Offices that oversee risk management, medical investigations and internal audits within the Veterans Health Administration continue to miss the mark, lacking the horsepower needed to improve the system as a whole, according to a new report from the Government Accountability Office .
Since 2015, the VHA, the Department of Veterans Affairs‘ medical system, is on GAO’s “high risk” list, a biennial compilation that names federal programs and operations that combat waste, fraud, abuse, mismanagement or need transformation.
This year, the VHA was placed on the list again due to concerns about the offices responsible for overseeing the system, which serves 9 million veterans in 170 medical centers and more than 1,000 clinics.
Read next: US believes Navy veteran Austin Tice alive after disappearing in Syria in 2012
According to the GAO, the VHA has mostly struggled to implement the goals it set when it reorganized its oversight offices this year, including the one tasked with reviewing investigations into allegations of misconduct. medical professional and make recommendations to improve system-wide safety.
“In 2024, VHA reorganized to eliminate overlap and fragmentation of responsibilities among its (control) offices,” GAO wrote the analysts in their report published Monday. “Among other things, the reorganization highlighted VHA’s need for a workforce plan. Having a plan would help ensure these offices have the staff they need to understand what works within the health system and manage remaining risks.
But the GAO also acknowledged that the department has improved enormously over the past decade in terms of efficiency and delivery of services to veterans.
“It’s been nearly a decade since we added VA health care to GAO’s high-risk list, and over those years the VHA has taken significant steps to improve its oversight of its vast health care system “, the analysts wrote.
GAO found that the department’s Audit, Risk, and Compliance Committee, which reviews the findings of investigations into adverse medical events and alleged malpractice, did not regularly perform its duties or provide recommendations for action. system-wide improvement – a gap that could harm the quality of care at VA healthcare facilities, according to the GAO.
The report also notes that the department’s Office of Integrity and Compliance has not implemented what are considered best practices in identifying and managing risks throughout its entire system. health.
“By taking additional steps to fully adhere to best practices, VHA can better respond to risks that could potentially interfere with the timeliness and quality of veterans’ health care,” GAO analysts wrote.
And the department’s Office of Internal Audit, created in 2016 after the GAO first placed the VHA on the “high risk” list, is struggling because the government watchdog described as “an unclear hierarchical structure and oversight role.”
“By clearly defining its purpose, VHA can better ensure that its internal audit office is used effectively, for example to provide VHA leadership with information on emerging trends and issues,” they wrote.
The VHA was placed on the list in 2015, largely due to problems with providing timely, quality health care to veterans. That year, GAO made more than 100 recommendations to improve administration.
This year, the number of GAO recommendations fell to four. They include: developing a workforce plan for monitoring offices; improve risk management practices; define the objective of the VA’s internal audit efforts; and ensuring that the results of medical surveys and other assessments are used for possible system-wide improvements.
In a letter to the GAO, VA Chief of Staff Meg Kabat said the department agrees with the recommendations and will complete three of the four by 2025, the last – the risk management portion – taking place by September 2027.
According to Kabat, the VA plans to implement a multi-year process to “integrate a broad range of best practices into the proposed risk framework for the VHA.”
Related: VA flagged as ‘high risk’ agency for waste and mismanagement