1.) The directive requires each VAMC to  conduct an ongoing staffing analysis to evaluate staffing plans annually,  at a minimum, and for VAMC directors to incorporate projected staffing  needs into their annual budget review. However, VAMCs experienced problems in both the development and  execution of their staffing plans. VAMCs in Our Review Have Implemented VHA’s Nurse Staffing Methodology by Developing Staffing Plans and Taking Steps to Execute Them

The seven VAMCs in our review have implemented VHA’s nurse staffing  methodology; specifically, each of these VAMCs has developed a facility- wide staffing plan, comprised of unit-level staffing plans for inpatient units,  and has taken steps to execute it. Time required. Improvements in Nurse Staffing Were Reported When VAMCs Executed Staffing Plan Initiatives

Some VAMC staff reported improvements in the adequacy and  qualifications of their units’ nursing staff when nurse staffing plan  initiatives were executed. For example, at two VAMCs at which the  number of nurses was increased or support services for nurses, such as  patient transporters or sitters, were put in place,adequacy of the nursing staff had improved. However, some VAMC unit staff reported that unit nurse staffing  continued to be inadequate and that nurse unit assignments and job  duties were not always appropriate for their qualifications. VHA’s Oversight to Ensure Its Nurse Staffing Methodology Is Implemented, Administered Appropriately, and Contributes to an Adequate and Qualified Nurse Workforce Is Limited

Our review of VHA’s oversight of its nurse staffing methodology found  that some internal controls—those related to environmental assessment,  a plan for monitoring compliance, evaluation, timeliness of  communication, and organizational accountability—are limited. Without these internal controls in place, VHA cannot ensure that its  methodology meets department goals, such as establishing a  standardized methodology for determining adequate and qualified nurse  staffing at all VAMCs, and ultimately, having nurse staffing that is  adequate to meet veterans’ health care needs. VHA did not comprehensively assess each  VAMC to ensure preparedness for implementing its methodology,  including having the necessary technical support and resources, prior to  the issuance of the methodology directive in 2010. ONS did not develop a plan for  monitoring VAMCs to ensure they were in compliance with the  implementation and ongoing administration of Phase I of the  methodology. The lack of a plan for monitoring VAMCs’ compliance  with the implementation and ongoing administration of the methodology  hinders VHA from being able to ensure that all VAMCs are staffing their  nurses using the same, standardized methodology. Evaluation. There have been limited evaluations of the methodology, and  one of these evaluations has been significantly delayed. Timeliness of Implementation and Communication. The long timeline  for implementing the pilots and national rollouts of Phases I and II, as well  as evaluating Phase I of the staffing methodology—more than 7 years— and for communicating methodology-related information to VAMCs may  have hindered the ability of VAMCs to develop their staffing plans and to  execute the initiatives contained in those plans. VHA did not define areas of  responsibility or establish the appropriate line of reporting within the  framework of VA’s management structure for the ongoing administration  and oversight of the methodology. VHA does not require VAMCs to submit any  information or reports on the implementation and ongoing administration  of the methodology to ONS or the VISNs. Although some improvements in nurse staffing were reported  with the implementation of the staffing methodology, the seven VAMCs in  our review experienced problems developing and executing the related  staffing plans, including problems pertaining to data resources, training,  and communication. We also found that VHA’s oversight of the staffing methodology is limited  and in many cases lacks sufficient internal controls, which could diminish  VHA’s ability to ensure an adequate and qualified nurse workforce.
Why GAO Did This Study

GAO and others have raised prior concerns about the adequacy and qualifications of VHA's nurse staffing. In part to address these concerns, VHA issued a directive in 2010 requiring all VAMCs to implement a standardized methodology for determining an adequate and qualified nurse workforce, which includes developing and executing nurse staffing plans. It also requires VAMCs to use the methodology on an ongoing basis to evaluate staffing plans.
GAO was asked to provide information on nurse staffing at VAMCs. This report reviews the extent to which (1) VAMCs have implemented VHA's nurse staffing methodology, and (2) VHA oversees VAMCs' implementation and ongoing administration of the methodology. GAO reviewed documents and interviewed officials from VHA, seven VAMCs selected to ensure variation in factors such as geographic location, and regional offices for these VAMCs. GAO used federal internal control standards to evaluate VHA's oversight. GAO also interviewed representatives of veterans service organizations, nursing organizations, and unions.

What GAO Found

The seven Department of Veterans Affairs medical centers (VAMC) in GAO's review implemented the Veterans Health Administration's (VHA) nurse staffing methodology, experienced problems developing and executing the related nurse staffing plans, and some reported improvements in nurse staffing. Specifically, GAO found that each of the seven VAMCs had developed a facility-wide staffing plan—which outlines initiatives needed to ensure appropriate unit-level nurse staffing and skill mix—and taken steps to execute it. However, VAMCs experienced problems—such as lack of data resources and difficulties with training—in both the development and execution of their staffing plans. Some VAMC staff reported improvements in the adequacy and qualifications of their units' nursing staff when nurse staffing plan initiatives were executed. For example, at two VAMCs where the number of nurses was increased or where support services for nurses were put in place, such as a designated group of staff to assist in transporting patients to and from appointments off the unit, unit staff said the adequacy of the nursing staff had improved. However, some VAMC unit staff reported that unit nurse staffing continued to be inadequate and that nurse unit assignments and job duties were not always appropriate for their qualifications.
VHA's oversight is limited for ensuring its nurse staffing methodology is implemented and administered appropriately. GAO found the following internal controls were limited in VHA's oversight process:
Environmental assessment. VHA did not comprehensively assess each VAMC to ensure preparedness for implementing the methodology, including having the necessary technical support and resources, prior to the issuance of the directive requiring each VAMC to implement the methodology.
Monitoring compliance. VHA does not have a plan for monitoring VAMCs to ensure compliance with the implementation and ongoing administration of the methodology.
Evaluation. VHA has conducted limited evaluations of the methodology, and at least one of these evaluations has been significantly delayed.
Timeliness of communication. VHA's protracted timeline for communicating methodology-related information may have hindered the ability of VAMCs to appropriately develop their staffing plans and to execute the initiatives contained in those plans.
Organizational accountability. VHA did not define areas of responsibility or establish the appropriate line of reporting within VA's management structure for oversight of the implementation and ongoing administration of the methodology.
Without these internal controls in place, VHA cannot ensure its methodology meets department goals, such as establishing a standardized methodology for determining an adequate and qualified nurse workforce at VAMCs, and ultimately, having nurse staffing that is adequate to meet veterans' growing and increasingly complex health care needs.

What GAO Recommends

GAO recommends VA: (1) assess VAMCs' ability to implement the methodology, (2) monitor VAMCs' ongoing compliance with the methodology, (3) complete timely evaluations, (4) improve the timeliness of communication with VAMCs, and (5) define areas of responsibility and reporting within VA's management structure. VA concurred with the recommendations.