    VA Health Care: Additional Efforts to Better Assess Joint
    Ventures Needed (28-MAR-08, GAO-08-399).

    The Department of Veterans Affairs (VA) and the Department of
    Defense (DOD) have a long history of partnering to achieve more
    cost-effective use of health care resources. Their partnerships
    have evolved to include joint ventures--joint efforts to
    construct or share medical facilities. VA has maintained eight
    joint ventures with DOD across the country. VA has also developed
    partnerships, or affiliations, with university medical schools to
    obtain health care services for veterans and provide training to
    medical residents. VA has not entered into a joint venture with
    an academic affiliate to date. However, several proposals for
    such joint ventures have surfaced in the last decade. This
    congressionally requested report discusses the (1) potential
    benefits and concerns associated with joint ventures and the
    extent to which they are documented and measured, (2) lessons
    learned from existing and proposed VA joint ventures, and (3)
    steps VA has taken to evaluate proposed joint ventures. To
    address these issues, GAO conducted site visits to and interviews
    with officials from all existing and proposed joint venture
    sites.
    -------------------------Indexing Terms-------------------------
    REPORTNUM:   GAO-08-399
        ACCNO:   A81438
      TITLE:     VA Health Care: Additional Efforts to Better Assess Joint
    Ventures Needed
         DATE:   03/28/2008
      SUBJECT:   Access to health care
    	     Cost effectiveness analysis
    	     Evaluation criteria
    	     Health care cost control
    	     Health care facilities
    	     Health care planning
    	     Health care policies
    	     Health care reform
    	     Health care services
    	     Health policy
    	     Health resources utilization
    	     Interagency relations
    	     Internal controls
    	     Joint ventures
    	     Lessons learned
    	     Military health services
    	     Performance measures
    	     Program evaluation
    	     Program management
    	     Risk factors
    	     Risk management
    	     Veterans
    	     Veterans hospitals
    	     Veterans' medical care
    	     Standards (health care)

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    GAO-08-399

    This is a work of the U.S. government and is not subject to copyright
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    material separately.

    Report to the Ranking Member, Committee on Veterans' Affairs, U.S.
    Senate:

    United States Government Accountability Office:
    GAO:

    March 2008:

    VA Health Care:

    Additional Efforts to Better Assess Joint Ventures Needed:

    GAO-08-399:

    GAO Highlights:

    Highlights of GAO-08-399, a report to the Ranking Member, Committee on
    Veterans� Affairs, U.S. Senate.

    Why GAO Did This Study:

    The Department of Veterans Affairs (VA) and the Department of Defense
    (DOD) have a long history of partnering to achieve more cost-effective
    use of health care resources. Their partnerships have evolved to
    include joint ventures�joint efforts to construct or share medical
    facilities. VA has maintained eight joint ventures with DOD across the
    country. VA has also developed partnerships, or affiliations, with
    university medical schools to obtain health care services for veterans
    and provide training to medical residents. VA has not entered into a
    joint venture with an academic affiliate to date. However, several
    proposals for such joint ventures have surfaced in the last decade.

    This congressionally requested report discusses the (1) potential
    benefits and concerns associated with joint ventures and the extent to
    which they are documented and measured, (2) lessons learned from
    existing and proposed VA joint ventures, and (3) steps VA has taken to
    evaluate proposed joint ventures. To address these issues, GAO
    conducted site visits to and interviews with officials from all
    existing and proposed joint venture sites.

    What GAO Found:

    VA and DOD officials identified a number of potential benefits and
    concerns associated with joint ventures, but they have not routinely or
    comprehensively documented and measured them. Among the potential
    benefits, VA and DOD officials and academic affiliate representatives
    cited improved access to care, lower or avoided costs, and improved
    training opportunities. While the identified benefits are many, these
    officials and representatives also cited a number of concerns
    associated with joint ventures, such as potential conflicts of missions
    and cultures, a loss of organizational identity and control, staffing
    uncertainties, and financial risks. Although able to provide anecdotal
    information of the benefits and concerns associated with joint
    ventures, officials at the joint ventures do not use performance
    measures to routinely or comprehensively document and assess the
    outcomes of the joint ventures. Without such efforts, it is difficult
    to know to what extent these benefits and concerns have materialized.
    VA also does not use performance measures at the department level to
    determine what is being achieved through the joint ventures�thereby
    making it difficult to determine the overall outcomes of the joint
    ventures and to hold joint venture partners accountable for results.

    Officials from VA and DOD and representatives from academic affiliates
    identified several lessons they have learned from their experiences
    with the existing and proposed joint ventures. These lessons include
    the importance of establishing joint committees to work through issues,
    communicating frequently with their partners, securing leadership buy-
    in and support at all levels, developing contingency plans, allowing
    adequate time to implement change, and establishing clear roles and
    responsibilities. For example, at most VA-DOD joint venture sites,
    officials have created jointly staffed committees to tackle specific
    issues, such as clinical, financial, and information management. Also,
    in New Orleans, Louisiana, VA and its academic affiliate signed a
    memorandum of understanding that, among other things, identifies the
    roles and responsibilities of the parties involved in the proposed
    joint venture negotiations.

    VA has taken steps to enhance its process for evaluating proposed joint
    ventures, but additional efforts are warranted. In response to our
    previous recommendations, VA developed and issued criteria for
    evaluating joint venture proposals in November 2007. In addition, VA
    established working groups in Charleston, South Carolina, and New
    Orleans to examine joint venture proposals with academic affiliates.
    However, VA�s criteria for evaluating joint venture proposals are not
    sufficiently specific, in terms of both the definition and the
    application of the criteria. As a result, VA�s evaluations of joint
    venture proposals could be inconsistent and, therefore, may not serve
    as a reliable guide for federal investments in joint ventures. In
    addition, the criteria are not tailored to take into account
    differences in prospective joint venture partners to ensure that VA
    applies the appropriate level of review and scrutiny to proposals.

    What GAO Recommends:

    GAO is recommending that the VA Secretary develop departmental
    performance measures for assessing joint venture outcomes and more
    specific criteria for evaluating joint venture proposals. VA generally
    agreed with GAO�s findings and recommendations.

    To view the full product, including the scope and methodology, click on
    [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-399]. For more
    information, contact Randall Williamson at (202) 512-2834 or
    williamsonr@gao.gov.

    [End of section]

    Contents:

    Letter:

    Results in Brief:

    Background:

    Officials Identified Potential Benefits and Concerns, but Have Not Used
    Performance Measures to Document and Assess the Outcomes of Joint
    Ventures:

    Officials Identified Lessons Learned from Their Experiences with
    Existing and Proposed Joint Ventures:

    VA Has Taken Steps to Evaluate Proposed Joint Ventures, but Additional
    Efforts Are Needed:

    Conclusions:

    Recommendations for Executive Action:

    Agency Comments:

    Appendix I: Objectives, Scope, and Methodology:

    Appendix II: Comments from the Department of Veterans Affairs:

    Appendix III: Comments from the Department of Defense:

    Appendix IV: GAO Contact and Staff Acknowledgments:

    Table:

    Table 1: Selected Laws and Initiatives Related to VA Collaboration with
    DOD and Academic Affiliates:

    Figures:

    Figure 1: Locations of the Eight Current VA-DOD Joint Ventures:

    Figure 2: VA's and LSU's Preferred Facility Sites for the Potential
    Joint Venture Medical Facility:

    Figure 3: The MRI Machine at North Chicago Purchased by VA and DOD:

    Figure 4: The North Chicago VA-DOD Joint Venture Local Working Groups:

    Figure 5: The VA-LSU Memorandum of Understanding for the Joint Venture:

    Abbreviations:

    DOD: Department of Defense:

    JIF: Joint Incentive Fund:

    LSU: Louisiana State University:

    MRI: magnetic resonance imaging:

    MUSC: Medical University of South Carolina:

    NDAA: Bob Stump National Defense Authorization Act for Fiscal Year
    2003:

    UCH: University of Colorado Hospital:

    VA: Department of Veterans Affairs:

    [End of section]

    United States Government Accountability Office:
    Washington, DC 20548:

    March 28, 2008:

    The Honorable Richard Burr:
    Ranking Member:
    Committee on Veterans' Affairs:
    United States Senate:

    Dear Senator Burr:

    For decades, Congress has encouraged the Department of Veterans Affairs
    (VA) and the Department of Defense (DOD) to increase their resource-
    sharing activities to achieve more cost-effective use of health care
    resources and to deliver health care services more efficiently. In
    1982, Congress passed the Veterans' Administration and Department of
    Defense Health Resources Sharing and Emergency Operations Act (Sharing
    Act).[Footnote 1] The Sharing Act authorizes VA and DOD to enter into
    sharing agreements or contracts with each other for the mutual use or
    exchange of health care resources, with the goal of improving access
    to, and the quality and cost-effectiveness of, the health care provided
    by the two departments. Since that time, VA has entered into a number
    of sharing arrangements with DOD to, for example, purchase emergency
    room services, specialty care, and inpatient care and to sell
    outpatient care and ambulatory services.[Footnote 2] Starting in the
    1990s, VA and DOD expanded their sharing agreements to include joint
    ventures--that is, joint efforts to construct or share medical
    facilities. VA has maintained eight joint ventures with DOD throughout
    the country. Congress and the administration have encouraged VA and DOD
    to look for more opportunities for joint ventures as a means of
    avoiding costs by maximizing available resources to build a new
    facility or to jointly use a facility. For example, in 2003, a
    presidential task force[Footnote 3] recommended that VA and DOD declare
    that joint ventures are integral to the standard operations of both
    departments and use the existing joint ventures as laboratories for
    developing future interdepartmental policy frameworks.

    VA also has a long history of developing partnerships, or affiliations,
    with university medical schools to help VA fulfill its mission of
    providing health care to the nation's veterans. As of January 2008, VA
    had affiliations with 107 medical schools. VA is further authorized to
    enter into sharing contracts or agreements for the mutual use or
    exchange of health care resources with its academic affiliates to
    secure health care resources that otherwise might not be feasibly
    available or to effectively use other health care resources.[Footnote
    4] Although VA routinely obtains medical services for veterans from its
    academic affiliates and provides training and education to the medical
    residents of its academic affiliates, VA has not entered into a joint
    venture with an academic affiliate. However, opportunities for VA to
    enter into joint ventures with several academic affiliates, including
    affiliates in Charleston, South Carolina, and New Orleans, Louisiana,
    have surfaced over the last decade. Congress has shown an interest in
    VA's exploring possible joint ventures with academic affiliates. For
    example, in 2003, Congress required the Secretary of Veterans Affairs
    to study the feasibility of coordinating health care services with
    representatives of VA's academic affiliate, the Medical University of
    South Carolina (MUSC) in Charleston,[Footnote 5] and, in 2006, Congress
    authorized VA to collaborate with its academic affiliate, Louisiana
    State University (LSU), on rebuilding the two New Orleans medical
    centers destroyed during Hurricane Katrina.[Footnote 6]

    This report discusses the (1) potential benefits and concerns
    associated with joint ventures and the extent to which they are
    documented and measured, (2) lessons learned from existing and proposed
    VA joint ventures with DOD and academic affiliates, and (3) steps VA
    has taken to evaluate proposed joint ventures. To address these issues,
    we used a combination of site visits and semistructured interviews to
    obtain information from all eight existing VA-DOD joint ventures and
    the three proposed joint ventures between VA and academic affiliates.
    Specifically, we visited three existing VA-DOD joint venture locations
    in El Paso, Texas; Las Vegas, Nevada; and North Chicago, Illinois. We
    also visited New Orleans, which is the site of a proposed joint venture
    between VA and the Louisiana State University Health Care Services
    Division[Footnote 7]. We conducted semistructured telephone interviews
    with officials from the remaining existing and proposed joint ventures
    [Footnote 8]. During the site visits and telephone interviews, we
    interviewed the parties involved in the existing or proposed joint
    ventures, including VA and DOD officials at the local and network
    level[Footnote 9] and representatives from the academic affiliates. In
    addition to the site visits and semistructured interviews, we reviewed
    agency documentation, reports, studies, and analyses on existing and
    proposed VA joint ventures, as well as legal authorities governing
    joint ventures between VA and DOD and between VA and its academic
    affiliates. We also interviewed department-level officials from VA and
    DOD and representatives from several veteran service organizations.
    Finally, we reviewed published research and studies, including GAO
    reports, on public-private partnerships; best practices in
    collaboration, partnering, and organizational transformation; and
    evaluation criteria. We conducted this performance audit from May 2007
    through March 2008 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.
    Appendix I provides additional details on our objectives, scope, and
    methodology.

    Results in Brief:

    VA and DOD officials and representatives of academic affiliates
    identified a number of potential benefits and concerns associated with
    joint ventures, but little effort has been taken to routinely or
    comprehensively document and measure them. Among the potential
    benefits, the officials and representatives with whom we spoke cited
    improved access to care, lower or avoided costs, and improved training
    opportunities. For example, officials from several VA-DOD joint venture
    sites said their joint ventures have enabled them to decrease their
    patient referrals to VA medical centers in other regions or to local
    community providers for care, thereby improving access to care and
    decreasing costs. In addition, in New Orleans, VA officials and LSU
    representatives said that the proposed joint venture could help in
    recruiting and retaining highly skilled medical staff by providing such
    staff with a new facility that offers a range of training
    opportunities. While the benefits that officials identified are many,
    these officials and representatives also identified a number of
    concerns associated with joint ventures, such as potential conflicts of
    missions and cultures, staffing uncertainties, a loss of organizational
    identity and control, and financial risks. For example, staffing
    uncertainties resulting from changes in leadership or the deployment of
    DOD personnel could affect the continuity and quality of care and
    access to care for veterans at joint venture sites. Although able to
    provide anecdotal information of the benefits and concerns associated
    with joint ventures, officials at the joint venture sites do not use
    performance measures to routinely or comprehensively document and
    assess the outcomes of the joint ventures. Without such efforts, it is
    difficult to know to what extent these benefits and concerns have
    materialized. VA also does not use performance measures at the
    department level to determine what is being achieved through the joint
    ventures, thereby making it difficult to determine the overall outcomes
    of the joint ventures and to hold joint venture partners accountable
    for results.

    Officials from VA and DOD and representatives from academic affiliates
    identified several lessons they have learned from their experiences
    with the existing and proposed joint ventures. These lessons include
    the importance of establishing joint committees to work through issues,
    communicating frequently with their partners, securing leadership buy-
    in and support at all levels, developing contingency plans, allowing
    adequate time to implement change, and establishing clear roles and
    responsibilities. For example, at most VA-DOD joint venture sites,
    officials have created jointly staffed committees to tackle specific
    issues, such as clinical, financial, and information management. Also,
    in New Orleans, VA and its academic affiliate signed a memorandum of
    understanding that provides a framework for collaboration and
    discussion between the two organizations on a proposed joint venture
    and identifies the roles and responsibilities of the parties in this
    process.

    VA has taken steps to enhance its process for evaluating proposed joint
    ventures, but further efforts are warranted. For example, VA
    established working groups in Charleston and New Orleans to examine
    proposals for joint ventures with academic affiliates. In addition, in
    response to our previous recommendations, VA developed and issued
    criteria for evaluating joint venture proposals in November 2007.
    However, VA's criteria for evaluating joint venture proposals are not
    sufficiently specific, in terms of both the definition and the
    application of the criteria. As a result, VA's evaluations of joint
    venture proposals could be inconsistent and, therefore, may not serve
    as a reliable guide for federal investments in joint ventures. In
    addition, the criteria are not tailored to take into account
    differences in prospective joint venture partners to help ensure that
    VA applies the appropriate level of review and scrutiny to proposals.

    For VA to develop a more robust framework for evaluating existing and
    future joint ventures, we are recommending that the Secretary of
    Veterans Affairs develop departmental performance measures to assess
    the outcomes of joint ventures and to determine the extent to which
    strategic goals are being achieved; develop more specific criteria for
    evaluating joint venture proposals; and analyze the differences among
    types of joint venture partners to determine whether the criteria
    should be tailored to the type of partner, and, if so, tailor the
    criteria. VA and DOD provided written comments on a draft of this
    report, which are reprinted in appendixes II and III, respectively. VA
    generally agreed with our findings, conclusions, and recommendations.
    Also, DOD generally agreed with the report's overall findings. The
    departments provided technical comments, which we incorporated in the
    report as appropriate.

    Background:

    VA's Partnerships with DOD:

    VA has a long history of partnering with DOD to enhance health care
    delivery to veterans, beginning in 1982 with the enactment of the
    Sharing Act, which aimed to promote more cost-effective use of health
    care resources through greater interagency sharing and coordination.
    Since that time, VA and DOD have participated in a wide array of
    sharing agreements for the mutual use or exchange of health care
    resources. Starting in the 1990s, VA and DOD expanded their sharing
    agreements to include joint ventures sharing agreements.[Footnote 10]
    Joint ventures are intended to avoid costs by maximizing available
    resources by jointly using a medical facility. According to VA, joint
    ventures involve a multi-entity, collaborative and strategic
    arrangement of at least 5 years in duration and a level of magnitude
    and scale comparable to VA's current major capital threshold ($10
    million). Joint ventures are complex in that they require an integrated
    approach because two separate health care systems must develop multiple
    sharing agreements that allow them to operate as one system at one
    location. VA currently has eight joint ventures with DOD (see fig. 1)

    Figure 1: Locations of the Eight Current VA-DOD Joint Ventures:

    [See PDF for image]

    This figure is a map of the United States depicting the locations of
    the eight current VA-DOD Joint Ventures. The eight locations are:

    Albuquerque, New Mexico;
    Anchorage, Alaska;
    Chicago, Illinois;
    El Paso, Texas;
    Fairfield, California;
    Honolulu, Hawaii;
    Key West, Florida;
    Las Vegas, Nevada.

    Source: Map Resources (map) and GAO.

    [End of figure]

    VA's Partnerships with Academic Affiliates:

    For decades, VA has also developed and maintained partnerships, or
    affiliations, with university medical schools to provide health care to
    veterans. Through these affiliations, VA has been able to obtain
    medical services for veterans and provide training and education to
    medical residents. Although VA maintains numerous sharing agreements
    with its academic affiliates, it has not yet entered into a joint
    venture with any of them. However, in recent years, VA has had the
    opportunity to consider proposed joint ventures with several academic
    affiliates. In particular:

    * University of Colorado Hospital (UCH): In the late 1990s, UCH
    proposed to integrate the VA Denver medical center and UCH into a new
    joint facility on the Fitzsimons campus, which is located in Aurora,
    Colorado.[Footnote 11] UCH and VA officials could not reach agreement
    on certain aspects of the proposal, and, therefore, discussions about a
    proposed joint venture between VA and UCH concluded in 2002. As
    required by law, in June 2007, VA issued a report that examined options
    for replacing its Denver facility, including the feasibility of
    entering into a partnership for constructing and operating a new
    facility with a federal, state, or local governmental agency or a
    suitable nonprofit organization.[Footnote 12] The report outlined three
    different options available to VA for replacing the facility and
    summarized their key advantages and disadvantages.

    * Medical University of South Carolina: In 2002, MUSC proposed to
    partner with VA in the construction and operation of a new medical
    center in Charleston. Since that time, VA and MUSC have conducted
    several feasibility studies examining the potential collaboration. In
    2006, Congress authorized the VA Secretary to enter into an agreement
    with MUSC to design and plan for the operation of a colocated joint-use
    medical facility.[Footnote 13] In November 2007, VA officials from the
    medical center in Charleston told us that VA and MUSC are still
    exploring a range of collaborative arrangements.[Footnote 14]

    * Louisiana State University Health Care Services Division: In 2005,
    Hurricanes Katrina and Rita damaged VA's New Orleans medical center and
    LSU medical facilities. In February 2006, VA and LSU signed a
    memorandum of understanding that established the framework for
    exploring whether any mutually beneficial sharing and contracting could
    occur between VA and LSU. In 2006, the VA Secretary was authorized to
    carry out the project as a collaborative effort with LSU.[Footnote 15]
    According to a VA official, no final decision on the proposed joint
    venture between VA and LSU has been made. However, VA has announced a
    preferred site for the joint facility in the downtown New Orleans area,
    adjacent to the site LSU has identified for its new facility (see fig.
    2). Although no final decision has been made, the proximity of the
    preferred sites keeps the possibility of some type of joint facility as
    an option.

    Figure 2: VA's and LSU's Preferred Facility Sites for the Potential
    Joint Venture Medical Facility:

    [See PDF for image]

    This figure is a map of VA's and LSU's preferred facility sites for the
    potential Joint Venture Medical Facility in New Orleans. Depicted are
    the existing VA campus, the future site for the new LSU facility, and
    the preferred site for the new VA facility.

    Source: New Orleans VA officials and GAO.

    [End of figure]

    Congressional and Administration Initiatives Related to VA's
    Collaboration with DOD and Academic Affiliates:

    Congress has had a long-standing interest in expanding VA's and DOD's
    sharing of health care resources. For example, the National Defense
    Authorization Act for Fiscal Year 2003 required VA and DOD to implement
    two programs--the joint incentive program and the demonstration
    program--to increase the sharing of health care resources between VA
    and DOD.[Footnote 16] The administration has also encouraged such
    collaboration between VA and DOD as a means to achieve more cost-
    effective use of health care resources. For example, in 2003, a
    presidential task force recommended that VA and DOD declare that joint
    ventures are integral to the standard operations of both departments
    and use the existing joint ventures as laboratories for developing
    future interdepartmental policy frameworks. Congress has also recently
    encouraged VA to explore opportunities for expanding its collaboration
    with academic affiliates as a potential cost-effective means of
    rebuilding and revitalizing VA's aging infrastructure. Table 1 briefly
    describes selected laws and initiatives that have authorized and
    encouraged collaboration between VA and DOD as well as between VA and
    academic affiliates.

    Table 1: Selected Laws and Initiatives Related to VA Collaboration with
    DOD and Academic Affiliates:

    Source: VA and DOD sharing - 38 U.S.C. � 8111: Veterans' Administration
    and Department of Defense Health Resources Sharing and Emergency
    Operations Act (Pub. L. No. 97-174);
    Description: Established a VA-DOD Health Care Resources Sharing
    Committee to promote the sharing of health care resources with
    responsibilities to (1) review existing policies, procedures, and
    practices relating to the sharing of health care resources between VA
    and DOD; (2) identify changes to promote sharing; and (3) monitor the
    implementation of activities designed to promote sharing; Authorized
    the VA and DOD Secretaries to jointly establish guidelines to promote
    the sharing of health care resources; Authorized the heads of
    individual VA and DOD facilities to enter into sharing agreements under
    the sharing guidelines if sharing did not adversely affect the range of
    services, the quality of care, or the established priorities for care
    provided by either department. Each agreement was to identify the
    health care resources to be shared and to provide reimbursement to the
    department providing the services.

    Source: VA and DOD sharing - 38 U.S.C. � 8111: Executive Order 13214 -
    President's Task Force to Improve Heath Care Delivery for Our Nation's
    Veterans (2001);
    Description: Established a 15-member presidential task force to, among
    other things, (1) identify ways to improve benefits and services for VA
    beneficiaries, and DOD military retirees who are also eligible for
    benefits from VA, through better coordination of the activities of the
    two departments; (2) review barriers and challenges that impede VA and
    DOD coordination, including budgeting processes, timely billing, cost
    accounting, information technology, and reimbursement; and (3) identify
    opportunities for improved resource use through partnership between VA
    and DOD to maximize the use of resources and infrastructure.

    Source: VA and DOD sharing - 38 U.S.C. � 8111: Department of Veterans
    Affairs and Department of Defense Health Resources Sharing: Staff
    Report to the Committee on Veterans' Affairs (2002);
    Description: Recommended legislation to achieve more resource sharing
    between VA and DOD[A].

    Source: VA and DOD sharing - 38 U.S.C. � 8111: Final Report of the
    President's Task Force to Improve Health Care Delivery for Our Nation's
    Veterans (2003);
    Description: Recommended, among other things, that VA and DOD declare
    that joint ventures are integral to the standard operations of both
    departments and use existing joint ventures as laboratories for
    developing future interdepartmental policy frameworks.

    Source: VA and DOD sharing - 38 U.S.C. � 8111: Bob Stump National
    Defense Authorization Act for Fiscal Year 2003 (Pub. L. No. 107-314);
    Description: Amended the Sharing Act to establish a program called the
    Joint Incentive Fund (JIF) to identify and provide incentives to
    implement, fund, and evaluate creative coordination and sharing
    initiatives. Required the VA and DOD Secretaries to contribute at least
    $15 million annually to a DOD-VA Health Care Sharing Incentive Fund.
    Initially, JIF was to expire on September 30, 2007, but it was
    extended, by law, until September 30, 2010; Amended the Sharing Act to
    (1) establish a VA-DOD Health Executive Committee whose
    responsibilities were, among other things, to recommend to the two
    Secretaries strategic direction for joint coordination and sharing
    efforts and to oversee the implementation of such efforts and (2)
    conduct a health care resource-sharing project to serve as a test for
    evaluating the feasibility, advantages, and disadvantages of programs
    designed to improve the sharing and coordination of health care and
    health care resources between VA and DOD.

    Source: VA and DOD sharing - 38 U.S.C. � 8111: National Defense
    Authorization Act for Fiscal Year 2004 (Pub. L. No. 108-136);
    Description: Established the VA-DOD Joint Executive Committee, whose
    responsibilities were, among other things, to recommend to the two
    Secretaries a strategic direction for joint coordination, share efforts
    between the two departments, and oversee the implementation of such
    efforts.

    Source: VA and DOD sharing - 38 U.S.C. � 8111: Veterans Benefits,
    Health Care, and Information Technology Act of 2006 (Pub. L. No. 109-
    461);
    Description: Authorized the VA Secretary, in conjunction with the
    Secretaries of DOD and the Air Force, to report on the placement of a
    VA Medical Center in Okaloosa County, Florida, including the
    feasibility of entering into a partnership with Eglin Air Force Base
    for the construction and operation of a new, joint VA-DOD facility.

    Source: VA and DOD sharing - 38 U.S.C. � 8111: John Warner National
    Defense Authorization Act for Fiscal Year 2007 (Pub. L. No. 109-364);
    Description: Extended JIF for 3 years, or until September 30, 2010.

    Source: VA and academic affiliate sharing - 38 U.S.C. �� 8151-8153:
    Veterans Hospitalization and Medical Services Modernization Amendments
    of 1966 (Pub. L. No. 89-785);
    Description: Authorized the VA Secretary to enter into agreements for
    specialized medical resources with hospitals, medical schools, and
    other medical installations for reimbursement when the exchange of
    specialized medical resources is determined to be in VA's best
    interests. Agreements for the exchange of specialized medical resources
    would be entered into where (1) an affiliate would provide specialized
    medical resources to VA if it would obviate VA's provision of a similar
    resource or (2) VA would provide the specialized medical resources to
    an affiliate at a VA facility that was not being used to its maximum
    capacity.

    Source: VA and academic affiliate sharing - 38 U.S.C. �� 8151-8153:
    Veterans Health Care Eligibility Reform Act of 1996 (Pub. L. No. 104-
    262);
    Description: Expanded the scope of VA's sharing authority to health
    care resources, which includes the use of space. Authorized the VA
    Secretary to enter into sharing agreements to acquire or provide the
    use of space to affiliates in exchange for payment and/or services.

    Source: VA and academic affiliate sharing - 38 U.S.C. �� 8151-8153:
    Veterans Health Care, Capital Asset, and Business Improvement Act of
    2003 (Pub. L. No. 108-170);
    Description: Required the VA Secretary to study the feasibility of
    coordinating VA's health care services with the pending construction of
    a new university medical center at the Medical University of South
    Carolina, Charleston.

    Source: VA and academic affiliate sharing - 38 U.S.C. �� 8151-8153:
    Veterans Benefits, Health Care, and Information Technology Act of 2006
    (Pub. L. No. 109-461);
    Description: Authorized the VA Secretary to carry out the project to
    rebuild the New Orleans VA Medical Center in collaboration with LSU
    consistent with the New Orleans Collaborative Opportunities Study Group
    Report dated June 2006; Required the VA Secretary to report on the
    feasibility of replacing facilities in Denver, Colorado, and San Juan,
    Puerto Rico, through a partnership with a federal, commonwealth, state,
    or local governmental agency, or a suitable nonprofit organization, for
    the construction and operation of a new facility; Authorized the VA
    Secretary to enter into an agreement with the Medical University of
    South Carolina to design and plan for the operation of a colocated
    joint-use medical facility in Charleston, South Carolina.

    Source: GAO summary of selected laws and initiatives related to VA
    collaboration.

    [A] Department of Veterans Affairs and Department of Defense Health
    Resources Sharing: Staff Report to the Committee on Veterans' Affairs,
    U.S. House of Representatives 107th Congress (Washington, D.C.: Feb.
    25, 2002).

    [End of table]

    VA and DOD have also taken steps to improve and expand their health
    care sharing activities. For example, since 2005, VA and DOD have
    convened annual conferences to highlight the progress and
    accomplishments of joint ventures as well as provided a forum for
    discussing common barriers to success, lessons learned, and best
    practices. In 2007, VA and DOD established the VA-DOD Joint Market
    Opportunities Working Group to examine the existing VA-DOD joint
    ventures and the potential for additional joint ventures. In the first
    phase of its review, the working group studied all eight existing VA-
    DOD joint ventures sites to identify best practices, lessons learned,
    and challenges. In the second phase of its review, the working group
    plans to assess potential opportunities for the colocation and
    comanagement of VA-DOD facilities.

    In addition, VA is exploring options to improve its partnerships with
    academic affiliates. For example, in 2006, VA established a blue ribbon
    panel to advise the VA Secretary on issues related to a comprehensive
    philosophical framework to enhance VA's partnerships with medical
    schools and affiliated institutions. Among other things, the panel will
    explore the different types of health care partnerships between VA and
    academic affiliates, including joint ventures, in light of changes of
    medical education, research priorities, and the health care needs of
    veterans.

    Guidance Related to Strategic Planning and Performance Measures:

    The National Defense Authorization Act for Fiscal Year 2003 also
    required VA and DOD to develop and publish a joint strategic plan to
    shape, focus, and prioritize coordination and sharing efforts within
    the departments and to incorporate the goals and requirements of the
    joint strategic plan into each department's strategic plan.[Footnote
    17] In response, VA and DOD approved their initial Joint Strategic Plan
    in April 2003 to guide the departments' health care resource-sharing
    activities. The plan is updated annually and included in the Joint
    Executive Council Annual Report to Congress.

    We have reported that there is no more important element in results-
    oriented management than an agency's strategic planning effort.
    [Footnote 18] This effort is the starting point and foundation for
    defining what the department seeks to accomplish, identifying the
    strategies it will use to achieve the desired results, and then
    determining how well it succeeds in reaching goals and achieving
    objectives. We also previously reported that traditional management
    practices involve the creation of long-term strategic plans and regular
    assessments of progress toward achieving the plans' stated
    goals.[Footnote 19] Moreover, the Government Performance and Results
    Act of 1993 requires agencies to set goals, measure performance, and
    report on their accomplishments.[Footnote 20] The use of performance
    measures is a key tool to help managers assess progress toward
    achieving the goals or objectives stated in their plans. This is also
    an important accountability tool to communicate a department's progress
    to Congress and the public.

    Officials Identified Potential Benefits and Concerns, but Have Not Used
    Performance Measures to Document and Assess the Outcomes of Joint
    Ventures:

    Officials from VA and DOD and representatives from academic affiliates
    identified a number of potential benefits and concerns associated with
    joint ventures, but have not used performance measures to routinely or
    comprehensively document and assess the outcomes of the joint ventures.
    The most commonly cited potential benefits of joint ventures include
    improved access to care, cost savings and avoidances, and improved
    training opportunities. According to the officials we interviewed,
    joint ventures also raise a number of potential concerns, including
    potential conflicts between organizations' missions and cultures, a
    potential loss of organizational identity and control, and
    uncertainties associated with staffing. While able to discuss these
    potential benefits and concerns, none of the officials involved in VA-
    DOD joint ventures use performance measures to routinely document or
    assess the outcomes of these endeavors at their facilities. Without
    this information, the extent to which identified benefits have been
    achieved and concerns mitigated at joint ventures is unknown. VA also
    does not use performance measures at the department level to determine
    what is being achieved through the joint ventures. As a result, VA has
    only limited and anecdotal information on the results of joint
    ventures.

    Officials Cite a Number of Benefits Associated with Joint Ventures:

    According to our interviews with officials from VA and DOD and
    representatives from academic affiliates, the potential benefits of
    joint ventures range from improved access to care to greater
    flexibility in the use of staff and other resources.[Footnote 21]

    * Joint ventures provide improved access to care: VA and DOD officials
    said that the existing and proposed joint ventures provide their
    patients with improved access to specialty care and services that may
    not otherwise be available. For example, VA officials said that
    veterans in Honolulu have access to orthopedic care at the DOD medical
    center that would not otherwise be readily available. Similarly,
    according to LSU representatives, the proposed joint venture between VA
    and LSU would provide veterans with access to the only Level I Trauma
    Center in the region. Also, according to DOD officials in Fairfield,
    the joint venture with VA provides their beneficiaries with access to
    specialty care, such as neurosurgery, dialysis, and radiation oncology
    services. VA officials also said that joint ventures have resulted in
    fewer referrals of veterans to VA medical centers in other geographic
    areas, and, as a result, veterans do not have to travel great distances
    to receive care. For example, VA officials in El Paso said that local
    veterans, who previously had to travel over 250 miles to the
    Albuquerque VA medical center, can now be treated at the local DOD
    hospital. VA officials in Anchorage said that before a joint venture
    with DOD was established there, they referred most of their joint
    replacement cases to the Seattle VA medical center. With the joint
    venture, many veterans requiring joint replacement can now be treated
    at the facility in Anchorage and do not have to travel to Seattle.

    * Joint ventures could reduce or avoid costs: Many of the officials
    from VA and DOD and representatives from the academic affiliates told
    us that joint ventures have resulted in or have the potential to result
    in lower or avoided costs by creating economies of scale, eliminating
    redundant or duplicative services, and reducing infrastructure and
    construction costs. In general, officials at many of the VA-DOD joint
    venture sites said that purchasing care from their joint venture
    partner was less expensive than purchasing the same services in the
    local community from private providers. In addition, officials said
    they lowered their costs through economies of scale or volume discounts
    that each agency--working alone--would not otherwise receive. Officials
    at some joint venture sites said they lower their costs by reducing
    redundancies and duplication of staffing, equipment, services, and
    space. For example, in North Chicago, DOD officials estimated that they
    will save about $352,000 annually by sharing a magnetic resonance
    imaging (MRI) machine purchased using joint incentive funds (see fig.
    3). In New Orleans, VA officials estimated that a joint facility with
    LSU would be more cost-effective than a stand-alone facility because a
    joint operation would enable the partners to share space and
    facilities, such as laboratories, kitchens, and the energy plant.
    Several of the officials at VA-DOD joint venture sites said they
    avoided several million dollars in construction costs by entering into
    a joint venture rather than building a stand-alone medical facility.
    Each partner thus expanded the services available to all patients,
    while avoiding the costs of separate, duplicative medical facilities.

    Figure 3: The MRI Machine at North Chicago Purchased by VA and DOD:

    [See PDF for image]

    This figure is a photograph of the MRI machine at North Chicago
    purchased by VA and DOD.

    Source: GAO.

    [End of figure]

    * Joint ventures offer additional training opportunities: VA and DOD
    officials at the existing VA-DOD joint venture sites said that the
    joint ventures provide educational and training opportunities to meet
    DOD's readiness mission. Several DOD officials said that the joint
    ventures give their medical staff opportunities to work on veteran
    patient cases that are more severe, complex, and varied than cases
    involving active duty personnel. Such opportunities help the military
    medical staff sustain their skill levels and provide greater assurance
    of medical readiness. According to VA and DOD officials we interviewed,
    joint ventures also offer knowledge-sharing opportunities. For example,
    in Key West, VA personnel train Navy staff to handle disruptive
    behavior, while Navy staff train VA personnel in a variety of areas,
    including basic life support and advanced cardiac life support.
    Finally, VA officials and academic affiliate representatives said that
    the educational and training opportunities at joint ventures can serve
    as a recruitment and retention tool. For example, in New Orleans, VA
    officials and LSU representatives said that the proposed joint venture-
    -specifically, a new, modern facility and the range of training
    opportunities that may be offered in the new facility--could help in
    recruiting and retaining highly skilled medical staff.

    * Joint ventures increase flexibility in the use of resources:
    According to many of the VA and DOD officials and academic affiliate
    representatives we interviewed, joint ventures offer flexibility in
    handling fluctuations in staffing and allow more efficient use of space
    and equipment. Since DOD staff is subject to deployments, VA staff can
    often help stabilize staffing at VA-DOD joint venture facilities. For
    example, because VA and DOD staff are extensively integrated among all
    commonly shared or used work units, DOD officials in Las Vegas said
    that VA and DOD staff are often seen as interchangeable and can,
    therefore, fill in for each other as needed, allowing continuity in
    service and care. LSU officials expected the proposed joint venture
    with VA in New Orleans to provide a similar opportunity, especially for
    hard-to-fill and specialty positions. Furthermore, joint ventures can
    provide additional flexibility with and access to space and equipment,
    according to officials from DOD and VA. In North Chicago, VA officials
    described how the joint venture helped them better use their
    underutilized capacity by integrating VA and DOD medical facilities and
    expanding the emergency room at the VA medical center. In Albuquerque,
    VA officials said they were able to use DOD's outpatient facility as
    backup space when VA's operating room was flooded due to a water leak.

    In addition to the benefits previously cited, some VA and DOD officials
    identified a benefit that is specific to VA-DOD joint ventures--that
    is, joint ventures support efforts to achieve a seamless transition
    between VA and DOD. Some VA and DOD officials noted that joint ventures
    support the Presidential Task Force objective for VA and DOD to
    collaborate at all levels to ensure a seamless transition for eligible
    military personnel from active duty to veteran status.[Footnote 22] DOD
    officials in Honolulu told us that the joint venture agreement with VA
    and the resulting close working relationship help them to seamlessly
    transfer beneficiaries from the DOD health system to the VA health
    system. VA officials at two joint venture sites said that the
    colocation of the VA and DOD facilities enables them to conduct medical
    evaluations of active duty personnel before they are transferred to
    veteran status, which helps to provide a smoother transition.

    Officials Acknowledge Potential Concerns Associated with Joint
    Ventures, but Offer Mitigation Strategies:

    VA and DOD officials and representatives from academic affiliates also
    identified a number of potential concerns associated with joint
    ventures, including maintaining timely access to care, potential
    conflicts between organizational missions and cultures, staffing
    uncertainties that can affect hospital operations, a loss of
    organizational identity or control, the potential to create
    dependencies, and financial risks. In identifying the potential
    concerns, they offered examples of the mitigation strategies they have
    used or could use to manage these concerns. Furthermore, federal
    statutes serve to safeguard the quality of care and access to care for
    veterans in a joint venture arrangement, and VA officials noted that
    veteran service organizations play an important oversight role in
    ensuring that these provisions are met.[Footnote 23]

    * Joint ventures may not maintain timely access to care: Limited access
    to joint venture facilities, resulting from either reduced capacity or
    increased security procedures, could hinder a patient from obtaining
    timely care. At a few VA-DOD sites, officials said that their patients
    may not always be able to access timely care from their joint venture
    partner because of capacity constraints. For example, in El Paso, VA
    and DOD officials said that an expected realignment of military
    personnel in the region may result in an increased demand for medical
    services. This increase, coupled with limits on available space and
    personnel, may reduce DOD's ability to meet the demands of both
    veterans and active duty personnel for timely care. To mitigate this
    concern, VA officials told us that the El Paso VA office has developed
    contingency plans, which are reviewed each day, to ensure that care is
    not delayed or denied to any veteran. Officials at the El Paso VA
    medical center also maintain a network of health care providers in the
    community and at other VA facilities. In addition, the high level of
    security at the military bases that host some of the VA-DOD joint
    ventures sometimes makes it difficult for the veterans to gain timely
    access to the medical facility. For example, in Fairfield, DOD
    officials said that it can be difficult to get VA staff and patients on
    and off the military base in a reasonable amount of time while adhering
    to security procedures. Furthermore, VA officials in Las Vegas noted
    that during national emergencies, such as the terrorist attacks of
    September 11, 2001, the military base can be "locked down" for hours or
    days, and, therefore, veterans would not then be able to access the
    base for care. VA and DOD have taken steps to mitigate these access
    issues. For example, VA and DOD have developed informal "work arounds"
    at the military base in Fairfield, and, in Las Vegas, VA officials
    worked with DOD to ensure that veterans can access the base by
    presenting their veteran identification card.

    * Joint ventures could lead to conflicts between organizational
    missions and cultures: Differences in organizational missions and
    cultures could affect the success of a joint venture. VA officials
    stated that DOD's readiness mission may be incompatible in certain
    situations with VA's mission to provide quality and timely care to
    veterans. Similarly, VA officials noted that VA and its academic
    affiliates have different missions and, at times, competing priorities,
    which has raised concerns among veterans that they may not always
    receive appropriate access to equipment and services. A director of a
    VA medical center said these types of access-to-care issues can be
    addressed by establishing a protocol during the formation of the joint
    venture and monitoring to ensure that the protocol is followed once the
    joint venture is fully operational. Different organizations also have
    different cultures, which can lead to conflicts. In Honolulu, for
    example, VA officials discussed differences in VA's and DOD's
    interpretations of certain guidelines, which resulted in friction
    between the two organizations. However, the officials said these types
    of conflicts are worked out within the joint venture's governance
    process. Although differences in missions cannot be completely
    eliminated, DOD officials in North Chicago said that using a phased
    approach to integrate staff, facilities, and services gave both VA and
    DOD the time to adjust to each other's staff, culture, and operations.

    * Staffing uncertainties could affect joint venture operations:
    Staffing uncertainties, such as those resulting from changes in
    leadership or the deployment of DOD personnel, can affect the
    continuity and quality of care and access to care for veterans. At the
    VA-DOD joint ventures, DOD's top-level administration rotates command
    about every 2 years, requiring VA to continually "sell" the concept of
    a joint venture to the new leadership, according to a VA official. LSU
    officials also noted that academic affiliates can experience frequent
    leadership turnovers. To facilitate a smooth transition, officials at
    one of the VA-DOD sites said that they hold transition briefings, while
    officials at other sites recommended maintaining documentation of joint
    policies and decisions to help the new leadership understand the
    ongoing operational agreements. Officials at most of the VA-DOD sites
    also discussed the concerns raised by the deployment of key DOD medical
    personnel and its potential negative effect on services--that is, when
    DOD personnel are deployed, the joint venture may not be able to
    maintain the same level of services or patient load. Although officials
    at some of the VA-DOD sites said that the integrated operations of the
    joint venture helped mitigate concerns about the potential impact of
    deployment, VA officials in Albuquerque said that they decided to
    mitigate these concerns by eliminating the joint staffing model and
    moving to an arrangement under which DOD purchases care from VA.

    * Joint ventures may result in a loss of identity or control: A joint
    venture could diminish VA's identity by changing a VA medical center
    from a facility that treats only veterans to a facility with a mixed
    patient population that is served by providers from different health
    care systems. The same would be true for the DOD and academic affiliate
    partners. Since the identity of a VA medical center as a veteran's
    hospital is important to veterans, initial construction proposals for
    joint ventures between VA and its academic affiliates in Charleston,
    Denver, and New Orleans included options to construct separate bed
    towers for VA and the academic affiliate. Another potential concern is
    the loss of some level of control. Because a joint venture binds the
    participating organizations together, one joint venture partner can be
    affected by the other partner's actions or circumstances--from
    deployments to changes in leadership or priorities. To mitigate this
    concern, joint venture partners recommended having governance and
    contingency plans that delineate roles and responsibilities, establish
    lines of authority, and identify work-arounds, among other things.

    * Joint ventures may create dependencies: When partners enter into a
    joint venture, a concern exists that they may become dependent on each
    other for equipment and services and not have immediate access to
    necessary equipment or services if the joint venture arrangement is
    disrupted or dissolved. For example, VA officials in El Paso said one
    of their primary concerns is that VA patients will become dependent on
    services provided by DOD, which could be interrupted or discontinued in
    the event of a military realignment or deployment. To handle this
    uncertainty, VA officials said that it is important to have back-up
    plans for the provision of health care and to maintain relationships
    with other health care providers in the community. Also, as we have
    previously noted, VA officials said the El Paso VA office has developed
    contingency plans, which are reviewed daily, to ensure that care is not
    delayed or denied to any veteran. LSU representatives also stated that
    in addition to considering what services and equipment can be shared in
    a proposed joint venture with VA, it is important to consider how the
    partners would separate or discontinue such sharing, if necessary, in
    the future.

    * Joint ventures may pose financial risks: Although joint ventures are
    often viewed as a way to avoid costs by pooling resources, joint
    ventures also raise some financial concerns, such as the possibility of
    incurring additional costs. For example, VA officials from two of the
    eight VA-DOD sites said that certain aspects of the joint venture have
    resulted in additional costs for their organizations. In addition, a
    feasibility study conducted by VA and MUSC on the proposed joint
    venture in Charleston showed that VA would not earn a positive return
    on investment on any of the joint venture options. Furthermore, joint
    ventures may have additional costs associated with the projects that
    would not occur otherwise. For example, a representative from MUSC said
    that the federal homeland security requirements that apply to a
    facility's construction and operations and other security
    considerations, which would apply to MUSC in a VA-MUSC joint venture,
    would add to the overall cost of the project for MUSC. In addition,
    joint ventures between federal and nonfederal organizations face more
    public scrutiny, because of concerns that the federal government may be
    viewed simply as a source of capital funding or may be financially
    taken advantage of by the nonfederal partner. To mitigate some of these
    financial concerns, the VA medical center director in New Orleans
    stated that joint venture partners should agree that neither partner
    should make a profit from the joint venture arrangement.

    VA Does Not Use Performance Measures to Routinely or Comprehensively
    Document and Assess Outcomes of Joint Ventures at the Local or
    Department Level:

    Although VA and DOD officials at existing joint venture sites
    identified a number of benefits and concerns associated with joint
    ventures, they stated that they do not use performance measures to
    routinely or comprehensively document and assess the outcomes of the
    joint ventures. For example, VA and DOD officials told us that they do
    not use performance measures to assess the extent to which the joint
    ventures produce the identified benefits, such as improved care or
    lower costs. VA and DOD officials at several joint venture sites said
    that they have information, such as patient referral rates, wait times
    and satisfaction survey data, as well as workload and financial
    statistics that could be used to indicate how the joint ventures are
    performing. However, officials do not use the information to routinely
    or comprehensively document and measure the results of the joint
    ventures for a number of reasons, including the following:

    * The VA-DOD sites have competing priorities for the limited resources
    that would be required to conduct such assessments, according to
    officials from several sites.

    * Officials at the VA-DOD sites said that differences in their computer
    systems and business processes can limit their ability to conduct such
    assessments.

    * VA officials said that since all of the existing joint ventures with
    DOD have been congressionally directed, there is little incentive to
    document or measure the results of the joint ventures.

    * VA officials noted that they are not required to conduct assessments.

    Officials at some VA-DOD joint venture sites have done one-time studies
    assessing certain aspects of the joint venture. For example, DOD
    officials in Albuquerque said they commissioned a study of the cost of
    services provided in their network compared with the cost of services
    provided through the joint venture with VA.[Footnote 24] Officials at
    several sites also provided examples of projected cost savings
    associated with JIF projects, which require business case analyses.
    However, VA and DOD officials at all of the VA-DOD joint venture sites
    said that they do not routinely or comprehensively assess the outcomes
    of the joint ventures. Rather, several VA and DOD officials said they
    intuitively knew they were saving money as a result of the joint
    venture, but they were unable to provide data to support this belief.
    Without comprehensive, supporting evidence, the extent to which the
    cited outcomes have been achieved at joint venture sites is largely
    unknown.

    From a department-level strategic planning perspective, VA has broadly
    defined what the joint ventures are to accomplish and identified some
    strategies it will use to achieve the desired results. However, VA does
    not use performance measures at the department level to determine what
    is being achieved through its joint ventures and how well VA succeeds
    in reaching the goals and achieving the desired outcomes. We have
    previously reported that performance measures are a valuable tool for
    holding agencies accountable for results, tracking progress toward
    agency goals, and giving managers crucial information on which to base
    their organizational and management decisions.[Footnote 25] Although VA
    has over a hundred performance measures that it uses to centrally
    monitor agency programs and activities, it does not have specific
    measures for its joint venture activities. The 2003 Presidential Task
    Force to Improve Health Care Delivery for Our Nation's Veterans also
    found that none of VA's and DOD's performance metrics measured the
    depth and breadth of VA-DOD collaboration and sharing, or the impact of
    successful collaboration on various health care indicators, such as
    improved access or reductions in the overall cost of furnishing
    services. Similarly, in March 2006, we found that VA and DOD had not
    established specific quantitative performance measures to track the
    progress of their health care resource-sharing activities.[Footnote 26]
    We concluded that such measures would be a useful tool for VA to help
    ensure that health care sharing is optimized, and that the departments
    are cost-efficiently achieving their resource-sharing goals.
    Furthermore, we recommended that VA develop performance measures that
    would be useful for determining the progress of their health care
    resource-sharing goals. Performance measures could also help VA use the
    existing joint ventures as laboratories for developing future
    interdepartmental policy frameworks, as recommended by the 2003
    presidential task force, by allowing VA to assess what is being
    achieved through the joint venture, including what is and what is not
    working.

    Officials Identified Lessons Learned from Their Experiences with
    Existing and Proposed Joint Ventures:

    Officials from VA and DOD and representatives from academic affiliates
    identified several lessons they have learned from their experiences
    with the existing and proposed joint ventures. These lessons included
    establishing joint committees to work through issues, communicating
    frequently with their partner, securing leadership buy-in and support
    at all levels, developing contingency plans, allowing adequate time to
    implement change, and establishing clear roles and responsibilities.

    * Establish joint committees to work through issues: Officials at many
    of the joint venture locations said that establishing joint committees
    to work through the various issues that arise in developing and
    implementing joint ventures is helpful. Almost all of the sites had
    established such committees, which typically consist of an equal number
    of representatives from VA and DOD. The joint committee structure
    allows the officials to work collaboratively in tackling joint venture
    issues. For example, in North Chicago, the joint committee structure
    consists of an Executive Steering Group that is co-chaired by VA and
    DOD and six joint working groups that are responsible for specific
    issues, such as finance, information management, and clinical issues
    associated with forming their joint venture (see fig. 4). Similarly, in
    Las Vegas, all joint venture activities are addressed and monitored
    through a series of jointly staffed committees, ensuring that both VA
    and DOD have equal input into joint venture activities and decisions.
    These committees report to the leadership of the joint venture. In New
    Orleans, VA and LSU formed a joint venture coordinating committee whose
    responsibilities include identifying opportunities for sharing
    information technologies and ensuring the availability of appropriate
    staffing for all aspects of the joint venture. Our previous work on
    organizational transformation cites such benefits of establishing
    jointly staffed teams as creating opportunities for employees from the
    merging organizations to interact with each other, helping accelerate
    the merger or transformation process by allowing the parties to learn
    more about each other, and breaking down organizational silos. Teams
    composed of a cross-section of individual members can also assist in
    integrating different perspectives, flattening organizational
    structure, streamlining operations, and making it easier to work
    together on future projects.[Footnote 27]

    Figure 4: The North Chicago VA-DOD Joint Venture Local Working Groups:

    [See PDF for image]

    This figure is an organizational chart of the North Chicago VA-DOD
    Joint Venture Local Working Groups. The structure is depicted as
    follows:

    Top level:
    Executive Steering Committee:
    * VA Director and Navy Commander (co-chairs).

    Second level, reporting to the Executive Steering Committee:
    * Communications (VA and DOD co-chairs);
    * Finance/Budget (VA and DOD co-chairs);
    * Human Resources (VA and DOD co-chairs);
    * Clinical (VA and DOD co-chairs);
    * Administration (VA and DOD co-chairs);
    * Information Management/Information Technology (VA and DOD co-chairs).

    Source: GAO.

    [End of figure]

    * Frequent communication between partners is important: Officials at
    most VA and DOD sites with whom we spoke said that frequent
    communication between partners helps reduce confusion, fosters a better
    work environment, helps ensure that vital information is shared with
    affected staff, and provides opportunities for each partner to learn
    from the other. For example, at one site, officials said that frequent
    meetings between VA and DOD leadership provide a convenient platform
    for the leaders to discuss joint venture issues, resolve problems, and
    evaluate a joint strategy or vision for going forward. At another site,
    the staff meets almost daily to plan and execute decisions related to
    the joint venture. At the site of a proposed joint venture between VA
    and an academic affiliate, VA officials adopted a communications
    strategy to use in communicating with VA's potential partner,
    employees, and stakeholders. In our previous work on organizational
    transformations, we have noted that creating an effective, ongoing
    communications strategy is essential to implementing significant
    organizational changes, such as the joint ventures.[Footnote 28] Such a
    strategy helps to build an understanding of the purpose of the planned
    change and establish trust among VA and its academic affiliates and
    stakeholders, such as employees and veterans. A communications strategy
    can also help ensure that these groups receive a message that is
    consistent in tone and content. Sharing a consistent message with
    stakeholders helps reduce the perception that some are more likely than
    others to get the "real" story when, in fact, all are receiving the
    same information.

    * Leadership buy-in and support at all levels are vital: Most VA and
    DOD officials and academic affiliate representatives with whom we spoke
    said that leadership buy-in and support play a key role in the success
    of a joint venture. This lesson is consistent with our previous work on
    organizational transformation, which indicates that support from top
    leadership is indispensable for fundamental change, such as a joint
    venture entails.[Footnote 29] Top leadership's clear and personal
    involvement in the transformation represents stability for both the
    organization's employees and its external partners. Top leadership must
    set the direction, pace, and tone for the transformation. Likewise,
    when a transformation requires extensive collaboration with another
    organization, as would be the case with a joint venture, committed
    leadership at all levels is needed to overcome the many barriers to
    working across organizational boundaries. Officials noted that forming
    a joint venture is very challenging and leadership buy-in and support
    are needed to encourage the partners to work through the challenges.
    Without such commitment from the top, the officials at one VA-DOD joint
    venture site said that they would have given up on the joint venture a
    long time ago because of the number of seemingly insurmountable
    challenges. Conversely, the proposed joint venture between VA and UCH
    in Denver did not come to fruition largely because of a lack of
    leadership buy-in.[Footnote 30]

    * Contingency plans are critical: Officials from an academic affiliate
    noted that it is important that joint venture partners develop
    appropriate contingency plans to ensure continuity of service, and
    officials from many of the joint venture sites had developed such plans
    to ensure continued care for their clients. For example, VA officials
    at several sites said they have contingency plans in place--such as
    plans to send patients to other health care providers in the community-
    -in case a military deployment threatens to disrupt services or care,
    or an increased demand for care by DOD beneficiaries reduces DOD's
    ability to meet VA's demand for care to veterans. As we have previously
    reported, contingency planning is important because it identifies
    alternative activities that can be employed to ensure the continuity of
    an agency's core business operations and will greatly improve response
    efforts. Not having such a plan in place increases the risk of
    unnecessary problems in an uncertain situation.[Footnote 31]

    * Allow adequate time to introduce and implement change: Joint ventures
    represent a significant change in how VA normally conducts business. As
    a result, VA and DOD officials told us that the implementation of joint
    ventures must be managed with care. Officials at one of the VA-DOD
    joint ventures noted that forming a joint venture often takes years--
    which helps ensure that the changes are carefully considered. This
    lesson is consistent with the finding in our prior work on
    organizational transformations that successful major change management
    in large private and public-sector organizations can often take at
    least 5 to 7 years. As a result, we have previously reported that it is
    essential to establish and track implementation goals and establish a
    timeline to pinpoint performance shortfalls and gaps and suggest
    midcourse corrections.[Footnote 32] By demonstrating progress toward
    these transformation goals, the organization builds momentum and
    demonstrates that real progress is being made. Similarly, some VA and
    DOD officials recommended using a phased implementation schedule to
    help employees and stakeholders get accustomed to the changes.

    * Clearly define roles and responsibilities: Many VA and DOD officials
    and representatives from academic affiliates we interviewed said that
    clearly defining the roles and responsibilities of each joint venture
    partner helped to avoid problems such as misunderstandings,
    duplication, and confusion. Similarly, our previous work on
    collaboration between organizations suggests that agreeing on roles and
    responsibilities is important.[Footnote 33] In particular,
    collaborating organizations should work together to define and agree on
    their respective roles and responsibilities, including how the
    collaborative effort will be led. In doing so, organizations can
    clarify who will do what, organize their joint and individual efforts,
    and facilitate decision making. VA, DOD, and academic affiliates have
    used several techniques to define their roles and responsibilities. For
    example, at one VA-DOD joint venture site, officials use joint policy
    letters to document roles, responsibilities, policies, and decisions.
    These joint policy letters also help to maintain continuity during
    transitions, such as changes in the top leadership at one of the joint
    venture partners. In New Orleans, VA and LSU signed a memorandum of
    understanding that identifies the roles and responsibilities of the
    parties and provides a framework for collaboration and discussion
    between the two organizations on a proposed joint venture. Figure 5
    shows the VA-LSU memorandum of understanding and highlights the
    specific roles and responsibilities of the parties.

    Figure 5: The VA-LSU Memorandum of Understanding for the Joint Venture:

    [See PDF for image]

    This figure depicts an illustration of the VA-LSU Memorandum of
    Understanding for the Joint Venture, with the following sections
    highlighted:

    3.0 Authority:

    3.1 Under 38 USC � 513, the Secretary of Veterans Affairs may �enter
    into contracts or agreements with private or public agencies or
    persons�for such necessary services�as the Secretary may consider
    practicable.�

    3.2 Pursuant to 38 USC � 8153, when the Secretary determines it to be
    in the best interest of the prevailing standards of the Department [of
    Veterans Affairs] medical care program, he may make arrangements, by
    contract or other form of agreement for the mutual use or exchange of
    use, of health-care resources between Department health-care facilities
    and any health-care provider, or other entity or individual.

    3.3 Pursuant to Article 8, Section 7 of the Louisiana Constitution, the
    Board of Supervisors of Louisiana State University and Agricultural and
    Mechanical College (Board) is granted authority to supervise and manage
    the institutions statewide and other programs administered through its
    system. The LSU Health Care Service Division is a part of the LSU
    System.

    4.0 Roles And Responsibilities Of The Parties:

    4.1 The Parties shall draft a Charter for a study group to be known as
    VA/LSU Collaborative Opportunities Study Group (COSG) for New Orleans
    (the �Group�).

    4.2 Subject to federal law, regulation and VA policy, the VA shall
    commit the appropriate resources (time, assets, personnel, etc.) to the
    formation and support the ongoing functioning of the Group.

    4.3 Subject to law, regulation and LSU policy, LSU shall commit the
    appropriate resources(time, assets, personnel, etc.) to the formation
    and the ongoing functioning of the Group.

    4.4 The Parties understand that other entities or organizations may
    have an interest in the goals and activities described in this MOU. In
    recognition of this, the Parties will invite the participation of other
    entities, organizations or associations as determined by the group.

    4.5 The Parties agree that the Group shall be tasked to study the
    following areas of mutual interest:

    4.5.1 The present and future demographics of the City of New Orleans
    (�City�) and metropolitan New Orleans area [�Region];

    4.5.2 The present and future need for LSU and VA health care services,
    medical research and medical education in the City and Region;

    4.5.3 An analysis of the present and future need for LSU and VA
    primary, tertiary, specialty and emergency health care services in the
    City and Region;

    4.5.4 Evaluation of state-of-the-art joint and collaborative health
    care delivery models, including the model known as the Texas Medical
    Center;

    4.5.5 An analysis of proposed sites and locations for future LSU and VA
    health care facilities, research and educational facilities in the City
    and Region, including analysis of sites for joint and collaborative
    facilities;

    4.5.6 An analysis of how the VA/LSU collaboration can contribute to the
    National and Louisiana advancement of health care services, in
    cooperation with medical education.

    Source: New Orleans VA officials and GAO.

    [End of figure]

    VA Has Taken Steps to Evaluate Proposed Joint Ventures, but Additional
    Efforts Are Needed:

    VA has taken steps to evaluate proposed joint ventures. For example, VA
    established working groups in Charleston and New Orleans to examine
    joint venture proposals with academic affiliates. In addition, in
    response to our previous recommendations,[Footnote 34] VA developed and
    issued criteria for evaluating joint venture proposals in November
    2007. However, VA's evaluation criteria are not sufficiently specific
    to ensure consistent evaluations of proposals, and are not sufficiently
    tailored to ensure the appropriate level of review.

    VA Has Taken Steps to Better Evaluate Proposed Joint Ventures:

    VA has undertaken steps to better assess proposed joint ventures.
    Specifically, in response to our recommendations, VA developed criteria
    for evaluating joint venture proposals at the department
    level.[Footnote 35] The criteria are contained in a handbook that VA
    issued in November 2007. The handbook represents an important step
    toward better assessing proposed joint ventures and managing existing
    joint ventures in that, among other things, it details departmental
    policy on joint ventures, defines joint ventures, identifies the
    process for reviewing and approving joint venture proposals, and
    outlines criteria for use in evaluating joint venture proposals--none
    of which had previously been developed, documented, or shared with
    joint venture partners. Developing evaluation criteria is a notable
    step because, as we have previously noted, the absence of criteria at
    the department level to evaluate joint venture proposals can result in
    inconsistent evaluations, misunderstandings, and delays.[Footnote 36]
    According to VA, the handbook was developed by a working group of over
    50 officials from various offices and levels within VA. The working
    group used a variety of methods to identify the evaluation criteria,
    including soliciting ideas from VA officials, identifying and analyzing
    relevant statutes and regulations, and reviewing related published
    research.

    As outlined in the November 2007 handbook, VA's evaluation criteria
    will be applied in a two-phase review process and will be applicable to
    all joint venture proposals, including those involving DOD, academic
    affiliates, and other health care providers.

    * Phase I: The first review phase is the initial evaluation of a joint
    venture proposal. In this phase, VA officials apply a set of criteria,
    referred to as the screening criteria, to determine if the proposal
    will be submitted to the department level for consideration. Depending
    on how well the proposal meets the criteria, VA officials assign it a
    pass or fail rating. If the proposal receives a pass rating, it moves
    to the second review phase.

    * Phase II: In the second phase, VA officials apply a more robust set
    of criteria, referred to as comprehensive criteria, to determine if the
    proposal will be submitted to the VA Secretary for consideration. If
    the proposal passes the second phase of review, it will be folded into
    VA's capital investment and budget processes and will compete with
    other projects for funding. The Secretary will make the final decision
    regarding whether VA will pursue the joint venture.

    In addition to developing the evaluation criteria, VA has taken other
    steps to better evaluate proposed joint ventures. For example, VA
    established Collaborative Opportunities Steering Groups and
    Collaborative Opportunities Planning Groups to study the proposed joint
    ventures with its academic affiliates in Charleston and New Orleans.
    The study groups were tasked with analyzing what, if any, mutually
    beneficial sharing and contracting could be done with each academic
    affiliate. Composed of VA officials and representatives from the
    respective academic affiliate, the study groups assessed a range of
    issues, including sharing options and the clinical, legal, and
    financial considerations associated with the different sharing options.
    The study groups were charged with issuing their findings to VA and the
    respective academic affiliate, which they did in a series of
    reports.[Footnote 37] The study groups did not make recommendations,
    but rather they laid out the advantages and disadvantages of the
    different options examined.

    VA's Evaluation Criteria Are Less Useful Than They Could Be:

    VA's development of criteria for evaluating joint venture proposals
    represents a step forward in VA's process for assessing joint venture
    proposals. However, the evaluation criteria are less useful than they
    could be.

    * The evaluation criteria are not sufficiently specific--in terms of
    both the definition and the application of the criteria: VA defined
    most of the screening and comprehensive criteria by outlining the
    different elements that make up each criterion. While this information
    is instructive, key elements of some of the criteria are sometimes not
    defined. For example, one of the screening criteria is "serendipitous
    win-wins." Other than instructing VA officials to determine if the
    proposal offers "unique promise and advantages for enhancing quality,"
    this term is not defined, and there are no examples of what might be
    considered a "serendipitous win-win" arrangement. Furthermore, although
    the handbook identifies a host of criteria that VA officials should
    consider in evaluating joint venture proposals, it generally does not
    provide guidance on whether certain criteria are more important than
    others or how each criterion will be used to make an overall
    assessment. For example, it is unclear whether all 4 screening
    criteria, plus their 18 sub-elements, must be met to receive a passing
    rating. The lack of specificity in the definition and application of
    the evaluation criteria could lead to inconsistent evaluations of joint
    venture proposals--thereby reducing the value of having such criteria
    in place.

    VA officials noted that the lack of specificity in the evaluation
    criteria reflects, in part, their view of a primary purpose of the
    criteria. Specifically, they noted that for the working group, a
    primary purpose of the criteria was to inform potential partners about
    VA's requirements for joint venture proposals. VA officials further
    noted that their familiarity with the processes involved in preparing
    proposals for community outpatient clinics and joint incentive
    projects, among other things, will help them to apply the criteria. We
    recognize the usefulness of the criteria as a communication tool and
    considered their usefulness for this purpose when we previously
    recommended that VA develop evaluation criteria and share them with
    proposed joint venture partners.[Footnote 38] In addition, we recognize
    that VA officials' experience with related processes will be useful in
    applying the criteria. However, our purpose in previously recommending
    that VA develop evaluation criteria was to ensure that proposals are
    evaluated consistently across the country. Given that multiple VA
    officials will be using the criteria to evaluate joint venture
    proposals, increasing the specificity of the criteria--by fully
    defining their key elements and the process for applying them--will
    help ensure that the criteria are applied consistently. Furthermore,
    given the magnitude of joint ventures compared with other projects,
    such as joint incentive projects, additional specificity in how to
    apply the criteria seems warranted.

    * The criteria are not tailored for the different types of joint
    ventures: VA plans to apply the same criteria and review process for
    all joint venture proposals, including those with DOD, academic
    affiliates, and other health care providers. However, according to some
    VA and DOD officials we interviewed, there are fundamental differences,
    risks, and experiences between joint ventures with DOD and joint
    ventures with other partners that should be taken into account. For
    example, since VA and DOD are federal departments, both are accustomed
    to working within the federal framework and following federal laws,
    regulations, guidance, and procedures--which may not be the case for
    academic affiliates or other health care providers. Furthermore, both
    VA and DOD follow the same federal appropriation cycle--which can help
    to synchronize joint investments. In contrast, academic affiliates or
    other health care providers may use a different fiscal year. In
    addition, federal law governs the availability of federal funds--and
    provides safeguards in the use of those funds, which helps mitigate
    some of the potential financial risks involved with a joint venture.
    For example, appropriation law provides that appropriated funds are
    available only for the objects for which the appropriations were made,
    except as otherwise provided by law.[Footnote 39] Thus, VA and DOD can
    spend their appropriated funds only to meet the health care needs of
    their beneficiaries, and neither department is permitted to pay for the
    health care needs of the other department's beneficiaries. In addition,
    the Sharing Act provides for the department providing the health care
    services to be reimbursed for the cost of the services under a rate of
    reimbursement determined by the two departments. Finally, VA and DOD
    have experience developing and implementing joint ventures, whereas VA
    has not developed a joint venture with any other health care provider.
    While some of the criteria that VA has found most useful in working
    through the challenges of forming joint ventures with DOD may be
    applicable to forming joint ventures with academic affiliates or other
    health care providers, other criteria may be less applicable or some
    potentially useful criteria may be lacking.

    Conclusions:

    A number of potential benefits are associated with joint ventures,
    including improved access to care and reduced costs. As a result,
    Congress and the administration have encouraged joint ventures between
    VA and DOD and, more recently, between VA and academic affiliates as a
    cost-effective means to stretch limited resources and replace aging
    infrastructure. However, comprehensive information is not readily
    available on whether joint ventures actually produce all of the
    identified benefits. Specifically, VA does not use performance measures
    at the local or department level to routinely or comprehensively assess
    the outcomes of its existing joint ventures, leaving VA with only
    limited and anecdotal information on the outcomes of joint ventures.
    While some of the benefits of joint ventures, such as gaining economies
    of scale, may be intuitive, and the anecdotal examples provided by
    officials at different joint venture sites suggest that some benefits
    are being achieved, the magnitude and extent of such benefits are
    unknown. Routine and comprehensive information on what is being
    achieved through the joint ventures could help VA leadership and
    policymakers make more informed decisions about how to improve the
    performance of existing joint ventures as well as whether to pursue
    different joint venture opportunities in the future.

    VA's effort to develop criteria for evaluating joint venture proposals
    is a positive step in improving VA's process for assessing joint
    venture proposals. However, without more specific criteria for
    evaluating future joint venture proposals, VA may not improve the
    consistency of its evaluations as we intended when we recommended that
    VA develop evaluation criteria. Given the long-term and resource-
    intensive nature of joint ventures, it is critical that VA have robust
    criteria that can be consistently applied to distinguish proposals that
    are in the best interest of our nation's veterans and the federal
    government from those proposals that are not. Furthermore, although the
    intent of our previous recommendations was to ensure consistency in the
    evaluation of joint venture proposals, we also recognize that each
    proposal could have unique aspects and should be evaluated on its
    merits and circumstances. To the extent that the application of a
    single set of criteria to all joint venture proposals excludes
    consideration of unique but important aspects of individual proposals,
    VA may overlook differences among different types of prospective joint
    venture partners that should be taken into account.

    Recommendations for Executive Action:

    To develop a more comprehensive framework for evaluating existing and
    future joint ventures, we recommend that the Secretary of Veterans
    Affairs take the following three actions:

    * Develop departmental performance measures to assess the outcomes of
    joint ventures and to determine the extent to which strategic goals are
    being achieved.

    * Revise the evaluation criteria for joint venture proposals to ensure
    they are measurable and specific--both in terms of definition and
    application.

    * Analyze the differences among types of joint venture partners to
    determine whether the evaluation criteria should be tailored to the
    type of partner (e.g., DOD or academic affiliate) and, if so, tailor
    the criteria accordingly.

    Agency Comments:

    We provided a draft of this report to VA and DOD for review and
    comment. VA and DOD provided written comments on a draft of this
    report, which are reprinted in appendixes II and III, respectively. VA
    generally agreed with our findings, conclusions, and recommendations.
    VA stated that the report is consistent with VA's direction and ongoing
    work toward enhancing existing and future joint ventures. As part of
    this ongoing work, VA's Joint Ventures Working Group is reviewing
    existing performance measures to develop specific measures for joint
    venture activities and will facilitate incorporation of the measures
    into VA's established processes. In addition, the working group will
    review and refine the proposed evaluation guide on a continual basis.
    Also, DOD generally agreed with the report's overall findings. The
    departments provided technical comments, which we have incorporated as
    appropriate.

    We are sending copies of this report to congressional committees with
    responsibilities for veterans' issues; the Secretary of Veterans
    Affairs; the Secretary of the Department of Defense; and the Director,
    Office of Management and Budget. We also will make copies available to
    others upon request. In addition, this report will be available at no
    charge on GAO's Web site at [hyperlink, http://www.gao.gov].

    If you or your staff have any questions on matters discussed in this
    report, please contact me on (202) 512-2834 or at williamsonr@gao.gov.
    Contact points for our Offices of Congressional Relations and Public
    Affairs may be found on the last page of this report. Key contributors
    to this report are listed in appendix IV.

    Sincerely yours,

    Signed by:

    Randall Williamson:
    Acting Director, Physical Infrastructure Issues:

    [End of section]

    Appendix I: Objectives, Scope, and Methodology:

    This report discusses the (1) potential benefits and concerns
    associated with joint ventures and the extent to which they are
    documented and measured, (2) lessons learned from existing and proposed
    Department of Veterans Affairs (VA) joint ventures with academic
    affiliates and the Department of Defense (DOD), and (3) steps VA has
    taken to better evaluate proposed joint ventures.

    To address these objectives, we used a combination of site visits and
    semistructured interviews to obtain information for all eight existing
    VA-DOD joint ventures and for the three proposed joint ventures between
    VA and academic affiliates. Specifically, we visited three existing VA-
    DOD joint ventures in El Paso, Texas; Las Vegas, Nevada; and North
    Chicago, Illinois. We also visited New Orleans, Louisiana, the site of
    a proposed joint venture between VA and the Louisiana State University
    (LSU) Health Care Services Division.[Footnote 40] We used several
    criteria to select these sites, including geographic dispersion, the
    maturity of the partnership, the nature of the shared services, the
    organizations involved in the partnership (e.g., the branch of the
    military), the structure or framework of the partnership, and the
    perceived effectiveness of the partnership. We conducted semistructured
    telephone interviews with officials from the remaining existing and
    proposed joint ventures.[Footnote 41] During the site visits and
    telephone interviews, we interviewed the parties involved in the
    existing or proposed joint ventures, including VA and DOD officials and
    representatives from the academic affiliates. We also performed a
    content analysis of the information we collected through the site
    visits and semistructured interviews to determine the benefits and
    concerns associated with joint ventures, as well as the lessons learned
    in developing joint ventures that were commonly cited by the officials
    involved in the VA joint ventures. We also interviewed department-level
    officials from VA and DOD and representatives from several veterans
    service organizations, including Disabled American Veterans, the
    Paralyzed Veterans of America, and the American Legion.

    In addition to conducting the site visits and semistructured
    interviews, we reviewed agency documentation, reports, studies, and
    analyses on existing and proposed VA joint ventures so that we could
    report on any issues or concerns associated with jointly planning,
    constructing, and sharing a medical center. For example, we reviewed
    the VA Strategic Plan Fiscal Year 2006-2011, the VA 5-Year Capital Plan
    Fiscal Year 2005-2010, the VA-DOD Joint Executive Council Strategic
    Plan Fiscal Year 2007-2009, VA-DOD Joint Executive Council annual
    reports, the VA-MUSC Collaborative Opportunities Steering Group final
    report, and the VA-LSU Collaborative Opportunities Study Group report.
    We reviewed legal authorities governing the sharing of health resources
    between VA and DOD, and VA and its academic affiliates, including
    appropriation and fiscal law authorities.

    To identify criteria for possible use in evaluating joint ventures and
    to help us assess the comprehensiveness of VA's criteria, we reviewed
    published research and studies, including GAO reports, on public-
    private partnerships; best practices in collaboration, partnering, and
    organizational transformation; and evaluation criteria. To identify
    applicable studies focusing on public-private partnerships for
    constructing joint public facilities or hospitals similar to VA's joint
    venture partnerships, we searched literature databases using the
    following criteria: (1) studies that identified any benefits and risks
    associated with forming public-private partnerships for hospitals or
    federal buildings, with a focus on cost savings or risk management; (2)
    studies that provided lessons learned from previous health-care-
    related, public-private partnerships, including any factors
    contributing to challenges or successes; and (3) studies that provided
    guidelines or evaluative criteria that could be used to evaluate a
    health-care-related, public-private partnership. After identifying the
    studies, we reviewed each study to determine its relevance and
    applicability to our objectives and to ensure the methodological
    soundness of the non-GAO studies.

    We conducted this performance audit from May 2007 through March 2008 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.

    [End of section]

    Appendix II: Comments from the Department of Veterans Affairs:

    The Secretary Of Veterans Affairs:
    Washington:

    February 29, 2008:

    Mr. Randall Williamson:
    Acting Director, Physical Infrastructure Issues:
    U. S. Government Accountability Office:
    441 G Street, NW:
    Washington, DC 20548:

    Dear Mr. Williamson:

    The Department of Veterans Affairs (VA) has reviewed the Government
    Accountability Office's (GAO) draft report, VA Health Care: Additional
    Efforts to Better Assess Joint Ventures Needed (GAO-08-399) agree with
    GAO's conclusions and concur with GAO's recommendations. GAO has
    generally provided a helpful document, which is consistent with VA's
    direction and ongoing work toward enhancing existing and future joint
    ventures.

    The enclosure specifically addresses each of GAO's recommendations and
    provides comments to the draft report. VA appreciates the opportunity
    to comment on your draft report.

    Sincerely yours,

    Signed by:

    James B. Peake, M.D.

    Enclosure:

    Department of Veterans Affairs (VA) Comments to Government
    Accountability Office (GAO) Draft Report:
    VA Health Care: Additional Efforts to Better Assess Joint Ventures
    Needed (GAO-08-399):

    To develop a more comprehensive framework for evaluating existing and
    future joint ventures, GAO recommends that the Secretary of Veterans
    Affairs take the following three actions:

    * Develop departmental performance measures to assess the outcomes of
    joint ventures and to determine the extent to which strategic goals are
    being achieved.

    Concur -- VA established the Joint Ventures Working Group under the VA
    Strategic Management Council in 2007. The Working Group has become a
    successful collaboration involving more than 60 subject matter experts
    from the Veterans Health Administration (VHA), Veterans Benefits
    Administration, National Cemetery Administration, staff offices and VHA
    field officials working with joint ventures. The Working Group is
    reviewing existing performance measures and working closely with VA
    field officials to develop specific measures for joint venture
    activities.

    Proper development of performance measures requires a detailed
    understanding of operational requirements as well as strategic
    management processes. This is especially true across departmental
    structures, processes, and authorities for VA and DoD joint ventures
    and potentially across public and private structures, processes, and
    authorities for VA and academic affiliate joint ventures.

    In addition, the Working Group is facilitating ongoing VA systems'
    enhancements that are integral to improving resource-sharing and joint
    venture operations between VA and DoD or academic affiliates, as well
    as improved performance measures. As part of this ongoing analysis, the
    Working Group will develop additional departmental performance measures
    to assess the outcomes of joint ventures and to determine the extent to
    which strategic goals are being achieved. The Working Group will
    facilitate incorporation of measures into established processes
    including review for potential enhancement of measures on a continual
    basis. The Working Group will provide the VA Strategic Management
    Council (SMC) with the proposed departmental measures for its review by
    the end of FY 2008.

    * Revise the evaluation criteria for joint venture proposals to ensure
    they are measurable and specific-both in terms of definition and
    application.

    Concur � The Working Group designed a new Departmental process for
    evaluating joint venture proposals and documented it in VA Handbook
    0311, Joint Ventures Program. The Working Group is beginning to employ
    the application process. This effort will include an analysis to
    determine whether evaluation criteria for joint venture proposals need
    to be more measurable and specific in terms of both definition and
    application. In addition, the Working Group plans to develop an
    evaluation guide to ensure optimal application of evaluation criteria.

    The Working Group will provide its analysis and the proposed evaluation
    guide to the VA SMC by the end of FY 2008. This is a new departmental
    process, which the Working Group will review and refine on a continual
    basis.

    * Analyze the differences between types of joint venture partners to
    determine whether the evaluation criteria should be tailored to the
    type of partner (e.g., DOD or academic affiliate) and, if so, tailor
    the criteria accordingly.

    Concur -- The Working Group will analyze the differences between the
    types of joint venture partners and determine how tailoring of criteria
    may be appropriate. The Working Group will provide their analysis and
    recommendations to the VA SMC by the end of FY 2008.

    [End of section]

    Appendix III: Comments from the Department of Defense:

    The Assistant Secretary Of Defense:
    Health Affairs:
    1200 Defense Pentagon:
    Washington, DC 20301-1200:

    March 12, 2008:

    Mr. Randall Williamson:
    Assistant Director, Physical Infrastructure Issues:
    U.S. Government Accountability Office:
    441 G Street, NW:
    Washington, DC 20548:

    Dear Mr. Williamson:

    This is the Department of Defense response to the Government
    Accountability Office (GAO) draft report, "VA Health Care: Additional
    Efforts to Better Assess Joint Ventures Needed," dated February 4, 2008
    (GAO Code 541033/GAO-08-399).

    Thank you for the opportunity to review and comment on the draft
    report. The Department concurs with the report's overall findings.
    Attached are our technical comments for your review and consideration.

    My points of contact for additional information are Mr. Ken Cox
    (Functional) at (703) 681-4258, and Mr. Gunther Zimmerman (Audit
    Liaison) at (703) 681-3492.

    Sincerely,

    Signed by:
    S. Ward Casscells, MD:

    Attachment: As stated:

    [End of section]

    Appendix IV: GAO Contact and Staff Acknowledgments:

    GAO Contact:

    Randall Williamson, (202) 512-2834 or williamsonr@gao.gov:

    Staff Acknowledgments:

    In addition to the individual named above, Nikki Clowers, Assistant
    Director; Vashun Cole; Elizabeth Curda; Jennifer DuBord; Elizabeth
    Eisenstadt; Cindy Gilbert; Alexander Lawrence; Susan Michal Smith; and
    James Musselwhite Jr. made key contributions to this report.

    [End of section]

    Footnotes:

    [1] The Sharing Act has been amended several times since 1982 and is
    codified at 38 U.S.C. � 8111.

    [2] Health care services shared under these agreements include
    inpatient and outpatient care; ancillary services, such as diagnostic
    and therapeutic radiology; dental care; pharmacy services; and
    specialty care services, such as treatment for spinal cord injuries.
    Shared support services include administration and management,
    research, education and training, patient transportation, and laundry.

    [3] The Presidential Task Force to Improve Health Care Delivery for Our
    Nation's Veterans was established by Executive Order 13214 in 2001 to
    promote resource sharing between VA and DOD.

    [4] 38 U.S.C. �� 8151-8153.

    [5] Veterans Health Care, Capital Asset, and Business Improvement Act
    of 2003, Pub. L. No. 108-170 � 232, 117 Stat. 2042, 2052-2053 (2003).

    [6] Veterans Benefits, Health Care, and Information Technology Act of
    2006, Pub. L. No. 109-461, � 801, 120 Stat. 3403, 3442 (2006).

    [7] In our Louisiana site visit, we also interviewed representatives
    from Tulane University about the proposed joint venture. Although the
    Tulane University Health Sciences Center does not have an ownership
    stake in the joint venture project, the university does have
    representatives involved in the process because it has working
    relationships with VA and LSU.

    [8] The remaining VA-DOD joint ventures were located in Anchorage,
    Alaska; Albuquerque, New Mexico; Fairfield, California; Honolulu,
    Hawaii; and Key West, Florida. The remaining proposed joint ventures
    between VA and academic affiliates involve (1) the Medical University
    of South Carolina and (2) the University of Colorado at Denver and
    Health Sciences Center and the University of Colorado Hospital.

    [9] The management of VA's facilities is decentralized to 21 regional
    networks referred to as Veterans Integrated Service Networks
    (networks).

    [10] In addition to joint venture sharing agreements, VA and DOD
    participate in local sharing agreements and national sharing
    initiatives. Local sharing agreements allow VA and DOD to take
    advantage of their facilities' capacity to provide health care by being
    providers of health services, receivers of health services, or both.
    National sharing initiatives are designed to achieve greater
    efficiencies, that is, to lower cost and improve access to goods and
    services when they are acquired on a national level, rather than by
    individual facilities--for example, VA and DOD jointly purchase
    pharmaceuticals and surgical instruments for nationwide distribution.

    [11] In 1995, the University of Colorado decided to relocate its Health
    Sciences Center campus, including its affiliated UCH, from downtown
    Denver to the former Fitzsimons Army Medical Base located in nearby
    Aurora, Colorado, which was closed as part of DOD's base realignment
    and closure process. For more information on the proposed joint venture
    in Denver, see GAO, VA Health Care: Experiences in Denver and
    Charleston Offer Lessons for Future Partnerships with Medical
    Affiliates, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-472]
    (Washington, D.C.: Apr. 28, 2006).

    [12] Veterans Benefits, Health Care, and Information Technology Act of
    2006, Pub. L. No. 109-461, � 801, 120 Stat. 3403, 3442 (2006).

    [13] Veterans Benefits, Health Care, and Information Technology Act of
    2006, Pub. L. No. 109-461, � 801, 120 Stat. 3403, 3442 (2006).

    [14] For more information on the proposed joint venture in Charleston,
    see [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-472].

    [15] Veterans Benefits, Health Care, and Information Technology Act of
    2006, Pub. L. No. 109-461, � 801, 120 Stat. 3403, 3442 (2006).

    [16] The Bob Stump National Defense Authorization Act for Fiscal Year
    2003 (NDAA), Pub. L. No. 107-314 (2002), required VA and DOD to
    establish a joint incentive program to identify and provide incentives
    to implement, fund, and evaluate creative health care coordination and
    sharing initiatives between VA and DOD. VA and DOD refer to this
    program as the Joint Incentive Fund program. NDAA also required VA and
    DOD to establish the Health Care Resources Sharing and Coordination
    Project to serve as a test for evaluating the feasibility, advantages,
    and disadvantages of programs designed to improve the sharing and
    coordination of health care resources between VA and DOD. VA and DOD
    refer to this program as the Demonstration Site Selection program. (See
    38 U.S.C. � 8111(d) and note to 38 U.S.C. � 8111.)

    [17] 38 U.S.C. � 8111(b).

    [18] GAO, Agencies' Strategic Plans Under GPRA: Key Questions to
    Facilitate Congressional Review, [hyperlink,
    http://www.gao.gov/cgi-bin/getrpt?GAO/GGD-10.1.16] (Washington, D.C.:
    May 1997).

    [19] GAO, Program Performance Measures: Federal Agency Collection and
    Use of Performance Data, [hyperlink,
    http://www.gao.gov/cgi-bin/getrpt?GAOGAO/GGD-92-65] (Washington, D.C.:
    May 4, 1992).

    [20] 31 U.S.C. �� 1115 and 1116.

    [21] Many of the benefits of joint ventures that were identified by VA
    and DOD officials and academic affiliate representatives are similar to
    benefits associated more generally with health resource-sharing
    activities between VA and DOD. See GAO, VA and DOD Health Care:
    Resource Sharing at Selected Sites, [hyperlink,
    http://www.gao.gov/cgi-bin/getrpt?GAO-04-792] (Washington, D.C.: July
    21, 2004); and VA and Defense Health Care: Evolving Health Care Systems
    Require Rethinking of Resource Sharing Strategies, [hyperlink,
    http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-00-52] (Washington, D.C.:
    May 17, 2000).

    [22] The President's Task Force to Improve Health Care Delivery for Our
    Nation's Veterans Final Report (May 2003).

    [23] The Sharing Act states that each sharing agreement shall specify
    procedures to ensure that the availability of direct health care
    resources to individuals who are not primary beneficiaries of the
    providing department is on a referral basis and does not adversely
    affect the range of services, the quality of care, or the established
    priorities for care provided to the primary beneficiaries of the
    providing department. (See 38 U.S.C. � 8111(e)(3)(D).) When VA enters
    into an agreement with a health care provider to provide services to
    nonveterans, the Secretary must determine that veterans will receive
    priority under the agreement and ensure that an acceptable level and
    quality of services is maintained for eligible veterans at that
    facility or will result in the improvement of services to veterans at
    that facility. (See 38 U.S.C. � 8153(e).)

    [24] The study concluded that the joint venture is more cost-effective
    than using the community. However, DOD officials said this study may no
    longer be valid under a new reimbursement schedule for VA and DOD.

    [25] GAO, DOD Civilian Personnel: Improved Strategic Planning Needed to
    Help Ensure Viability of DOD's Civilian Industrial Workforce, [hyperlink,
    http://www.gao.gov/cgi-bin/getrpt?GAO-03-472] (Washington, D.C.:
    Apr. 30, 2003).

    [26] GAO, VA and DOD Health Care: Opportunities to Maximize Resource
    Sharing Remain, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-315]
    (Washington, D.C.: Mar. 20, 2006).

    [27] GAO, Results-Oriented Cultures: Implementation Steps to Assist
    Mergers and Organizational Transformations, [hyperlink,
    http://www.gao.gov/cgi-bin/getrpt?GAO-03-669] (Washington, D.C.:
    July 2, 2003).

    [28] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-03-669].

    [29] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-03-669].

    [30] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-472].

    [31] GAO, Year 2000 Computing Crisis: National Credit Union
    Administration's Efforts to Ensure Credit Union Systems Are Year 2000
    Compliant, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO/T-AIMD-98-20]
    (Washington, D.C.: Oct. 22, 1997).

    [32] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-03-669].

    [33] GAO, Results-Oriented Government: Practices That Can Help Enhance
    and Sustain Collaboration among Federal Agencies, [hyperlink,
    http://www.gao.gov/cgi-bin/getrpt?GAO-06-15] (Washington, D.C.:
    Oct. 21, 2005).

    [34] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-472].

    [35] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-472].

    [36] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-472].

    [37] VA-MUSC Collaborative Opportunities Steering Group, Ralph H.
    Johnson Veterans Affairs Medical Center and Medical University of South
    Carolina: Collaborative Opportunities Steering Group Final Report (Dec.
    7, 2005); and VA-LSU Collaborative Opportunities Study Group, New
    Orleans Collaborative Opportunities Study Group Report (June 2006).

    [38] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-472].

    [39] 31 U.S.C. � 1301(a).

    [40] In our Louisiana site visit, we also interviewed representatives
    from Tulane University about the proposed joint venture. Although the
    Tulane University Health Sciences Center does not have an ownership
    stake in the joint venture project, the university does have
    representatives involved in the process because it has working
    relationships with VA and LSU.

    [41] The remaining VA-DOD joint ventures were located in Anchorage,
    Alaska; Albuquerque, New Mexico; Fairfield, California; Honolulu,
    Hawaii; and Key West, Florida. The remaining proposed joint ventures
    between VA and academic affiliates involve (1) the Medical University
    of South Carolina and (2) the University of Colorado at Denver and
    Health Sciences Center and the University of Colorado Hospital.

    [End of section]

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