[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]




 
IMPROVING THE DEPARTMENT OF VETERANS AFFAIRS EFFECTIVENESS: RESPONDING 
               TO RECOMMENDATIONS FROM OVERSIGHT AGENCIES

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

                                HEARING

                               before the

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        WEDNESDAY, MAY 22, 2019

                               __________

                           Serial No. 116-13

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
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             U.S. GOVERNMENT PUBLISHING OFFICE 
 39-917               WASHINGTON : 2021        
        
        
        
                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

JULIA BROWNLEY, California           DAVID P. ROE, Tenessee, Ranking 
KATHLEEN M. RICE, New York               Member
CONOR LAMB, Pennsylvania, Vice-      GUS M. BILIRAKIS, Florida
    Chairman                         AUMUA AMATA COLEMAN RADEWAGEN, 
MIKE LEVIN, California                   American Samoa
MAX ROSE, New York                   MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire          NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia            JACK BERGMAN, Michigan
SUSIE LEE, Nevada                    JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina       ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR.,           DANIEL MEUSER, Pennsylvania
    California                       STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota        CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
                 Ray Kelley, Democratic Staff Director
                 Jon Towers, Republican Staff Director

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                 CHRIS PAPPAS, New Hampshire, Chairman

KATHLEEN M. RICE, New York           JACK BERGMAN, Michigan, Ranking 
MAX ROSE, New York                       Member
GILBERT RAY CISNEROS, JR.,           AUMUA AMATA COLEMAN RADEWAGEN, 
    California                           American Samoa
COLLIN C. PETERSON, Minnesota        MIKE BOST, Illinois
                                     CHIP ROY, Texas

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
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of converting between various electronic formats may introduce 
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                            C O N T E N T S

                              ----------                              

                        Wednesday, May 22, 2019

                                                                   Page

Improving The Department Of Veterans Affairs Effectiveness: 
  Responding To Recommendations From Oversight Agencies..........     1

                           OPENING STATEMENTS

Honorable Chris Pappas, Chairman.................................     1
Honorable Jack Bergman, Ranking Member...........................     3
Honorable Mark Takano, Chairman, Full Committee on Veterans' 
  Affairs........................................................     8

                               WITNESSES

The Honorable Gene Dodaro, Comptroller General of the United 
  States, U.S. Government Accountability Office (GAO)............     5
    Prepared Statement...........................................    25

The Honorable Michael Missal, Inspector General, U.S. Department 
  of Veterans Affairs............................................     6
    Prepared Statement...........................................    45

                       STATEMENTS FOR THE RECORD

The Honorable Robert Wilkie, Secretary, U.S. Department of 
  Veterans Affairs...............................................    54
Department of Veterans Affairs (VA) and the Department of Defense 
  (DOD) Graduate Medical Education (GME) Programs................    55

                        QUESTION FOR THE RECORD

U.S. Government Accountability Office (GAO)......................    60


IMPROVING THE DEPARTMENT OF VETERANS AFFAIRS EFFECTIVENESS: RESPONDING 
               TO RECOMMENDATIONS FROM OVERSIGHT AGENCIES

                              ----------                              


                        Wednesday, May 22, 2019

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 2:00 p.m., in 
Room 210, House Visitors Center, Hon. Chris Pappas, [Chairman 
of the Subcommittee] presiding.
    Present: Representatives Rose, Cisneros, Takano, Bergman, 
Radewagen, Bost, Roy.

          OPENING STATEMENT OF CHRIS PAPPAS, CHAIRMAN

    Mr. Pappas. Today's hearing will come to order. Today's 
hearing of the Oversight and Investigation Subcommittee is 
entitled, ``Improving the Department of Veterans Affairs 
Effectiveness: Responding to Recommendations from Oversight 
Agencies.''
    Both, the Government Accountability Office, the oversight 
arm of Congress, and the Department of Veterans Affairs Office 
of Inspector General, have made many recommendations for 
improving the Department.
    Today, we will examine whether the VA is responding to 
these recommendations with effective and meaningful actions 
that better address the needs of our Nation's veterans. Today's 
hearing is the first during this congressional session for the 
Oversight and Investigation Subcommittee.
    I, Ranking Member General Bergman, and all 7 of the other 
Members of this Subcommittee, are charged with conducting 
oversight across the programs and operations of the Department 
of Veterans Affairs, as well as those of other Federal agencies 
that serve our veterans. In carrying out its responsibilities, 
this Subcommittee will conduct hearings, site visits, and 
investigations nationwide. Oversight is a critical 
responsibility of Congress, as described by Article I of our 
Nation's constitution and the Subcommittee will not take our 
duties lightly.
    During the coming months and through the remainder of the 
session, we will examine important topics that span the entire 
range of the Federal programs meant to serve our Nation's 
veterans. The Subcommittee will, at times, delve into some 
arcane topics and at other times, we may stir some controversy, 
even, but the Subcommittee will likely reveal failings of the 
Department of Veterans Affairs and also show whether the VA is 
heading in the right direction.
    We will also find examples where Congress must take action, 
whether to update and correct current laws, or require better 
accountability from Federal agencies and officials; however, 
all the Subcommittee's work will have a central goal: ensuring 
the Nation provides the support we need to give it to our 
veterans who earned it, the men and women who served our Nation 
at home and abroad.
    Today's hearings will reveal the work of two independent 
and non-partisan government agencies that have a long history 
in oversight of the Department of Veterans Affairs. Both, the 
Government Accountability Office and the Department's Office of 
Inspector General, regularly identify key concerns about VA 
operations and each year, hundreds of reports are issued that 
recommend improvements. Their work is critical for the 
Department, for Congress, and for the public to understand the 
workings, the needs, and at times, the shortcomings of the VA.
    Of course, it is ultimately up to the VA to implement the 
recommendations GAO and the IG make, but it does not always do 
so in a timely manner. For example, some of the GAO priority 
recommendations have remained unimplemented since 2012. The VA 
health care system has been on the GAO's high-risk list since 
2015 and the Department still has not developed a viable action 
plan for getting off that list.
    GAO has added a second VA operational area, acquisition 
management, to its high-risk list this year. The inspector 
general has more than 500 recommendations that VA still needs 
to implement and about a quarter of those have been awaiting 
implementation for more than a year.
    Through their oversight work, GAO and the VA Inspector 
General repeatedly find systemic weaknesses at the VA, such as 
poor governance structures, a lack of leadership continuity, 
and failure to communicate effectively. These problems 
translate into real risks for veterans. For example, just last 
fall, GAO found that a lack of consistent program leadership 
resulted in VA spending only about 23 percent of $6.5 million 
allocated for suicide prevention outreach during fiscal year 
2018.
    As part of their testimony, the witnesses will describe the 
importance of strong and consistent leadership to ensure 
recommendations are implemented and major management challenges 
are addressed. Unfortunately, a key witness is missing and that 
is represented by the chair that is empty. Secretary Wilkie of 
the Department of Veterans Affairs declined our invitation, and 
he elected not to arrange for a representative of the 
Department to come in his place.
    The secretary did not offer any scheduling conflicts or 
other credible reasons for why he decided not to participate; 
rather, he seemed to feel it would not be in his or the 
Department's best interests to share a panel with our two 
oversight witnesses who are here with us today.
    Frankly, I find the VA's absence unacceptable. Contrary to 
what the secretary claimed in his communications with Chairman 
Takano and Ranking Member Roe when declining to participate in 
the hearing, House Veterans Affairs Committee has had a long 
history of seating the VA witnesses on panels with witness from 
the GAO and the IG. This is also quite common across other 
Congressional committees.
    One question I had planned to ask the secretary today was 
whether he considers addressing the audits, the examinations, 
and the recommendations of the GAO and the IG to be a high 
priority and whether these findings have helped shape his 
leadership of the Department. The Department's refusal to 
participate in today's hearing speaks volumes about the degree 
to which it values the insights and recommendations that Mr. 
Dodaro and Mr. Missal have to offer.
    It is my sincere hope that the secretary will soon come to 
the conclusion that the VA cannot go it alone. And to be clear, 
this Subcommittee invited the secretary to appear today in 
order to allow for greater dialogue and discussion on this 
critical path forward. Congress is at its best when it invites 
those of different views to share their analysis and opinions, 
even when they strongly disagree, so we can endeavor to find 
the best solutions to the problems faced by our Nation and our 
veterans.
    With that, I would like to recognize Ranking Member Bergman 
for 5 minutes for any opening remarks he may wish to make here 
today.
    General Bergman?

       OPENING STATEMENT OF JACK BERGMAN, RANKING MEMBER

    Mr. Bergman. Thank you, Mr. Chairman, and congratulations 
on holding your first hearing as Chairman of the O & I 
Subcommittee. Historically, and especially last term, it was a 
very bipartisan Subcommittee focused on asking tough questions 
and getting good results and dialogue, not only from the likes 
of, you know, GAO and the IG, but the VA, as well.
    We are here today to understand how the Department of 
Veterans Affairs responds to recommendations of the VA 
Inspector General and the Government Accountability Office. In 
an organization as large and complex as VA, there will be 
challenges and there will be problems, and sometimes the people 
who are responsible need to be held accountable for the good of 
the organization. Other times, challenges and problems are more 
systemic.
    In either case, a good measure of leadership and 
organizational health is an agency's response to these 
challenges. Unfortunately, VA is not participating in today's 
hearing. It has not been the recent past practice of the 
Committee to invite the secretary to testify at a Subcommittee 
hearing. Additionally, we generally place the secretary on a 
panel of his own out of deference. I understand that attempts 
were made to accommodate the Agency, but in the end, compromise 
could not be reached. I hope that in the future, we can 
overcome these issues because we need to hear from the VA to 
fully understand the issues.
    We are fortunate, however, to have the comptroller general 
and the VA Inspector General here today representing their 
organizations, which are working day-in and day-out, to improve 
VA's effectiveness and efficiency. Comptroller General Dodaro, 
Inspector General Missal, thank you for being here. Your 
organizations provide a valuable service to VA and the men and 
women who rely on VA for benefits and health care.
    My interest today is on what happens after the GAO or the 
IG issue recommendations in their reports. What procedures are 
in place at VA to ensure timely and proper implementation of 
recommendations and how does GAO and the IG help VA close 
recommendations.
    I am also interested in understanding who at VA is 
accountable for monitoring implementation of GAO and IG 
recommendations across the department and what happens when the 
process foreclosing those recommendations stalls. As you know, 
the Department of Veterans Affairs Office Accountability and 
Whistleblower Protection Act of 2017 created the Office of 
Accountability and Whistleblower Protection and tasked it with 
the responsibility for recording, tracking, reviewing, and 
confirming implementation of recommendations. It is clear from 
VA's statement that the OAWP is not performing those functions 
as of yet, so I would appreciate our witnesses' ideas on how 
OAWP can improve the state of affairs.
    I am also interested in hearing from the comptroller 
general what he sees as best practices and how other agencies 
developed and executed successful work plans to work their way 
off the high-risk list.
    Again, it is unfortunate that VA is not here today, because 
it appears that there are good facts for VA to highlight. 
According to the data on the inspector general's website, VA 
has closed approximately 94 percent of the over 8,600 
recommendations issued by the IG since October of 2012. 
Additionally, of the 510 open recommendations, only 123, or 
less than 1.5 percent of all recommendations are over one- year 
old.
    Similarly, according to the GAO's priority open 
recommendation letter, dated March 28th, 2019, VA has 
implemented 90 percent of GAO's recommendations issued within 
the last 4 years, which is higher than the government-wide 
average of 77 percent and 10 percent above GAO's target of 80 
percent. This is not to say that the VA is perfect, but it 
suggests that in recent years, VA is trending in the right 
direction. The question now is whether VA is properly 
addressing the highest priority recommendations and what 
barriers, if any, exist to closing them out. I look forward to 
a constructive hearing as we look for opportunities to improve 
how VA responds to GAO and IG recommendations.
    With that, Mr. Chairman, I yield back.
    Mr. Pappas. Thank you very much, General Bergman. I look 
forward, as well, to working with you over this term.
    I will now recognize our first witness, Mr. Gene Dodaro, 
Comptroller General of the United States, and Head of the 
Government Accountability Office. Mr. Dodaro was confirmed by 
the Senate in his role in 2010 and is serving a 15-year term, 
but his career at the GAO goes back 45 years. His agency 
produces hundreds of reports each year leading to billions of 
dollars of savings by Federal agencies and important 
improvement agencies and programs.
    The Subcommittee thanks you for appearing today, and Mr. 
Dodaro, you have 5 minutes.

                  STATEMENT OF GENE L. DODARO

    Mr. Dodaro. Thank you very much, Mr. Chairman. Good 
afternoon to you, Ranking Member Bergman, Congressmen Bost, 
Cisneros, and Rose. It is very nice to see you all here this 
afternoon.
    I want to highlight the fact that our work at the VA has 
shown that there are many dedicated and talented people there 
working very diligently to try to serve our veterans; however, 
the agency is seriously hobbled by underlying fundamental 
management weaknesses that make it very difficult for them to 
implement management reforms.
    In order to highlight the attention of the administration 
and the Congress to these areas, I have placed a number of VA 
management issues on our high-risk list. In 2015, we added 
managing risk and improving health care to the list due to 
ambiguous policies and procedures, inadequate oversight and 
accountability, information technology challenges and 
inadequate training, and unclear resource needs and allocation 
priorities.
    This past March, when we updated the high-risk list, which 
we do across government at the beginning of each new Congress, 
we added the acquisition management area at VA to the list, as 
well. Here, again, they had outdated policies and procedures. 
They hadn't been updated in over 10 years. There was not an 
effective strategy for medical and surgical procurements in 
place. Contract managers, management, and staff were overworked 
and in a lot of cases, there wasn't adequate training, and so 
these areas were problematic.
    In 2003, we also added across the Federal Government, 
managing disability programs. One of the most significant 
disability programs, in addition to the Social Security 
Administration, is at VA. There were concerns with processing 
of initial claims, as well as appeals and backlogs and 
timeliness, as well as updating the eligibility criteria, which 
hasn't been updated in decades, despite efforts on the part of 
the Veterans Administration.
    These are very serious management problems and I would make 
the point, though, that while implementation of our 
recommendations is an appropriate benchmark to use. It really 
is not going to be sufficient alone to solve VA's underlying 
management weaknesses and get off the high-risk list. The 
criteria for getting off the list is leadership commitment that 
is sustained, the fact that they have the capacity, the 
resources, and the people, and importantly, there needs to be a 
corrective-action plan that deals with the underlying root 
causes of the problems. And there needs to be a monitoring 
effort with milestones and metrics to be able to gauge 
progress, and there needs to be actually some demonstrated 
progress in fixing the problems.
    The high-risk list includes the highest management risks 
across the Federal Government--there are 35 areas on the list--
the reason I put VA on there is because while we can make 
recommendations, VA can address them, but then we make new 
recommendations that are still dealing with the same underlying 
problems. And that is the pattern we are in with the Veterans 
Administration.
    Therefore, just addressing our recommendations isn't going 
to deal with the underlying management weaknesses there. I 
think the Department recognizes this and is embarking at the 
VHA on a modernization program that has 10 lines of effort and 
is trying to put things in place. VA has come to the Congress 
requesting legislation to modernize its disability claims 
process and is implementing those reforms right now.
    But in order for these reforms to be successful, VA leaders 
are going to have to energize an entrenched bureaucracy that is 
challenged in successfully implementing management reforms. GAO 
is dedicated to working with the Department in order to help it 
achieve success, and I am happy to share our experiences with 
other agencies in the Q&A portion. Twenty-six areas have come 
off the high-risk list over time. There is a prescription for 
success here. I have discussed this prescription with the 
Veterans Administration, and we are trying to work with them to 
implement it there, as well, but we are not there yet.
    And so, I look forward to taking questions from you at the 
appropriate time.

    [The prepared statement of Gene L. Dodaro appears in the 
Appendix]

    Mr. Pappas. Thank you, Mr. Dodaro.
    I would now like to recognize Mr. Michael Missal, Inspector 
General of the Department of Veterans Affairs. Mr. Missal was 
confirmed by the Senate in his role in 2016. He had had 
previous experience in both, the private sector and in other 
government agencies, including the Securities and Exchange 
Commission.
    The Office of Inspector General conducts investigations, 
audits, evaluations, and inspections of VA programs to 
eliminate waste and fraud, as well as to detect and prevent 
criminal activity.
    The Subcommittee thanks you for appearing today Mr. Missal. 
You have 5 minutes.

                 STATEMENT OF MICHAEL J. MISSAL

    Mr. Missal. Thank you. Chairman Pappas, Ranking Member 
Bergman, Chairman Takano, and Members of the Subcommittee, as 
we approach Memorial Day, the Office of Inspector General 
honors the men and women who have laid down their lives in 
defense of our country.
    At the outset, I want to express our appreciation for the 
work of this Subcommittee on behalf of veterans. I thank you 
for the opportunity to discuss recommendations issued by the 
OIG that assist VA in improving services and benefits to 
veterans and their families and caregivers.
    I also appreciate testifying with Mr. Dodaro, as we work 
closely together to ensure coordination and avoid duplication 
on our respective oversight responsibilities.
    OIG recommendations are directed at every level of VA 
operations. They affect the quality and access to health care 
for veterans, and benefits for veterans with disabilities, 
their caregivers, and family members, and the effective 
stewardship of VA's approximately two-hundred-billion-dollar 
budget.
    OIG reports focus not only on solutions to a defined 
problem, but also identify the underlying root causes of issues 
that negatively impact current programs and future initiatives. 
As a result, these recommendations may also be a roadmap that 
other facilities, offices, or programs can follow to apply any 
lessons learned across VA and to take corrective actions 
applicable to other relevant VA operations.
    Our critical work could not be accomplished without 
congressional support of OIG efforts through its appropriations 
and the attention given to OIG reports and recommendations. The 
OIG looks forward to working with our many stakeholders to 
advance recommendations for improvement in all VA programs, 
services, and systems. This includes recommendations proposed 
in the 100 reports issued during the first half of fiscal year 
2019.
    When developing recommendations, we focus on several key 
principles, including the following: first, recommendations are 
directed to the specific VA office or program official that has 
the responsibility and authority required to implement them. 
While our recommendations may be narrowly addressed to a 
particular VA facility or operation, VA should be disseminating 
information about identified problems and remediation plans to 
officials in all VA offices that could potentially have the 
same issues and are positioned to take positive action. We meet 
often with senior leaders and other VA staff to discuss 
specific issues and trends we identify in our work.
    Second, recommendations are current with ongoing issues and 
except in rare circumstances, should not require more than 1 
year to implement from the report's publication. This helps 
minimize the risk that OIG recommendations languish, become 
outdated, or lag behind VA policy and program changes.
    Third, OIG recommendations are objective and driven by all 
documentation and other information collected and analyzed in 
accordance with audit, inspection, review, and investigative 
standards.
    Finally, while we make recommendations, we do not direct 
how they are executed. It is important to note that OIG staff 
cannot mandate that VA accept OIG recommendations or pursuant 
to Federal law, direct specific action to carry them out. 
Consistent with this limitation, OIG reports may contain 
recommendations for VA to take appropriate administrative 
action against a specific VA employee for misconduct, but VA 
leaders and managers are then responsible for determining any 
appropriate administrative action.
    As of the last reporting period, there were 84 OIG reports 
and 403 recommendations that had been open less than 1 year. 
The total monetary benefit associated with these 
recommendations is more than $2.7 billion. There were also 40 
reports and 133 recommendations that remained open for more 
than 1 year. The total monetary benefit related to these 
reports is more than $329 million.
    The OIG is deeply committed to serving veterans and the 
public by conducting effective oversight of VA programs and 
operations through independent audits, inspections, review, and 
investigations. That commitment can only be realized by making 
practical, meaningful recommendations that enhance VA's 
programs and operations, as well as prevent and address fraud, 
waste, and abuse.
    Mr. Chairman, this concludes my statement. I am happy to 
answer any questions that you or other Members of the 
Subcommittee may have.

    [The prepared statement of Michael J. Missal appears in the 
Appendix]

    Mr. Pappas. Well, thank you very much, Mr. Missal for your 
testimony.
    I would now like to recognize the Chairman of the Full 
Committee, Chairman Takano, who has joined us for this first 
hearing of our Subcommittee. If there are no objections, I 
recognize Chairman Takano for 5 minutes.

 OPENING STATEMENT OF MARK TAKANO, CHAIRMAN, FULL COMMITTEE ON 
                       VETERANS' AFFAIRS

    Mr. Takano. Thank you, Chairman Pappas and Ranking Member 
Bergman.
    I came to today's hearing for two important reasons. First, 
I wanted to note that this is the first hearing of the session 
for the Subcommittee on Oversight and Investigations. The 
Subcommittee has a long and successful history of reviewing 
issues of great importance to our Nation's veterans. Past 
hearings have examined concerns with veteran's health care, 
delved into major problems with agency contracts, and reviewed 
whether the Department's money is well spent. I know that 
Chairman Pappas, Ranking Member Bergman, and the rest of the 
Subcommittee will move forward with sharp eyes and an even-
handed approach, as it examines the gamut of issues and 
challenges facing the Department.
    The best oversight is conducted with nonpartisan approach 
based on evidence and facts. The comptroller general and VA 
Inspector General are here today to help us understand the 
evidence and facts and I want to welcome them, too. Welcome, 
gentlemen.
    However, I also must note that we have an empty chair at 
the witness table. The Department of Veterans Affairs decided 
not to show up for the hearing today. This is unacceptable. By 
not appearing today, the VA secretary is ignoring an 
opportunity to show that the Department cares about addressing 
the serious concerns GAO and the IG have identified.
    The Veterans Health Administration and VA contracting are 
both at high risk, according to the Government Accountability 
Office. The comptroller general is here to testify about needed 
action by the Department. We need to hear from VA leadership 
about their plan to be removed from the Department's--from the 
high-risk list.
    The VA Inspector General is here to testify about the 510 
recommendations totaling approximately $3 billion that have not 
been yet implemented by the Department. These include 
recommendations to address medical-supply chain failures that 
have, at times, led to delayed procedures at the DC VA Medical 
Center. Other recommendations focus on inappropriate denial of 
claims for veterans who experienced military sexual trauma. The 
IG is also here to discuss its work on how VA is can and should 
improve its suicide prevention programs and the Veterans Crisis 
Line.
    It is Congress' constitutional duty, and I say that again, 
it is Congress' constitutional duty to oversee the Federal 
Government. This Committee will not abandon its duty to protect 
the interests of veterans, their families, and taxpayers.
    Now, the secretary wrote to me and Ranking Member Phil Roe, 
stating that participating on a panel with the Department's 
watchdogs was somehow a break with tradition or practice. 
Frankly, this is a terrible excuse. VA doesn't get to pick and 
choose which hearings they will attend. His refusal to show up 
sends Congress the wrong message.
    Instead, we need to hear that VA will address the concerns 
identified by independent, credible investigators and auditors. 
The Department and the Committee have a history of working 
cooperatively with each other. I expect VA to show up and be 
accountable for the next hearings of the Committee.
    I look forward to the hearings and other work that the 
Committee will undertake in this session of Congress, and with 
the remaining time, I do want to ask a question for Mr. Missal 
of the VA OIG.
    Mr. Missal, your testimony discussed some important work by 
your office regarding the prevention of suicides. As you know, 
it is the number one priority for this Committee. It is a 
continuing tragedy that on average, 20 veterans commit suicide 
each day. I understand that the Office of Inspector General 
released a report on March 2017 that examined the VA's Veterans 
Crisis Line. The report revealed many serious problems with the 
crisis line, substantially impacting the quality of responses 
to veterans' needs. Sixty recommendations followed on a range 
of issues, such as improved crisis line staff training, more 
modern technology, and better cooperation with the VA Office of 
Suicide Prevention.
    Mr. Missal, did VA implement all of those recommendations 
and how timely was VA's response?
    Mr. Missal. Chairman Takano, I believe all of those 
recommendations are now closed out. We share the seriousness of 
suicide. We have a number of different active projects on it 
right now and with respect to the Veterans Crisis Line, we put 
out a report in 2016 and followed that up with one in 2017. We 
recently went back just to ensure that it is operating as 
effectively as possible, given how many veterans it touches.
    Mr. Takano. Well, thank you very much.
    And I yield back, Mr. Chairman.
    Mr. Pappas. Thank you very much, Chair Takano.
    And since we are on to the question portion of the 
Subcommittee hearing, I would like to recognize myself for 5 
minutes.
    It is noteworthy that both of our witnesses here today 
understand the importance of strong and consistent leadership 
for ensuring that major problems are addressed and that the 
recommendations are ultimately implemented. Unfortunately, the 
VA faces a major challenge. Currently, too many top positions 
remain unfilled at hospitals and within VA headquarters, 
itself; further, many of the leadership positions are filled 
with people serving in an acting capacity.
    The Subcommittee staff has analyzed some data regarding 
leadership instability within the Veterans Health 
Administration, which is charged with taking care of the health 
care needs of more than 9 million veterans across this country.
    I have a few charts here today. Chart number 1 here behind 
me shows that during the past 5 years, the Veterans Health 
Administration has gone for a total of 824 days without a 
confirmed leader. Dr. Richard Stone is currently leading the 
VHA in an acting capacity.
    Also behind me, we found that 48 percent of senior 
leadership positions within the Veterans Health Administration 
are currently held by individuals serving in an acting or 
interim role. In addition to that, the Veterans Health 
Administration has been affected by turnover in the position of 
the VA's chief information officer. Since January 2017 alone, 4 
different individuals have led the VA's Office of Information 
Technology. With a significant number of major IT projects in 
the works for the VHA, this level of top-leadership turnover 
has presented numerous risks to the successful completion of 
those very projects.
    I know that Dr. Stone and the vast majority of the VA and 
VHA leaders, even those serving in an acting capacity, are 
working really hard and are very dedicated to serving our 
veterans; however, a lack of permanence when leaders are, at 
times, wearing multiple hats within the agency, dividing their 
attention between key management responsibilities, is hardly 
the best situation for ensuring quality care.
    So, for both witnesses, Inspector General Missal and 
Comptroller Dodaro, do these charts point to a major problem 
for the VA? And do these leadership problems challenge the 
ability for the Department to address your recommendations?
    Mr. Missal. I agree that they present major challenges for 
VA. Continuity of leadership is a key issue. Leadership sets 
the tone at the top. VA is a very large, complex organization. 
It takes anyone a significant amount of time to really 
understand the programs, operations, and culture. In addition, 
when you have somebody in an acting position, they don't have 
the authority or the support of many of the staff that they are 
going to be able to move a program or initiative forward. We 
have found in many situations; leadership has been a key issue 
that has caused or resulted in some of the problems.
    Mr. Dodaro. I agree with Mr. Missal. And, actually, I was 
about ready to downgrade the Veterans Health Administration in 
the health care area in our rating on leadership commitment to 
not met, But I kept it at partially met, based upon a 
conversation I had with Secretary Wilkie--I am giving him the 
benefit of the doubt--and I have had a lot of follow-up with 
Dr. Stone, as well.
    But this is a serious problem and there needs to be 
sustained leadership at the VA. I have met with each of the 
last 4 secretaries. They have all had different priorities and 
initiatives that have taken the Department in somewhat 
different directions and kept it from having sustained 
leadership.
    One of the reasons I put things on the high-risk list is 
that most of the problems need to be addressed across multiple 
administrations. These are the hardest management problems in 
the government, and in order to have them succeed, there have 
to be plans in place that sustain it across a period of time, 
and it is difficult to do it with a lot of turnover and lack of 
sustained leadership.
    Mr. Pappas. Well, thank you for that response.
    Mr. Comptroller, looking at a parallel example in a 
different agency, the Department of Homeland Security was 
unable to pass a major financial audit. Among other things, 
this led it to be included on the Department's high-risk list. 
And I am wondering if you could talk a little bit about what 
happened in that case and what DHS has done to address its 
high-risk designation and what it might hold for the VA.
    Mr. Dodaro. Yes. We designated the Department of Homeland 
Security high risk the day it was stood up and created back in 
2003. They have made a lot of progress over a period of time. 
We have met with a lot of secretaries, deputy secretaries, and 
other key officials there.
    In the early days, it was difficult to see a lot of 
progress, but eventually they became more engaged with us. And 
several years ago we agreed on the 30 outcomes that we use to 
gauge whether or not they were going to be successful or not. 
So, we both agreed on what outcomes we were trying to achieve 
in this area.
    I just reported in March, 17 of the 30 areas they have met 
now and are on their way. One of them is for 4 years running 
now. They received a clean opinion on their financial audit, 
which they hadn't for more years previously, and most of the 
other areas, they are on their way to make some progress.
    They still have significant issues, particularly in getting 
more modern financial management systems and improving their 
acquisition procedures. They still have issues, which is why 
they are still on the list, but they have a plan. Now, that 
plan has remained the same with changes in administration over 
time, because we have agreed on it. We meet on a quarterly 
basis. The Department of Homeland Security rates themselves 
against the criteria we have for coming off the list, we review 
it, and then we respond to them and their efforts. So, we have 
a very constructive working relationship there.
    Of course, they have some vacancies themselves, but I am 
hoping to continue to work with them. I just testified a few 
weeks ago, and Congressman Rose is on that Committee, on the 
management challenges at the Department of Homeland Security.
    But I have mentioned to VA that DHS is a good model and 
that is what we are trying to work toward both, with VHA and 
VBA. And so, I am hopeful that we can take those success 
factors.
    Now, the other important thing that I want to emphasize, is 
that hardly any area on the high-risk list gets off the list 
without sustained congressional oversight, as well, and action 
by the Congress. Engagement by the Congress is absolutely 
critical to the success of agencies coming off the high-risk 
list.
    I would encourage this Committee to remain focused on that 
and continue to work to ensure VA is addressing these 
fundamental management weaknesses, because otherwise, the 
efforts will keep repeating themselves and there will be 
serious problems with any reform that needs to be implemented.
    Mr. Pappas. Thank you, sir.
    I would now like to turn it over to General Bergman, the 
Ranking Member, for 5 minutes.
    Mr. Bergman. Thank you, Mr. Chairman.
    And both, Mr. Dodaro and Mr. Missal, you used the terms 
symptoms versus root causes. I am glad to hear you say that, 
because we can waste a lot of time dealing with symptoms, and 
unless we deal with the root causes and we are not going to get 
the results that we know we need.
    And Mr. Dodaro, you said VA is hobbled by fundamental 
management weaknesses. Is one of those weaknesses the ability 
to identify root causes versus symptoms?
    Mr. Dodaro. That is part of it. We had a difficult time 
getting VA to do root-cause analysis a few years ago. For 
example, when we put the health care area on the list. But, 
eventually, they came to a list of root causes and I outlined 
what those were that they identified themselves and they 
comport with a lot of what we identified.
    Mr. Bergman. Okay. So, actually, they were able to--
    Mr. Dodaro. They were able to come up with the root cause. 
What they haven't been able to do, though, is translate that 
into an action plan to deal with the root causes that have 
metrics and milestones and clear accountability and a lot of 
other fundamental--
    Mr. Bergman. I have to--because I know we are on the same 
wavelength here, and Mr. Missal, you mentioned that GAO can 
recommend, but not require; is that correct?
    Mr. Missal. Our office can recommend, but not require.
    Mr. Bergman. Yeah, so the point is, as we then go back and 
forth in between what you both are articulating, this is pretty 
much the same question for both of you: Would you please 
explain how your office and the VA collaborate to close 
recommendations and who within VA is responsible for 
facilitating that collaboration.
    Mr. Missal. We have a very active program on outstanding 
recommendations. Once a recommendation has been published in a 
report, we review them quarterly with VA to see what progress 
they are making. We expect to get in writing the progress that 
they have made, and we continue that throughout, until the 
recommendation is closed.
    The responsible person would be the person to whom the 
recommendation is addressed. All of our recommendations are 
addressed to an individual, whether it is the secretary, deputy 
secretary, or on down from there.
    Mr. Bergman. Okay. Mr. Dodaro?
    Mr. Dodaro. Yes, we coordinate through their Office of 
Congressional Liaison and that individual, then, has us work 
with the individual officials that are responsible for the 
area. For example, at the Veterans Health Administration, our 
people meet with them on a monthly basis. We go over their 
recommendations every 4 to 6 weeks and then we meet with the 
VBA separately.
    So, we have regular meetings with them to help them 
understand what they need to do to implement the recommendation 
and very specifically answer any questions they have, and then 
make it clear that when we will recommend that something will 
be fixed. VA will come up with a plan to fix it and will want 
us to close the recommendation. We will say, No, no, no, no. It 
takes more than a plan. You actually have to implement the plan 
and you have to deal with this issue.
    Those are the kinds of conversations that we have with 
them. I think we have an effective process working with them to 
close these recommendations.
    Mr. Bergman. I see my time is running out here, but, Mr. 
Dodaro, I have one more here for you. Roughly 26 areas have 
been removed from the high-risk list. Some areas were removed 
in as little as 3 years, while one took 29 years. What are the 
top three, best practices that GAO has found effective in 
helping agencies address high-risk concerns?
    Mr. Dodaro. Number one is an effective action plan that 
deals with root causes, as well as the metrics, milestones. You 
need a roadmap and you need to evaluate how well you are 
getting there in achieving those objectives and dealing with 
the underlying root causes. That has not been done at VA in any 
of the areas that we have designated on the high- risk list 
yet.
    Number two is sustained congressional leadership. There 
also needs to be buy-in from the agency leadership at the top 
and at all levels. And that leadership has to engage with GAO, 
but importantly, send the proper messages to their agencies.
    Number three is congressional engagement in this process. 
Congress is a key stakeholder in the process, not only from an 
oversight standpoint, but also to make sure that whatever VA 
needs to implement these actions, that Congress is willing to 
provide.
    Those are the top three.
    Mr. Bergman. Okay. I yield back.
    Mr. Pappas. Thank you, General Bergman.
    I now recognize Mr. Cisneros for 5 minutes.
    Mr. Cisneros. Good afternoon, gentlemen. Thank you for 
being here.
    Mr. Dodaro, in adding VA's acquisition management to the 
high-risk list last year, the GAO cited evidence from its 
September 2018 report on the Veterans First program, which 
requires VA to give preference to veteran-owned small 
businesses when awarding contracts.
    Among other things, the GAO found that VA training lacked 
clarity on how contracting officers should balance the 
preference for veteran-owned small businesses with fair and 
reasonable price determination when lower prices might be found 
on the open market. In addition, the GAO found that the VA's 
online training sessions on the Veterans First policy were not 
mandatory, so only about 52 percent of VA contracting officers 
had completed the training.
    You recommended that the VA design more targeted training, 
considered making it mandatory. Can you tell me about the 
extent to which the VA has implemented this recommendation?
    Mr. Dodaro. First, VA has clarified the guidance to 
contracting officers to have them document the determinations 
that they make. They are actually doing some compliance checks 
now to make sure that the new policy is being implemented 
effectively. They are moving toward making the training 
mandatory and then providing it to all people. That hasn't 
fully happened yet, but they are on their way to having that 
accomplished.
    Mr. Cisneros. So, this is, I guess, some of the problems 
that we are seeing, right, when you talk about the management 
weakness. I mean, how difficult is it to make a mandatory 
training? It seems like it should be something that could be 
done with a simple letter.
    Mr. Dodaro. At GAO, I make that decision and I make it 
right away.
    Mr. Cisneros. Uh-huh.
    Mr. Dodaro. It is important. They should be able to do 
this, but they also have to work with their union and all the 
union bargaining agreements and how the training would be 
provided, and so that may take some time.
    Mr. Cisneros. You know, Mr. Missal, you said you could not 
implement--and this is just to kind of really follow up on some 
of General Bergman's questions--but you said you can make 
recommendations, but you can't make the VA implement these 
recommendations.
    Mr. Missal. That is correct.
    Mr. Cisneros. Like you said, you will designate an 
individual as to who is responsible for this needs to handle 
it. I mean, some of these recommendations have been on the list 
for a long time. Are they being worked? Are they being ignored 
sometimes? Why aren't these recommendations being implemented 
if they are really trying to make change?
    Mr. Missal. It really varies. About 85 to 90 percent of the 
recommendations we make are closed within a year. And just with 
respect to the recommendations, while we can't require them to 
implement them, what we do when we make the recommendation is 
ask VA if they are going to concur in it. VA concurs with 
almost all of our recommendations. We then ask them for an 
action plan: How are you going to implement it?
    So, VA commits to the action plan, including the date when 
they think they will be finished with it. That gives us a 
structure to follow through. It is still VA's decision to do 
it. We can't require them, but by having an action plan, we can 
watch closely what they are doing.
    Mr. Cisneros. As you are going along, and like if a plan--
let me ask you this: How often is a recommendation that you 
make, where they say, you know, we are not going to do this.
    Mr. Missal. It is very rare. I think we have had a handful 
in the last few years.
    Mr. Cisneros. All right. So, they are working on all of 
these recommendations that you are saying, but when something 
is taking 29 years, what is the root cause of that? Is it 
really coming back down to management again?
    Mr. Missal. It is a few that are open more than 5 years. It 
is typically a staffing issue, or we get the sense that it is 
not their priority.
    But if we see recommendations that are open for a long time 
that we think really need to be closed out, I don't hesitate to 
escalate it. For instance, if it is at a mid- level person, I 
will escalate it at VA, and I typically get a very positive 
reaction when I bring it up. They explain that VA is committed 
to doing it, we think it is important, and it needs to have the 
right attention.
    Mr. Cisneros. And one last question for Mr. Dodaro, and you 
can probably give us this one for the record because I am 
running out of time, but there is always going to be turnover. 
We know that there is always, with each new administration, 
there is going to be new secretaries, there is going to be new 
assistant secretaries, but you talked about the weakness in 
management there at the VA.
    Is it at the bureaucratic level or do we not have sustained 
professional managers there at the VA that can manage the day-
to-day operations there? And I am out of time, so if you could 
just submit that for the record, I would appreciate that.
    Mr. Dodaro. I will do that.
    Mr. Cisneros. Thank you. I yield back my time.
    Mr. Pappas. Thank you, Mr. Cisneros.
    I now recognize Mr. Bost for 5 minutes.
    Mr. Bost. Thank you, Mr. Chairman.
    Mr. Dodaro, I kind of want to go down that same path, and 
that is because a couple of years ago our office discovered, 
because we thought it was just the VA just adjacent to my 
district that was having this problem, but that was the fact 
that the management there at the individual VAs were--they had 
had, I think, 6 or 7 temporary managers over a 6-year period, 
because there was a rule that you could not be assigned a 
temporary management position for more than 280 days. If you 
continue down that path, what you have is--I was in small 
business. I couldn't memorize the names of the people I was 
even working within 280 days, let alone, figure out what the 
problems were and get them fixed.
    So, we actually moved forward with a bill at that time to 
try to have them show us a plan where they would correct this 
problem. And what we also discovered was it wasn't just that 
VA; there were a total of about 20 we discovered that were in 
that same type situation.
    Have you noticed any change at all and is that the type of 
management problem you are talking about?
    Mr. Dodaro. That is one of many, yes. That is definitely 
one of them. You know, for example, you can have somebody 
operate in an acting position longer than 210 days under the 
Federal Vacancies Act, but they can't carry out non-delegable 
functions, but most of the functions are delegable and should 
be in place.
    But part of the problem here is that there are weaknesses 
at every level in lines of accountability. Sometimes at the 
medical center level, there are issues. The VISNs, do not have 
clear accountability. There are headquarters offices, and it is 
really not clear exactly what the line of accountability is.
    What we find in health care, for example, there were 800 
national policies. There were 55,000 local policies. And there 
was no alignment between the national policies and the local 
policies. If you don't have that, how are you going to train 
people to implement things? Nobody is really in charge.
    What we have recommended in the past--and it may be 
something that this Committee should consider--is there needs 
to be a chief management officer in certain positions, and I 
have recommended in the past that this person be given a term 
appointment. So, they would be confirmed by the Congress. They 
wouldn't set policy, but they would make sure that the 
management infrastructure is there to work properly to 
implement whatever policy, that whatever administration it is, 
would want going forward.
    We have successfully had that position installed at the 
Department of Defense. There is a position like that at the 
Department of Homeland Security. There is not, really, a 
management integration function at the VA right now, which I 
think is something that needs to be remedied.
    We have not been able to succeed, though, in getting term 
positions. But some positions in the government, like the 
commissioner of the Internal Revenue Service, the Social 
Security Administration, FAA, they have 5-year terms that can 
be renewed for 5 years, and that has helped provide more 
management stability at those 3 entities.
    So, I think this is something that the Committee should 
consider. I would be happy to work with the Committee on these 
types of structural changes.
    Mr. Bost. One more question I have, and either one of you 
could possibly answer this, but another thing we discovered, 
also, is that there is not a set standard for certain jobs and 
I'm going to give one example. At one of our VA's, it was a 
personnel officer. There was no requirement of an education 
level. There was no requirement of anything of past experience 
in the field.
    But then when we asked the VA about this, I mean, obviously 
if you are hiring a doctor, you are going to get a doctor, but 
in the position of management, there are no set standards or 
criteria that are met, and I think that is one of the problems 
why when we use the term ``when you visit one VA, you visited 
one VA.'' Because we had in this case, a very inexperienced 
person in charge of personnel, and because of that, you got a 
lot of unique hires, to say.
    Mr. Dodaro. I would say--and I know Mr. Missal will say it, 
so I will be very brief on this--I would say VA is a large, 
decentralized organization, but it only works because of 
individual actions at levels. There is not a system in place 
that ensures these things are dealt with in a uniform matter on 
almost any issue.
    Mr. Bost. Thank you. My time is up.
    I yield back.
    Mr. Pappas. Thank you. Mr. Rose is now recognized for 5 
minutes.
    Mr. Rose. Mr. Missal--I am always very respectful of--I 
have a name that no one ever messes up--I want to talk very 
briefly about staff vacancies. You know, we have noted in the 
past the top-five shortages being psychiatrists, human 
resources professionals, primary care providers, psychologists, 
and med techs.
    Do you find right now that there is enough of a sense of 
urgency, that there is enough resourcing around this? What is 
your perception of the ongoing work in this area?
    Mr. Missal. I think it is due to a variety of reasons. We 
do a staffing report on a yearly basis pursuant to 
congressional mandate. And what we do is we actually survey the 
medical centers and say, ``Tell us what your priorities are, 
where your important vacancies are.''
    As you correctly point out, psychiatrist was mentioned, I 
believe it was by 83 out of the 141 medical centers.
    Mr. Rose. Sure.
    Mr. Missal. And when you think of suicide as being the 
number one clinical priority, psychiatrists play such an 
important role.
    Number two is HR. How can they hire people if their HR 
function isn't fully staffed? We found a significant problem in 
our report on the Washington, D.C. Medical Center where there 
were vacancies in many of the support areas that ensure quality 
health care, like sterilization, like housekeeping to clean 
rooms--
    Mr. Rose. Right.
    Mr. Missal [continued]. --and they had a deficient HR--
    Mr. Rose. Well, what is interesting to me is that when you 
are sitting down with a four-star general, they never complain 
about the absence of colonels, right, because they grow them 
themselves. Do you think that it is time for the VA to start to 
consider ways in which we could actually--God forbid in this 
town, we think long term--and build a pipeline of medical 
professionals? Is it time to start thinking about that?
    Mr. Missal. One of our recommendations on the staffing plan 
is for them to build staffing models to do precisely what you 
are talking about.
    Mr. Rose. What about a training model, though? What about 
starting to pay for people's education with a guaranteed time 
of service required on the back end?
    Mr. Missal. VA has some of those programs. They do have it 
for physicians and other positions, as well.
    Mr. Rose. I am talking about dramatically expanding it. Is 
there something that we can do to guarantee a pipeline? Again, 
I have never heard a four-star or a two-star or whatever 
complain, Man, I don't have enough majors.
    Mr. Missal. Well, we made a number of recommendations on 
how they can improve staffing. It is frustrating that they 
haven't implemented all of those, because to me, staffing one 
of the core functions of an organization.
    Mr. Rose. I agree.
    Mr. Missal. If you can't get that right, it is hard to get 
the other things.
    Mr. Rose. I agree. I know that, Chairman Pappas, that is 
something that, you know, we would love to think about.
    Mr. Dodaro, you mentioned that Congress needs to continue 
to assert its role in this. How, in the absence of--the fact 
that the VA is not even showing up right now, the secretary or 
a designee, leads me to believe that they don't care that much. 
Is it possible to have progression reports? Are there things--
what is your recommendation for how, beyond oversight hearings, 
what can we do as a Committee to highlight the absence of any 
progress or some suitable progress on this matter and to push 
or shame or compel the VA leadership to do something?
    Mr. Dodaro. Yes. In the past, what I have recommended 
Congress has done is on several issues, they will ask for 
quarterly reports from the agencies on--
    Mr. Rose. And so your recommendation is to legislatively 
mandate quarterly reports?
    Mr. Dodaro. Well, if they are not coming to the hearings, I 
mean, you need to get the information.
    Mr. Rose. How do you do that?
    Mr. Dodaro. You have the power to--both, in the 
appropriation process, as well as authorization. You can compel 
them to provide regular reports.
    Mr. Rose. What are examples where there has been mandated 
quarterly reports in other departments?
    Mr. Dodaro. IRS is one example. I think you are going to 
really need it in the electronic health care record area.
    Mr. Rose. I agree.
    Mr. Dodaro. The IRS tried the big bang and the long- term 
effort on tax-system modernization and that didn't work well.
    You need incremental reports. You are talking about 
anywhere from a $10-16 illion-dollar program being implemented 
over a ten-year period of time. You need incremental reports. 
You could have them report on how well they are responding to 
GAO and IG recommendations, how well they are dealing with the 
high-risk areas. You can have them do that.
    They will complain it is onerous and whatever, but you need 
to get the information, and, particularly, if they are not 
appearing at hearings, that is a way to get it.
    Mr. Rose. That is very helpful.
    Mr. Dodaro. Yes. Also, through the appropriation process, 
we have worked with the Congress in the past to fence some of 
the money. In other words, like on some of these IT systems, 
you can only spend so much, and actually, there are quarterly 
reports required in some agencies before they can spend the 
money to go into the next tranche on IT.
    Mr. Rose. Cash and shame.
    Mr. Dodaro. Yes.
    Mr. Rose. Cash and shame.
    Mr. Dodaro. Yes, I would also say, if I might, on the 
graduate medical-education area, the Government spends about 
$16 billion a year right now on these--to pay for graduate 
medical education for doctors both, at VA and DoD, as well. And 
the part of the issue that we have identified, though, is that 
they have never evaluated the success of those programs. And if 
they could evaluate those programs, I think there would be a 
basis for supporting what you are suggesting.
    Mr. Rose. And just to close out, I mean, it seems that 
there is a crisis with staffing in the VA, but not a crisis in 
staffing at the DoD health care facilities and I am curious as 
to why that is when everyone is just trying to take care of 
soldiers and vets. So, we should look at that.
    Mr. Dodaro. Yes, one thing we could do is look at the two 
programs and compare. [GAO provided additional information for 
the record. See insert A.]
    Mr. Rose. That is great. Thank you.
    Mr. Pappas. Thank you, Mr. Rose.
    I now recognize Ms. Radewagen for 5 minutes.
    Ms. Radewagen. Thank you, Mr. Chairman, and Ranking Member. 
I want to welcome the panel.
    So, my question is, the latest addition to the high-risk 
list, VA Acquisition Management, could you please describe how 
this area was identified for the high-risk list.
    Mr. Dodaro. Yes, we had been asked by the Congress to look 
at the functions that have been put in place; particularly, the 
surgical and medical procurement strategy they had in place. VA 
was hoping to achieve about $150 million of savings. We went in 
and found that they didn't really involve the clinicians in the 
development of that process. It was expected that 40 percent of 
all the procurements would be made off of their master list on 
that area, but it was only about 20 percent. So, they weren't 
achieving the savings.
    We found that they were still using a lot of emergency 
purchases, rather than going through a competitive process and 
having a better system. The regulations hadn't been updated 
since 2008. They have been working on an update since 2011. We 
talked to the contracting officers and they felt their workload 
was excessive and that they weren't getting necessary training.
    There was a range of issues. We did a number of audits and 
that led us to the conclusion that there was a systemic problem 
here that needed to be addressed.
    Ms. Radewagen. Okay. So, also, it stands to reason that VA 
would close the easiest recommendations first. So, if we are 
talking about moving the needle in terms of closing 
recommendations with the greatest impact to solving the 
overarching problem, where would you--and it is a bit 
subjective--where would you say VA stands today?
    Mr. MissalMissal. VA closes anywhere between--or we close--
so, we don't close a recommendation unless we get confidence 
that the solution that VA has agreed to is going to be 
sustainable. We close 85 to 90 percent of the recommendations 
we make within a year. And so, we watch it very carefully. We 
monitor what they are doing. We test it. We require everything 
in writing before we close out a recommendation.
    And to make sure they are effective; it is really our 
responsibility to come up with recommendations that get to the 
root cause of the issue. Because when we do a report, we not 
only identify what went wrong, but why it went wrong, and our 
recommendations really have to focus on the fact that we want 
to address the issue, make sure it doesn't happen again, and 
that other VA facilities or programs that may have similar 
issues, can learn from that, as well.
    Mr. Dodaro. Yes, I would say that--
    Ms. Radewagen. Thank you, Mr. Chairman.
    Oh, go ahead.
    Mr. Dodaro. Yes, I would say from my standpoint, they are 
doing a pretty good job of implementing our recommendations, 
working hard to do that. They are not doing such a good job in 
addressing the underlying root causes for the problems. And 
unless they do that, they will fix a set of recommendations and 
we will make a whole new set of recommendations and we will get 
into that kind of pattern.
    I think addressing the underlying management weaknesses has 
to be done in order for all of us to say that our Government 
has the very best management operation at the VA to serve 
veterans.
    Ms. Radewagen. Thank you both.
    Thank you, Mr. Chairman. I yield back.
    Mr. Pappas. Thank you, Ms. Radewagen.
    If the witnesses will oblige, General Bergman and I just 
want to take a few more minutes to get in a couple more 
questions. And I wanted to just follow up on a question that 
Chairman Takano referenced. He asked about the VA Office of 
Suicide Prevention.
    And, Mr. Missal and Mr. Dodaro, is your office currently 
conducting any audits or examinations of any of the VA's 
suicide prevention programs?
    Mr. Missal. Yes, we have a number of active projects going 
on right now. We have approximately 4 to 5 on individual 
suicides, including the one in the West Palm Beach medical 
facility where a veteran was in in-patient mental health and 
while there, committed suicide. And, we are also exploring 
other areas, as well.
    Because of the critical importance of this issue and the 
tragedy of the issue, we are expanding out to look at broader 
programs, with respect to suicide. And as I previously said, 
with respect to the VCL, we went out recently, again, to review 
that. That touches about 750,000 contacts a year.
    Mr. Pappas. Thank you.
    Mr. Dodaro. Yes, we are, at the request of Chairman Takano, 
looking at the pattern that has emerged recently of veterans 
committing suicide on VA campuses and what is, perhaps, behind 
that issue.
    Mr. Pappas. Well, thank you. I know the entire Committee 
looks forward to working with you on these matters.
    I just wanted to call up one thing that Secretary Wilkie 
provided in his testimony. He said, ``The Department is 
currently working on establishing a process to create 
functionality within the Office of Accountability and 
Whistleblower Protection, which would both, track and confirm, 
implementation of recommendations of both, the GAO and the 
IG.''
    Congress established this statutory requirement 2 years 
ago, however, the secretary did not provide a target deadline 
for following that particular law, and so I just wanted to make 
it clear that we will be following up with the Department on 
the timeline for ensuring that there is a clear and effective 
process to ensure implementation of that.
    One final thing--and Congressman Rose had asked a bit about 
what can Congress do to ensure action on these 
recommendations--and one thing I wanted to ask you both if 
there is anything the Committee should be looking into to 
consider how we can empower you both and both of your agencies 
to do your job even better?
    Mr. Missal. I think having hearings like this and shining a 
spotlight on the issue is one great way to do that. We publish 
semiannually, the number of recommendations that have been 
outstanding for more than a year with details. So, we provided 
that information. We try to put as much transparency on our 
work as possible. And given the importance of recommendations, 
we feel that we can't do enough with respect to that.
    Mr. Dodaro. One of the things I was pleased to see last 
year is that Congress passed the GAO/IG legislation that will, 
in future years, require certain agencies, as part of their 
annual budget submission to the Congress, to identify actions 
that they are taking to implement open GAO recommendations. So, 
there'll be a systematic process to do that.
    In the interim, every year I send a letter to each 
department agency head outlining the highest-priority 
recommendations from our standpoint, and you could ask what 
they are doing to implement those recommendations, to have them 
report to you on that, and we can help critique that submission 
and other reports.
    But I agree with Mr. Missal that the most effective tool to 
Congress is to have hearings and to have people come up. The 
action that occurs, just because Congress holds a hearing is, 
has a cathartic effect on the agencies and prompts them to take 
action. And I have seen this not just at VA; it is across the 
government.
    Mr. Pappas. Thank you. General Bergman, you are recognized 
for 5 minutes.
    Mr. Bergman. Thank you, Mr. Chairman.
    And on the subject of oversight of the electronic health 
record modernization, I was the proud cosponsor of the Veterans 
EHR Modernization Oversight Act, which was enacted last 
December, and is one of the toughest pieces of reporting 
legislation to ever come out of this Committee. So, we know we 
have our work cut out for us on that, but we are going to be 
like a dog on a bone on that one.
    Now, this question is for both of you. The Accountability 
and Whistleblower Protection Act, which I referenced earlier, 
of 2017, established the Office of Accountability and 
Whistleblower Protection and tasked it with recording, 
tracking, reviewing, and confirming implementation of 
recommendations from GAO and the IG.
    From each of your organization's perspective, what are 
practices that OAWP could build into their policies and 
procedures that could help VA address recommendations and 
improve services?
    Mr. Missal. We meet regularly with OAWP to talk about how 
they are going to be implementing a number of their policies, 
that they have not done so yet. I have a regular meeting with 
Dr. Bonzanto to do so. I know this is one area where they are 
working hard to try to implement it, to get it off the ground.
    From our perspective, we coordinate from the OIG, all of 
the recommendations from VA. VA doesn't do the same thing. If 
it is a VHA recommendation, it goes to VHA. If it is VBA, VBA 
deals with it. If it is Office of Information and Technology, 
they take it.
    So, I think having a practice where VA has the reservoir of 
all of the recommendations, will get greater attention, 
certainly, from the most senior leaders of VA. They really need 
to put that together to have a better indication of the number, 
types, and extent of recommendations that they have.
    Mr. Dodaro. I agree with Mr. Missal on that. That is a very 
good suggestion and a good potential outcome.
    The head of that office came to visit with me, and I 
pledged to work with them, to coordinate with them on their 
responsibilities. I still think the Department is working out 
exactly how this is going to operate, because we are basically 
still operating as we have in the past, as I mentioned earlier, 
dealing with the Office of the Congressional Liaison and other 
things. And so, until we hear further from them on how they are 
going to work their internal coordination on the GAO 
recommendations, it is pretty much status quo.
    But whatever they work out internally, I can pledge that we 
will work with them. It is to our benefit and everybody's 
benefit that our recommendations be implemented.
    Mr. Bergman. Okay. And one final question. You know, in the 
military, we routinely change commanders, because you don't 
command a unit forever; you are there for a while and then you 
move on. But one of the things that we have is we have 
turnovers. Whether it be in the form of a brief, face-to-face, 
whether it be in the form of a folder or a binder or some 
record of what that unit is doing, where they have made their 
gains, where they have their challenges, et cetera, et cetera.
    We talked about sustained leadership within the different 
levels of the VA. Do you sense, is there any corporate 
knowledge, if you will, that is passed along when someone is 
leaving a position of leadership and someone new coming in, is 
there a pass-down?
    Mr. Missal. Again, it is going to depend on the situation, 
but if I could just generalize, I don't think they do as good 
of a job as they can. There has been an extraordinary number of 
senior leaders who have turned over--and I don't just mean at 
the very top, but at program offices, et cetera--and they don't 
frequently have a good sense of the history, what the 
priorities have been, and it takes them a long time to get up 
to speed.
    And given all the critical issues facing VA now, that 
really does hamper implementing it, and that is why when we 
look at continuity of leadership, we think that is a really 
critical and important issue that VA just needs to get better 
at.
    Mr. Dodaro. Yes, I really don't know whether they do that 
or not, but I do know that if they do, it is not evident.
    Mr. Bergman. Okay. Well, thank you very much.
    Mr. Chairman, I yield back.
    Mr. Pappas. Thank you. I recognize Ms. Radewagen for 5 
minutes.
    Ms. Radewagen. Thank you, Mr. Chairman.
    One last question here. DoD's supply chain management was 
removed from the high-risk list this year. Could you please 
share how that came around, what type of engagement GAO had 
with DoD to get off the list, and lessons learned from that 
engagement. And as a follow-up, would you please also explain 
what, if any, best practices from that successful removal are 
now being applied to VA offices on the high-risk list.
    Mr. Dodaro. Yes. The DoD supply chain management was one of 
the charter members of the high-risk list when we created the 
list in 1990. That was the one that has been on there for 29 
years. And for many years, DoD ignored our recommendations and 
didn't make any movement until Congress required them to 
develop plans, on inventory management, and to report to the 
Congress. Then, they saw the benefit of those plans, which 
turned into the plans on asset visibility and material 
distribution. As a result, they have saved millions of dollars 
and they have a better system now to get the materials to the 
military at the right place and the right time and the right 
amounts.
    That was a very good example of how Congress was the 
catalyst in that case, and then once DoD started implementing 
our recommendations and seeing the value of it, then it took 
over from there and we had a very constructive working 
relationship with them.
    But it took too long. That could have been handled a long 
time ago and I am hoping at VA, we can take the lessons learned 
from DoD and help it to be a faster process. But so far, we 
don't have the plans. We are still lacking the plans that were 
lacking at DoD when we first put the area on the high-risk 
list. Until they have those plans and their reports against 
those plans, you aren't going to see any material change in our 
ratings.
    Ms. Radewagen. Thank you, Mr. Chairman.
    I yield back.
    Mr. Pappas. Well, thank you very much.
    Before closing today's hearing, I just want to make a 
couple final points. I know that General Bergman and I share 
the same outlook, that we are really committed to ensuring that 
the work of this Subcommittee remains bipartisan, that there 
may be points in times where members disagree with one another, 
but we certainly have to move past the point where we are 
disagreeable and focus on the job that we are here to do, and I 
know that all the Members of this Subcommittee share that 
outlook.
    I really want to thank our two witnesses, as well, for 
being here with us today. I want to express, you know, a real 
great appreciation to both, Comptroller Dodaro and General 
Missal, for their ongoing oversight work at the Department of 
Veterans Affairs. The audits, the inspections, the 
examinations, and reviews provide critical facts, analysis and 
recommendations for the Department, for Congress, certainly, 
and ultimately, for the general public.
    And also please relay to your staff, you know, our thanks 
for the incredible work that they do. As was shown today, the 
impact on both, the GAO and the Office of the Inspector 
General, results in very real improvements to the Department of 
Veterans Affairs and our veterans are ultimately better served 
because of the work that they do and that you do.
    General Bergman, I am happy to recognize you, if you would 
like to close.
    Mr. Bergman. Well said, Mr. Chairman. My time is finite.
    Mr. Pappas. Thank you. Members will have 5 legislative days 
to revise and extend their remarks and include extraneous 
material, and, without objection, the Subcommittee stands 
adjourned.

    [Whereupon, at 3:13 p.m., the Subcommittee was adjourned.]




                            A P P E N D I X

                              ----------                              

                  Prepared Statement of Gene L. Dodaro
Why GAO Did This Study

    VA is responsible for providing benefits and services to veterans, 
including health care, disability compensation, and various types of 
financial assistance. In fiscal year 2019, VA received a total budget 
of $201.1 billion and a discretionary budget of $86.6 billion-the 
largest in VA's history-to carry out its mission. GAO, along with the 
VA Inspector General and other entities, continues to identify 
significant deficiencies in VA's governance structures and operations-
all of which can affect the care provided to our nation's veterans.

    This testimony focuses on the status of VA's efforts to address 
GAO's high-risk designations and open GAO recommendations in the 
following areas: VA health care, acquisition management, and disability 
claims workloads and benefit eligibility criteria, among other areas. 
It is primarily based on GAO's March 2019 high-risk update and a body 
of work that spans more than a decade.

What GAO Recommends

    Since 2000, GAO has made more than 1,200 recommendations to reduce 
VA's high-risk challenges, and VA has implemented approximately 70 
percent. GAO will continue to monitor VA's progress in implementing the 
remaining open recommendations.
        Sustained Leadership Needed to Address High-Risk Issues
What GAO Found

    The Department of Veterans Affairs (VA) has longstanding management 
challenges. As a result, GAO added several VA programs to its High-Risk 
List. This list focuses attention on government operations that are 
most vulnerable to fraud, waste, abuse, or mismanagement, or in need of 
transformation. These include managing risks and improving VA health 
care, VA acquisition management, and improving and modernizing VA 
disability programs, including managing claims and updating eligibility 
criteria.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Note: VA acquisition management was a newly designated high-risk 
area in 2019. As such, it was not rated on the five criteria in March 
2019.
    VA health care was designated high risk in 2015 due to concerns 
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. GAO identified five areas of concern: (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. VA's efforts to address each of these areas have been 
impeded by leadership instability. However, since his July 2018 
confirmation, Secretary Wilkie has demonstrated his commitment to 
address the department's high-risk designations. His actions to date 
have allowed the department to maintain its leadership commitment 
rating of partially met in GAO's 2019 High- Risk update. VA also 
partially met the action plan criteria. As of March 2019, it did not 
meet the other three criteria for removal from the High-Risk List 
(agency capacity, monitoring, and demonstrated progress). This is, in 
part, because GAO continues to have audit findings that illustrate that 
the five areas of concern have not been fully addressed. For example:

      In a series of reports from 2012 through 2018, GAO found 
VA's wait time data unreliable for primary and specialty care as well 
as for care in the community. GAO also found that VA did not measure 
the full wait times that veterans experience in obtaining care across 
these settings.
      In November 2017, GAO reported that VA medical center 
officials did not always conduct or document timely required reviews of 
providers when allegations of wrongdoing were made against them.
      In April 2019, GAO found that VA's governance plan for 
modernizing its electronic health record system was not fully defined, 
potentially jeopardizing its fourth attempt at modernization.
      In April 2019, GAO reported that VA's appraisal process 
for assessing medical center director performance relies heavily on a 
system with long- identified deficiencies that remain unaddressed, thus 
diminishing VA's ability to hold officials accountable.

    In its 2019 High-Risk Report, GAO added VA acquisition management 
as a high- risk area in light of the department's numerous contracting 
challenges and the significant Federal investment in serving veterans. 
To date, GAO has identified challenges in the following areas: (1) 
outdated acquisition regulations and policies; (2) lack of an effective 
medical supplies procurement strategy; (3) inadequate acquisition 
training; (4) contracting officer workload challenges; (5) lack of 
reliable data systems; (6) limited contract oversight and incomplete 
contract documentation; and (7) leadership instability. For example, as 
of May 2019, VA does not have updated acquisition regulations and 
officials expect to have a full update by 2021; a process which has 
been in place since 2011.
    GAO designated improving and modernizing Federal disability 
programs, including VA's program, as high risk in 2003. GAO identified 
two areas of concern related to VA: (1) managing disability claims 
workload and (2) updating disability benefit eligibility criteria. As a 
result of these concerns, veterans may not have their disability claims 
and appeals processed in a timely manner. GAO reported in March 2018 
that VA is making a major effort to reform its appeals process by 
onboarding new staff and implementing new technology. However, its 
appeals planning process does not provide reasonable assurance that it 
will have the capacity to successfully implement the new process and 
manage risks. VA agreed with GAO's recommendation to better assess 
risks associated with appeals reform.
    VA leadership has committed to addressing GAO's high-risk concerns 
and has launched several transformational efforts. For example, VA is 
currently implementing the Veterans Health Administration Plan for 
Modernization, a framework that aims to modernize the department, as 
well as the VA MISSION Act of 2018. This Act requires VA to consolidate 
programs that allow veterans to receive care outside VA. If successful, 
these efforts could be transformative for VA. However, such success 
will only be achieved through sustained leadership attention and 
detailed action plans that include metrics and milestones to monitor 
and demonstrate VA's progress. Sustained congressional oversight will 
also be essential.

    Chairman Pappas, Ranking Member Bergman, and Members of the 
Subcommittee:

    I am pleased to be here today to discuss the Department of Veterans 
Affairs' (VA) efforts to address longstanding management challenges. As 
a result of these challenges, we added several VA programs to our High- 
Risk List. \1\ This list focuses attention on government operations 
that are most vulnerable to fraud, waste, abuse, or mismanagement, or 
in need of transformation.
---------------------------------------------------------------------------
    \1\ GAO, High-Risk Series: Substantial Efforts Needed to Achieve 
Greater Progress on High- Risk Areas, GAO-19-157SP (Washington, D.C.: 
Mar. 6, 2019).
---------------------------------------------------------------------------
    VA is in need of transformation. We, along with VA's Inspector 
General and other entities, continue to identify significant 
deficiencies in VA's governance structures and operations-all of which 
can affect the care provided to our nation's veterans. \2\ To address 
these deficiencies, we have made over 1,200 recommendations to VA since 
2000; VA has implemented approximately 70 percent of them. However, 
important recommendations remain unimplemented (open), and we continue 
to identify similar deficiencies in recent and ongoing work. In March 
2019, we sent a letter to the Secretary of VA that detailed 30 open 
recommendations that we deem the highest priority for implementation 
(priority recommendations). \3\ Fully addressing these open 
recommendations could significantly improve VA operations; however, the 
recommendations highlight issues that are symptomatic of broader, 
systemic management and oversight challenges that will only be 
addressed through transformative action. Our High-Risk Report provides 
VA a roadmap for this needed transformation.
---------------------------------------------------------------------------
    \2\ See VA Management Challenges: Actions Needed to Improve 
Management and Oversight of VA Operations, GAO-19-422R (Washington, 
D.C.: Apr. 10, 2019); Commission on Care, Final Report of the 
Commission on Care (Washington, D.C.: Jun. 30, 2016); The MITRE 
Corporation, Independent Assessment of the Health Care Delivery Systems 
and Management Processes of the Department of Veterans Affairs, 
(Washington, D.C: Sep. 1, 2015); and Department of Veterans Affairs, 
Inspector General's Management and Performance Challenges, (Washington, 
D.C.: 2018).
    \3\ GAO, Priority Open Recommendations: Department of Veterans 
Affairs, GAO-19-358SP (Washington, D.C.: Mar. 28, 2019), GAO-19-157SP. 
Priority recommendations are those that GAO believes warrant priority 
attention from heads of key departments or agencies. They are 
highlighted because, upon implementation, they may significantly 
improve government operation, for example, by realizing large dollar 
savings; eliminating mismanagement, fraud, and abuse; or making 
progress toward addressing a high-risk or duplication issue.
---------------------------------------------------------------------------
    Secretary Wilkie has said that VA is committed to addressing our 
high- risk concerns and has launched several transformational efforts. 
For example, VA is currently implementing its modernization plan, a 
framework through which the department intends to systemically overhaul 
its structure, culture, governance, and systems through organizational 
improvements. Congress has also acted to drive overarching change by, 
for example, passing the VA MISSION Act of 2018 (VA MISSION Act). \4\ 
Among other things, this Act requires VA to consolidate several 
community care programs into a permanent program. \5\ VA is currently 
implementing aspects of this Act.
---------------------------------------------------------------------------
    \4\ Pub. L. No. 115-182, 132 Stat. 1393 (2018).
    \5\ The Veterans Access, Choice, and Accountability Act of 2014 
created the Veterans Choice Program as a temporary program to address 
problems with veterans' timely access to care at VA medical facilities. 
Under the Veterans Choice Program, when eligible veterans face long 
wait times, lengthy travel distances, or other challenges accessing 
care at VA medical facilities, they may obtain health care services 
from community providers- that is, providers who are not directly 
employed by VA. Pub. L. No. 113-146, 128 Stat. 1754 (2014). The 
Veterans Choice Program's authority sunsets on June 6, 2019.
---------------------------------------------------------------------------
    My statement today focuses on the status of VA's efforts to address 
its high-risk designations and open GAO recommendations in the 
following areas: (1) managing risks and improving VA health care; (2) 
VA acquisition management; (3) improving and modernizing Federal 
disability programs; and (4) other government-wide high-risk areas that 
have direct implications for VA and its operations. This statement also 
describes VA's ongoing efforts to transform and modernize the 
department.
    This statement is based on our 2019 high-risk update and our body 
of work that spans more than a decade. \6\ For these products we 
analyzed VA's documents related to the department's efforts to address 
its high- risk areas and interviewed VA officials, among other things. 
More detailed information on the scope and methodology of our prior 
work can be found within each specific report. 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.
---------------------------------------------------------------------------
    \6\ GAO-19-157SP. For more information on the GAO High-Risk List, 
see https://www.gao.gov/highrisk/overview, which we accessed May 16, 
2019. For more information on our body of work on VA, see https://
www.gao.gov/key--issues/managing--risks--improving--va--health--care/
issue--summ ary?from, which we accessed May 16, 2019.

---------------------------------------------------------------------------
Background

    VA is responsible for providing benefits to veterans, including 
health care, disability compensation, and various types of financial 
assistance. In fiscal year 2019, VA received a total budget of $201.1 
billion, and the largest discretionary budget in its history-$86.6 
billion, about $20 billion higher than in 2015. The department operates 
one of the largest health care delivery systems in the nation through 
its Veterans Health Administration (VHA), with 172 medical centers and 
more than 1,000 outpatient facilities organized into regional networks. 
VA has faced growing demand by veterans for its health care services, 
with the total number of veterans enrolled in VA's health care system 
rising from 7.9 million to more than 9 million from fiscal year 2006 
through fiscal year 2017. In fiscal year 2019, VHA received $73.1 
billion of VA's $86.6 billion discretionary budget.
    In addition to providing health care services, VA provides cash 
benefits to veterans for disabling conditions incurred in or aggravated 
by military service. To carry out its mission, VA spends tens of 
billions of dollars to procure a wide range of goods and services, 
including medical supplies; to construct hospitals, clinics, and other 
facilities; and to provide the information technology (IT) to support 
its operations.
    We have made hundreds of recommendations to improve VA's management 
and oversight of the services it provides to veterans. Specifically, 
since 2000, we have made 1,225 recommendations to VA. While VA has 
implemented most of the recommendations, a number remain open, as of 
April 2019. Specifically,

      more than 125 recommendations related to VA health care 
remain open, including 17 recommendations that have remained open for 3 
years or more;
      15 recommendations related to improving VA acquisition 
management remain open, including 1 recommendation that has remained 
open for 3 years or more; and
      12 recommendations related to management of disability 
claims workloads.

    In 2017, we began sending letters to VA and appropriate 
congressional committees identifying priority recommendations for VA to 
implement in order to significantly improve its operations. We 
categorized these recommendations into nine areas: (1) veterans' access 
to timely health care; (2) veterans' community care program; (3) human 
capital management; (4) information technology; (5) appeals reform for 
disability benefits; (6) quality of care and patient safety; (7) 
national policy documents; (8) contracting policies and practices; and 
(9) veterans' access to burial options. \7\
---------------------------------------------------------------------------
    \7\ GAO-19-358SP.

Overall Rating for the Managing Risks and Improving VA Health Care 
---------------------------------------------------------------------------
    High-Risk Area Remained Unchanged in 2019

    Since we designated VA health care as a high-risk area in 2015, VA 
has begun to address each of the identified five areas of concern 
related to managing risks and improving VA health care: (1) ambiguous 
policies and inconsistent processes; (2) inadequate oversight and 
accountability; (3) IT challenges; (4) inadequate training for VA 
staff; and (5) unclear resource needs and allocation \8\priorities \9\.
---------------------------------------------------------------------------
    \8\ GAO, High-Risk Series: An Update, GAO-15-290 (Washington, D.C.: 
Feb. 11, 2015).
    \9\ The five criteria for removal are the agency must have (1) a 
demonstrated strong commitment and top leadership support to address 
the risks; (2) the capacity-the people and other resources-to resolve 
the risks; (3) a corrective action plan that identifies the root 
causes, identifies effective solutions, and provides for substantially 
completing corrective measures in the near term, including but not 
limited to steps necessary to implement solutions we recommended; (4) a 
program instituted to monitor and independently validate the 
effectiveness and sustainability of corrective measures; and (5) the 
ability to demonstrate progress in implementing corrective measures. 
Each criterion is rated as met, partially met, or not met.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Since our 2017 High-Risk Report, ratings for all five criteria 
remain unchanged as of March 2019. Specifically, the leadership 
commitment and action plan criteria remain partially met. Although VA 
has experienced leadership instability over the past 2 years in several 
senior positions, a new Secretary was confirmed in July 2018. Secretary 
Wilkie has demonstrated his commitment to addressing the department's 
high- risk designation by, among other things, creating an office to 
direct an integrated, focused high-risk approach and communicating to 
VA leaders the importance of addressing our recommendations and working 
with GAO. The Secretary's actions, to date, have allowed the department 
to maintain its leadership commitment rating as of March 2019.
    The action plan criterion also remains partially met as of March 
2019. In March 2018, VA submitted an action plan to address the 
underlying causes of its high-risk designation, but the plan did not 
clearly link actions to stated outcomes and goals or establish a 
framework to assess VA's progress. VA officials told us that instead of 
revising the March 2018 action plan, it will incorporate its plans to 
address the high-risk designation into the department's current 
initiatives. Specifically, VA is currently implementing the VHA Plan 
for Modernization, through which the department intends to modernize 
VA's structure, culture, governance, and systems through organizational 
improvements. VA officials have indicated that the VHA Plan for 
Modernization is intended, among other things, to address the high-risk 
areas for VA health care. VA officials also told us they are currently 
developing operational plans for the VHA Plan for Modernization, and 
these plans will include goals, time frames, and metrics, among other 
things. VA estimates that the operational plans will be complete by 
September 2019.
    The monitoring, demonstrated progress, and capacity criteria remain 
unmet since our 2017 High-Risk Report. In order to address the 
monitoring and demonstrated progress criteria, VA's ongoing revisions 
to its action plan need to include the addition of certain essential 
components, including metrics, milestones, and mechanisms for 
monitoring and demonstrating progress in addressing the high-risk areas 
of concern. VA's capacity rating also remains not met. Though the 
department took steps to establish offices, workgroups, and initiatives 
to address its high-risk designation, many of these efforts are either 
in the initial stages of development or resources have not been 
allocated.
    For each of the five identified areas of concern related to 
managing risks and improving VA health care, ratings reflect the level 
of progress VA has made to address them.
    Ambiguous policies and inconsistent processes. Since our 2017 High-
Risk Report, ratings for all five criteria remain unchanged for this 
area of concern as of March 2019.

      Leadership commitment: partially met. In September 2017, 
we reported that VHA had approximately 800 national policies, the 
majority of which were outdated. \10\ VHA reported reducing the number 
of national policies by 26 percent, and work continues in this area. In 
addition, VHA established an inventory of approximately 55,000 local 
policies as of October 2017. In October 2018, VHA noted its plans to 
determine who is responsible for monitoring implementation of national 
and local policy, as well as the alignment between these levels of 
policy. At that time, VHA also discussed its future plans to monitor 
the implementation and alignment of national and local policy and 
update its national policy directive by the end of June 2019. 
Additionally, VA has implemented a structure for leadership input into 
the policy process, such as at the VHA Chief of Staff level. However, 
senior leadership has lacked the stability needed to ensure issued 
policy meets agency goals.
---------------------------------------------------------------------------
    \10\ GAO, Veterans Health Care: Additional Actions Could Further 
Improve Policy Management, GAO-17-748. (Washington, D.C.: Sept. 22, 
2017).

      Capacity: not met. Since 2017, VA has issued an updated 
directive on policy management, and put in place procedures to train 
staff and obtain input from all levels on policy development. However, 
VA continues to face challenges in this area because it is reliant on 
contracts and information technology resources, which if delayed, can 
impede progress toward meeting goals.
      Action plan: partially met. Since 2017, VA has further 
refined its root cause analysis for this area of concern. In June 2017, 
VA also identified the following as enterprise-wide root causes of its 
high-risk designation:

      disjointed strategic planning;
      poorly defined roles, responsibilities, and decision 
authorities;
      poor horizontal and vertical integration;
      lack of reliable data and analysis;
      ineffective human capital management; and
      inadequate change management.

    VA relied on these root cause analyses as the foundational drivers 
for the VHA Plan for Modernization. However, VA has not used these 
analyses to develop and prioritize appropriate milestones and metrics 
in the action plan.

      Monitoring: not met. Since the March 2018 action plan 
lacked specific metrics and mechanisms for assessing and reporting 
progress, it is not clear how VA is monitoring its progress.
      Demonstrated progress: not met. Our work continues to 
indicate VA is not yet able to show progress in this area. Since its 
2015 high-risk designation, we have made 50 new recommendations in this 
area of concern, 32 of which were made since our 2017 report was 
issued. For example,
      In November 2017, we reported that, due in part to 
misinterpretation or lack of awareness of VHA policy, VA medical center 
officials did not always conduct or document timely required reviews of 
providers when allegations were made against them. We also found that 
VHA was unable to reasonably ensure appropriate reporting of providers 
to oversight entities such as state licensing authorities. As a result, 
VHA's ability to provide safe, high quality care to veterans is 
hindered because other VA medical centers, as well as non-VA health 
care entities, may be unaware of serious concerns raised about a 
provider's care.

    We recommended that VHA direct medical centers to document and 
oversee reviews of providers' clinical care after concerns are raised, 
among other recommendations. All of our recommendations remain open. As 
of January 2019, VA estimated completing the recommended revisions to 
its policy and audit processes in August 2019 and August 2020, 
respectively. \11\
---------------------------------------------------------------------------
    \11\ GAO, VA Health Care: Improved Policies and Oversight Needed 
for Reviewing and Reporting Providers for Quality and Safety Concerns, 
GAO-18-63 (Washington, D.C.: Nov. 15, 2017).

      In July 2018, we reported that VA collected data related 
to employee misconduct and disciplinary actions, but data 
fragmentation, reliability issues, and inadequate guidance impeded 
department-wide analysis of those data. Thus, VA management is hindered 
in making knowledgeable decisions regarding the extent of misconduct 
---------------------------------------------------------------------------
and how it was addressed.

    We recommended that VA develop and implement guidance to collect 
complete and reliable misconduct and associated disciplinary-action 
data department-wide, whether through a single information system, or 
multiple interoperable systems. VA concurred with this priority 
recommendation, which remains open. VA reported that it expects to 
implement one or more information systems that will collect misconduct 
and associated disciplinary action data in January 2020. \12\
---------------------------------------------------------------------------
    \12\ GAO, Department of Veterans Affairs: Actions Needed to Address 
Employee Misconduct Process and Ensure Accountability, GAO-18-137 
(Washington, D.C.: July 19, 2018).
---------------------------------------------------------------------------
    Inadequate oversight and accountability. Since our 2017 High-Risk 
Report, ratings for one criterion improved and four remain unchanged 
for this area of concern as of March 2019.

      Leadership commitment: partially met. VA has made 
organizational changes, including establishing the Office of Integrity, 
to standardize and streamline the agency's oversight of its programs 
and personnel. However, since 2017, the lack of stability in the Under 
Secretary for Health position has hindered its ability to demonstrate 
sustained commitment to improving this area of concern.
      Capacity: not met. VA has begun to implement capacity-
building initiatives directed at improving oversight and 
accountability. For example, VHA's Office of Internal Audit and Risk 
Assessment, a key component of the department's oversight and 
accountability model, began conducting audits in 2018. However, 
according to VA's action plan, the department has yet to allocate 
resources for this office, such as sufficient staff to carry out its 
activities.
      Action plan: partially met. In March 2019, the rating for 
this criterion improved to partially met. In 2018, VA conducted an 
analysis of the root causes contributing to findings of inadequate 
oversight and accountability, an important step in identifying the 
underlying factors contributing to this area of concern.

    However, the resulting action plan lacked key elements, including 
clear metrics to monitor and assess progress.

      Monitoring: not met. The March 2018 action plan lacked 
specific metrics and mechanisms for assessing and reporting progress in 
this area.
      Demonstrated progress: not met. Our work continues to 
indicate a lack of progress in this area. Since its 2015 designation, 
we made 89 new recommendations in this area of concern, 54 of which 
were made since our 2017 report was issued. For example:
      In October 2017, we reported that VHA is unable to 
accurately count the total number of physicians who provide care in its 
VA medical centers. VHA has data on the number of mission-critical 
physicians, which includes primary care and mental health physicians, 
it employs (more than 11,000) and who provide services on a fee-basis 
(about 2,800). \13\ However, VHA lacks data on the number of contract 
physicians and physician trainees, and thus has no information on the 
extent to which medical centers nationwide use these arrangements and 
whether contract physicians are working in mission-critical 
occupations. As such, VHA cannot ensure that its workforce planning 
process sufficiently addresses gaps in physician staffing, including 
those for mental health providers, which may affect veterans' access to 
care, among other issues.

    \13\ VHA obtains data from its Veterans Integrated Service Networks 
and VA medical centers on which occupations are the highest priority 
for recruitment and retention based on known recruitment and retention 
concerns, among other factors. VHA then consolidates this data to 
identify the nationwide top 10 mission-critical occupations and top 5 
mission-critical physician occupations. In fiscal year 2016, the ten 
mission-critical clinical occupations were physician, registered nurse, 
human resource manager, physical therapist, physician assistant, 
psychologist, medical technologist, occupational therapist, diagnostic 
radiologic technologist, and pharmacist. See U.S. Department of 
Veterans Affairs, Veterans Health Administration, Mission Critical 
Occupation Report (2016).
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    We recommended that VHA should develop and implement a process to 
accurately count all physicians providing care at each medical center, 
including physicians who are not employed by VHA. VHA did not concur 
with this recommendation, which we reiterated in our priority 
recommendation letter. \14\
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    \14\ GAO, Veterans Health Administration: Better Data and 
Evaluation Could Help Improve Physician Staffing, Recruitment, and 
Retention Strategies, GAO-18-124 (Washington, D.C.: Oct 19, 2017).

      In a series of reports from 2012 through 2018, GAO found 
VA's wait time data unreliable for primary and specialty care, as well 
as for care in the community. GAO also found that VA did not measure 
the full wait times that veterans experience in obtaining care across 
these settings. Specifically, in December 2012, we made two 
recommendations to VA to improve the reliability and oversight of wait 
time measures, both of which are designated as priority, and remain 
open. \15\
---------------------------------------------------------------------------
    \15\ GAO, VA Health Care: Reliability of Reported Outpatient 
Medical Appointment Wait Times and Scheduling Oversight Need 
Improvement, GAO-13-130. (Washington, D.C.: Dec 21, 2012).

    Similarly, in June 2018, we reported that VHA could not 
systematically monitor the timeliness of veterans' access to Veterans 
Choice Program care because it lacked complete, reliable data to do so. 
Specifically, we found (1) a lack of data on the timeliness of 
accepting referrals and opting veterans in to the program, (2) 
inaccuracy of clinically indicated dates, which are used to measure the 
timeliness of care, and (3) unreliable data on the timeliness of urgent 
care. \16\
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    \16\ The Veterans Choice Program allows eligible veterans to obtain 
health care services from providers not directly employed by VA.
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    We recommended that VA take steps to improve the timeliness and 
accuracy of data on veterans' wait times for care and its oversight of 
the future community care program that will consolidate other community 
care programs with the Veterans Choice Program, whose authority sunsets 
on June 6, 2019. VA concurred with eight of the 10 recommendations 
related to these findings, all of which remain open. \17\ VA reported 
that, in order to improve wait times data accuracy under the Veterans 
Community Care Program, it intends to implement several initiatives 
through September 2019. \18\
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    \17\ In June 2018, we recommended that the Under Secretary for 
Health should implement a mechanism to separate clinically urgent 
referrals and authorizations from those for which the VA medical 
facility or the third-party administrator has decided to expedite 
appointment scheduling for administrative reasons. VA did not agree 
with this recommendation and stated there will no longer be a need to 
separate clinically urgent referrals for care from those that need 
expediting under the Veterans Community Care Program. However, we 
maintain that our recommendation is warranted. In particular, we found 
that VA's data did not always accurately reflect the timeliness of 
urgent care because both VA medical center and third-party 
administrator staff inappropriately re- categorized some routine care 
referrals and authorizations as urgent ones for reasons unrelated to 
the veterans' health conditions.
    \18\ GAO, Veterans Choice Program: Improvements Needed to Address 
Access-Related Challenges as VA Plans Consolidation of its Community 
Care Programs, GAO-18-281 (Washington, D.C.: June 4, 2018).
---------------------------------------------------------------------------
    In September 2018, we reported on the timeliness of third-party 
administrators' payments to community providers under VA's largest 
community care program, the Veterans Choice Program. Although VA has 
taken steps to improve the timeliness of claim payments to these 
providers, VA is not collecting data or monitoring compliance with 
third-party administrators' customer service requirements for provider 
calls. This could adversely affect the timeliness with which community 
providers are paid, possibly making them less willing to participate 
and affecting veterans' access to care.
    We recommended that VA collect data on and monitor compliance with 
its requirements pertaining to customer service for community 
providers. VA agreed with the recommendations, but has not yet 
implemented them. \19\
---------------------------------------------------------------------------
    \19\ See GAO, Veterans Choice Program: Further Improvements Needed 
to Help Ensure Timely Payments to Community Providers, GAO-18-671 
(Washington, D.C.: Sep. 28, 2018).

      In November 2018, we reported that VHA's suicide 
prevention media outreach activities declined in recent years due to 
leadership turnover and reorganization. Additionally, we found that VHA 
did not assign key leadership responsibilities or establish clear lines 
of reporting for its suicide prevention media outreach campaign, which 
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hindered its ability to oversee the campaign.

    In April 2019, VA implemented one of the recommendations by 
providing a new oversight plan for its suicide prevention media 
outreach campaign. It plans to implement the remaining recommendation 
by working with communications experts to develop metrics, targets, and 
an evaluation strategy to improve its outreach efforts. \20\
---------------------------------------------------------------------------
    \20\ GAO, VA Health Care: Improvements Needed in Suicide Prevention 
Media Outreach Campaign Oversight and Evaluation, GAO-19-66 
(Washington, D.C.: Nov. 15, 2018).

      In April 2019, we reported that VHA's appraisal process 
for assessing medical center director performance relies heavily on 
medical center performance information. VHA designed the Strategic 
Analytics for Improvement and Learning (SAIL) system to provide 
internal benchmarking of medical center performance and to promote high 
quality health care delivery across its system of regional networks and 
medical centers. SAIL was evaluated in 2014 and 2015 by VHA and an 
external contractor, respectively, but VHA has not assessed the 
recommendations from those evaluations, or taken action on them. The 
evaluations, which found issues related to the validity and reliability 
of SAIL and its ratings for measuring performance and fostering 
accountability, together included more than 40 recommendations for 
---------------------------------------------------------------------------
improvement.

    Without ensuring that the recommendations resulting from these 
previous evaluations are assessed and implemented as appropriate, the 
identified deficiencies may not be adequately resolved, and VHA's 
ability to hold officials accountable for taking the necessary actions 
may be diminished. VA concurred with the two recommendations we made to 
address these findings, both of which remain open. \21\
---------------------------------------------------------------------------
    \21\ GAO, Veterans Health Administration: Past Performance System 
Recommendations Have Not Been Implemented GAO-19-350 (Washington, D.C.: 
Apr. 30, 2019).
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    Information technology challenges. Since our 2017 High-Risk Report, 
ratings for one criterion regressed, one improved, and three remain 
unchanged this area of concern as of March 2019.

      Leadership commitment: not met. In March 2019, the rating 
for this criterion declined to not met. In January 2019, the Senate 
confirmed a new VA Chief Information Officer (CIO). This is the fourth 
official to lead VA's IT organization since our 2017 High-Risk Report, 
and the frequent turnover in this position raises concerns about VA's 
ability to address the department's IT challenges.
      Capacity: not met. In May 2018, VA awarded a contract to 
acquire the same commercial electronic health record system as the 
Department of Defense (DoD). However, VA is early in the transition and 
its actions are ongoing. Additionally, VA has developed a strategy for 
decommissioning its legacy IT systems, which are tying up funds that 
could be reallocated for new technology to enable improved veteran 
care, but has made limited progress in implementing this effort.
      Action plan: partially met. In March 2019, the rating for 
this criterion improved to partially met. In 2018, VA conducted an 
analysis to identify the root causes of IT challenges, which informed 
the goals in its action plan. However, VA's action plan contained 
significant information gaps, including missing interim milestone 
dates. These information gaps raise questions about VA's commitment to 
addressing IT-related root causes and need to be addressed before we 
can consider this criterion met.
      Monitoring: not met. The March 2018 action plan lacked 
specific metrics and mechanisms for assessing and reporting progress.
      Demonstrating progress: not met. Our work continues to 
indicate VA is not yet able to show progress in this area. Since its 
2015 high-risk designation, we have made 14 new recommendations in this 
area, 12 of which were made since our 2017 report was issued. For 
example:
      In June 2017, to address deficiencies we found related to 
VA's pharmacy system, we recommended that VA take six actions to 
provide clinicians and pharmacists with improved tools to support 
pharmacy services to veterans and reduce risks to patient safety. This 
included assessing the extent to which the interoperability of VA and 
DoD's pharmacy systems impacts transitioning service members. VA 
generally concurred with these recommendations, all of which remain 
open. \22\
---------------------------------------------------------------------------
    \22\ GAO, VA Information Technology: Pharmacy System Needs 
Additional Capabilities for Viewing, Exchanging, and Using Data to 
Better Serve Veterans, GAO-17-179 (Washington, D.C.: June 14, 2017).
---------------------------------------------------------------------------
      In April 2019, we testified that from 2001 through 2018, 
VA pursued three efforts to modernize its health information system- 
the Veterans Health Information Systems and Technology Architecture 
(VistA). (See Fig. 2.) However, these efforts resulted in high costs, 
created challenges ensuring the interoperability of health data, and 
ultimately did not result in a modernized VistA. Specifically, in 
December 2017, we reported that VA obligated over $1.1 billion for 
contracts with 138 contractors during fiscal years 2011 through 2016 
for two modernization initiatives, an Integrated Electronic Health 
Record program with the DoD and VistA Evolution. We have ongoing work 
that examines the cost to VA of VistA and the department's actions to 
transition from VistA to a new electronic health record system. \23\
---------------------------------------------------------------------------
    \23\ GAO, Veterans Affairs: Addressing IT Managements Challenges Is 
Essential to Effectively Supporting the Department's Mission, GAO-19-
476T (Washington, D.C.: Apr. 2, 2019).

    Regarding the department's most recent effort, the Electronic 
Health Record Modernization, we testified in April 2019 that the 
governance plan for this program was not fully defined, which could 
jeopardize its fourth attempt to modernize its electronic health record 
system. VA plans to implement the same electronic health record system 
the DoD is currently deploying. The new system is intended to be the 
authoritative source of clinical data to support improved health, 
patient safety, and quality of care provided by VA.
    VA has not fully implemented our priority recommendation calling 
for the department to define the role of the Interagency Program Office 
in the governance plans for acquisition of the department's new 
electronic health record system. VA concurred with this recommendation 
and reported that the Joint Executive Committee, a joint governance 
body, approved a role for the Interagency Program Office, but as of 
April 2019 VA has yet to provide us with documentation of this 
development. \24\
---------------------------------------------------------------------------
    \24\ GAO, Electronic Health Records: Clear Definition of the 
Interagency Program Office's Role in VA's New Modernization Effort 
Would Strengthen Accountability, GAO-18-696T (Washington, D.C.: Sept. 
13, 2018).

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    (a) The HealtheVet initiative was VA's first VistA modernization 
project, which had the goals of standardizing the department's health 
care system and eliminating the approximately 130 different systems 
used by its field locations at that time.
    (b) The integrated Electronic Health Record program was VA's second 
VistA modernization initiative, which it launched in conjunction with 
the Department of Defense (DoD). The program was intended to replace 
the two separate electronic health record systems used by the two 
departments with a single, shared system.
    (c) The VistA Evolution program was a joint effort of the Veterans 
Health Administration and VA's Office of Information and Technology. 
The program was to be comprised of a collection of projects and efforts 
focused on improving the efficiency and quality of veterans' health 
care, modernizing the department's health information systems, 
increasing the department's data exchange and interoperability with DoD 
and private sector health care partners, and reducing the time it takes 
to deploy new health information management capabilities.

      We also testified in April 2019 that VA has not yet fully 
addressed the recommendation we made in September 2014 to expedite the 
process for identifying and implementing an IT system for the Family 
Caregiver Program. We reported in September 2014 that the Family 
Caregiver Program, which was established to support family caregivers 
of seriously injured post-9/11 veterans, has not been supported by an 
effective IT system. Specifically, we reported that, due to limitations 
with the system, the program office did not have ready access to the 
types of workload data that would allow it to routinely monitor 
workload problems created by the program. Without such information, the 
program's workload issues could persist and impact the quality and 
scope of caregiver services, and ultimately the services that veterans 
receive.

    VA concurred with our recommendation and subsequently began taking 
steps to implement a replacement system. However, the department has 
encountered delays and reported recently initiating an effort to 
implement a new IT system to support the program based on existing 
commercially available software. We have ongoing work to evaluate VA's 
effort to acquire a new IT system to support the Family Caregiver 
Program. \25\
---------------------------------------------------------------------------
    \25\ GAO, VA Health Care: Actions Needed to Address Higher-Than-
Expected Demand for the Family Caregiver Program, GAO-14-675 
(Washington, D.C.: Sept. 18, 2014) and GAO, Veterans Affairs: 
Addressing IT Management Challenges Is Essential to Effectively 
Supporting the Department's Mission GAO-19-476T (Washington, D.C.: Apr 
2, 2019).
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    Inadequate training for VA staff. Since our 2017 High-Risk Report, 
ratings for one criterion improved and four remain unchanged for this 
area of concern as of March 2019.

      Leadership commitment: not met. VA officials have 
reported progress in establishing a process to develop an enterprise-
wide annual training plan to better ensure that VA staff are adequately 
trained to provide high-quality care to veterans. However, the actions 
necessary to complete and implement this training plan are not 
reflected in VA's March 2018 action plan for the training area of 
concern, raising questions about the process through which it will be 
developed. The lack of progress in setting clear goals for improving 
training demonstrates that VA lacks leadership commitment to address 
our concerns in this area.
      Capacity: not met. VA has created working groups and task 
forces- such as the Learning Organization Transformation Subcommittee 
in the National Leadership Council-with specific responsibilities. 
However, VA's ability to demonstrate capacity is limited because, 
according to VA's March 2018 action plan, the department relies on 
external contractor support services to meet training goals.
      Action plan: partially met. In March 2019, the rating for 
this criterion improved to partially met. VA completed a root cause 
analysis for training deficiencies, which informed the goals underlying 
its action plan. However, the action plan continues to have 
deficiencies identified in 2017. For example, not all goal descriptions 
correspond to planned actions and the action plan lacks detail about 
how and which data will be collected to assess progress.
      Monitoring: not met. The March 2018 action plan lacked 
specific metrics and mechanisms for assessing and reporting progress.
      Demonstrated progress: not met. Our work continues to 
indicate that VA is not yet able to show progress in this area. Since 
its 2015 designation, we have made 11 new recommendations in this area 
of concern, 3 of which were made since our 2017 report was issued. For 
example, in April 2018 we reported that, while the department has 
recommended training for patient advocates-staff members who receive 
and document feedback from veterans or their representatives-it has not 
developed an approach to routinely assess their training needs or 
monitored training completion. The failure to conduct these activities 
increases VA's risk that staff may not be adequately trained to 
advocate on behalf of veterans. As a result, we recommended VHA develop 
an approach to routinely assess training needs and monitor training 
completion. VA concurred with our recommendations, which remain open. 
\26\
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    \26\ GAO, VA Health Care: Improved Guidance and Oversight Needed 
for the Patient Advocacy Program, GAO-18-356 (Washington, D.C.: Apr 12, 
2018).

    Unclear resource needs and allocation priorities. Since our 2017 
High-Risk Report, ratings for one criterion improved and four remain 
---------------------------------------------------------------------------
unchanged for this area of concern as of March 2019.

      Leadership commitment: partially met. In December 2017, a 
VA Chief Financial Officer (CFO) was confirmed after the department 
spent over 2.5 years under an interim CFO. In addition, VA is in the 
process of establishing a new office to estimate workforce resource 
requirements.
      Capacity: not met. VA has established functions intended 
to inform cost analyses of major VA initiatives, including a new 
financial management process to replace its outdated financial systems. 
However, it is unclear in its action plan the extent to which VA has 
identified the resources needed to establish and maintain these 
functions.
      Action plan: partially met. In March 2019, the rating for 
this criterion improved to partially met. Since our 2017 High-Risk 
Report, VA conducted a root cause analysis of this area of concern. 
However, VA's action plan lacks metrics for monitoring progress and 
does not include all of VA's ongoing actions, such as efforts to assess 
current and future regional demand for veterans' health care services.
      Monitoring: not met. Since VA's action plan lacks 
specific metrics and mechanisms for assessing and reporting progress, 
it is not clear how VA is monitoring its progress.
      Demonstrating progress: not met. Our work continues to 
indicate VA is not yet able to show progress in this area. Since its 
2015 designation, we have made 16 new recommendations in this area of 
concern, 10 of which were made since our 2017 report. For example:
      In May 2017, we reported identifying several limitations 
with VA's clinical productivity metrics and statistical models for 
tracking clinical efficiency; this limits VA's ability to assess 
whether resources are being used effectively to serve veterans. 
Specifically, we found that productivity metrics may not account for 
all providers or clinical services, reflect the intensity of clinical 
workload, and reflect providers' clinical staffing levels. 
Additionally, we found that efficiency models may also be adversely 
affected by inaccurate workload and staffing data. As a result, VA 
cannot systematically identify best practices to address low 
productivity and inefficiency as well as determine the factors VA 
medical centers commonly identify as contributing to low productivity 
and inefficiency.

    We made four recommendations to address these findings; three of 
which VA implemented in the spring of 2018 by improving productivity 
metrics and staffing and workload data. To implement the remaining 
recommendation, VA should establish a process to oversee medical 
centers' plans for addressing low clinical productivity and 
inefficiency. \27\
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    \27\ GAO, VA Health Care: Improvements Needed in Data and 
Monitoring of Clinical Productivity and Efficiency, GAO-17-480 
(Washington, D.C.: May 24, 2017).

      In August 2018 we reported that VA medical centers face 
challenges operating their Sterile Processing Services programs- 
notably, addressing workforce needs, such as lengthy hiring time frames 
and limited pay and professional growth potential. VHA's Sterile 
Processing Services workforce challenges pose a potential risk to VA 
medical centers' ability to ensure access to sterilized medical 
equipment. Until VHA examines these workforce needs, VHA won't know 
whether or to what extent the reported challenges adversely affect VA 
medical centers' ability to effectively operate their Sterile 
Processing Services programs and ensure access to safe care for 
---------------------------------------------------------------------------
veterans.

    We recommended that VA examine workforce needs and take action 
based on this assessment, as appropriate. VA concurred with this 
recommendation, which remains open. \28\
---------------------------------------------------------------------------
    \28\ GAO, VA Health Care: Improved Oversight Needed for Reusable 
Medical Equipment, GAO-18-474 (Washington, D.C.: Aug. 3, 2018).

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VA Acquisition Management Was Added to GAO's High-Risk List in 2019

    In light of numerous contracting challenges that we have 
identified, and given the significant investment in resources to 
fulfill its critical mission of serving veterans, we added VA 
acquisition management as a new high- risk area in 2019. \29\ VA has 
one of the most significant acquisition functions in the Federal 
government, both in dollar amount of obligations and number of contract 
actions. Specifically, about a third of VA's discretionary budget in 
fiscal year 2018, or about $27 billion, has been used to contract for 
goods and services.
---------------------------------------------------------------------------
    \29\ GAO-19-157SP.
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    We have identified challenges in the following areas of concern 
related to VA's acquisition management: (1) outdated acquisition 
regulations and policies; (2) lack of an effective medical supplies 
procurement strategy;
    (3)inadequate acquisition training; (4) contracting officer 
workload challenges; (5) lack of reliable data systems; (6) limited 
contract oversight and incomplete contract file documentation; and (7) 
leadership instability.
    Outdated acquisition regulations and policies. VA's procurement 
policies have historically been outdated, disjointed, and difficult for 
contracting officers to use. In September 2016, we reported that (1) 
the acquisition regulations contracting officers currently follow have 
not been fully updated since 2008 and (2) VA had been working on 
completing a comprehensive revision of its acquisition regulations 
since 2011. \30\
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    \30\ GAO, Veterans Affairs Contracting: Improvements in Policies 
and Processes Could Yield Cost Savings and Efficiency, GAO-16-810 
(Washington, D.C.: Sep. 16, 2016).
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    VA's delay in updating this fundamental source of policy has 
impeded the ability of contracting officers to effectively carry out 
their duties. We recommended in September 2016 that VA identify 
measures to expedite the revision of its acquisition regulations and 
clarify what policies are currently in effect. VA concurred with this 
priority recommendation and, as of January 2019, had rescinded or re-
issued updated policy memoranda for all information letters, which VA 
previously used to provide guidance that was temporary in nature.
    VA has also made some progress in updating its acquisition 
regulations, but more work remains to be done over the next several 
years. As of April 2019, VA reports that 15 of the 41 parts in its 
acquisition regulations update were published as final rules, 10 were 
issued as proposed rules for public comment, and the remainder are at 
an earlier stage of the rulemaking process. All parts are scheduled to 
be out for public comment by March 2020, but the final rules are not 
expected to be published until April 2021.
    Lack of an effective medical supplies procurement strategy. VA's 
program for purchasing medical supplies has not been effectively 
executed, nor is it in line with practices at leading hospitals. To 
support more efficient purchasing of medical supplies for its 172 
medical centers that serve the needs of about 9 million veterans, VA 
launched the Medical Surgical Prime Vendor-Next Generation (MSPV-NG) 
program in December 2016. MSPV-NG was part of VA's overall effort to 
transform its supply chain and achieve $150 million in cost avoidance.
    In November 2017, we reported that VA's approach to developing its 
catalog of supplies was rushed and lacked key stakeholder involvement 
and buy-in. It also relied on establishing non-competitive blanket 
purchase agreements for the overwhelming majority of products, 
resulting in low utilization by medical centers. VA had set a target 
that medical centers would order 40 percent of their supplies from the 
MSPV-NG catalog, but utilization rates were below this target with a 
nationwide average utilization rate across medical centers of about 24 
percent as of May 2017. This low utilization adversely affected VA's 
ability to achieve its cost avoidance goal.
    We recommended in November 2017 that VA develop, document, and 
communicate to stakeholders an overarching strategy for the program. VA 
concurred with this priority recommendation and is developing 
strategies to address it. First, in February 2019, VA developed and 
documented a new, overarching acquisition strategy for its Medical 
Surgical Prime Vendor (MSPV) program, and has begun the process of 
communicating it to key stakeholders, including clinical and logistics 
staff. Further, VA is developing a separate strategy to involve 
clinicians in developing requirements with plans to complete a pre-
pilot of this strategy by September 2019. In response to a 
congressional request to assess these and other program changes, we 
recently began a review of VA's MSPV program. \31\
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    \31\ GAO, Veterans Affairs Contracting: Improvements in Buying 
Medical and Surgical Supplies Could Yield Cost Savings and Efficiency, 
GAO-18-34 (Washington, D.C.: Nov 9, 2017).
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    Inadequate acquisition training. VA acquisition training, at times, 
has not been comprehensive nor provided to staff that could benefit 
from it. A 2006 statute required, and a 2016 Supreme Court decision 
(Kingdomware Technologies, Inc. v. United States) reaffirmed, that VA 
is to give preference to veteran-owned small businesses when 
competitively awarding contracts-a program known as Veterans First. In 
September 2018, we reported that training on VA's Veterans First policy 
did not address some of its more challenging aspects. For example, many 
of the contracting officers we interviewed were uncertain about how to 
balance the preference for veteran-owned small businesses with fair and 
reasonable price determinations when lower prices might be found on the 
open market. \32\
---------------------------------------------------------------------------
    \32\ GAO, Veterans First Program: VA Needs to Address 
Implementation Challenges and Strengthen Oversight of Subcontracting 
Limitations, GAO-18-648 (Washington, D.C.: Sep. 24, 2018).
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    In addition, VA provided several installments of online training 
sessions on the Veterans First policy to contracting officers but did 
not make them mandatory. As a result, only 52 percent of VA contacting 
officers completed the follow-up training by the spring of 2018. We 
recommended in September 2018 that VA provide more targeted training to 
contracting officers on how to implement the Veterans First policy, 
particularly in the area of making fair and reasonable price 
determinations, and assess whether this training should be designated 
as mandatory. VA concurred, and in April 2019, VA's Chief Acquisition 
Officer (CAO) stated that VA is taking steps to make this training 
mandatory. VA also reported that its Acquisition Academy will provide 
Veterans First training to all contracting staff on May 30, 2019.
    Contracting officer workload challenges. The majority of our 
reviews since 2015 have highlighted workload as a contributing factor 
to the challenges that contracting officers face. Most recently, in 
September 2018, we reported that about 54 percent of surveyed VA 
contracting officers said their workload was not reasonable and found 
that workload stresses have exacerbated the struggles that they face 
implementing the department's Veterans First policy. \33\
---------------------------------------------------------------------------
    \33\ GAO-18-648.
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    In addition, in September 2016, we reported that VHA contracting 
officers processed a large number of small dollar-value actions to 
support medical center operations, many of which involve emergency 
procurements of routine items to support immediate patient care. 
Contracting officers and the department's Acting CAO told us that these 
frequent and urgent small-dollar transactions reduce contracting 
officers' efficiency and ability to take a strategic view of VHA's 
overarching procurement needs. We reported in November 2017 that 
emergency procurements accounted for approximately 20 percent-$1.9 
billion-of VHA's overall contract actions in fiscal year 2016. Figure 3 
shows the percent of VHA contract actions designated as emergencies in 
fiscal year 2016 by each network contracting office. \34\
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    \34\ GAO-16-810.
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    
    
    (a) Veterans Integrated Service Networks, organizations that manage 
medical centers and associated clinics across a given geographic area, 
are served by a corresponding network contracting office. Some Veterans 
Integrated Service Networks have been consolidated over time, and in 
fiscal year 2016, there were 19 Veterans Integrated Service Networks 
despite being numbered up to 23. As of fiscal year 2017, there were 
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only 18 in total.

    We recommended in November 2017 that VHA network contracting 
offices work with medical centers to identify opportunities to more 
strategically purchase goods and services frequently purchased on an 
emergency basis. VA concurred with this recommendation and recently 
offered to provide us with a demonstration of the supply chain 
dashboard that VA uses to track items purchased on an emergency basis, 
which we plan to attend by the end of May 2019. VA also agreed to 
conduct an analysis of its purchase card spending to identify items 
that should be purchased through its MSPV program. VA expects to 
complete this analysis by July 2019. If implemented, this would allow 
for both greater contracting officer efficiency and cost savings. For 
example, based on a similar recommendation we made in 2012, VA began 
more systematically employing strategic sourcing in FY 2013, and in 
subsequent fiscal years reported about $10 billion in savings over a 5-
year period.
    Lack of reliable data systems. The lack of accurate data has been a 
long-standing problem at VA. In September 2016, we reported that VA had 
not integrated its contract management and accounting systems, 
resulting in duplicative efforts on the part of contracting officers 
and increased risk of errors. \35\ We and VA's Inspector General each 
recommended that VA perform data checks between the two systems. VA 
concurred with this recommendation and some VA contracting 
organizations have made efforts to address this risk. Further, VA 
reported in March 2019, that it plans to adopt a new integrated 
financial and contract management system, which it plans to install VA-
wide over a 9- year period, with the final site receiving the system in 
2027.
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    \35\ GAO-16-810.
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    Limited contract oversight and incomplete contract file 
documentation. VA has had difficulty ensuring that its contracts are 
properly monitored and documented. In September 2018, we reported that, 
although VA obligated $3.9 billion to veteran-owned small businesses in 
fiscal year 2017, its contracting officers were not effectively 
monitoring compliance with key aspects of the department's Veterans 
First policy, such as limits on subcontracting (which ensure that the 
goal of the program-to promote opportunities for veteran-owned 
businesses-is not undermined). In many cases, we found that clauses 
requiring compliance were not included in the VA's contracts and orders 
with veteran businesses because the contracting officers either forgot 
to include them or were unaware of the requirement. \36\
---------------------------------------------------------------------------
    \36\ GAO-18-648.
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    The contracting officers we spoke with also said that they do not 
have sufficient time or knowledge to conduct oversight. Through limited 
reviews, VA has identified a number of violations that would warrant a 
broader assessment of the fraud risks to the program. We recommended in 
September 2018 that VA establish a mechanism to ensure that mandatory 
subcontracting-related clauses be consistently incorporated into set-
aside contracts with veteran-owned businesses and that VA conduct a 
fraud risk assessment for the Veterans First program. VA concurred with 
these recommendations and is taking steps to implement them. For 
example, VA reported in April 2019 that it had made modifications to 
its electronic contract management system to ensure the clauses would 
be included in set-aside contracts and anticipated completing testing 
of the modifications in May 2019.
    We also reported in September 2016 that a number of VA contract 
files we reviewed were missing key documents, increasing the risk that 
key processes and regulations were not followed. \37\ We recommended 
that VA focus its internal compliance reviews to ensure that required 
contract documents are properly prepared and documented. VA concurred 
with this recommendation. Since then, VA has made policy changes that 
revised its processes for compliance reviews of contract documentation. 
We are currently following up with VA to obtain the results of its 
compliance reviews to determine if VA has fully implemented this 
recommendation.
---------------------------------------------------------------------------
    \37\ GAO-16-810.
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    Leadership instability. We have previously reported, most recently 
in September 2018, that procurement leadership instability has made it 
difficult for the VA to execute and monitor the implementation of key 
acquisition programs and policies. For example, changes in senior 
procurement leadership, including the CAO and VHA's Chief Procurement 
and Logistics Officer, occurred during the implementation of MSPV-NG 
and similar instability in leadership affected the MSPV-NG program 
office itself. Overall, the MSPV-NG program office has had four 
directors, two of whom served in an acting capacity, since its 
inception in 2014. \38\
---------------------------------------------------------------------------
    \38\ GAO-18-648.
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    To address this instability, we recommended in November 2017 that 
VA appoint a non-career employee as the CAO and prioritize the hiring 
of the MSPV-NG program office's director position on a permanent basis. 
VA concurred with these recommendations and implemented them in 2018. 
Stable leadership should help bring consistent and much needed 
direction to the MSPV-NG program, but we recently identified other 
areas within the VA where sustained leadership is also needed. For 
instance, in September 2018, we reported there have been six Acting 
Directors within the past 2 and a half years within an oversight office 
that helps assess whether VA is in compliance with aspects of its 
Veterans First policy.

Ratings for the VA Disability High-Risk Areas Either Remained Unchanged 
    or Regressed in 2019

    We designated improving and modernizing Federal disability programs 
as high risk in 2003. An estimated one in six working-age Americans 
reported a disability in 2010. Many of these Americans need help 
finding or retaining employment, or rely on cash benefits if they 
cannot work.
    Three of the largest Federal disability programs-one run by VA- 
disbursed about $270 billion in cash benefits to 21 million people with 
disabilities in fiscal year 2017. However, Federal disability programs, 
including VA's, struggle to meet their needs. In particular, VA 
struggles to manage its disability claims workloads, and, when 
determining whether individuals qualify for disability benefits, VA 
relies on outdated eligibility criteria.
    Managing disability claims workloads. Since our 2017 High-Risk 
Report, our assessment of ratings for all five criteria remains 
unchanged for this area of concern for VA as of March 2019.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

      Leadership commitment: met. VA has maintained leadership 
focus on managing initial disability claims and appeals workloads 
through various initiatives to improve benefits processing and reduce 
backlogs. Enhancing and modernizing VA's disability claims and appeals 
processes are goals in its 2018-2024 strategic plan.
      Capacity: partially met. VA has continued building the 
capacity to process initial disability claims, such as using an 
electronic system to distribute claims ready for decisions to available 
staff. On appeals, VA is reforming its process, onboarding hundreds of 
new staff, and implementing new technology. However, as we reported in 
March 2018, VA's appeals plan does not provide reasonable assurance 
that it will have the capacity to implement the new process and manage 
risks. VA agreed with our recommendation to better assess risks 
associated with appeals reform and took some steps to address risks, 
such as limited testing of the new process. However, as of April 2019 
VA has not fully addressed this recommendation. For example, VA has not 
developed plans to fully address risks, such as veterans choosing more 
resource-intensive options at higher rates than expected. \39\
---------------------------------------------------------------------------
    \39\ GAO, VA Disability Benefits: Improved Planning Practices Would 
Better Ensure Successful Appeals Reform. GAO-18-352. (Washington, D.C.: 
Mar. 22, 2018).
---------------------------------------------------------------------------
      Action plan: partially met. VA continues to implement 
plans to reduce the initial disability claims backlog. For appeals 
reform, VA submitted its appeals plan in November 2017 and provided 
several progress reports throughout 2018. In March 2018, we reported 
that VA's plan for implementing a new disability appeals process did 
not explain how VA would assess the new process compared to the legacy 
process, and did not fully address risks associated with implementing a 
new process.

    We made two recommendations to improve VA's disability benefit 
appeals process, including that VA (1) clearly articulate in its 
appeals plan how it will monitor and assess the new appeals process 
compared to the legacy process, and (2) ensure that its appeals plan 
more fully addresses related risks, given the uncertainties associated 
with implementing a new process. As of April 2019, VA has taken actions 
to address our recommendations, although key steps remain. For example, 
VA has not fully articulated detailed steps and time frames for 
assessing the relative performance of the new and legacy appeals 
processes. Without this assessment, VA cannot determine the extent to 
which the new process will achieve final resolution of veterans' 
appeals sooner than the legacy process. \40\
---------------------------------------------------------------------------
    \40\ GAO-18-352.

      Monitoring: partially met. VA monitors the timeliness of 
initial disability claims and legacy appeals, and has set timeliness 
goals for some, but not all, of the appeal options under the new 
process. VA's plans also signal how it intends to monitor the 
allocation of staff for concurrent workloads in its legacy and new 
appeals processes. However, as of April 2019, VA has yet to specify a 
complete set of balanced goals for monitoring the new and legacy 
appeals processes (including timely and accurate processing of appeals 
while ensuring veteran satisfaction).
      Demonstrated progress: partially met. VA reported it 
reduced the backlog of initial disability claims from 611,000 in March 
2013 to about 81,000 at the end of fiscal year 2018. However, VA's 
Inspector General reported in September 2018 that VA overstated its 
performance by only reporting about 79 percent of the backlog. For 
appeals, VA addressed some gaps in its plan for implementing appeals 
reform, in accordance with our 2017 and 2018 recommendations, and has 
prioritized processing of legacy appeals. However, as of September 
2018, VA still had a backlog of about 396,000 legacy appeals.

    Updating disability benefit eligibility criteria. Since our 2017 
High-Risk Report, VA's ratings for the action plan and monitoring 
criteria regressed while the other three remain unchanged as of March 
2019.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

      Leadership commitment: met. VA has sustained leadership 
focus on updating its Veterans Affairs Schedule for Rating Disabilities 
(VASRD)-used to assign degree of disability and compensation levels for 
veterans with military service-connected injuries or conditions-to 
reflect advances in medicine and labor market changes.
      Capacity: partially met. In August 2017, VA officials 
told us that it had taken actions to hire more staff for the 
regulations updates and leverage outside researchers to evaluate 
veterans' loss of earnings in the current economy. However, as of 
September 2018, the agency was still working to hire these staff. 
Moreover, VA's current earnings loss study covers only 8 of over 900 
diagnostic codes and 2 of 15 body systems. VA needs to continue its 
current hiring and earnings loss planning efforts to ensure it has the 
capacity to comprehensively update the VASRD.
      Action plan: partially met. In March 2019, the rating for 
this criterion declined to partially met. As of April 2019, VA's 
efforts to update the VASRD included new plans to conduct earnings loss 
studies. Veterans Benefits Administration officials stated they 
completed a study for eight diagnostic codes under two body systems, 
and the agency is determining whether its current approach for 
evaluating earnings loss is applicable to updating other diagnostic 
codes. However, we lowered VA's prior rating of met to partially met 
because its latest August 2018 updated plan, issued since our 2017 
High-Risk Report, provided limited detail on key planned activities, 
potentially jeopardizing its third attempt at modernization over the 
past decade. For example, VA's plans do not indicate how and when VA 
will assess the applicability of its current approach, and does not 
include plans for updating earnings loss information for the remaining 
diagnostic codes and body systems.
      Monitoring: partially met. In March 2019, the rating for 
this criterion declined to partially met. According to VA officials, VA 
continues to track its progress toward finishing the medical updates by 
fiscal year 2020 and has updated its project plan to reflect delayed 
time frames. However, we lowered VA's prior rating for this criterion 
from met to partially met because VA's plans have changed since our 
last update, and although it is conducting a study to update earnings 
loss information for some diagnostic codes and body systems, its plan 
does not include timetables for monitoring these or future updates to 
earnings loss information.
      Demonstrated progress: partially met. VA reported that as 
of December 2018, it promulgated final regulations for 6 of 15 body 
systems, proposed regulations for 2, and is reviewing draft regulations 
for the remaining 7. However, VA has fallen about 4 years behind in its 
efforts to fully update the VASRD and has not completed earnings loss 
updates.

Other Government- Wide High-Risk Areas Have Implications for VA 
    Operations

    Several other government-wide high-risk areas include VA and its 
operations. These areas include (1) improving the management of IT 
acquisitions and operations, (2) strategic human capital management, 
(3) managing Federal real property, and (3) ensuring the cybersecurity 
of the nation.

      Improving the management of IT acquisitions and 
operations. The executive branch has undertaken numerous initiatives to 
better manage the more than $90 billion that is annually invested in IT 
across the government. However, our work shows that Federal IT 
investments, including those made by VA, too frequently fail or incur 
cost overruns and schedule slippages while contributing little to 
mission-related outcomes. Thus, in 2015, we added improving the 
management of IT acquisitions and operations to the High-Risk List. 
\41\ To address the portion of the high-risk area for which it is 
responsible, VA should, among other things, implement our past 
recommendations on improving IT workforce planning practices and 
establishing action plans to modernize or replace obsolete IT 
investments. \42\
---------------------------------------------------------------------------
    \41\ GAO-15-290.
    \42\ GAO-19-157SP.
---------------------------------------------------------------------------
    In August 2018, for example, we found that VA's policies did not 
fully address the role of its CIO consistent with Federal laws and 
guidance in the areas of IT workforce, IT strategic plan, IT budgeting, 
and IT investment management. Until VA fully addresses the role of the 
CIO in all of its policies, it will be limited in addressing 
longstanding IT management challenges. We recommended that VA's IT 
management policies address the role of the CIO for key 
responsibilities in the four areas we identified. VA concurred with 
this recommendation, which remains open. \43\
---------------------------------------------------------------------------
    \43\ GAO, Federal Chief Information Officers: Critical Actions 
Needed to Address Shortcomings and Challenges in Implementing 
Responsibilities, GAO-18-93 (Washington, D.C.: Aug. 2, 2018).

      Strategic human capital management. This area was added 
to our High-Risk List in 2001 and continues to be at risk today because 
mission-critical skills gaps both within Federal agencies and across 
the Federal workforce are impeding the government from cost-effectively 
serving the public and achieving results. \44\ As of December 2018, VA 
reported an overall vacancy rate of 11 percent at VHA medical 
facilities, including vacancies of over 24,000 medical and dental 
positions and around 900 human resource positions. Also, with 32 
percent of the VA workforce eligible to retire in the next 5 fiscal 
years, VA must address these mission-critical skill gaps and vacancies 
that we continue to identify in our work. \45\
---------------------------------------------------------------------------
    \44\ GAO, High-Risk Series: An Update, GAO-01-263 (Washington, 
D.C.: Jan. 1, 2001).
    \45\ Percentage based on VA employees on board at the start of 
fiscal year 2017.
---------------------------------------------------------------------------
    In December 2016, for example, we found that VHA's limited human 
resources capacity combined with weak internal control practices has 
undermined VHA's human resources operations and its ability to improve 
delivery of health care services to veterans. Further, VHA is 
challenged by inefficiencies in its performance management processes, 
including the lack of a performance appraisal IT system, which prevents 
it from identifying trends and opportunities for improvement. VHA can 
better support medical centers by establishing clear lines of 
accountability for engagement efforts, collecting and leveraging 
leading practices, and addressing barriers to improving engagement. We 
made three recommendations to VA to improve its performance management 
system. VA partially concurred with these recommendations, which remain 
open. \46\
---------------------------------------------------------------------------
    \46\ GAO, Veterans Health Administration: Management Attention Is 
Needed to Address Systemic, Long-standing Human Capital Challenges, 
GAO-17-30 (Washington, D.C.: Dec. 23, 2016).

      Managing Federal real property. Since Federal real 
property management was placed on the High-Risk List in 2003, the 
Federal government has given high-level attention to this issue. 
However, Federal agencies, including VA, continue to face long-standing 
challenges, including (1) effectively disposing of excess and 
underutilized property, (2) relying too heavily on leasing, (3) 
collecting reliable real property data for decision making, and (4) 
protecting Federal facilities.
    In January 2019, for example, we reported that VA has enhanced its 
data collection on vacant properties, but the agency does not collect 
information needed to track and monitor disposal projects at the 
headquarters level. Without information on the status of disposal 
projects, VA cannot readily track and monitor its progress and identify 
areas where facilities' managers may need additional assistance. As a 
result, we recommended that VA improve its procedures related to 
disposal of excess and underutilized property to help local facility 
managers plan, implement, and execute projects to dispose of those 
properties. In addition, VA should collect key information on the 
status of these disposal projects to help manage the process and 
identify areas where management attention is needed. VA concurred with 
the three recommendations we made related to these findings, all of 
which remain open. \47\
---------------------------------------------------------------------------
    \47\ GAO, VA Real Property: Clear Procedures and Improved Data 
Collection Could Facilitate Property Disposals, GAO-19-148 (Washington, 
D.C.: Jan. 9, 2019).

      Ensuring the cybersecurity of the nation. We have 
designated information security as a government-wide high-risk area 
since 1997. We expanded this high-risk area in 2003 to include 
protection of critical cyber infrastructure and, in 2015, to include 
protecting the privacy of personally identifiable information. Federal 
agencies and our nation's critical infrastructures are dependent on IT 
systems and electronic data to carry out operations and to process, 
maintain, and report essential information. The security of these 
systems and data is vital to public confidence and national security, 
prosperity, and well- being. Because many of these systems contain vast 
amounts of personally identifiable information, agencies must protect 
the confidentiality, integrity, and availability of this information. 
In addition, they must effectively respond to data breaches and 
security incidents when they occur.
    In May 2016, for example, we found that VA had developed a risk 
assessment for their selected high-risk systems, but had not always 
effectively implemented access controls. These control weaknesses 
included those protecting system boundaries, identifying and 
authenticating users, authorizing access needed to perform job duties, 
and auditing and monitoring system activities. Weaknesses also existed 
in patching known software vulnerabilities and planning for 
contingencies. An underlying reason for these weaknesses is that the 
key elements of information security programs had not been fully 
implemented. VA concurred with all of our five recommendations related 
to improving its cybersecurity controls. However, two recommendations-
which specifically call for the department to conduct security control 
assessments and develop a continuous monitoring strategy-remain open. 
\48\
---------------------------------------------------------------------------
    \48\ GAO, Information Security: Agencies Need to Improve Controls 
over Selected High- Impact Systems, GAO-16-501. (Washington, D.C.: May 
18, 2016).
---------------------------------------------------------------------------
    In November 2018, the department's inspector general reported that 
VA had made progress in developing, documenting, and distributing 
policies and procedures to support its security program, but identified 
IT security as a major management challenge due to the persistence of 
deficiencies. \49\ For example, the inspector general identified 
significant deficiencies related to access, configuration management, 
change management, and service continuity. In addition, VA's financial 
statement auditor reported deficiencies in the department's IT security 
controls as a material weakness for financial reporting purposes. \50\ 
The auditor has reported IT security controls as a material weakness 
for more than 10 years.
---------------------------------------------------------------------------
    \49\ Department of Veterans Affairs, Agency Financial Report Fiscal 
Year 2018. (Washington, D.C.: November 26, 2018).
    \50\ A material weakness is a deficiency, or combination of 
deficiencies, in internal control, such that there is a reasonable 
possibility that a material misstatement of the entity's financial 
statements will not be prevented, or detected and corrected in a timely 
basis.

---------------------------------------------------------------------------
VA's Transformational Efforts Are Ongoing

    Since his confirmation in July 2018, Secretary Wilkie has 
demonstrated his commitment to addressing the department's high-risk 
designations by, among other things, creating an office to direct an 
integrated approach for high-risk concerns and communicating to VA 
leaders the importance of addressing our recommendations. Additionally, 
VA leadership has also encouraged senior leaders to meet with GAO 
subject matter experts from acquisition, performance, human capital, 
and financial management, among other areas, to discuss leading 
practices and VA's modernization efforts. In addition, senior leaders 
from GAO and VA meet regularly to identify and address the root causes 
of high-risk issues, and discuss the status of our recommendations and 
VA's efforts to address them.
    Fully addressing these issues will require sustained leadership 
attention on these issues as well as leadership stability-something 
that VA has not had in recent years. In particular, in the 2 years 
prior to Secretary Wilkie's confirmation, VA experienced leadership 
instability with senior- level vacancies in key positions, including 
the Under Secretary for Health, CIO, and Deputy Under Secretary for 
Health for Community Care.
    In addition to sustained leadership, VA must develop action plans 
for addressing the high-risk issues. \51\ As noted earlier, VA 
officials have stated that they are currently working to address our 
high-risk concerns through the implementation of the VHA Plan for 
Modernization. The plan, which identifies high-level implementation 
targets through 2020, provides a framework to address the Secretary's 
four priorities: (1) improving training and customer service; (2) 
implementing the VA MISSION Act and improving veterans' access to care; 
(3) connecting the VA's electronic health records system to the DoD's 
to ensure a continuum of care for transitioning service members; and 
(4) transforming VA's business systems. As part of this effort, VA is 
focused on ``10 lanes of effort,'' including transitioning to the same 
electronic health record system the DoD is currently deploying, and 
transforming its business systems- including its human resource 
management, finance and acquisition management, and supply chain 
functions-to improve the quality and availability of services at VA 
medical centers. \52\
---------------------------------------------------------------------------
    \51\ GAO-19-157SP.
    \52\ The 10 lanes of effort for the VHA Plan for Modernization are 
(1) Commit to Zero Harm; (2) Streamline VHA Central Office; (3) Develop 
Responsive Shared Services; (4) Reduce Unwarranted Variation Across 
Integrated Clinical and Operational Service lines; (5) Engage Veterans 
in Lifelong Health, Well-Being and Resilience; (6) Revise Governance 
Processes and Align Decision Rights; (7) VA MISSION Act: Improving 
Access to Care; (8) Modernize Electronic Health Records; (9) Transform 
Financial Management System; and (10) Transform Supply Chain.
---------------------------------------------------------------------------
    In closing, VA has launched several significant efforts to address 
many of the underlying management challenges it faces, including 
transforming its electronic health record and financial management 
systems, updating its medical surgical prime vendor program, and 
implementing the VA MISSION Act. Any one of these efforts would be a 
significant undertaking for an agency given their scope, time frames, 
and costs, and VA is attempting to concurrently implement them. If 
successful, these efforts could be transformative for VA. Sustained 
congressional oversight of VA's efforts will also be needed. We stand 
ready to support this oversight through continued monitoring of VA's 
efforts as it ensures that the modernization efforts integrate and 
address many of the concerns that led to the designation of various VA 
areas as high risk.
    Chairman Pappas, Ranking Member Bergman, and Members of the 
Subcommittee, this concludes my statement. I would be pleased to 
respond to any questions you may have.

GAO Contacts and Staff Acknowledgments

    For further information about this statement, please contact Debra 
A. Draper at (202) 512-7114 or [email protected] or Sharon M. M. Silas at 
(202) 512-7114 or [email protected] for VHA health care issues; Shelby S. 
Oakley at (202) 512-4841 or [email protected] for VA acquisition 
management issues; or Elizabeth H. Curda at (202) 512-7215 or 
[email protected] for VA disability claims issues. Contact points for our 
Offices of Congressional Relations and Public Affairs may be found on 
the last page of this statement. Key contributors to this statement 
were Ann Tynan, Mark Bird, David Bruno, Keith Cunningham, Cathleen 
Hamann, Lisa Gardner, Steven Lozano, William Reinsberg, Maria Storts, 
Jamie Whitcomb, Amanda Cherrin (Analyst-in-Charge), Kate Tussey, Jeff 
Hartnett, and Teague Lyons. Vikki Porter and Jacquelyn Hamilton also 
contributed to this statement.

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7814, Washington, DC 20548

                                 
                Prepared Statement of Michael J. Missal
    Chairman Pappas, Ranking Member Bergman, and members of the 
Subcommittee, thank you for the opportunity to discuss the Office of 
Inspector General's (OIG's) oversight of the operations of the 
Department of Veterans Affairs (VA). The mission of the OIG is to 
conduct effective oversight of VA's programs and operations through 
independent audits, inspections, reviews, and investigations.
    This statement focuses on the processes the OIG uses to develop 
recommendations that will assist VA in improving services and benefits 
to veterans and their caregivers and families. Examples of critical 
recommendations are highlighted, as well as OIG-identified Major 
Management Challenges facing VA. OIG recommendations generally address 
specific allegations or concerns in particular VA facilities, offices, 
or programs. OIG reports focus not only on solutions to a defined 
problem, but also identify the underlying root causes of issues that 
negatively impact current programs and future initiatives whenever 
possible. As a result, these recommendations may also be a road map 
that other facilities, offices, or programs can follow to apply any 
lessons learned across VA and to take corrective actions applicable to 
other relevant VA operations.
    In addition to using data to drive OIG oversight work, stakeholders 
within VA and the larger veteran community-as well as Congress and 
other oversight bodies-play an invaluable role in identifying problems 
and pushing for implementation of recommendations for positive change. 
This critical work would not be accomplished without congressional 
support of OIG efforts through its appropriations and the attention 
given to OIG reports and recommendations. The OIG looks forward to 
working with its many stakeholders to advance recommendations for 
improvement in all VA programs, services, and systems, including those 
proposed in the 100 reports issued during the first half of fiscal year 
(FY) 2019.

AUTHORITY AND PRINCIPLES GUIDING OIG RECOMMENDATIONS

    The OIG was created by the Inspector General (IG) Act of 1978 and 
strengthened through amendments to the IG Act in 1988, the IG Reform 
Act of 2008, and the IG Empowerment Act of 2016. Pursuant to Section 4 
of the United States Code Title 5 Appendix, the Inspector General is 
responsible for

    (1) conducting and supervising audits and investigations;
    (2) recommending policies designed to promote economy and 
efficiency in the administration of, and to prevent and detect criminal 
activity, waste, abuse, and mismanagement in VA programs and 
operations; and
    (3) keeping the Secretary and Congress fully and currently informed 
about significant problems and deficiencies in VA programs and 
operations and the need for corrective action.

    When developing recommendations, OIG staff focus on several key 
principles, including the following:
    First, carefully articulated recommendations are directed to the 
specific VA office or program official that has the responsibility and 
authority required to satisfactorily implement them. Recommendations 
could be directed to anyone from the Secretary to a service line chief 
at a medical facility. Recommendations must be clear, be capable of 
execution, and specify who is accountable within VA for implementation. 
While the OIG's recommendations may be narrowly addressed to a 
particular VA facility or operation, VA should be disseminating 
information about identified problems and remediation plans to 
officials in all VA offices that could potentially have the same issues 
and are positioned to take positive action.
    Second, recommendations are contemporaneous with ongoing issues 
and, except in rare circumstances, should not require more than one 
year to implement from the report's publication. As explained later, 
this helps align implementation with reporting requirements to 
Congress, while also minimizing the risk that OIG recommendations 
languish, become outdated, or lag behind VA policy and program changes. 
In the instance that a recommendation would require implementation over 
a longer period, VA and OIG staff work to develop implementation plans 
that have quarterly milestones to support tracking progress towards 
implementation.
    Third, OIG recommendations are objective and nonpartisan-driven by 
data, evidence, and all documentation that are collected and analyzed 
in accordance with audit, inspection, and investigative standards. The 
OIG's statutory independence allows it to determine which VA programs, 
services, operations, and systems to examine that will have the 
greatest impact on veterans' lives and taxpayers' investments, and to 
then communicate those findings with Congress, VA's stakeholders, and 
the public.
    Finally, the OIG makes recommendations, but does not direct how 
they are executed. It is important to note that OIG staff cannot 
mandate that VA accept OIG recommendations or direct specific action to 
carry them out. Consistent with this limitation, OIG reports may 
contain recommendations for VA to ``take appropriate administrative 
action'' against a specific VA employee for misconduct, but under 
Federal law, VA leaders and managers are then responsible for 
determining any appropriate administrative action. VA determines the 
level of disciplinary or adverse actions to be taken, if any. The OIG 
closes out these recommendations upon VA providing acceptable 
documentation that no action was deemed necessary, that specific 
administrative action was taken, or the individual left Federal 
employment. VA leaders are solely responsible for managing VA and 
setting its policy, including determining how best to implement OIG 
recommendations. VA and the OIG may disagree about a specific 
recommendation, but those situations are rare and are noted in the 
published report.

OIG RECOMMENDATIONS DEVELOPMENT

    When OIG staff perform an audit, review, inspection, or 
administrative investigation, they conduct months of work that can 
involve on-site inspections, interviews, document and record reviews, 
data collection, and more. Using all information collected, staff 
prepare a draft report with findings that are based on thorough, 
objective, and balanced analyses. These reports usually include 
recommendations for VA corrective action or improvement. The draft 
report is typically sent to appropriate VA managers for review prior to 
publication to ensure accuracy. This process provides VA an opportunity 
to comment on the report's factual content and findings. The comments 
also outline VA management's position on implementing OIG 
recommendations and are included in the final OIG report. If management 
concurs with the recommendation, their response must include an 
implementation plan and a self-determined estimated date of completion. 
OIG staff will then review the implementation plan to determine if it 
satisfies the intent of the recommendation. In the event VA concurs 
with an OIG finding but not the recommendation, VA will need to provide 
an alternative action they believe will satisfy the intent of the 
recommendation. The VA workplan to carry out the recommendation and 
address the underlying finding is key to OIG staff's follow-up process, 
as detailed later in this statement.
    In some occasions, consistent with the OIG's statutory independence 
from VA, a final report may be issued without VA's response or 
concurrence of the findings and recommendations, or an acceptable 
implementation plan. However, it is rare for VA to not concur with OIG 
findings or recommendations, averaging just one percent of all 
responses over FYs 2017, 2018, and 2019 to date. OIG staff and leaders 
have open lines of communication with VA counterparts to resolve these 
situations. If VA does not concur with a finding or recommendation, and 
OIG staff cannot reach agreement with the VA office, OIG leaders will 
escalate the matter with VA managers up to the Deputy Secretary, who is 
the final VA deciding official, prior to publishing a report with 
nonconcurrence on recommendations.
    In addition, VA may ``concur in principle'' or ``partially concur'' 
with a recommendation, but OIG requires VA to clearly explain the 
concern with the finding or recommendation (including a perceived 
inability to implement) that is cause for the qualified response. 
Overall, it is important for comments to make clear whether VA concurs 
or nonconcurs with each finding, as well as with specific 
recommendations.

TRACKING OIG RECOMMENDATIONS

    OIG recommendations can be accessed in several ways. The most up-
to-date information can be found on the OIG website, www.va.gov/oig. 
The recommendations webpage provides live tracking on the status of OIG 
published reports and recommendations open for less than a year, open 
for more than a year, and closed as implemented. \1\ This online 
dashboard also provides the realized and potential monetary impact of 
VA's implementation of OIG recommendations. The webpage search 
functionality allows users to isolate reports with open 
recommendations.
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    \1\ https://www.va.gov/oig/recommendation-dashboard.asp.
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    Pursuant to the IG Act of 1978, the Semiannual Report (SAR) to 
Congress presents the OIG's accomplishments during the prior six-month 
reporting period. \2\ Within the SAR, the OIG lists all open 
recommendations, including recommendations that have been open more 
than one year.
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    \2\ An archive of SARs is available at https://www.va.gov/oig/
publications/semiannual-reports.asp.
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    On January 3, 2019, the Good Accounting Obligation in Government 
Act (P. L. 115-414) was enacted, mandating each agency include in its 
annual budget justification submitted to Congress an explanation for 
the reasons why no final action has been taken regarding a Government 
Accountability Office or OIG recommendation open more than 12 months, 
as well as a timeline to implement the recommendation if the agency 
concurred. It is expected that the agency budget justification will 
include this information in the FY 2021 budget submission.

Current State of OIG Recommendations

    As of March 31, 2019, there were 84 OIG reports and 403 
recommendations that had been open less than one year. The total 
monetary benefit associated with these recommendations is more than 
$2.7 billion. Also, as of March 31, 2019, there were 40 reports and 133 
recommendations that remained open for more than one year. The total 
monetary benefit related to these reports is more than $329 million.

FOLLOW-UP PROCESSES

    While there have been instances in which VA has resolved an issue 
at the time of a report's publication, the vast majority of 
recommendations take time to implement fully. To ensure completion, the 
OIG engages its centralized follow-up staff to track the implementation 
of all report recommendations with the responsible VA office. This 
consolidated function helps ensure specially trained staff provide 
consistent management of OIG follow-up activities, frees report authors 
to work on other projects, and helps the OIG prepare timely and 
accurate status reporting for the website, SAR, and other products.

Timelines

    In addition to VA's comments on a draft report, the responsible VA 
office provides a workplan describing the process and timeline for each 
recommendation to be implemented. After the report is issued, the OIG 
follow-up group is responsible for entering all this information into a 
tracking system, analyzing the report's recommendations and VA 
comments, and then preparing the appropriate documentation request to 
the responsible VA office.
    At quarterly intervals starting 90 days after report issuance, the 
follow-up group requests the VA office provide an accounting of actions 
taken to implement open recommendations, as well as whether the VA 
office believes a recommendation may be closed. Each VA administration 
and staff office maintains a point of contact for this process, which 
helps with consistency in addressing implementation issues, tracking 
progress, and coordinating the response of the VA office assigned the 
recommendation. After receiving the VA office's report, the follow-up 
staff draft a preliminary assessment to the responsible OIG office, 
which wrote the report, as to whether any recommendations appear ready 
to close. The responsible OIG office then reviews the materials and 
provides a final determination whether any recommendations have been 
satisfactorily implemented and can be closed. If the VA office does not 
provide any response, follow-up staff can escalate the issue for 
resolution by connecting OIG leaders to the appropriate VA leaders.

Recommendation Closure or Suspension

    The responsible OIG office has the subject-matter expertise related 
to the recommendation at issue, and no recommendation may be closed 
without that office's approval. The decision to close a recommendation 
is based on a review of VA's supporting documentation or independent 
information obtained by OIG that indicates the corrective action has 
occurred or progressed enough to show recommendation implementation. 
For example, a recommendation to train employees on a particular issue 
is not closed if the VA office says it will conduct the training, but 
rather if the VA provides syllabus and scheduling documentation showing 
adequately developed training is underway and will continue in a 
systematic fashion.
    In a very few cases, there may be a need for OIG leadership to 
temporarily suspend follow-up activities or close recommendations as 
``not able to be implemented.'' For example, suspension may be 
warranted when a planned corrective action has gone stagnant due to 
circumstances beyond the control of the VA office (such as the need for 
a technology solution) and no viable alternatives exist, or if the 
program materially changes or is terminated and so the recommendation 
no longer applies. As mentioned earlier, if VA does not concur with a 
recommendation following OIG outreach at report publication or during 
follow-up, that nonconcurrence is noted and reported publicly and to 
Congress. If a new report is issued that repeats not-yet-implemented 
recommendations from a prior report, follow-up staff would close out 
the initial recommendations and consolidate all recommendations related 
to unresolved concerns into the new report.
    Aligned with the schedule for preparing the SAR, follow-up staff 
work with responsible OIG staff every six months to review open 
recommendations to determine whether any problems exist in 
implementation or whether circumstances would allow closure of any 
recommendations. As needed, OIG staff can confer with VA offices to 
examine the issues preventing implementation and work to revise related 
implementation plans.

IMPACTFUL RECOMMENDATIONS AFFECT A RANGE OF VA PROGRAMS

    OIG recommendations are directed at every level of VA operations, 
affecting the quality and access to health care for more than 7 million 
veterans; benefits for veterans with disabilities, their caregivers, 
and family members; and the effective stewardship of appropriated 
funds. They can be directed at individual facilities, regional 
networks, or national program or administrative offices. The following 
reports are highlighted to demonstrate how OIG staff perform sustained 
follow-up on identified areas of weakness to ensure meaningful 
improvement within VA.

Veterans Health Administration Examples

    Critical Deficiencies at the Washington DC VA Medical Center. In 
March 2017, the OIG received a confidential complaint and additional 
subsequent allegations that the Washington DC VA Medical Center had 
equipment and supply issues that could be putting patients at risk for 
harm. The OIG conducted an inspection, issuing an interim report in 
April 2017, and a final report in March 2018. \3\ The final report 
provided findings in four areas: (1) risk of harm to patients, (2) 
hospital service deficiencies affecting patient care, (3) lack of 
financial controls, and (4) failures in leadership. These deficiencies 
spanned many years, impacting the core medical center functions that 
health care providers need to effectively provide quality care. In 
particular, the report detailed the failure to ensure supplies and 
equipment reached patient care areas when needed, in part due to the 
facility's failure to use its inventory management IT system. The OIG 
made 40 recommendations, and VA concurred with each one. While VA 
provided detailed action plans on how the recommendations would be 
implemented and identified progress made, of the 40 recommendations, 13 
are still open as of May 14, 2019.
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    \3\ Interim Summary Report, April 17, 2017; Critical Deficiencies 
at the Washington DC VA Medical Center, March 7, 2018.
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    This report was meant to not only improve conditions at the DC VA 
Medical Center, but also to serve as a guide for other VA medical 
facilities' logistical services and to improve integrated reviews and 
oversight by Veterans Integrated Service Networks (VISNs) and VA 
central offices.
    Expendable Inventory Management System: Oversight of Migration from 
Catamaran to the Generic Inventory Package. As a result of the 
inventory management issues identified at the DC VA Medical Center, the 
OIG conducted a national audit in which the audit team surveyed 21 
medical centers and conducted unannounced on-site visits to 11 of those 
21. They found other medical centers also encountered challenges as 
part of the migration to a new inventory management system and that 
significant discrepancies existed between actual inventory and the data 
for tracking expendable medical supplies. \4\ Also, they found proper 
inventory monitoring and management practices were lacking. Some of the 
issues stemmed from the failure to provide adequate oversight of the 
migration at the Veterans Health Administration (VHA) level, while 
others stemmed from a lack of oversight from the VISN. The OIG's May 1, 
2019, report included six recommendations to the Executive in Charge 
for the Office of the Under Secretary for Health regarding inventory 
distribution and controls, which VA is now implementing.
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    \4\ Expendable Inventory Management System: Oversight of Migration 
from Catamaran to the Generic Inventory Package, May 1, 2019.
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    Veterans Crisis Line. The OIG is monitoring VA's delivery of mental 
health care and the operations of its suicide prevention programs. The 
OIG conducted a review of the Veterans Crisis Line (VCL) in 2016 and 
again in 2017 because of VHA's inability to implement OIG 
recommendations for this critical program in a timely manner, as well 
as the receipt of additional allegations.
    On March 20, 2017, the OIG issued Evaluation of the Veterans Health 
Administration Veterans Crisis Line, reporting deficiencies in multiple 
areas of the VCL's administration. \5\ Although the OIG was impressed 
with the dedication of VCL staff assisting veterans and loved ones, the 
OIG staff found VCL's management team faced significant obstacles 
providing suicide prevention and crisis intervention services to 
veterans, service members, and their families. The VCL's biggest 
challenges included meeting the operational and business demands of 
responding to over 500,000 calls per year, and training staff to assess 
and respond to the needs of individual contacts with veterans and 
family members under stressful, time-sensitive conditions.
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    \5\ Evaluation of the Veterans Health Administration Veterans 
Crisis Line, March 20, 2017.
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    The OIG staff found deficiencies in the governance and oversight of 
VCL operations following its realignment under VHA's Office of Member 
Services, a business operations group with expertise in call center 
operations. While VA leaders stated that Member Services and the Office 
of Mental Health Operations would work closely together to manage VCL 
services, the review found decisions were made with insufficient 
clinical input. The OIG also identified internal quality assurance 
deficiencies, including that there was an inadequate process to 
collect, analyze, and effectively review relevant quality management 
data to improve outcomes for callers. OIG staff made 16 recommendations 
to VA to improve crisis intervention services for veterans in distress. 
Among other weaknesses, the OIG identified in response to a complaint 
that there was a failure to properly respond to a veteran during 
multiple calls, resulting in missed opportunities to provide crisis 
intervention services. The OIG closed out the report recommendations on 
March 28, 2018, after accepting VA's implementation plan for the final 
open recommendation.
    It is important to note that the March 2017 report resulted, in 
part, from VA's failure to implement prior OIG recommendations made in 
a February 2016 report, Healthcare Inspection-Veterans Crisis Line 
Caller Response and Quality Assurance Concerns, Canandaigua, New York. 
\6\ The OIG's seven recommendations from the 2016 report remained open 
for more than a year. OIG staff conducted the subsequent review because 
the failure to implement previous recommendations was impairing the 
VCL's ability to increase the quality of crisis intervention services 
to callers. The OIG's February 2016 report recommendations were 
eventually closed out on July 31, 2017.
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    \6\ Healthcare Inspection-Veterans Crisis Line Caller Response and 
Quality Assurance Concerns, Canandaigua, New York, February 11, 2016.
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    Suicide Prevention. Many OIG reports also provide recommendations 
for facilities after reviewing the care provided to individual 
patients. The recommendations often can be used as guidance for other 
facilities within the VA system as well. For example, a September 2018 
Review of Mental Health Care Provided Prior to a Veteran's Death by 
Suicide Minneapolis VA Health Care System, Minnesota examined the care 
of a patient who died from a self-inflicted gunshot wound less than 24 
hours after being discharged from an inpatient mental health unit. \7\ 
Even though the action plans had target implementation dates no later 
than January 31, 2019, six of the seven recommendations remain open. 
The recommendations for corrective action relate to care provider 
coordination, accuracy of documentation, inclusion of family members in 
a veteran's health care and discharge, and completion of analyses after 
a tragic event.
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    \7\ Review of Mental Health Care Provided Prior to a Veteran's 
Death by Suicide Minneapolis VA Health Care System, Minnesota, 
September 25, 2018.
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    The OIG previously reported on the performance of multiple VHA 
facilities by conducting a trends analysis of suicide prevention 
programs. In an Evaluation of Suicide Prevention Programs in Veterans 
Health Administration Facilities, the OIG examined suicide prevention 
efforts in VHA facilities to assess facility compliance with relevant 
VHA guidelines. \8\ OIG conducted this review at 28 VHA medical 
facilities during its comprehensive assessment program reviews from 
October 1, 2015, through March 31, 2016. The OIG found that most 
facilities had a process for responding to referrals from the VCL and a 
process to follow up on high-risk patients who missed appointments. 
However, the OIG identified system weaknesses in areas such as outreach 
activities; suicide prevention safety plan completion, content, and 
distribution; flagging records of high-risk inpatients and notifying 
the Suicide Coordinator of the admission; and evaluating high-risk 
inpatients during the 30 days following discharge. The OIG's six 
recommendations to the then-Acting Under Secretary for Health are now 
closed.
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    \8\ Evaluation of Suicide Prevention Programs in Veterans Health 
Administration Facilities, May 18, 2017.
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    Routine Inspections. The OIG continues to conduct unannounced 
cyclical assessments of operations and quality control programs at VHA 
medical facilities, now known as Comprehensive Healthcare Inspection 
Program (CHIP) reports. These reports focus on leadership within a 
facility and key factors that affect patient care, such as quality, 
safety, and value; the credentialing and privileging process; 
environment of care; and medication management. Additionally, the OIG 
annually rotates high-interest topics in these fields, such as 
posttraumatic stress disorder care, mammography results and follow-up, 
and controlled substances inspection programs. \9\ OIG staff may also 
conduct more frequent follow-ups to assess VA's progress in 
implementing recommendations when a facility appears unable to address 
OIG findings. These additional inspections help ensure issues do not 
remain unresolved over long periods of time.
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    \9\ Semiannual Report to Congress, Issue 80.
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    For example, in May 2015, an OIG assessment of the VA St. Louis 
Health Care System in Missouri identified 45 recommendations to address 
concerns across the facility's operations. \10\ Due to the wide-ranging 
issues, in November of the same year, OIG staff conducted another 
review of the facility to assess progress on the action plans, with a 
particular focus on quality and environment of care. \11\ While some 
progress was noted, OIG staff made additional recommendations in those 
areas of focus. OIG staff returned to the facility yet again in June 
2016. In that report, the OIG made one recommendation related to the 
environment of care. \12\ Finally, OIG staff conducted an inspection of 
the facility in 2018 that resulted in seven recommendations, which have 
all been closed. \13\
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    \10\ Combined Assessment Program Review of the VA St. Louis Health 
Care System, St. Louis, Missouri, May 18, 2015.
    \11\ Combined Assessment Program Follow-Up Review of the VA St. 
Louis Health Care System, St. Louis, Missouri, January 20, 2016.
    \12\ Combined Assessment Program Follow-Up Review of Environment of 
Care at the VA St. Louis Health Care System, St. Louis, Missouri, 
January 18, 2017.
    \13\ Comprehensive Healthcare Inspection Program Review of the VA 
St. Louis Health Care System, Missouri, August 23, 2018.
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    VISN Reviews. To augment oversight of VHA-related recommendations, 
the OIG is launching routine reviews of VISNs. There is limited utility 
to having medical facilities implement recommendations if those 
corrective actions are not supported by the VISN. This expanded focus 
on VISNs is meant to address the oversight and services that VISNs 
provide all medical centers within their network that affect efficient 
operations and quality patient care. After completing several 
successful pilot visits, the OIG will be conducting unannounced reviews 
for four VISNs during the remainder of FY 2019. OIG staff conducting 
facility- and VISN-level inspections are engaging in coordination 
efforts to ensure reports regarding medical facilities make relevant 
connections to their VISN responsible for leadership, support, and 
oversight. The reports will include recommendations to improve 
accountability for the provision of high-quality health care.

Veterans Benefits Administration Examples

    In October 2017, the OIG implemented a new national inspection 
model for oversight of the Veterans Benefits Administration (VBA). 
Previously, the OIG largely conducted oversight through inspections of 
VBA's 56 regional offices. Under the new model, the OIG conducts 
nationwide audits and reviews of high-impact programs and operations 
within VBA to accomplish the following objectives:

      Identify systemic issues that affect veterans' benefits 
and services
      Determine the root causes of identified problems
      Make useful recommendations to drive positive change 
across VBA

    Since October 1, 2017, the OIG has published 19 VBA-related 
oversight reports. VBA has generally concurred with the recommendations 
and provided acceptable action plans, with the closure of most 
recommendations that have been open for over one year.
    Two recent OIG reports regarding VBA claims processing for complex 
claims related amyotrophic lateral sclerosis (ALS or Lou Gehrig's 
disease) and to military sexual trauma (MST) demonstrate the value of 
OIG recommendations. In 2016, VBA moved to a National Work Queue (NWQ) 
for the processing of disability compensation claims. Previously, VBA 
used Segmented Lanes to process claims. Under that approach, 
specialized claims, like those for MST and ALS, were routed to staff 
experienced with those claims. Under the NWQ, VBA no longer directed 
complex claims to specialized teams, but rather distributed daily to 
each VA regional office (VARO) new claims, which the VARO then assigned 
to processors by workload. These OIG reports detail how national policy 
changes have had negative impacts on claims processing. While well-
intentioned efforts to expedite overall benefits processes were carried 
out, there was an unintended impact on VBA's ability to review and 
process certain claims accurately.
    Accuracy of Claims Involving Service-Connected Amyotrophic Lateral 
Sclerosis. In November 2018, the OIG examined whether VBA accurately 
decided veterans' claims involving service-connected ALS. \14\ VA 
describes ALS as a rapidly progressive neurological disease that 
attacks the nerve cells responsible for directly controlling voluntary 
muscles. Because a statistical correlation was found between military 
service activities and the development of ALS, VA established a 
presumption of service connection for this disease in 2008. Thus, 
veterans who develop the disease during service, or any time after 
separation from military service, generally receive benefits if they 
had active and continuous service of 90 days or more. Although VBA 
prioritizes these claims, staff must also accurately decide these 
claims because it is a serious condition that often causes death within 
three to five years from the onset of symptoms.
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    \14\ Accuracy of Claims Involving Service-Connected Amyotrophic 
Lateral Sclerosis, November 20, 2018.
---------------------------------------------------------------------------
    OIG staff reviewed a statistical sample of 100 veterans' cases 
involving service-connected ALS from April through September 2017. The 
team found that VBA staff made 71 errors involving 45 veterans' ALS 
claims, projecting that 430 of 960 total ALS veterans' cases had 
erroneous decisions. For example, rating personnel incorrectly decided 
ALS claims related to one or more of the following categories:

      Special monthly compensation benefits
      Evaluations of medical complications of ALS
      Effective dates
      Additional benefits related to adapted housing or 
automobiles
      Inaccurate or conflicting information in decisions
      Proposals to discontinue service connection

    These errors resulted in estimated underpayments of about $750,000 
and overpayments of about $649,000 over a six-month period, for a 
potential $7.5 million in underpayments and $6.5 million in 
overpayments over a five year period. Also, VBA staff generally did not 
tell veterans about available special monthly compensation benefits. 
Most rating personnel indicated that they do not often receive claims 
involving ALS or higher levels of special monthly compensation, which 
makes these claims more difficult to evaluate. The Under Secretary for 
Benefits concurred with the OIG's two recommendations to implement a 
plan to improve and monitor decisions involving service-connected ALS 
and to provide notice regarding additional special monthly compensation 
benefits that may be available. These recommendations are still open.
    Denied Posttraumatic Stress Disorder Claims Related to Military 
Sexual Trauma. In August 2018, the OIG reviewed VBA's denied PTSD 
claims related to veterans' MST to determine whether staff correctly 
processed the claims. \15\ Some service members are understandably 
reluctant to submit a report of MST, particularly when the perpetrator 
is a superior officer. Service members may also have concerns about the 
potential for negative performance reports or punishment for collateral 
misconduct. There is also sometimes the perception of an unresponsive 
military chain of command. If the MST leads to PTSD, it is often 
difficult for victims to produce evidence to support the assault's 
occurrence. VBA policy correctly requires staff to follow additional 
steps for processing MST-related claims so veterans have further 
opportunities to provide adequate evidence.
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    \15\ Denied Posttraumatic Stress Disorder Claims Related to 
Military Sexual Trauma, August 21, 2018.
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    VBA reported that it processed approximately 12,000 claims per year 
over the last three years for PTSD related to MST. In FY 2017, VBA 
denied about 5,500 of those claims (46 percent). The OIG review team 
assessed a sample of 169 MST-related claims that VBA staff denied from 
April through September 2017. The review team found that VBA staff did 
not properly process veterans' denied MST-related claims in 82 of 169 
cases. As a result, the OIG estimated that VBA staff incorrectly 
processed approximately 1,300 of the 2,700 MST-related claims denied 
during that time (49 percent). The OIG found that multiple factors led 
to the improper processing and denial of MST-related claims. Included 
among these factors were the lack of reviewer specialization, lack of 
an additional level of review, discontinued special focused reviews, 
and inadequate training.
    The OIG made six recommendations to the Under Secretary for 
Benefits including that VBA review all approximately 5,500 MST-related 
claims denied from October 2016 through September 2017, take corrective 
action on those claims in which VBA staff did not follow all required 
steps, assign MST-related claims to a specialized group of claims 
processors, and improve oversight and training on addressing MST-
related claims. The Under Secretary concurred with the recommendations 
and has already taken steps to address them, particularly in the area 
of training, with four recommendations currently still open. The Under 
Secretary also stated that, in FY 2019, VBA will review every denied 
MST-related claim decided since the beginning of FY 2017.

STEWARDSHIP OF APPROPRIATED FUNDS EXAMPLES

    While some OIG recommendations focus primarily on improving quality 
of care for veterans, or program effectiveness, others emphasize 
deficiencies in the efficient use of taxpayer dollars or misusing 
appropriated funds. Several examples follow demonstrating the need for 
more effective controls, stronger oversight practices, and greater 
accountability so that VA funding is put to the most efficient and 
effective use to the benefit of veterans, their caregivers, and 
families.
    VA's Oversight of State Approving Agency Program Monitoring for 
Post-9/11 GI Bill Students. A December 2018 OIG report examined the 
effectiveness of VA and State Approving Agencies' (SAAs') monitoring of 
participating educational programs, which identified serious concerns, 
including gaps in approval practices that led to ineligible and 
potentially ineligible schools participating in the program. \16\ The 
OIG conducted this audit to determine if VA and SAAs were effectively 
reviewing and monitoring education and training programs that enrolled 
Post-9/11 GI Bill students to ensure only eligible programs 
participated. Prior OIG reports noted financial risks for these 
programs. \17\ Based on its review, the OIG estimated that 86 percent 
of SAAs did not adequately oversee the education and training programs 
to make certain only eligible programs participated. In total, the 
audit team projected that VBA annually issues an estimated $585 million 
in related improper Post-9/11 GI Bill tuition and fee payments to 
ineligible or potentially ineligible schools and that $473.8 million of 
this amount will be paid to for-profit schools. \18\ Oversight 
deficiencies occurred, in part, because VBA maintained it has a limited 
role for oversight of SAAs. The OIG recommended clarifying requirements 
for approvals, requiring periodic re-approval of programs, reporting 
schools with misleading advertising, strengthening compliance surveys 
for program eligibility, revising program assessment standards, and 
confirming that SAA funding can support the recommended steps. Of 
those, one recommendation has been closed as implemented, and OIG staff 
are monitoring VBA's progress on the remaining five.
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    \16\ VA's Oversight of State Approving Agency Program Monitoring 
for Post-9/11 GI Bill Students, December 3, 2018.
    \17\ Id. at 49-50.
    \18\ ``Under OMB Circular A-123, App. C, Pt. I-A, Risk Assessing, 
Estimating, and Reporting Improper Payments, (October 20, 2014), 
improper payments are payments that should not have been made or were 
made in an incorrect amount under statutory, contractual, 
administrative, or other legally applicable requirements; payments made 
to ineligible recipients; and payments where an agency's review is 
unable to discern it is proper due to insufficient documentation.'' Id. 
at 3.
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    Audit of Compensation and Pension Benefit Payments to Incarcerated 
Veterans. On occasion, OIG staff audit programs and monitor 
recommendation implementation, but continue to receive allegations of 
specific acts of wrongdoing through the OIG Hotline. In June 2016, the 
OIG audited whether VBA was adjusting compensation and pension (C&P) 
benefit payments for veterans incarcerated in federal, state, and local 
correctional institutions in a timely manner and as required by Federal 
law. \19\ The OIG identified program weaknesses and determined that VBA 
did not consistently take action to adjust C&P benefits for 
incarcerated veterans as legally required. VBA's ineffective actions in 
processing incarceration adjustments resulted in significant improper 
benefit payments totaling more than $100 million. If conditions 
remained the same and improvements were not made, VBA could have made 
additional inaccurate payments (improper payments) of more than $200 
million over a 5-year period from FY 2016 through FY 2020. The report's 
six recommendations are now closed.
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    \19\ Audit of Compensation and Pension Benefit Payments to 
Incarcerated Veterans, June 28, 2016.
---------------------------------------------------------------------------
    However, this was not the first time OIG reported on problems with 
C&P benefit payments adjustments. In 1986 and 1999, OIG identified 
similar issues with C&P benefit payments to incarcerated veterans, and 
VA provided remediation plans. \20\ Because problems in this area have 
tended to reoccur or new problems emerge, the OIG continues to identify 
and follow up on similar improper payments reported through the OIG 
Hotline. One recent example involves a veteran improperly receiving 
$46,200. \21\
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    \20\ Evaluation of Benefit Payments to Incarcerated Veterans, 
February 5, 1999.
    \21\ Semiannual Report to Congress, Issue 80.

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MAJOR MANAGEMENT CHALLENGES

    Each year, pursuant to Section 3516 of United States Code Title 31, 
the OIG provides Congress with an update summarizing the most serious 
management and performance challenges identified by OIG work as well as 
an assessment of VA's progress in addressing them. \22\ These 
challenges are aligned with the OIG's six areas of focus outlined in 
its strategic plan: (1) leadership and workforce investment, (2) health 
care delivery, (3) benefits delivery, (4) financial management, (5) 
procurement practices, and (6) information management.
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    \22\ U.S. Department of Veterans Affairs Office of Inspector 
General Management and Performance Challenges, November 2018.
---------------------------------------------------------------------------
    The OIG has made VA leadership and governance a top priority in 
recognition that deficiencies in these areas ultimately affect the care 
and services provided to veterans and allow significant problems to 
persist unresolved for years. And, as in prior years, access to health 
care remains a significant challenge for VA. This is a particular 
concern as prodigious changes are underway for expanding community care 
and enhancing access to care in VA facilities and as VA implements 
changes to its benefit appeals process. The OIG has noted specific 
progress in quality improvement and patient care processes during CHIP 
inspections and other work in individual facilities, yet deficiencies 
remain in other areas affected by inadequate staffing and IT systems.
    The OIG has also focused on problems identified VA-wide regarding 
information management, financial management, and procurement practices 
that, while critical to VA carrying out its missions, have been at the 
heart of failures in providing medical care and a range of benefits and 
services to veterans and their families. OIG audits and reviews, such 
as the audit of VA's consolidated financial statements, as required 
under the Chief Financial Officer's Act and the review of VA's 
compliance with the Improper Payments Elimination and Recovery Act, 
establish that eliminating continued shortfalls in VA's financial 
management systems would improve VA's effectiveness at using 
appropriated funds to benefit veterans. \23\
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    \23\ Audit of VA's Financial Statements for Fiscal Years 2018 and 
2017, November 26, 2018; VA's Compliance with the Improper Payments 
Elimination and Recovery Act for FY 2017, May 15, 2018.

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CONCLUSION

    A strength of the OIG's oversight work is the commitment to 
identifying underlying causes, which is the foundation for developing 
meaningful and comprehensive recommendations. By addressing these 
causes, VA can more effectively address not only the symptoms but 
prevent future occurrences. The OIG has commonly found the following 
through its oversight work:

      Poor governance structures
      Lack of continuity of leadership
      Failure to communicate effectively
      Failure to ensure accountability
      Poor financial management
      IT failures and not using IT effectively
      Poor planning and forecasting
      Failure to anticipate the consequences of policy changes
      HR and staffing issues
      Poor training
      Poor quality assurance
      Inadequate, outdated, conflicting, or absent policies
      Culture of complacency
      Bureaucracy ahead of veterans

    The OIG is committed to serving veterans and the public by 
conducting effective oversight of VA programs and operations through 
independent audits, inspections, reviews, and investigations. That 
commitment can only be realized by making practical, meaningful 
recommendations that enhance VA's programs and operations as well as 
prevent and address fraud, waste, and abuse.
    Mr. Chairman, this concludes my statement. I would be happy to 
answer any questions you or other members of the Subcommittee may have.

                                 
                       STATEMENTS FOR THE RECORD
                             ROBERT WILKIE
    The Department of Veterans Affairs (VA) appreciates the work of the 
U.S Government Accountability Office (GAO) and the VA Office of 
Inspector General (OIG) to help the Department make improvements to 
programs throughout our enterprise that facilitate more effective and 
efficient services and benefits to our Nation's Veterans. VA has a 
strong collaborative relationship with both GAO and OIG. VA treats all 
recommendations seriously and strives to implement the concurred upon 
recommendations in a timely manner.
    The Department would have liked to participate in this hearing; 
unfortunately, to do so would have been contrary to the longstanding 
practice of prior Administrations and this Administration by allowing 
Executive Branch officials to testify at a Congressional hearing on a 
panel that includes non-Executive Branch witnesses.
    According to GAO, VA leads the Federal government with a 90 percent 
recommendation implementation rate. In March 2019, GAO issued its 
biennial high-risk report in which GAO added VA Acquisition Management 
as a high-risk area. This is the third high-risk area for VA-Managing 
Risks and Improving VA Health Care was added in 2015, and Improving and 
Modernizing Federal Disability Programs was added in 2003. The 
Department is committed to implementing all concurred upon GAO 
recommendations and moving off of GAO's high-risk list. In November, 
Secretary Wilkie met with the Comptroller General to discuss the high-
risk report areas and high priority recommendations. During that 
meeting, Secretary Wilkie assured the Comptroller General that the 
Department appreciates GAO's work and that VA is working on taking 
corrective action on all open GAO recommendations.
    With regard to the GAO high priority recommendations, in 2018, GAO 
identified 26 priority recommendations. Since that time, VA implemented 
5 of the 26 open priority recommendations and GAO closed 1 priority 
recommendation on a program that recently underwent significant 
statutory changes. When GAO issued its March 2019 priority open 
recommendations report, VA had 20 open priority recommendations and GAO 
added 10 new priority recommendations bringing the total to 30 priority 
recommendations. VA provides GAO with updates on all open priority 
recommendations. Within the Department, several initiatives are 
underway to more directly focus administrations and staff offices on 
the development of milestones and metrics and demonstrated progress on 
implementing GAO recommendations. VA leaders and staff meet 
periodically with GAO to discuss VA's efforts to implement action plans 
related to open recommendations and receive feedback from GAO on the 
progress being made.
    The VA OIG is the independent oversight entity within VA that 
conducts reviews and recommends improvements that are designed to 
promote economy, efficiency, and effectiveness throughout VA programs 
and operations. The VA OIG issues hundreds of reports and 
recommendations each year involving programs throughout the VA 
enterprise. During the last 12 months, OIG issued 128 reports with 715 
recommendations on VA programs and operations. The administrations and 
staff offices work with OIG inspectors and investigators to come to 
agreed upon corrective action plans to resolve audit recommendations. 
The Department strives to complete OIG recommendations with the same 
urgency as all oversight recommendations.
    In June 2017, the Department of Veterans Affairs Accountability and 
Whistleblower Protection Act was enacted. The Act, among other things, 
statutorily established the Office of Accountability and Whistleblower 
Protection (OAWP) and codified its establishment under section 323 of 
title 38 of the United States Code (U.S.C.). As prescribed by Congress 
under 38 U.S.C. Sec.  323(c)(1)(F), one of OAWP's core functions is to 
record, track, review, and confirm ``implementation of recommendations 
from audits and investigations carried out by [VA OIG], the Medical 
Inspector of the Department, the Special Counsel, and the Comptroller 
General of the United States, including the imposition of disciplinary 
actions and other corrective actions contained in such 
recommendations.'' The Department is currently working on establishing 
processes to create this functionality within OAWP which would enhance 
oversight on the implementation of recommendations issued by, among 
other entities, GAO and VA OIG. The Department looks forward to 
updating the Committee on its implementation.

Conclusion

    Our mission is to serve our Veterans. We are committed to taking 
corrective action on all oversight recommendations to ensure that VA is 
the most efficient and effective organization possible for our 
Veterans. Your continued support is essential to providing the best 
services and benefits for Veterans and their families.

                                 
Overview and Comparison of the Department of Veterans Affairs (VA) and 
   the Department of Defense (DOD) Graduate Medical Education (GME) 
                                Programs
Key Points of Comparison between VA and DOD GME Programs

      In contrast with DOD, which administers its own residency 
programs, VA generally does not sponsor or administer residency 
programs. Instead, the VA physician training program is administered 
through affiliations with academic institutions and teaching hospitals.
      VA does not directly pay salaries to the medical 
residents that rotate through its facilities. Instead, VA uses 
disbursement agreements to reimburse affiliated institutions for the 
health care services provided at VA medicals centers (VAMC) by medical 
residents. The affiliate institutions are ultimately responsible for 
administering salaries to their GME participants that are completing 
rotations at VAMCs.
      Medical residents who participate in VA's GME program 
have no service obligation to VA after the completion of their 
residency programs.

VA GME Program Overview

    The Veterans Health Administration (VHA) GME program is carried out 
through coordinated programs and activities in partnership with 
affiliated U.S. academic institutions (affiliates), such as medical 
schools and teaching hospitals.

      While VHA's GME program is administered by its Office of 
Academic Affiliation (OAA), VAMCs enter into separate affiliation 
agreements with each affiliate-under which the VA medical center and 
the affiliate agree to share responsibility for the academic program.
      In the vast majority of cases, VAMCs do not serve as the 
primary sponsor and training site for medical residents. VA reports 
that 99 percent of its GME programs are sponsored by an affiliate.
      Residents complete service rotations at VAMCs that are 
affiliated with their academic institution.
      VAMCs enter into disbursement agreements with the 
affiliates in order to reimburse them for services provided by 
residents rotating through the VA medical centers. VA reports that its 
GME program is affiliated with 144 of the 152 accredited allopathic 
medical schools and all 34 of the accredited osteopathic medical 
schools in the United States.

    Number of residents in the pipeline. VA is the largest provider of 
medical training in the United States.

      VHA statistics for the 2017-18 academic year show that 
45,296 medical residents trained at VAMCs.
      Physician residents represent approximately 50 percent of 
the total number of physicians working in VA facilities.
      The Veterans Access, Choice, & Accountability Act of 2014 
authorized the addition of up to 1,500 additional physician residency 
positions over a ten year period, with a focus on medical specialties 
and geographic locations of high priority for VA. Through the first 
five years of this effort, VHA had approved 1,055 additional physician 
resident positions.

    Recruitment of VA Physicians through GME

    Lack of a service requirement. Medical residents who participate in 
VA's GME program have no service obligation to VA after the completion 
of their residency programs. However, VA sees its GME program as having 
a major impact on developing the VA health care workforce.

      In our 2017 report on VHA physician staffing and 
recruitment, agency officials noted that access to the GME pool of 
potential hires serves as an important recruitment resource. \1\
---------------------------------------------------------------------------
    \1\ See GAO, Veterans Health Administration: Better Data and 
Evaluation Could Help Improve Physician Staffing, Recruitment, and 
Retention Strategies, GAO-18-124 (Washington, D.C.: Oct 19, 2017).

      Additionally, officials reported that physician training 
programs provide current physicians with teaching opportunities that 
also bolster recruitment and retention.
      VA reports that about 60 percent of its physicians 
participated in VA training programs prior to employment.
      According to the VA Trainee Satisfaction Survey completed 
by more than 23,000 trainees during the 2016-17 academic year, 73 
percent of respondents indicated a willingness to work at VA after 
their VA clinical training experience.

    Recruitment challenges. Despite VHA's large and expanding graduate 
medical training program, VAMCs experience difficulties hiring 
physicians who receive training through its residency programs. We have 
reported on some of these difficulties in physician recruitment, 
including barriers to recruiting VA GME participants for permanent 
employment after the completion of their residency programs.

      In October 2017, we reported that VHA did not track the 
number of physician trainees who were hired following graduation, but 
VA officials stated that the number was small in comparison to the 
almost 44,000 physician trainees educated at VAMCs each year. \2\
---------------------------------------------------------------------------
    \2\ See GAO-18-124.
---------------------------------------------------------------------------
      We found that VAMCs faced challenges hiring physician 
trainees, in part, because VHA did not share information on graduating 
physician trainees for recruitment purposes with VAMCs across the 
system.
      Our October 2017 report also described delays in VAMCs' 
hiring offers to graduates. Agency officials noted that VAMCs could not 
make employment offers to medical resident trainees until they had 
completed their training programs. Competitors often make hiring offers 
as early as trainees' second year of residency, according to VAMC 
officials.
      VHA officials said some VAMCs use existing policy 
flexibilities to recruit trainees more proactively by making early 
hiring offers that are contingent on the trainee meeting certain 
conditions, such as completing training, and that these actions improve 
the likelihood of successful recruitment.

Other Recruitment and Retention Efforts-National Recruitment Service 
    and Financial Incentives

    VHA has a National Recruitment Service within VHA's Workforce 
Management and Consulting Office.

      In fiscal year 2016, the National Recruitment Service, 
comprised of 19 VHA physicians, referred 2,200 candidates to VAMCs, 
which resulted in 325 physicians hired, according to VHA officials.
    VHA uses a variety of financial incentives to recruit new 
physicians.

      Financial incentives include market-based salaries, an 
education debt reduction program, bonus pay for recruitment, retention, 
and relocation, and continuing medical education funding.
      The VA MISSION Act of 2018 created two new scholarship 
opportunities and a loan repayment program to recruit medical students 
and residents.
      The Veterans Healing Veterans Medical Access and 
Scholarship Program provides four years of tuition, fees, and stipend 
support for two veterans at nine medical schools in exchange for four 
years of clinical practice at a VA facility after completion of a 
residency and/or fellowship.
      The VA Health Professions Scholarship Program provides 
annual medical or dental school scholarships (tuition, fees, and 
stipend) in exchange for 18 months of service at a VA facility for each 
year of support.
      The Specialty Education Loan Repayment Program is a loan 
repayment program targeted towards physician residents. Its purpose is 
to provide VA with needed medical specialists in geographic areas and 
VA facilities where VA needs those specialists. Applicants can apply 
right after the residency match or up to two years before completion of 
the residency. The program can repay up to $160,000 of education loans 
total; each year of service at a VA facility qualifies for $40,000 in 
loan repayment, with a minimum of two years of service required.
      In our October 2017 report, we recommended that VHA 
conduct a comprehensive, system-wide evaluation of the physician 
recruitment and retention strategies used by VAMCs to determine their 
overall effectiveness, identify and implement improvements, ensure 
coordination across VHA offices, and establish an ongoing monitoring 
process.
      VHA concurred with our recommendation, and in May 2019, 
VHA submitted an evaluation of its physician recruitment and retention 
programs. The report covered the use of the Education Debt Reduction 
Program, physician pay tables, and recruitment, retention, and 
relocation incentives. One result of the evaluation is that VHA 
provided Veterans Integrated Service Networks with recommendations on 
how to efficiently allocate their recruitment, retention, and 
relocation incentives.

    Other health professions: VAMCs serves as training sites for other 
health professions, including dentistry, nursing, and social work, 
among others. VA statistics from the 2017-18 academic year indicate 
that 49,958 individuals participated in dental, nursing, or associated 
health profession training at VAMCs.
    For more information about VHA's GME program contact Sharon M. 
Silas at (202) 512-7114 or [email protected], and for more information 
about VHA physician staffing and recruitment, contact Debra A. Draper 
at (202) 512-7114 or [email protected].

DOD GME Programs

Military Residency Programs

    The military services' GME programs provide specialty training to 
medical school graduates who agree to an active duty service 
obligation. Through GME programs, military medical officers acclimate 
to the military while developing core competencies and critical wartime 
medical readiness skills, such as combat casualty care and treatment of 
injuries from explosive or biological incidents. According to military 
service officials, specialty training through GME programs is an 
important recruitment and retention tool because it may encourage 
continued service beyond the fulfillment of the initial active duty 
service obligation. Programs are accredited by and follow the standards 
of the Accreditation Council for Graduate Medical Education, a civilian 
organization, and managed by each respective military services. The 
military services generally partner with civilian teaching hospitals, 
where residents rotate for training in areas or populations not seen at 
a DOD hospital.

      Service requirement: While in a military residency 
program, participants incur an additional 6 months of active duty 
service obligation for each 6 months in training, with a minimum of 2 
years active duty service obligation.
      Number of residents: In fiscal year 2018, there were 
3,189 residents and fellows enrolled in DOD GME programs, training in 
70 specialties, at military treatment facilities. \3\
---------------------------------------------------------------------------
    \3\ An additional 23 specialties did not have any residents in 
fiscal year 2018. The count of students only includes residents and 
fellows at military treatment facilities, although residents and 
fellows may be trained in civilian GME programs as well. See GAO, 
Defense Health Care: DOD's Proposed Plan for Oversight of Graduate 
Medical Education Programs, GAO-19-338 (Washington, D.C.: Mar. 28, 
2019).

    The National Defense Authorization Act for Fiscal Year 2017 (NDAA 
2017) directed the Secretary of Defense to establish and implement a 
process to oversee GME programs, and transferred administrative and 
management responsibility for military treatment facilities from the 
military services to the Defense Health Agency and requires the agency 
to assume responsibility for the policy, procedures, and direction of 
GME programs. However, each military service's medical command remains 
responsible for recruiting, organizing, training, and equipping their 
medical personnel.
    While we have done recent work on DOD's proposed plan for oversight 
of GME programs, we have not done work on DOD's GME/residency programs. 
The following is related work specific to medical students.

DOD Programs for Medical Students

    In addition to recruiting medical school graduates, DOD's two 
primary programs for creating a pipeline of future military physicians 
are its scholarship program, managed by the services-the Armed Forces 
Health Professions Scholarship Program (AFHPSP)-and DOD's sponsored 
medical school-the Uniformed Services University of the Health Sciences 
(USUHS). \4\
---------------------------------------------------------------------------
    \4\ For more information about these programs and the data that 
follow, see GAO, Military Personnel: Additional Actions Needed to 
Address Gaps in Military Physician Specialties, GAO-18-77 (Washington, 
D.C.: Feb 28, 2018).

      Benefits and service requirement: AFHPSP medical students 
receive a monthly stipend and incur an obligation to serve 6 months of 
active duty service for each 6 months of benefits received, with a 2-
year minimum obligation. \5\ In addition, DOD pays for all qualified 
educational expenses, including tuition, books, and fees. USUHS medical 
students receive the pay and benefits of an officer at the O-1 level 
and incur a minimum 7-year service obligation. Most AFHPSP and USUHS 
participants go on active duty and perform their GME training at 
military hospitals, although some AFHPSP participants are granted 
deferments while they pursue civilian GME.
---------------------------------------------------------------------------
    \5\ There are some exceptions to active duty service obligation 
incurred. For example, Department of Defense Instruction 6000.13 states 
that an AFHPSP participant may serve his or her service obligation in a 
component of the Selected Reserve for a period twice as long as the 
participant's remaining active duty obligation.
---------------------------------------------------------------------------
      Number of medical students: The services reported that 
they generally met their recruitment goals for AFHPSP, and that the 
program enabled DOD to successfully recruit approximately 800 to 850 
medical students per year from fiscal years 2011 to 2016. Further, 
USUHS successfully recruits an additional 170 medical students per 
year.
      Recruitment challenges: However, although the services 
report that they are generally meeting their AFHPSP recruitment goals, 
we found that they are not recruiting the maximum number of 
participants (that is, 2,100) they are allowed. Instead, for fiscal 
years 2011 through 2015, the Army enrolled in its program approximately 
71 percent to 85 percent of the maximum allowed; the Navy about 59 
percent to 63 percent; and the Air Force approximately 70 percent to 79 
percent.
      Officials from these services cited various factors that 
limit their ability to recruit the maximum number of participants they 
are allowed-such as restrictions on the number of physicians they are 
authorized to bring into the military in any given year; concern that 
increasing AFHPSP goals could reduce the overall quality of medical 
student recruits; and the limited number of slots available in military 
GME programs-making it difficult to place an increased number of AFHPSP 
participants in these residency programs.
      Medical students who do not meet their service 
requirement: In 2008, we examined the number of participants in two DOD 
programs who do not enter active duty following completion of the 
program of studies for which they were enrolled, including the extent 
to which the military services have sought and received reimbursement 
for stipends or annual grants paid. \6\
---------------------------------------------------------------------------
    \6\ See GAO, Military Personnel: Better Debt Management Procedures 
and Resolution of Stipend Recoupment Issues Are Needed for Improved 
Collection of Medical Education Debts, GAO-08-612R (Washington, D.C.: 
Apr. 1, 2008).
---------------------------------------------------------------------------
      Our analyses of service and Defense Finance and 
Accounting Service data showed that, for fiscal years 2003 through 
2007, fewer than 1 percent (171) of the total number of participants 
(19,921) withdrew from the programs or, alternatively, graduated but 
did not go on to active duty service.
      Upon withdrawal or release from the program, participants 
are obligated to reimburse the government for all or some portion of 
their medical education expenses unless relieved of that obligation by 
their respective service secretary. We found that DOD has procedures in 
place to recoup medical education expenditures from participants who 
fail to complete their education or serve their active duty obligation, 
and many cases we reviewed were processed in a timely manner. However, 
in some cases, it took more than 5 years from the time recoupment 
actions on individuals' debts were initiated until the time the Defense 
Finance and Accounting Service established an official debt account and 
began collection efforts.
      At that time, we made five recommendations to strengthen 
DOD's debt collection efforts, all of which DOD has since implemented.
      Retention challenges: Nonetheless, we also found that 
retaining fully qualified physicians is challenging for the military 
services, and that the added stresses of deployments and the general 
perceptions of war, along with the potential for health care providers 
to earn significantly more money in the private sector, have caused 
some physicians to separate from military service once they have 
fulfilled their service obligations. \7\
---------------------------------------------------------------------------
    \7\ See GAO-08-612R, and GAO, Military Personnel: Status of 
Accession, Retention, and End Strength for Military Medical Officers 
and Preliminary Observations Regarding Accession and Retention 
Challenges, GAO-09-469R (Washington, D.C.: Apr. 16, 2009).

---------------------------------------------------------------------------
Examples of Other Military Physician Recruitment Programs

      Financial Assistance Program (FAP). Provides annual 
grants of up to $45,000 and monthly stipends of more than $2,000 for 
physicians accepted or enrolled in a residency program. Participants 
incur a minimum 2-year active duty obligation or 6-month active duty 
obligation for every 6 months or portion thereof of FAP sponsorship, 
whichever is greater. FAP participants will serve on active duty in a 
grade commensurate with their educational experience. Participants 
receive full pay and allowances for their respective grades for a 
period of 14 days active duty for annual training performed for each 
year of participation.
      Health Professions Loan Repayment Program. Provides 
repayment of educational loans for fully qualified health 
professionals. Participants incur a 2-year active duty obligation or 1 
year of active duty obligation for each year of repayment, whichever is 
greater.
      Specialized Training Assistance Program. Provides a 
monthly stipend of more than $2,000 for physicians in designated 
specialties currently accepted or enrolled in a residency program. 
Participants incur a 1-year obligation in the Army Selected Reserve for 
every 6 months or portion thereof of financial assistance.

    For more information about DOD's GME programs or physician 
recruitment, contact Brenda S. Farrell, (202) 512-3604 or 
[email protected].

Succession Planning

    The most recent work we have on succession planning is Human 
Capital: Selected Agencies Have Opportunities to Enhance Existing 
Succession Planning and Management Efforts, GAO-05-585. This work 
included a review of how four agencies including the Census Bureau, 
Department of Labor (DOL), Environmental Protection Agency (EPA) and 
Veterans Health Administration (VHA) are implementing succession 
planning and management efforts. Key findings include:

      All four agencies had implemented succession planning and 
management efforts that collectively are intended to strengthen 
organizational capacity. However, in light of governmentwide fiscal 
challenges, we found that the agencies had opportunities to enhance 
some of their succession efforts.
      While all of the agencies assigned responsibility for 
their succession planning and management efforts to councils or boards, 
VHA had established a Subcommittee and high-level positions that are 
directly responsible for its succession efforts.
      The four agencies had begun to link succession efforts to 
strategic planning. DOL, EPA, and VHA had identified gaps in 
occupations or competencies, undertaken strategies to address these 
gaps, and were planning or taking steps to monitor their progress in 
closing these gaps.
      All of the agencies' succession efforts included training 
and development programs at all organizational levels. However, there 
were opportunities to coordinate and share these programs and create 
synergies through benchmarking with others, achieving economies of 
scale, limiting duplication of efforts, and enhancing the effectiveness 
of programs, among other things.

    In the report we made eight recommendations, including two 
recommendations to VA. All eight recommendations have been closed and 
implemented. For more information on this work and the recommendations: 
https://www.gao.gov/products/GAO-05-585.
    In addition to this work, GAO is currently looking at whether VA's 
succession planning policies and procedures are consistent with OPM's 
guidance for succession planning. For additional information on this 
work contact Robert Goldenkoff, [email protected].

          Examples of Quarterly Reporting Requirements for GAO
------------------------------------------------------------------------
                 GAO Section(s)/
   Authority          Title                       Summary
------------------------------------------------------------------------
  P.L 115-141      Explanatory         Requires VA to submit quarterly
              ConStatement. Div.     reports on implementation of VA's
 Appropriations    J. Military    electronic health records. Report to
     Act, 2018                Constructioinclude detailed obligations,
                 VA and Related   expenditures, and deployment strategy
                      Agencies    by VA facility. Directs GAO to perform
                 Appropriations   quarterly performance reviews of the
                    Act, 2018.             VA electronic health record
                      Veterans      deployment. GAO reporting date not
                    Electronic                              specified.
                 Health Records
------------------------------------------------------------------------
   P.L 115-55           Sec. 3               Requires VA to submit to Congress and
      Veterans                CompreheGAO, no later than 90 days after
       Appeals        Plan for     enactment, a comprehensive plan for
   Improvement   Processing of       processing legacy appeals and for
           and   Legacy Appeals      implementing a modernized appeals
 Modernization             and    system. VA to report quarterly until
  Act of 2017.    Implementing        the modernized appeals system is
                   New Appeals      implemented and semiannually for 7
                   System. (a)         years following implementation.
                 Plan Required.        Requires GAO to (1) assess VA's
                 (b) Elements.     initial plan, including whether the
                 (c) Review by       plan comports with sound planning
                              Comptpractices, (2) identify any gaps in
                 General of the              the plan, and (3) provide
                 United States.     recommendations for improvement as
                 (1) In General.  appropriate. Report no later than 90
                 (A). (B). (2)       days after VA submits the initial
                 Elements. (A).                                  plan.
                        (B). (C).
------------------------------------------------------------------------


                                 
                        QUESTION FOR THE RECORD
              U.S. GOVERNMENT ACCOUNTABILITY OFFICE (GAO)
    July 1, 2019

    The Honorable Chris Pappas
    Chairman
    Subcommittee on Oversight and Investigations
    Committee on Veterans' Affairs
    House of Representatives

    Dear Mr. Chairman

    This letter responds to your request that we address questions 
submitted for the record related to the May 22, 2019, hearing entitled 
Improving the Department of Veterans Affairs Effectiveness: Responding 
to Recommendations from Oversight Agencies. GAO's responses to these 
questions are enclosed.
    If you have any questions about this response or need additional 
information, please contact please contact Debra A. Draper at (202) 
512-7114 or [email protected] or Sharon M. M. Silas at (202) 512-7114 or 
[email protected] for VHA health care issues; Shelby S. Oakley at (202) 
512-4841 or [email protected] for VA acquisition management issues; or 
Elizabeth H. Curda at (202) 512-7215 or [email protected] for VA 
disability claims issues.

    Sincerely yours,

    Debra Draper
    Director, Health Care

    Sharon Silas
    Acting Director, Health Care

    Shelby Oakley
    Director, Contracting and National Security Acquisitions

    Elizabeth Curda
    Director, Education, Workforce, and Income Security

    Enclosure
            Attachment - Additional Questions for the Record
The Honorable Gil Cisneros

    1. At the hearing, Rep. Cisneros asked GAO to provide a response 
for the record on VA turnover and management weaknesses. Specifically, 
Rep. Cisneros asked GAO's thoughts about whether the issue is primarily 
among career employees or political appointees or both.

    In recent years, VA's workforce has experienced instability among 
both career employees and political appointees.
    First, VA has experienced mission-critical skill gaps and vacancies 
throughout the department, which includes career employees. As of 
December 2018, VA reported an overall vacancy rate of 11 percent at 
Veterans Health Administration (VHA) medical facilities, including 
vacancies of over 24,000 medical and dental positions and around 900 
human resource positions. With 32 percent of the VA workforce eligible 
to retire in the next 5 fiscal years, VA must address these mission-
critical skill gaps and vacancies that we continue to identify in our 
work. \1\ For example:
---------------------------------------------------------------------------
    \1\ Percentage based on VA employees on board at the start of 
fiscal year 2017.

      In December 2016, we found that VHA's limited human 
resources capacity combined with weak internal control practices has 
undermined VHA's human resources operations and its ability to improve 
delivery of health care services to veterans. \2\ Further, VHA is 
challenged by inefficiencies in its performance management processes, 
including the lack of a performance appraisal IT system, which prevents 
it from identifying trends and opportunities for improvement. VHA can 
better support medical centers by establishing clear lines of 
accountability for engagement efforts, collecting and leveraging 
leading practices, and addressing barriers to improving engagement. We 
made three recommendations to VA to improve its performance management 
system. VA partially concurred with these recommendations, which remain 
open.
---------------------------------------------------------------------------
    \2\ GAO, Veterans Health Administration: Management Attention Is 
Needed to Address Systemic, Long-standing Human Capital Challenges, 
GAO-17-30 (Washington, D.C.: Dec. 23, 2016).
---------------------------------------------------------------------------
      In October 2017, we reported that VHA is unable to 
accurately count the total number of physicians who provide care in its 
VA medical centers. \3\ VHA has data on the number of mission-critical 
physicians, which includes primary care and mental health physicians, 
it employs (more than 11,000) and who provide services on a fee-basis 
(about 2,800). \4\ However, VHA lacks data on the number of contract 
physicians and physician trainees, and thus has no information on the 
extent to which medical centers nationwide use these arrangements and 
whether contract physicians are working in mission-critical 
occupations. As such, VHA cannot ensure that its workforce planning 
process sufficiently addresses gaps in physician staffing, including 
those for mental health providers, which may affect veterans' access to 
care, among other issues. Additionally, we found that VHA has not 
evaluated the effectiveness of its physician recruitment and retention 
strategies. One such strategy-hiring physician trainees-is weakened by 
ineffectual hiring practices, such as delaying employment offers until 
graduation. VHA could strengthen its strategies by comprehensively 
evaluating the causes of recruitment and retention difficulties and 
identifying effective solutions.
---------------------------------------------------------------------------
    \3\ GAO, Veterans Health Administration: Better Data and Evaluation 
Could Help Improve Physician Staffing, Recruitment, and Retention 
Strategies, GAO-18-124 (Washington, D.C.: Oct. 19, 2017).
    \4\ VHA obtains data from its Veterans Integrated Service Networks 
and VA medical centers on which occupations are the highest priority 
for recruitment and retention based on known recruitment and retention 
concerns, among other factors. VHA then consolidates this data to 
identify the nationwide top 10 mission-critical occupations and top 5 
mission-critical physician occupations. In fiscal year 2016, the ten 
mission-critical clinical occupations were physician, registered nurse, 
human resource manager, physical therapist, physician assistant, 
psychologist, medical technologist, occupational therapist, diagnostic 
radiologic technologist, and pharmacist. See U.S. Department of 
Veterans Affairs, Veterans Health Administration, Mission Critical 
Occupation Report (2016).
---------------------------------------------------------------------------
    As a result of these findings, we made five recommendations, 
including that VA develop a process to count all physicians, provide 
guidance on productivity measurement, and evaluate its physician 
recruitment and retention strategies. VA concurred with four of the 
five recommendations, but did not concur with the one to accurately 
count all physicians, stating that its workforce assessment tools are 
sufficient. However, GAO maintains that this is essential for effective 
workforce planning.
    VA has implemented two of the five recommendations. For example, in 
May 2019, VA submitted an evaluation of its physician recruitment and 
retention programs. The report covered use of the Education Debt 
Reduction Program, physician pay tables, and recruitment, retention, 
and relocation incentives. One result of the evaluation is that VHA 
provided Veterans Integrated Service Networks (VISNs) with 
recommendations on how to efficiently allocate their recruitment, 
retention, and relocation incentives. Evaluating physician recruitment 
and retention programs will allow VHA to ensure that funds for these 
activities are effective and efficient.
    Also since the 2017 High-Risk Report was issued in February 2017, 
VA experienced leadership instability in several senior positions, some 
of which are political appointments. For example, there was notable 
turnover in critical politically appointed positions including the VA 
Secretary, Chief Information Officer, and Chief Financial Officer. 
Secretary Robert Wilkie was confirmed in July 2018. As a result, in our 
2019 High-Risk Report, GAO determined that VA partially met the 
leadership commitment criterion for managing risks and improving VA 
health care high-risk area, as it did in 2017. As of June 2019, key 
leadership vacancies remain, including the political appointments for 
VA Deputy Secretary and Under Secretary for Health positions; according 
to the Partnership for Public Service, VA is second among Federal 
departments in terms of Senate confirmations with 83 percent of key 
positions filled. \5\
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    \5\ See https://ourpublicservice.org/political-appointee-tracker/, 
which we accessed on June 17, 2019.
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    Fully addressing GAO's open recommendations could significantly 
improve VA operations; however, the recommendations highlight issues 
that are symptomatic of broader, systemic management and oversight 
challenges that will only be addressed through transformative action. 
As the Comptroller General testified during the hearing, the reason 
that VA was added to the High-Risk List in 2015 was due, in part, to 
underlying management weaknesses. As a result, VHA is embarking on an 
administration-wide modernization program, and VBA is implementing 
reforms to modernize its disability claims process. Per the statements 
of the Comptroller General during the hearing, in order for these 
efforts to be successful, VA leaders are going to have to energize an 
entrenched bureaucracy that is challenged in implementing management 
reforms. Successfully implementing these reforms and fully addressing 
the issues that led to VA's high-risk designations will require 
sustained leadership attention on high-risk related issues as well as 
leadership stability.