	High Risk List Designation Status Depends on Program Significance, Effects, and Status of Corrective Measures

		Criteria for Addition to the High Risk List

To determine which federal government programs and functions should  be designated high risk, we use our guidance document, Determining  Performance and Accountability Challenges and High Risks.consider qualitative factors, such as whether the risk  involves public health or safety, service delivery, national security,  national defense, economic growth, or privacy or citizens’ rights; or  could result in significantly impaired service, program failure, injury or  loss of life, or significantly reduced economy, efficiency, or  effectiveness. Criteria for Removal of High-Risk Designation

Since 1990, more than one-third of the areas previously designated as  high risk have been removed from the High Risk List because sufficient  progress was made in addressing the problems identified. The five criteria for removal are
Leadership Commitment. Agency has the capacity (i.e., people and resources) to  resolve the risk(s). Action Plan. Monitoring. Demonstrated Progress. Five Broad Areas of Concern Contributed to Designation of VA Health Care as High Risk

In designating VA as a high-risk area, we categorized our concerns about  VA’s ability to ensure the timeliness, cost-effectiveness, quality, and  safety of veterans’ health care, into five broad areas: (1) ambiguous  policies and inconsistent processes, (2) inadequate oversight and  accountability, (3) information technology challenges, (4) inadequate  training for VA staff, and (5) unclear resource needs and allocation  priorities. We have made numerous recommendations that aim to  address weaknesses in VA’s management and oversight of its health  care system. Ambiguous VA  policies lead to inconsistency in the way VA facilities carry out  processes at the local level. In numerous reports, we have found that  this ambiguity and inconsistency may pose risks for veterans’ access  to VA health care, or for the quality and safety of VA health care they  receive. We also have found  weaknesses in VA’s ability to hold its health care facilities accountable  and ensure that identified problems are resolved in a timely and  appropriate manner. Of particular concern is the outdated,  inefficient nature of certain systems, along with a lack of system  interoperability—the ability to exchange information—which presents  risks to the timeliness, quality, and safety of VA health care. In a number of reports, we have  identified gaps in VA training that could put the quality and safety of  veterans’ health at risk. In many of our  reports, we have found gaps in the availability of data required by VA  to efficiently identify resource needs and to ensure that resources are  effectively allocated across the VA health care system. Sustained Attention and Focus Needed to Resolve More than 100 Recommendations for Improvement in VA Health Care

VA has taken actions to address some of the recommendations we have  made related to VA health care; however, there are currently more than  100 that have yet to be fully resolved, including recommendations related  to the five broad areas of concern highlighted above. For example, to  ensure that its facilities are carrying out processes at the local level more  consistently—such as scheduling veterans’ medical appointments—VA  needs to clarify its existing policies. The recently enacted Veterans Access, Choice, and Accountability Act  included a number of provisions intended to help VA address systemic  weaknesses. In the spring and summer of 2014, congressional committees  held more than 20 hearings to address identified weaknesses in the VA  health care system. Sustained congressional attention to these issues will  help ensure that VA continues to make progress in improving the delivery  of health care services to veterans. We plan to continue monitoring VA’s efforts to improve the timeliness,  cost-effectiveness, quality, and safety of veterans’ health care. An assessment of the status of VA health  care’s high-risk designation will be done during our next update in 2017. Veterans’ Health Care: Oversight of Tissue Product Safety. VA Health Care: Actions Needed to Improve Administration of the  Provider Performance Pay and Award Systems.
Why GAO Did This Study

VA operates one of the largest health care delivery systems in the nation, including 150 medical centers and more than 800 community-based outpatient clinics. Enrollment in the VA health care system has grown significantly, increasing from 6.8 to 8.9 million veterans between fiscal years 2002 and 2013. Over this same period, Congress has provided steady increases in VA's health care budget, increasing from $23.0 billion to $55.5 billion.
Risks to the timeliness, cost-effectiveness, quality, and safety of veterans' health care, along with other persistent weaknesses GAO and others have identified in recent years, raised serious concerns about VA's management and oversight of its health care system. Based on these concerns, GAO designated VA health care a high-risk area and added it to GAO's High Risk List in 2015.
Since 1990, GAO has regularly updated the list of government operations that it has identified as high risk due to their vulnerability to fraud, waste, abuse, and mismanagement or the need for transformation to address economy, efficiency, or effectiveness challenges.
This statement addresses (1) the criteria for the addition to and removal from the High Risk List, (2) specific areas of concern identified in VA health care that led to its high-risk designation; and (3) actions needed to address the VA health care high-risk area.

What GAO Found

To determine which federal government programs and functions should be designated high risk, GAO considers a number of factors. For example, it assesses whether the risk involves public health or safety, service delivery, national security, national defense, economic growth, or privacy or citizens' rights, or whether the risk could result in significantly impaired service, program failure, injury or loss of life, or significantly reduced economy, efficiency, or effectiveness. There are five criteria for removal from the High Risk List: leadership commitment, capacity (people and resources needed to resolve the risk), development of an action plan, monitoring, and demonstrated progress in resolving the risk.
In designating the health care system of the Department of Veterans Affairs (VA) as a high-risk area, GAO categorized its concerns about VA's ability to ensure the timeliness, cost-effectiveness, quality, and safety of veterans' health care, into five broad areas:
1. Ambiguous policies and inconsistent processes. GAO found ambiguous VA policies lead to inconsistency in the way its facilities carry out processes at the local level, which may pose risks for veterans' access to VA health care, or for the quality and safety of VA health care.
2. Inadequate oversight and accountability. GAO found weaknesses in VA's ability to hold its health care facilities accountable and ensure that identified problems are resolved in a timely and appropriate manner.
3. Information technology challenges. Of particular concern is the outdated, inefficient nature of certain systems, along with a lack of system interoperability.
4. Inadequate training for VA staff. GAO has identified gaps in VA training that could put the quality and safety of veterans' health at risk or training requirements that were particularly burdensome to complete.
5. Unclear resource needs and allocation priorities. GAO has found gaps in the availability of data required by VA to efficiently identify resource needs and to ensure that resources are effectively allocated across the VA health care system.
VA has taken actions to address some of the recommendations GAO has made related to VA health care, including those related to the five broad areas of concern highlighted above; however, there are currently more than 100 that have yet to be fully resolved. For example, to ensure that processes are being carried out more consistently at the local level--such as scheduling veterans' medical appointments--VA needs to clarify its existing policies, as well as strengthen its oversight and accountability across its facilities. The Veterans Access, Choice, and Accountability Act of 2014 included a number of provisions intended to help VA address systemic weaknesses in its health care system. Effective implementation, coupled with sustained congressional attention to these issues, will help ensure that VA continues to make progress in improving the delivery of health care services to veterans. GAO plans to continue monitoring VA's efforts to improve veterans' health care. An assessment of the status of VA health care's high-risk designation will be done during GAO's next update in 2017.