VHA Directive 6330

VHA Directive 6330 governs the organization’s policy management; the  June 2016 revisions established clearer definitions for national policy and  guidance documents. Specifically, the revised directive defines national policy as  a document that “establishes a definite course of action for VHA and  assigns responsibilities for executing that course to identifiable individuals  or groups.” The directive stipulates that two primary document types are  to be used for national policy—directives and notices:
Directives are to be used to establish national policy and contain  certain types of information, such as the roles and responsibilities for  each component of the organization. VHA Has Taken Steps to Align Existing National Policy Documents with New Definitions, but It Continues to Use Program Office Memos to Issue Policy VHA Is Aligning Existing Policy Documents with Its New Definitions

We found that VHA is in the process of reviewing existing national policy  documents to align with its new policy definitions as outlined in Directive  6330. However, existing guidance documents, such as program office memos,  have not been included in this review because there is no central  repository that would facilitate their identification, and the number of these  documents is unknown. Without further steps to  clarify how and when program office memos should be used, the  continued use of these memos by program offices may undermine VHA’s  efforts to implement new policy and guidance definitions, as intended. VHA Has a Standard Process for Making National Policy Documents Accessible to VISNs and VAMCs, but Lacks Such a Process for Guidance Documents VHA Has a Standard Process to Make National Policy Documents Accessible to VISNs and VAMCs

As a part of its updated Directive 6330 on national policy management,  VHA established a standard process to make national policy documents  accessible to VISNs and VAMCs. VHA Does Not Have a Process to Consistently Make Guidance Documents Accessible to VISNs and VAMCs

Unlike with national policy documents, there is no standard process used  to ensure guidance documents issued by various VHA program offices  are consistently made accessible to VISNs and VAMCs. Guidance documents, such as program  office memos, that do not go through the formal VHA review process are  not posted on VHA’s publications website and are maintained in different  ways by the program offices that develop them. Without a standard process for consistently maintaining and  disseminating guidance documents to VISNs and VAMCs, the agency  lacks assurance that staff members receive and follow the same  guidance, as intended. VHA Does Not Routinely Collect Information on Local Challenges with National Policy Implementation and Lacks Information on Policy Exemption Waivers for VAMCs VHA Does Not Consistently Collect Information on the Challenges VISNs and VAMCs Face in Implementing National Policy

VHA has not consistently solicited input on national policies either prior to  issuance or after implementation from VISNs and VAMCs. Officials from  the four VISNs and eight VAMCs in our review outlined a variety of  challenges they face when implementing national policy, including  insufficient or undefined time frames and conflicting policies on the same  topic. Resource constraints. However, VHA officials have yet to  finalize it. VHA Lacks Information on Approved Policy Exemption Waivers Because It Has Not Established a Process for Approving, Tracking, and Reassessing Them

In certain cases, when VAMCs may be unable to comply with all or part of  a national policy, program offices may approve policy exemption waivers  on an informal and ad hoc basis. No central tracking. There is no VHA requirement for  program offices to reassess issued policy exemption waivers to determine  whether they are still needed. VISNs and VAMCs in Our Review Develop and Maintain Various Local Policies, but VHA Does Not Ensure That They Align with National Policies

		VISNs and VAMCs in Our Review Develop Their Own Policies That Are Maintained Locally

Almost all of the VISNs and VAMCs in our review told us that they had  developed their own local policies. VHA Does Not Have a Process to Systematically Ensure That Local Policies Are Aligned with National Policies

VHA has not established a process for systematically ensuring that local  policies are aligned with national policies, which increases the risk of  inconsistent policy implementation across VAMCs—one of the primary  reasons that VA health care was placed on our high-risk list. Without a standard  process to ensure local policy alignment with national policy, VHA may  continue to experience inconsistent practices across its health care  system.
Why GAO Did This Study

GAO was asked to conduct a management review of VHA; this is the sixth report in the series. In this review of VHA's policy management, GAO examines the extent to which (1) VHA has implemented its new definitions for national policy and guidance documents; (2) VHA ensures that national policy and guidance documents are accessible to VISNs and VAMCs; (3) VHA collects information on local challenges with implementing national policy, including the exemptions granted when policy requirements cannot be met; and (4) local policies are developed and maintained by VISNs and VAMCs, and whether they are aligned with national policies.
GAO reviewed agency documentation, including VHA's revised directive on policy management. GAO also interviewed VHA officials involved with policy improvement efforts, as well as officials from a nongeneralizable sample of four national program offices, four VISNs, and eight VAMCs selected to provide geographic variation, among other factors.

What GAO Found

The Veterans Health Administration (VHA)—within the Department of Veterans Affairs (VA)—is taking steps to align existing national policy documents with newly revised definitions that streamline and clarify document use. According to the new definitions in its June 2016 directive on policy management, directives and notices are now the sole documents for establishing national policy; other types of documents, such as program office memos, are considered guidance. VHA is reviewing about 800 existing national policy documents to eliminate those that no longer meet its new definitions, and to rescind or recertify those that are outdated. At this time, VHA is not planning to review guidance documents, such as program office memos and standard operating procedures, to assess whether they align with its updated directive, because there is no central repository for these documents and it would be too resource intensive to locate all of them. Further, GAO's review found—contrary to VHA's updated directive—that program offices are continuing to use memos to issue policy. The continued use of program office memos to establish national policy undermines VHA's efforts to improve its policy management.
VHA has a standard process for making national policy documents accessible to VA medical centers (VAMC) and the Veterans Integrated Service Networks (VISN) to which the medical centers report, but lacks a process for making guidance documents accessible. VHA makes national policy documents accessible to all organizational levels through a publications website and e-mail distribution list as outlined in its June 2016 directive. However, GAO found that VHA has not established a similar process for program offices to make guidance documents accessible at the local level. Specifically, there is no central repository, such as a publications website, for guidance documents, and the program offices do not track or consistently disseminate the guidance documents they issue. Without a standard process for consistently maintaining and disseminating guidance, VHA lacks assurance that staff receive and follow the same guidance, as intended.
VHA does not routinely collect information on local challenges with national policy implementation or on exemption waivers. The four VISNs and eight VAMCs in GAO's review reported various challenges they face when implementing national policy, such as resource constraints and undefined time frames. In instances where VAMCs cannot meet policy requirements, program offices may approve policy exemption waivers on an ad hoc basis. However, GAO found that VHA lacks complete information on approved policy exemption waivers because it does not have a standard process for approving, tracking, and reassessing them. In recognition of this issue, VHA established a committee to develop a waiver process in June 2017.
VISNs and VAMCs in GAO's review develop and maintain various local policies, but VHA does not ensure that they align with national policies. Specifically, GAO found that VHA does not have a process for program offices to systematically ensure that local policies align with national policies. Without such a process, VHA may continue to experience inconsistent policy implementation across its health care system.

What GAO Recommends

GAO is making six recommendations to VHA, which include clarifying national policy and guidance documents, ensuring access to guidance documents, incorporating local feedback into national policy, establishing a process to approve and track policy exemption waivers, and ensuring alignment of local and national policy. VHA generally concurred with GAO's recommendations.