There are 168 VA medical centers. In fiscal year  2015, VA obligated about $10.1 billion to purchase care from non-VA  providers. 3. Facility Alignment Is Affected by Shifts in Veteran Population and Care Delivery, and an Aging Infrastructure

Long-standing factors, such as shifts in the veteran population and the  delivery of care, as well as an aging infrastructure affect VA’s efforts to  fully align its real property portfolio with the veteran population. This shift in the utilization of  inpatient to outpatient services will likely result in underutilized space  once used for inpatients, as a majority of VA medical facilities were  originally designed for the delivery of inpatient care. Planning officials at five of the seven medical facilities in our review told  us it is often difficult and costly to modernize, renovate, and retrofit older  facilities—including converting inpatient facilities into outpatient facilities. Limitations in the Capital-Planning Processes Impede VA’s Alignment of Facilities with Veterans’ Needs

		VA’s SCIP Has Limitations

SCIP has several limitations in the scoring and approval process, time  frames, and access to information that can limit its utility to effectively  facilitate the alignment of facilities with veterans’ needs. According to federal standards for internal control,  agencies should identify quality information and ensure that it is  accessible. Specifically, in 2015, the Independent Assessment found that SCIP’s  scoring and approval processes and time frames, among other things,  undermined VA’s capital-planning and prioritization process. Not addressing important, known  limitations runs counter to federal standards for internal control, which  note that agencies should evaluate and determine appropriate corrective  action for identified limitations and deficiencies on a timely basis. VAIP Facility Master Plans Have Limited Usefulness Because They Do Not Adequately Consider Care in the Community, among Other Weaknesses

VA’s ongoing VAIP Process (estimated by VA officials to cost $108 million  upon completion) was designed to provide a more strategic vision for  aligning VA’s medical facilities and services with veterans’ needs. However, the facility master-planning process has several limitations,  including that it assumes that all future growth in services will be provided  directly through VA facilities without considering alternatives, including the  status quo and purchasing care from the community. Long- term costs for capital assets are particularly relevant for VA as its data  project that the number of enrolled veterans will begin to fall after 2024. Officials  who oversee the VAIP Process told us that the facility master plans’ lack  of analyses regarding care in the community was because they were  awaiting further guidance from VA on the proportion of care and types of  services to obtain from the community versus in VA facilities. The limitations of the VAIP Process’s facility master plans reduce its utility  for the VA’s planning officials to the point where some local officials said  that they do not use VAIP results and planning officials from five of the  seven medical facilities in our review told us that they already contract for  their own facility master plans, separate from VAIP. Local Approaches to Stakeholder Involvement Vary due to a Lack of VA Guidance

		VA Has Not Consistently Integrated Stakeholders into Facility Alignment Decisions

VA does not always include stakeholders in facility alignment decisions  that affect veterans’ health care. We also found that when stakeholders were not always engaged  consistently with best practices, VA’s facility alignment efforts were  challenged by external stakeholders. VA Lacks Guidance That Incorporates the Best Practice of Fully Engaging Stakeholders and Does Not Evaluate Communication Efforts

VA does not provide officials at VISNs and medical facilities with  guidance that incorporates best practices on fully engaging both internal  and external stakeholders about facility alignment decisions, or evaluate  the effectiveness of local stakeholder engagement efforts. In addition, VA officials stated that they do not monitor and evaluate their  communication methods for best practices or for the methods’  effectiveness in reaching their intended audiences. Also, VA does  not have a process for monitoring and evaluating its communication  methods, which runs counter to federal standards for internal control. Recommendations for Executive Action and Our Evaluation

To improve VA’s ability to plan for and facilitate the alignment of its  facilities with veteran needs, we recommend that the Secretary of  Veterans Affairs direct the appropriate offices and administrations to take  the following four actions:  1. 2. Develop and implement a mechanism to evaluate VISN and facility  communication efforts with stakeholders to ensure that these  communication efforts are working as intended and align with  guidance and best practices. VA partially concurred with  our first recommendation. VA fully concurred with the other three  recommendations and outlined a plan to implement them.
Why GAO Did This Study

VA operates one of the largest health care systems in the United States, with 168 VA medical centers and more than 1,000 outpatient facilities. Many of these facilities are underutilized and outdated. A previous effort aimed at modernizing and better aligning facilities was not fully implemented.
GAO was asked to review the current alignment of VA medical facilities with veterans' needs. This report examines: (1) the factors that affect VA facility alignment with veterans' needs, (2) the extent to which VA's capital-planning process facilitates the alignment of facilities with the veteran population, and (3) the extent to which VA has followed best practices by integrating stakeholders in facility alignment decisions. GAO reviewed VA's facility- planning documents and data, and interviewed VA officials in headquarters and at seven medical facilities selected for their geographic location, population, and past alignment efforts. GAO also evaluated VA's actions against federal standards for internal control and best practices for capital planning.

What GAO Found

Geographic shifts in the veteran population, changes in health care delivery, and an aging infrastructure affect the Department of Veterans Affairs' (VA) efforts to align its services and real property portfolio to meet the needs of veterans. For example, a shift over time from inpatient to outpatient care will likely result in underutilized space once used for inpatient care. In such instances, it is often difficult and costly for VA to modernize, renovate, and retrofit existing facilities given the challenges associated with these older facilities.
VA relies on the Strategic Capital Investment Planning (SCIP) process to plan and prioritize capital projects, but SCIP's limitations—including subjective narratives, long time frames, and restricted access to information—undermine VA's ability to achieve its goals. Although VA acknowledges many of these limitations, it has taken little action in response. Federal standards for internal control state that agencies should evaluate and determine appropriate corrective action for identified limitations on a timely basis. Without doing so, VA lacks reasonable assurance that its facility-alignment reflects veterans' needs.
A separate planning process—VA Integrated Planning (VAIP)—was designed to supplement SCIP and to provide planners with a more strategic vision for their medical facilities through the creation of facility master plans. However, GAO found limitations with this ongoing effort, which VA estimated to cost $108 million. Specifically, the facility master plans assume that all future growth in services will be provided directly through VA facilities without considering alternatives, such as purchasing care from the community. However, VA's use of care in the community has increased to an obligated $10.1 billion in fiscal year 2015. Federal capital-acquisition guidance identifies inefficient spending as a risk of not considering other options for delivering services. This consideration is particularly relevant as VA's data project that the number of enrolled veterans will begin to fall after 2024. Officials who oversee the VAIP process said that they were awaiting further analyses required by recently released VA guidance on the proportion of care and types of services to obtain from the community. As a result of this and other limitations, some local VA officials said that they make little use of the VAIP facility master plans and contract for their own facility master plans outside the VAIP process.
Although VA instructs local VA officials to communicate with stakeholders, its guidance is not detailed enough to conform to best practices. VA has not consistently followed best practices for effectively engaging stakeholders in facility consolidation efforts—such as in utilizing two-way communication early in the process and using data to demonstrate the rationale for facility alignment decisions. GAO found that when stakeholders were not always engaged consistently with best practices, VA's efforts to align facilities with veterans' needs were challenged. Also, VA officials said that they do not monitor or evaluate these communications efforts and, therefore, have little assurance that the methods used effectively disseminate information to stakeholders. This approach runs counter to federal standards for internal control, which instruct agencies to monitor and evaluate activities, such as communications methods.

What GAO Recommends

GAO made four recommendations, including that: VA improve SCIP's scoring and approval process among other limitations and discontinue or improve the utility of the VAIP facility master plans, and improve guidance to effectively communicate facility alignment decisions with stakeholders and to evaluate these efforts. VA partially concurred with the first recommendation and fully concurred with the other recommendations. GAO believes the recommendations are sound, as described in the report.