
have been taken to improve consult timeliness. Are you confident those 
steps are sufficient and do you believe they will appropriately address 
factors that contribute to delays in care for veterans?
    Response. In comments to our draft report (which are included in 
the final report), leadership described ongoing steps to address 
factors within the system's control that contributed to consult delays. 
We will monitor system leadership's actions on these issues, which 
include hiring additional staff to administratively process consults 
and reducing the number of unnecessary consults. We anticipate that 
completion of those steps will have a positive impact on timeliness of 
care for some Montana veterans. However, consult delays for many 
veterans will likely persist because of other factors outside the 
system's control, including the adequacy of the provider network for 
the Veteran's Choice Program. We highlighted our concerns about network 
adequacy in another report, Review of VHA's Implementation of the 
Veterans Choice Program (January 30, 2017), and made recommendations to 
the Under Secretary for Health that will help to address nationwide 
issues that hinder consult timeliness.
                             high risk list
    Question 2.  Have you met with Dr. Shulkin in his capacity as 
Secretary? And have you received assurances of a high level of 
engagement on these issues?
    Response. Yes, I have met with Dr. Shulkin several times since he 
was confirmed. We have a regularly scheduled monthly meeting. I have 
also called him and requested a meeting when I felt that an issue 
needed to be addressed. Also the OIG meets monthly with leaders in the 
Veterans Health Administration.
                      implementing recommendations
    Question 3.  As of the day of the hearing, how many open 
recommendations does VA have that are over 60 days old?
    Response. As of March 15, 2017, there were 120 reports and 366 
recommendations that had been open for greater than 60 days.

    Question 4.  What progress is being made by VA in addressing these 
recommendations, and do you believe that they have been cooperative in 
this process?
    Response. Overall, VA is receptive to OIG recommendations and 
provides action plans to correct the identified issues. At times, 
however, VA may underestimate the time it takes for corrective actions 
to be implemented and demonstrate a sustainable improvement.

    Question 5.  When VA and OIG agree on root problems but disagree on 
the path to address those problems how is that resolved?
    Response. If VA management concurs with a finding but non-concurs 
with a recommendation, VA should provide an alternative course for 
corrective action that VA believes is responsive to satisfying the 
intent of the OIG recommendation. If the issuing OIG office agrees with 
management's proposal, follow-up will be on the agreed-to corrective 
action. If VA continues to non-concur with an OIG recommendation and 
does not propose corrective action, the Assistant Inspector General of 
the appropriate OIG Directorate will discuss the matter with the 
Inspector General and the Deputy Inspector General for an OIG decision 
on whether to submit the unresolved issues to the Deputy Secretary for 
final resolution or to publish the final report without the concurrence 
of VA on the findings and recommendations or without an implementation 
plan acceptable to OIG.
    In most instances, whenever VA and OIG disagree on an action plan 
to implement a recommendation that VA has concurred with, both sides 
will have productive discussions to address the issues.
                         information technology
    Question 6.  The GAO report lays out a number of outdated IT 
systems operating at VA right now. What do you think is the most 
critical IT system for Secretary Shulkin to address immediately from 
the perspective of risk to veterans?
    Response. We believe the following are some of most critical IT 
systems that Secretary Shulkin should address that have a direct impact 
on veterans:

     Veterans Health Information Systems and Technology 
Architecture (VistA)
     VA's Outpatient Appointment Scheduling System--The OIG is 
currently conducting an audit of the VistA Scheduling Enhancement (VSE) 
which is considered the near-term solution for updating VA's archaic 
scheduling system
     Veterans Benefits Management System (VBMS)--VBMS is the 
replacement for the Veterans Benefits Administration's (VBA) legacy 
systems, Benefits Delivery Network (BDN) and Veterans Service Network 
(VETSNET). BDN still has some functionality related to processing 
entitlements for three of the five business lines (Compensation and 
Pension, Education, and Vocational Rehabilitation and Employment). 
Until there is confidence that VBMS can process payments, VA will have 
to maintain these legacy systems which is a costly both in time, staff, 
and funding.
     Financial Management System (FMS)--While FMS is not 
involved in direct patient care, it supports payments to vendors that 
provide the goods and services the Veterans Health Administration needs 
to operate, as well as keeps track of the status of VA's budgetary 
resources.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to 
   Michael J. Missal, Inspector General, U.S. Department of Veterans 
                                Affairs
                       appointment cancellations
    Introduction: Mr. Missal, in your testimony you refer to OIG's 
(June 2016) report that claimed supervisors at a VA facility in Houston 
instructed staff to cancel appointments for veterans who were offered 
appointments at alternative locations but declined. Even though staff 
canceled these appointments, they were instructed to record them as 
canceled by the veterans themselves.

    Question 7.  Do you have reason to believe that these kinds of 
situations could have occurred in VA facilities in Hawaii or in other 
states?
    Response. We conducted investigations at over 100 VA facilities 
regarding the manipulation of wait time data. We discovered that the 
over-riding issue was the lack of training and understanding of VA's 
policy regarding scheduling. We did review allegations received by the 
OIG Hotline concerning Matasunga VA Medical Center (VAMC) in Honolulu, 
Hawaii. The allegations were different from the scheme uncovered at the 
Houston VAMC. Our Honolulu review did not develop any information that 
management instructed staff to disregard patient desired dates when 
inputting appointments.

    Question 8.  Can you discuss the recommendations that OIG made to 
address these situations? How can we ensure that veterans, especially 
veterans in rural communities who may have difficulty traveling to a 
nearby VA facility, do not have their appointments canceled?
    Response. We recommended the Veterans Integrated Service Network 16 
Director provide scheduling staff training; improve scheduling audit 
procedures for use of dates and appropriateness of the cancellation 
type used; and take actions when the audits identify deficiencies.
    VA facilities should follow VHA's Directive 1231, Outpatient Clinic 
Practice Management, November 15, 2016, which states that staff should 
determine which patients can be seen by another provider, and contact 
patients that need to be rescheduled as soon as possible prior to their 
scheduled appointment in order to avoid them arriving at the facility 
without the ability to be seen.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Joe Manchin III to 
    John D. Daigh, Jr., M.D., CPA, Assistant Inspector General for 
Healthcare Inspections, Office of Inspector General, U.S. Department of 
                            Veterans Affairs
    Question 9.  Over the course of the Inspector General's reports, 
what are the most pressing issues you have uncovered concerning opioid 
prescribing in the VA? How is the VA addressing the concerns IG 
investigations have discovered?
    Response. The most pressing issue that VA providers must address is 
the creation of an appropriate treatment plan for veterans who are 
prescribed narcotic medications. One group of patients has a history of 
chronic pain, co-morbid mental health issues, and a long history of 
narcotic use. The other group of patients are relatively naive to 
narcotic medications, and yet present with an acute pain syndrome, that 
if not properly managed, may lead to a life of chronic narcotic use/
dependence.
    VA has produced a number of directives and undertaken a number of 
efforts to improve VA providers' ability to effectively treat these 
veterans' symptoms to include the creation and dissemination of: a 
Clinical Practice Guideline Management of Opioid Therapy for Chronic 
pain, an Opioid Safety Initiative, an Opioid Safety Initiative Tool 
Kit, a Pain Management Opioid Safety Education Guide, and a Pain 
Management Opioid Safety Quick Reference Guide.
    The OIG recommended that VA improve the supervision of providers to 
ensure that the best insights of the most experienced VA providers can 
influence the care of each veteran. In addition, the OIG encouraged VA 
to partner with non-VA entities to improve clinical research trials in 
these populations with the hope of improving the guidance providers can 
offer over time. In discussions with VA leaders and providers, they 
appear dedicated to addressing these issues by improving the 
capabilities of VA providers and increasing reliance upon community 
resources.
                                 ______
                                 
 Response to Posthearing Questions Submitted by Hon. Sherrod Brown to 
   Michael J. Missal, Inspector General, U.S. Department of Veterans 
                                Affairs
                             whistleblowers
    Mr. Missal, thank you for the work that your office has done 
investigating allegations of misconduct and mismanagement at the 
Cincinnati VAMC. I look forward to reading the report, which should be 
forthcoming. VA employees, acting as whistleblowers, raised concerns 
and demanded change for our veterans. There are still concerns however 
that VA employees who reach out through appropriate channels to raise 
concerns are retaliated against. We've seen this over and over 
throughout the system.

    Question 10.  What steps does OIG take to protect those interviewed 
so that they don't face reprisal?
    Response. The OIG takes all possible steps to protect the identity 
of complainants. Often complainants have made similar complaints to 
management, so it is possible for management to identify them. However, 
we do not provide the identity of complainants, confidential sources, 
or self-identified whistleblowers to VA. We advise complainants to 
contact the Office of Special Counsel (OSC) regarding protection under 
the Whistleblower Act. OSC is a separate Federal agency with authority 
to review allegations of prohibited personnel practices, including 
reprisal for whistleblowing. The VA OIG is certified by OSC as having 
met the statutory obligations to inform the employees about the rights 
and remedies under the Civil Service Reform Act, the Whistleblower 
Protection Act, and the Whistleblower Protection Enhancement Act.
                      oversight and accountability
    Question 11.  Mr. Missal, has OIG received requests to review the 
self-reporting processes at VAMCs?
    Response. The OIG has completed numerous evaluations of the 
accuracy of VA-reported data. For example, in our recent report, Audit 
of Veteran Wait Time Data, Choice Access, and Consult Management in 
VISN 6, we described our evaluation of the accuracy of wait time data 
within the Veterans Integrated Service Network (VISN) 6 medical 
facilities and through Choice. We raised concerns that VA-reported wait 
time data understated the actual amount of time veterans waited for 
health care services. To address our concerns, we made 10 
recommendations, four to the Under Secretary for Health and six to the 
VISN 6 Director. Last year, we reviewed whether information contained 
in a letter from VISN 23 to Congressman Walz accurately reported 
information on primary care staffing at the St. Cloud VA Health Care 
System. In our report, Healthcare Inspection--Reported Primary Care 
Staffing at St. Cloud VA Health Care System, we indicated that data 
reported were inaccurate and that VISN and facility leadership 
acknowledged that no data validation steps were taken prior to 
submitting information to the Congressman. We made one recommendation 
to the VISN Director to address the inaccuracies we identified.
                                 ______
                                 
   Response to Posthearing Questions Submitted by Hon. Jon Tester to 
    Carolyn M. Clancy, M.D., Deputy Under Secretary for Health for 
     Organizational Excellence, U.S. Department of Veterans Affairs
                          fort harrison report
    Question 1.  GAO issued a consult audit in 2014 with 6 
recommendations that are still open. In one open recommendation from 
this report, VHA promised to complete a first round of VAMC consult 
audits by September 2016. Was this completed, and what were Ft. 
Harrison's results?
    Response. All facilities, including Ft. Harrison, were included in 
the two national consult audits (completed in September 2016 and 
January 2017) conducted by the Office of Compliance and Business 
Integrity (CBI). CBI is finalizing the results of these audits. The 
findings will be published once the results are compiled.

    Question 2.  In another recommendation from the same report, VHA 
indicated calls to share best practice with respect to consults were 
forthcoming. If these happened, did Ft. Harrison participate? What 
actions are continuing in VHA to share practices on consult management?
    Response. To promote nationwide communication, VHA established a 
system-wide process for identifying and sharing best practices. 
Facility level consult steering committees were created and 
participated in weekly national consult performance improvement calls. 
VHA began holding national calls with these Veterans Integrated Service 
Network (VISN) and facility consult points of contact (POC) on 
November 14, 2014. Each week, more than 400 attendees participate in 
these calls, which include training on consult policies and processes, 
review of consult performance data, and presentations on best 
practices. The calls also provide a forum for discussion and answering 
questions, which are published for reference in a Frequently Asked 
Questions (FAQ) document. In addition, VHA has created a Consult Cube 
with many different Pyramid views enabling easy access to consult data 
and developed a SharePoint page, which serves as a repository for all 
consult policy documents, training materials, FAQs, and contact 
information for VISN and facility consult experts and steering members.
    VISN and facility staffs from all sites, including Ft. Harrison, 
are invited to these calls. There has been significant leadership and 
staff turnover at Ft. Harrison since calls started. When questioned 
again in March, 2017, leadership was unsure if anyone was attending the 
calls. This issue is currently in the process of being corrected.

    Question 3.  Overall, given the continued concern with consults, 
what is VA doing to improve the consult process and ensure no 
additional veterans are harmed by delays in care?
    Response. VHA has taken many actions such as those listed below to 
improve consult processes and ensure timeliness of care:

     VHA finalized Directive 1232 ``Consult Processes and 
Procedures'' in September 2016. VHA also distributed the Standard 
Operating Procedure (SOP). These policy documents clarify procedures 
for completing consults and provide guidance for tracking and 
monitoring consults throughout the organization and provide the basis 
for consult oversight.
     A Consult Management Trigger report was developed to 
measure VISN and facility consult performance. The Consult Trigger Tool 
automatically sends notifications to leadership at facilities not 
meeting requirements to assist in consult oversight and management.
     VHA provided extensive national, VISN, and facility 
consult training:

        - October and November 2014, national training was provided to 
        facility level staff via webinars and to 975 employees via VA 
        eHealth University (VeHU) training. This training was also made 
        available in the Talent Management System (TMS).
        - March, April, October, and November 2015, training with VISN 
        and facility leadership and staff of all VISNs was provided.
        - Weekly consult best practice/training calls began in 
        November 2014. Over 400 consult POCs attended training calls.
        - National consult training module #24762 was deployed in TMS. 
        As of August 2015, 97 percent of Licensed Independent 
        Practitioners (LIP) assigned the TMS training completed it. An 
        additional 12,740 staff who were not assigned the consult 
        training module in TMS also completed the training. Residents/
        trainees were provided separate consult training by October 1, 
        2015.
        - Approximately 60,000 schedulers and 600 VISN and facility 
        consult POCs and Group Practice Managers (GPM) completed 
        training on the Consult Directive. Updated LIP consult training 
        including training on the Consult Directive will be available 
        in TMS in April 2017. Residents/trainees will receive updated 
        mandatory consult training in July 2017.

     VHA implemented the Consult Improvement Initiative (CII) 
from March thru June 2016 to provide assistance to selected facilities 
identified by the Consult Trigger tool as having issues in consult 
processes and timeliness of completion. All participating facilities 
demonstrated improvement by reducing consult process failures and 
reducing delays.
     CBI, in conjunction with the Office of Veteran's Access to 
Care (OVAC), developed and implemented an independent consult audit 
process. CBI reviewed all facilities reviewed in two national consult 
audits. CBI will release the results once finalized. During FY 2017 and 
until further notice, routine audits will be conducted by compliance 
staff at a minimum of twice annually for the use of VHA's standardized 
consultation process and to identify causes of delays of outpatient 
specialty care consults.

    Question 4.  Can VHA certify that every employee who is involved in 
the consult process has been trained on last year's new Directive 1232, 
Consult Processes and Procedures? What training has been provided, and 
what metrics will measure adherence to Directive 1231, Outpatient 
Clinic Practice Management?
    Response. Consult Directive Training was developed for the roles of 
schedulers, VISN and facility consult POCs, GPMs, residents/trainees 
and LIPs. Training for schedulers, facility consult POCs and GPMs was 
delivered by live and recorded webinars and completion of training is 
tracked in TMS. Approximately 600 facility consult POCs, GPMs, and 
60,000 schedulers completed the training. This group is considered 
complete.
    Training content for LIPs has been updated and is in the process of 
being delivered and tracked in TMS. Residents/trainees will be required 
to take training on the Consult Directive as part of Mandatory Training 
in July 2017. Consult Directive training is also included in current 
Medical Support Assistant (MSA) and new MSA onboarding training and 
will be part of recently-updated scheduling training modules in TMS 
required for all new schedulers. Generally, as a result of the 
training, VHA expects to see outcome improvements in areas such as the 
time to schedule and complete clinical consults, the number of consults 
linked to appointments, and improvements in the associated consult 
process metrics.
                             high risk list
    Question 5.  Can you provide a timeline for when the root cause 
analysis for each deficient area in GAO's report will be complete? VA 
needs to have a well-established timeline.
    Response. VA will submit the root cause analyses and VA corrective 
action plan to GAO in June 2017. The corrective action plan will 
include schedules and milestones for each initiative by which to gauge 
VA's progress in achieving the desired outcomes.
                      implementing recommendations
    Question 6.  What progress is VA making in addressing the hundreds 
of open recommendations?
    Response. During the past 2 years, VHA closed 91 GAO 
recommendations. GAO added 75 new recommendations during that same 
timeframe. As of March 2017, VHA is actively working on 81 open 
recommendations, of which GAO provided more than half during the past 
12 months. VHA has completed actions on 20 recommendations and awaits 
GAO's decision regarding closure.

    Question 7.  When VA and GAO or OIG agree on root problems but 
disagree on the path to address those problems how is that resolved?
    Response. In the event, GAO or the VA Office of Inspector General 
(OIG) are seeking a different resolution than the actions VHA has 
taken, VHA engages the OIG or GAO team in discussions regarding the 
details of actions taken and provides evidence of the effectiveness of 
those actions. Upon learning more detail, the OIG or GAO may find that 
the actions have been effective and close the recommendation, on 
occasion they request additional data collection over time to assess 
for lasting effectiveness, or they specify what additional actions 
would be needed to satisfy the intent of the recommendation.

    Question 8.  Does VA have any Department-level tracking of the 
administration's open and oldest recommendations? If so, please provide 
the name of the accountable office. What actions is Dr. Shulkin taking 
to focus attention on these issues, or is this not a priority?
    Response. VA's Office of Congressional and Legislative Affairs 
maintains a list of open GAO recommendations. Dr. Shulkin appreciates 
GAO's work to improve services to our Veterans and takes GAO's 
recommendations to the Department very seriously. The Department's 
Administrations and Staff Offices that have open recommendations are in 
the process of implementing action plans outlined in the responses to 
GAO draft and final reports.
                             staffing model
    Question 9.  Three OIG reports have been issued on staffing 
shortages, and all have recommended VA create a staffing model that 
considers demand and complexity and matches that to budget requests and 
allocations. Why has this not yet been completed?
    Response. As reported in the VHA concurrence to the OIG 
Recommendation (Report No. 16-00351-453, 9/28/2017), VHA is pursuing 
multiple courses of action. These include the following:

    (1) Completion of the draft Specialty Care Clinical Staffing Model. 
As noted, in the OIG report, this is a project to research, develop and 
ultimately implement a cross-disciplinary staffing model. In 
January 2015, the Under Secretary for Health chartered a working group 
for a staffing model across all 25 Specialty Care disciplines, at all 
VA medical centers, both inpatient and ambulatory. The objective of 
this team is to develop a model that correlates Veteran population and 
utilization with productivity and capacity, and then to cost. From 
there, the model can be used to assist in both individual staffing 
determination and for overall ``make/buy'' decision on expanding or 
contracting clinics and other medical facilities.
    The draft model is complete and is undergoing review by several VHA 
senior leaders and by VA's OIG. The final draft will incorporate 
feedback from each of these offices, which will then lead to field 
validation and development of policy for implementation.
    (2) Evaluation and enhancement of other VHA clinical staffing 
models continues across multiple fields, including the Primary Care 
Patient Aligned Care Team (PACT) model, Nurse Professionals, and 
Medical Support Assistant staffing. Each of these efforts is making 
significant progress in their respective arenas and is also being 
connected with similar enhancements to hiring and onboarding practices. 
Feedback will be solicited from field clinics to validate the ongoing 
work.

    The ongoing clinical staffing work at the James A. Lovell Federal 
Health Care Center (FHCC) in Chicago, Illinois is another staffing 
modeling activity, focused on leveraging best practices and common 
strategies in a joint clinical environment. Since September 2016, a 
team of Department of Defense (DOD) and VHA professionals have 
regularly convened to review alignment of VHA and DOD staffing models 
in such practice areas as Primary Care and Nursing. VHA is currently 
exploring mechanisms to import staffing data from DOD, and incorporate 
the information into VHA's productivity tools--regarded by both DOD and 
VHA as a potential asset for productivity and integration. As the joint 
VHA-DOD staffing strategy matures, VHA will examine the applicability 
of DOD staffing techniques in VHA-specific environments.
                         information technology
    Question 10.  The GAO report lays out a number of outdated IT 
systems operating at VA right now. How does Dr. Shulkin intend to 
prioritize funding amongst the various systems that need to be upgraded 
or replaced, and what role will OIT play in those decisions?
    Response. The VA does have a large number of legacy systems and 
have embarked on a strategy to prioritize the divestiture of legacy 
systems. In FY 2017 we will retire the Bi-directional Health 
Information Exchange (BHIE) and have started a project to divest our 
legacy Financial Management System (FMS) and other ancillary financial 
systems. We also have projects currently underway with our business 
partners in VBA, NCA and BVA to retire the Benefits Delivery Network 
(BDN), Burial Operations and Support System (BOSS), and Veterans 
Appeals Control and Logistics System (VACOLS), respectively. The 
Secretary will also announce the VA's path forward on Electronic Health 
Record modernization by July 2017. Divestiture of legacy systems and 
the modernization of the VA's IT infrastructure is one of our highest 
priorities and we are aligning resources around these projects to 
reflect that commitment. The process and decisionmaking has involved 
close cooperation between the CIO and senior VA leadership by reviewing 
and discussing the IT and operational risks associated with each 
system.

    Question 11.  I understand that VA had a goal of having 50 percent 
of the active IT projects on budget and on schedule by the end of 2016. 
Did VA meet that goal? What is the new goal moving forward?
    Response. VA has met the on-time rate of 50 percent of projects 
being on budget for the end of 2016. VA has exceeded the on-time rate 
of 50 percent of projects being on schedule for the end of 2016. At 
this time, the goal is 50 percent for 2017.

    Question 12.  VA appears poised to make an announcement in early 
Summer 2017 regarding its intent to procure a commercial electronic 
health record as a replacement for VistA. Please describe how VA has 
been consulting with the Department of Defense (DOD) during DOD's 
ongoing EHR transition and what lessons VA has learned from that 
implementation. Please describe the experience VHA and VHA patients who 
are receiving care at Fairchild Air Force Base or any other facility 
deploying the Cerner Millenium EHR have had to date.
    Response. VA continues to consult and work closely with DOD to 
learn lessons from its acquisition and ongoing implementation of the 
Military Healthcare System (MHS) GENESIS efforts.
    VA continues to consult and working closely with DOD to gather 
information on the acquisition of MHS GENESIS. VA has received and 
reviewed the business and clinical workflow models which were developed 
as part of the MHS GENESIS scope of work. DOD has pledged to provide 
additional information to VA as it becomes available through the DOD/VA 
Interagency Program Office, in consultation with the functional and 
program offices in the Defense Health Agency and Program Executive 
Office, Defense Healthcare Management System.
    VA has worked with DOD to obtain information on the acquisition of 
MHS GENESIS, such as market research information, certain contract 
clauses related to compliance with national health data standards and 
basic contract structure, and request for proposal statements of work. 
VA has also worked with DOD to receive business and clinical workflow 
models developed as part of DOD's scope of work on the Department of 
Defense Healthcare Management System Modernization (DHMSM) effort. VA 
will receive additional information from DOD through the DOD/VA 
Interagency Program Office (IPO) as information becomes available in 
consultation with the functional and program offices in the Defense 
Health Agency and Program Executive Office, Defense Healthcare 
Management Systems.
    As an example of VA and DOD's coordination, on October 26, 2016, VA 
held an Electronic Health Record (EHR) Roundtable with the objective to 
discuss EHR transformation best practices and lessons learned with 
public and private sector health care industry leaders to inform the 
way forward for VHA. This meeting included participation from external 
partners including the Office of the National Coordinator and Colonel/
Dr. Aronson who has been the Chief Medical Information Officer for the 
DHMSM. Key lessons learned included: 1) need for highly resource 
intensive change management strategies; 2) best practices for 
addressing legacy systems, including re-training of staff; and 3) 
strategies, such as phased roll-outs, to mitigate impacts to patient 
access.
    Meetings and coordination between VA and DOD to ensure 
interoperability and lessons learned are and will be ongoing throughout 
the DHMSM/MHS GENESIS program.
    Finally, VA officials were pleased to attend the ribbon cutting 
ceremony and lessons learned sessions at the Fairchild Air Force Base 
(AFB) in February 2017. An example of the lessons learned was the 
central role organizational change management plays in any large 
deployment of this kind. We do not have any information on VHA patients 
receiving care at Fairchild AFB or another facility where MHS GENESIS 
is deployed, but we will continue to monitor.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Richard Blumenthal 
   to Carolyn M. Clancy, M.D., Deputy Under Secretary for Health for 
     Organizational Excellence, U.S. Department of Veterans Affairs
    Question 13.  During last week's hearing, Dr. Lee responded to a 
question on how the Department of Veterans Affairs (VA) provides care 
to survivors of military sexual trauma (MST) by saying that VA's policy 
is to provide care to Servicemembers, former Servicemembers with an 
other than honorable (OTH) discharge for MST care regardless of how 
they enter the VA system. Previous communications with both VA and 
Department of Defense staff have indicated that these services are only 
being provided to active duty Servicemembers, including members of the 
National Guard and Reserves, and those with an OTH discharge at Vets 
Centers but not at VA medical centers (VAMC) or Community-Based 
Outpatient Clinics (CBOC). Could you please clarify whether such 
services are available at VAMCs and CBOCs and if there are any 
locations in which MST services are not available for active duty 
Servicemembers and former Servicemembers with an OTH discharge?
    Response. VA has been offering a full range of health care services 
to Active Duty Servicemembers (ADSM) under sharing agreement authority 
for many years; this care has been available at both VA medical centers 
(VAMC) and community-based outpatient clinics (CBOC) depending on the 
nature of specific sharing agreements. Services provided under this 
authority likely have included care for conditions related to military 
sexual trauma (MST), but because such care was provided under VA's 
sharing agreement authority, not its MST treatment authority (as 
specified in 38 United States code (U.S.C.) Sec. 1720D), it has not 
historically been tracked as part of VA's national MST monitoring 
efforts. ADSMs typically must receive a referral from TRICARE or a 
military treatment facility to seek care at a VAMC or CBOC under the 
sharing agreement authority.
    The amendments to 38 U.S.C. Sec. 1720D in section 402 of the 
Veterans Access, Choice, and Accountability Act of 2014, which became 
effective on August 7, 2015, authorize VA to extend VA's MST-specific 
treatment authority to ADSMs without the need for a DOD referral. 38 
U.S.C. Sec. 1720D(a)(2). VA has implemented this discretionary 
authority to permit ADSMs to receive counseling to overcome 
psychological trauma resulting from MST at Vet Centers without a DOD 
referral. Vet Center records are confidential and maintained 
independent of DOD and VA medical records. Additionally, Vet Centers 
have staff with particular expertise in MST and are located in the 
community, apart from DOD installations. In addition to treatment 
available to ADSMs under VA/DOD sharing agreements, VA is collaborating 
with DOD to provide MST-related care and services to ADSMs at VAMCs and 
CBOCs without the need for a referral.
    Eligibility criteria and services available for former 
Servicemembers with an Other Than Honorable (OTH) discharge are 
separate and distinct from the above description pertaining to ADSMs. 
In general, to qualify for VA health care, a former Servicemember must 
meet the definition of a ``Veteran'' as this term is defined in 38 
U.S.C. Sec. 101: ``a person who served in the active military, naval, 
or air service, and who was discharged or released therefrom under 
conditions other than dishonorable.'' An OTH discharge is not 
necessarily a bar to receipt of VA services, and individuals with OTH 
discharges can potentially receive VA health care, including MST-
related care, upon review of their discharge by the Veterans Benefits 
Administration (VBA). If VBA determines that the individual qualifies 
as a ``Veteran,'' the individual may enroll in VA's health care system 
and be placed in the priority group for which he or she qualifies. 
Former Servicemembers with OTH discharges may receive VA emergency care 
pending these Veterans Benefits Administration reviews.
    A former Servicemember with an OTH discharge who is subsequently 
determined (by VBA) to be a ``Veteran,'' as described above, is 
eligible to receive counseling and treatment to overcome psychological 
trauma resulting from MST, as described in Sec. 1720D.
    If VBA determines that the character of discharge is a bar to 
receiving VA benefits, and thus that the individual does not qualify as 
a ``Veteran,'' the individual is still eligible for VA health care 
needed to treat a service-incurred or service-aggravated disability 
(unless subject to one of the statutory bars to benefits set forth in 
38 U.S.C. Sec. 5303(a)). See Section 2 of Public Law 95-126 (Oct. 8, 
1977). VA is reviewing whether such an individual who is determined 
pursuant to Sec. 1720D to have psychological trauma resulting from MST 
would qualify for care for that trauma under section 2 of Public Law 
95-126.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to 
    Carolyn M. Clancy, M.D., Deputy Under Secretary for Health for 
     Organizational Excellence, U.S. Department of Veterans Affairs
                          va scheduling system
    Question 14.  Dr. Clancy, in the testimony of Mr. Missal, he 
indicates that VA's continued issues with their scheduling system stem 
from the VA's failure to identify their requirements for such a system. 
However, Secretary Shulkin has indicated that VA is giving up on the 
in-house solution for a scheduling system and will be buying one off 
the shelf-what measures will the VA be taking to ensure the produce 
will integrate with the electronic health records of the VA, the Choice 
program, and the DOD?
    Response. In February 2017, VA announced it has decided to proceed 
with rolling out VistA Scheduling Enhancement (VSE) as a low-cost, 
temporary improvement to the current outdated scheduling system. VSE 
will be VA's interim scheduling solution to fulfill requirements for 
patient scheduling until a robust, commercial scheduling system can be 
implemented. VSE provides a more user-friendly interface that makes it 
easier to view available appointment times and reduces errors on entry. 
This functionality improves our ability to schedule Veterans 
efficiently and accurately.
    VA will still pursue the Medical Appointment Scheduling System 
(MASS) scheduling pilot as part of a longer term, comprehensive 
strategy to modernize VA scheduling and meet all of VA's scheduling 
needs, like resource-based scheduling. VA's overall electronic health 
record modernization plan is set to be released this summer. VA will 
roll out VSE nationally over the next several months as safely and 
quickly as possible.

    Question 15.  Do you have a target date for complete 
interoperability between the VA and the DOD? The move by the VA to 
capitalize on using military treatment facilities will be a failure if 
you cannot make the systems work seamlessly.
    Response. VA and DOD systems are interoperable today. In 
April 2016, VA and DOD were proud to certify to Congress that VA had 
met the National Defense Authorization Act for Fiscal Year 2014 
interoperability standards. But meeting those standards was only one 
part of our ongoing work, not the end state. We continue to push our 
interoperability efforts every day to include interoperability with the 
private sector.
    As of March 19, 2017, more than 236,000 VA health care and benefits 
professionals have access to real-time EHR information, which they can 
access from VA, DOD, and VA external partner facilities (including 
private sector) where a patient has received care. On a daily basis, 
approximately 1.5 million data elements are shared between DOD and VA. 
The tool that provides this capability is called the DOD/VA Joint 
Legacy Viewer (JLV). Since its implementation, JLV has allowed VA staff 
to view more than 2.5 million records. VA's Enterprise Health 
Management Program (eHMP) incorporates JLV's capabilities and provides 
even more robust capabilities, including team management and 
communications, task management, and clinical decision support. eHMP is 
built upon an event-driven architecture and includes the ability to 
search the comprehensive patient record for specific terms and 
conditions.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Joe Manchin III to 
    Carolyn M. Clancy, M.D., Deputy Under Secretary for Health for 
     Organizational Excellence, U.S. Department of Veterans Affairs
    Question 16.  Two of the high risk issues identified by GAO are 
ambiguous policies and inconsistent processes throughout the VA system. 
If a policy or procedure is developed at the VA Central Office level in 
Washington, DC, how is VA guaranteeing proper articulation of that new 
policy to VA employees at the local level?
    Response. First, VHA has developed a system to ensure field review 
during development, so that policies produced by VA Central Office have 
already been thoroughly analyzed and commented on by the field before 
they are published. Under the new development process, each policy is 
placed into a portal where field offices at the local and VISN level 
can read and provide detailed comments on every aspect of the policy. 
Although this process is still relatively new, it has already yielded 
hundreds of comments and has led to major revisions of several 
developing policies.
    Second, after VHA publishes a policy, the policy is communicated 
through a variety of means including an e-mail to all publication 
control officers nationwide and specific communications, which are 
developed by the responsible program office and tailored specifically 
for the primary users of the policy.
    The new development process was piloted in 2016 and put in place in 
January 2017. We are continuing to assess how well it is working by 
focusing on existing policies that need to be updated and recertified, 
and we meet regularly to revise based on user experience. We also have 
long-term plans to develop pre- and post-publication assessments, 
metrics, feedback loops, and communication tools that will apply to all 
national policy.

    Question 17.  The Inspector General Audit of VA's Recruitment, 
Relocation and Retention (3R) Initiatives exposed a lack of oversight 
and accountability in the program that had expensive consequences. If 
certain individuals are taking advantage of this program, money is not 
reaching essential recruitment programs needed for rural VA hospitals 
and CBOCs, like those in West Virginia. What is the VA doing to 
adequately monitor the critical 3R incentive program?
    Response. There are various monitoring and reporting requirements 
outlined in current VA policy regarding recruitment, relocation, and 
retention incentives. On an annual basis, each servicing human 
resources office is responsible for compiling a certification report 
attesting to the strategic and prudent use of all incentives authorized 
during the prior calendar year. The report requires information from 
each incentive authorization, and the Network, Area, or Deputy 
Assistant Secretary level or higher must sign-off. These reports are 
submitted to the Deputy Assistant Secretary for Human Resources 
Management and form the basis for a Department-wide report to the 
Secretary.
    In addition to the annual certification report, the VA Office of 
Human Resources Management (OHRM) Compensation and Classification 
Service extracts data from the human resources information system on a 
quarterly basis to identify any trends or anomalies in usage. As 
needed, the Compensation and Classification Service contacts servicing 
human resources offices to verify information and to obtain copies of 
authorizations or other relevant documents needed for the analysis.
    Additionally, OHRM's Oversight and Effectiveness Service will 
continue to review a facility's incentive authorizations during onsite 
visits and reviews. This review includes verifying justifications and 
authorizations and ensuring incentives are approved in accordance with 
VA policies and Federal Government regulations.
    There are also impending policy revisions that will strengthen 
monitoring requirements for Recruitment, Relocation, and Retention 
incentives. One of the proposed changes to the policy is the addition 
of a template for the mandatory annual review of all recruitment, 
relocation, and retention incentives. The Annual Certification on Usage 
of Recruitment, Relocation, and Retention Incentives template was 
developed to collect mandatory information on the usage of recruitment, 
relocation, and retention incentives. Section 5 of this proposed 
template requires a narrative description and information to the 
following: Description of any workforce or succession planning efforts 
used or proposed that have or will eliminate or reduce the use of 
recruitment, relocation, or retention incentives. In addition to the 
workforce or succession planning narrative, each report must provide 
certification.

    Question 18.  Given the historically long process of agency removal 
from the GAO's High-Risk List, how long do you anticipate it will take 
VA to make it off the list? What do you need from Congress to expedite 
this process?
    Response. The average removal time from the High-Risk List is 9 
years. VA will do everything possible to achieve success more rapidly 
than average and keep the Committee informed about our progress.
    VA requests Congress work with VA on Choice eligibility criteria, 
pass VA accountability legislation and appeals modernization 
legislation.

    Question 19.  West Virginia has a population with a high number of 
veterans and a high number of individuals utilizing the Affordable Care 
Act. If the ACA is repealed, it is safe to assume there will be changes 
to coverage, deductibles, and out-of- pocket costs for many. How, if at 
all, do you foresee the repeal of the Affordable Care Act affecting VA 
Healthcare? For example, do you expect to see an uptick in enrollment?
    Response. Changes in health insurance coverage, deductibles and 
out-of-pocket costs as a result of Affordable Care Act (ACA) reform 
depend largely upon how the ACA isrepealed and replaced. As such, we 
cannot speculate as to how ACA repeal and replace might impact VA 
health care. West
    The chart below depicts the Veteran population in West Virginia 
including Veterans enrolled in VHA, Medicare and Medicaid, as reported 
in the 2015 American Community Survey.

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 
 Response to Posthearing Questions Submitted by Hon. Sherrod Brown to 
    Carolyn M. Clancy, M.D., Deputy Under Secretary for Health for 
     Organizational Excellence, U.S. Department of Veterans Affairs
                             sterilization
    Question 20.  Dr. Clancy, during your testimony you referenced 
steps VA took to correct safety and quality concerns as it relates to 
sterilization of medical equipment. This is an issue that many medical 
facilities face and was a focal point during last year's allegations of 
misconduct at the Cincinnati VAMC. Please provide me with an overview 
of the sterilization concerns that VA has review this past year and the 
steps taken to address each concern.
    Response. The VA National Program Office for Sterile Processing 
(NPOSP) ensures the safety of Veterans by developing national policy 
and oversight of all sterile processing and high-level disinfection 
activities for critical and semi-critical Reusable Medical Equipment 
(RME).
    During FY 2016, NPOSP conducted 81 site review inspections 
identifying the continued need for oversight and auditing of RME on an 
annual basis. NPOSP conducts facility site visits in collaboration with 
subject matter experts to review and advise on sterile processing 
activities and to provide special assistance when failures in sterile 
processing activities might pose potential risks to Veterans. For 
example, NPOSP diligently looks for errors in not only documentation 
but sterile processing activities that do not meet manufacturer's 
guidelines which could potentially pose a risk to Veterans. If NPOSP 
discovers errors, they will apply corrective actions dependent on the 
complexity of the error to ensure Veteran safety. In addition to 
conducting site visits, NPOSP also provides guidance and policies for 
facility and VISN-led inspections of sterile processing activities and 
assists with the analysis of data to identify trends. Using the trends 
and data from the facilities, NPOSP recommends corrective actions 
across the health care system.
    NPOSP conducts training and continuing education programs to ensure 
competencies in the sterile processing workforce and develops national 
policy and guidance for sterile processing activities. Such direction 
and policy may include technical specifications, competency 
assessments, oversight of sterile processing functions at the facility 
level, and integration of sterile processing activities with other 
clinical services.
    NPOSP collaborates with the VA National Center for Patient Safety 
(NCPS), Biomedical Engineering, Center for Engineering, Occupational 
Safety and Health (CEOSH), Food and Drug Administration (FDA) and 
multiple vendors/manufacturers to correct defects in design and 
reprocessing of RME issues. During this past fiscal year, NPOSP offered 
guidance and provided corrective action to ensure Veteran safety with 
the following instruments used in VA facilities:

     General Electric (GE) ultrasound Endocavity Transducer 
(IC5-9D)
        - The transducer could not be deemed bioburden free due to the 
        design of the instrument. NPOSP worked with GE to redesign the 
        transducer probe and update Instructions For Use (IFU).
     Olympus rigid cystoscope bridge
        - The bridge was identified to have defective adhesive material 
        that deteriorated after the sterilization process. NPOSP is 
        working with Olympus for corrective design options.
     3M Attest Biological indicator
        - The testing indicator was not compatible with the sterilizer. 
        NPOSP collaborated with the manufacturer to provide the correct 
        guidelines for use that meet quality assurance indicators of 
        VA.
     Arobella Quostic Wound Therapy System Model AR1000 
ultrasound debridement
        - The design of the Arobella Quostic Wound Therapy System Model 
        AR1000 hand piece did not allow for proper reprocessing. NPOSP 
        provided guidance and discontinued using the old version of the 
        ultrasound hand piece nationally in VA and now only purchases 
        the up-to-date model from the manufacturer that could be 
        effectively reprocessed.
     Conmed Hyfrecator
        - The Hyfrecator was noted to only have 100 uses validated for 
        proper usage; however, the manufacturer representative failed 
        to inform end users that the hand piece must be disposed of, 
        tracked, and disposed of after 100 uses. NPOSP implemented a 
        national quality assurance program to ensure proper tracking 
        and disposal of the Hyfrecator. NPOSP also worked with the 
        manufacturer to create a sheath with correct guidelines for use 
        to ensure the sheath covered the Hyfrecator which protects 
        patients from biohazard material.
     Parks Medical Doppler Probe
        - The manufacturer only allows for the Doppler probe to be used 
        on intact, external skin only. NPOSP identified the Doppler was 
        being used intraoperatively with a sterile sheath that had not 
        been approved by the vendor. NPOSP implemented a national 
        quality assurance program to ensure proper usage of the Doppler 
        and education and training was provided for the end-user. VA no 
        longer uses the Doppler perioperative setting.
     Custom Ultrasonics Automatic Endoscope Reprocessor (AER)
        - The AER had not been validated for multiple high-level 
        disinfection solutions but was sold for the use of multiple 
        high-level disinfection solutions without any FDA validation. 
        NPOSP worked with FDA and Custom Ultrasonics to pull and 
        replace all AERs that did not meet FDA clearance.
                            same day access
    Question 21.  Dr. Clancy, in GAO's testimony Dr. Draper raises 
concerns regarding access to same day care throughout VHA for veterans 
in need of mental health and primary care. These findings are based on 
GAO reports from 2015 and 2016. VHA says that there are same day 
appointments for mental health and primary care in all facilities. 
Please provide me with a snapshot from one day of all the VAMCs and 
CBOCs in Ohio that illustrate same day availability for veterans.
    What metrics are used to measure same day availability for veterans 
and is there any way for a facility to report inaccurate data regarding 
availability?
    Response. Asking our Veteran patients to tell us about their 
experience is the most important way to find out if a facility is 
meeting same day service expectations. In VHA, one way this is done is 
through the standardized survey called Consumer Assess of Health Care 
Providers and Systems (CHAPS), a standardized tool used in the health 
care industry. One of the CHAPS questions is, ``In the last 6 months, 
when you made an appointment for a check-up or routine care with this 
provider, how often did you get an appointment as soon as you needed?''
    Since survey results report past performance, lag, and are 
available less frequently, VHA is also using objective, process 
measures believed to provide a daily snapshot of system performance in 
achieving same day services for Veterans. One process measure is the 
number of face-to-face appointments completed the same day they are 
scheduled. VA recognizes not all appointments represented by this 
measure meet the definition of ``same day services;'' however, many of 
them are a result of same day requests from patients. This measure is 
readily available to VA staff and actionable. The definition of same 
day services includes not only requests from traditional face to face 
visits but also responses to requests made by phone, secure messaging 
email, and responses from appropriate support services such as 
Pharmacy, Social Work, Nursing, etc. For this reason, VHA continues to 
work to identify ways in which to measure these individual types of 
same day services and develop more useful collective process and 
outcome measures.
    As of December 31, 2016, same day services in mental health and 
primary care were made available at all medical centers across VHA. 
This included those in Ohio, i.e., Chillicothe, Cincinnati, Cleveland, 
Columbus and Dayton. Facilities have continued to work to expand same 
day services to their CBOCs. In Ohio, a snapshot of same day services 
availability as reported by facility leadership as of March 31, 2017, 
is listed below.

 
----------------------------------------------------------------------------------------------------------------
                                                                             Primary Care        Mental Health
----------------------------------------------------------------------------------------------------------------
  (3V10) (538) Chillicothe VAMC                                                       Yes                 Yes
(3V10) (538GA) Athens                                                                 Yes                 Yes
(3V10) (538GB) Portsmouth                                                             Yes                 Yes
(3V10) (538GC) Marietta                                                               Yes                 Yes
(3V10) (538GD) Lancaster                                                              Yes                 Yes
(3V10) (538GE) Cambridge                                                              Yes                 Yes
(3V10) (538GF) Wilmington                                                             Yes                 Yes
  (3V10) (539) Cincinnati VAMC                                                        Yes                 Yes
(3V10) (539A4) Cincinnati VAMC-Fort Thomas                                             No                  No
(3V10) (539GA) Bellevue                                                               Yes                 Yes
(3V10) (539GB) Clermont County                                                        Yes                 Yes
(3V10) (539GC) Dearborn                                                               Yes                 Yes
(3V10) (539GD) Florence                                                               Yes                 Yes
(3V10) (539GE) Hamilton                                                               Yes                 Yes
(3V10) (539GF) Georgetown                                                             Yes                 Yes
(3V10) (539QB) Highland Avenue                                                         No                  No
  (3V10) (541) Louis Stokes Cleveland VAMC                                            Yes                 Yes
(3V10) (541BY) Canton                                                                 Yes                 Yes
(3V10) (541BZ) Youngstown                                                             Yes                 Yes
(3V10) (541GB) Lorain                                                                 Yes                 Yes
(3V10) (541GC) Sandusky                                                               Yes                 Yes
(3V10) (541GD) David F Winder VA CBOC                                                 Yes                 Yes
(3V10) (541GE) McCafferty                                                             Yes                 Yes
(3V10) (541GF) Painesville                                                            Yes                 Yes
(3V10) (541GG) Akron                                                                  Yes                 Yes
(3V10) (541GN) State Street                                                           Yes                 Yes
  (3V10) (552) Dayton VAMC                                                            Yes                 Yes
(3V10) (552GA) Middletown                                                             Yes                 Yes
(3V10) (552GB) Lima                                                                   Yes                 Yes
(3V10) (552GC) Richmond                                                               Yes                 Yes
(3V10) (552GD) Springfield                                                            Yes                 Yes
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