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. The administration has also encouraged such collaboration  between VA and DOD as a means to achieve more cost-effective use of  health care resources. 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. 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 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. 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. 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. 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. 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, 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. 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. 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. 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.
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.