Women’s Health Care at VA Medical Facilities

Through its medical facilities, VA provides a wide range of sex-specific  health care services to women veterans. More specialized sex-specific care for  women is typically provided by a gynecologist. Current VA care in the community  options include:
Veterans Choice Program. Specifically, after the TPAs have confirmed  veterans would like to receive Choice care, the TPAs are contractually  required to, among other things:  schedule appointments within 5 business days (for routine care)  from the time the veteran agrees to participate in Choice or within  2 business days (for urgent care) of accepting the authorization  from the referring VA medical facility; ensure that veterans receive care within 30 days of scheduling an  appointment for routine care or within 2 business days (for urgent  care) of accepting the authorization from the referring VA medical  facility;  return authorizations to the referring VA medical facility when  appointments cannot be scheduled within required time frames;  and  track the number of authorizations for which they did not schedule  appointments for veterans and the reasons why. VHA Lacks Complete and Accurate Data on VAMC Compliance with Environment of Care Requirements for Women Veterans and Does Not Consistently Identify or Address Noncompliance

VHA Central Office lacks complete and accurate data on the extent to  which VAMCs are in compliance with environment of care requirements. Among the six VAMCs we visited, based on our inspections, we observed  varying levels of compliance with selected VHA requirements related to  the environment of care for women veterans, ranging from 65 percent to  81 percent. Some common areas of noncompliance that we observed in outpatient  clinics included the following:
Lack of auditory privacy at check-in clerk station. VHA  policy requires that all examination rooms be equipped with a  privacy curtain. VHA’s Oversight Processes Do Not Consistently Identify or Address Noncompliance Due to Weaknesses in Environment of Care Rounds and Related Policies

We found weaknesses in VHA’s oversight processes of the environment  of care rounds and related policies. This failure to verify reported information is inconsistent with federal  internal control standards for monitoring, which call for management to  establish activities to monitor the quality of performance over time and  promptly resolve the findings of audits and other reviews. While the Number of VHA Gynecologists and Women’s Health Primary Care Providers Has Increased Overall, Availability Was Limited in Some Locations

		The Number of VA Gynecologists Has Increased Over Time, but More than a Quarter of VAMCs and VA Health Care Systems Did Not Have an Onsite Gynecologist

Our analysis of VHA data shows that the number of VHA gynecologists  increased about 3 percent nationally from fiscal year 2014 to fiscal year  2015. VHA Central Office officials said that, based on  workload, not all VA medical facilities need an onsite gynecologist, and  women veterans may receive necessary gynecological services through a  care in the community program. The increase in providers significantly outpaced the increase in women  veteran enrollment (1 percent) during the same time period. The fact that nearly 18 percent of VAMCs and outpatient clinics providing  primary care lacked a women’s health primary care provider in fiscal year  2015 suggests that VHA may face challenges ensuring that all women  veterans have timely access to these providers, as required under VHA  policy. In our interviews with VHA officials, they acknowledged a shortage of  women’s health primary care providers at VA medical facilities. While the number of obstetricians and  gynecologists increased, some geographic areas lacked these types of  providers, which provided access challenges for women veterans seeking  care. 3). VHA Does Not Have Performance Measures for Monitoring Access to Sex- Specific Care under Choice

VHA lacks performance measures for the availability under Choice of sex- specific care, such as mammograms, maternity care, or gynecology. However, VHA data show that the  TPAs did not meet VHA’s performance standards for providing timely  access for veterans, including women veterans. Federal standards of internal control for monitoring call for management  to establish activities to monitor the quality of performance over time and  promptly resolve the findings of audits and other reviews. In  addition, we found instances where women veterans’ care under Choice  was significantly delayed and we found a lack of participating  obstetricians and gynecologists in some areas, both of which further  underscore the importance of VHA’s ability to monitor access to sex- specific care for women veterans. If VHA does not strengthen its  environment of care inspections policies, it will remain unable to provide  reasonable assurance that it is protecting the privacy, safety, and dignity  of women veterans who receive care at VA medical facilities. Recommendations for Executive Action

To improve care for women veterans, we recommend that the Secretary  of Veterans Affairs direct the Under Secretary for Health to take the  following two actions:
Strengthen the environment of care inspections process and VHA’s  oversight of this process by expanding the list of requirements that  facility staff inspect for compliance to align with VHA’s women’s health  handbook, ensuring that all patient care areas of the medical facility  are inspected as required, clarifying the roles and responsibilities of  VA medical facility staff responsible for identifying and addressing  compliance, and establishing a process to verify that noncompliance  information reported by facilities to VHA Central Office is accurate and  complete. Monitor women veterans’ access to key sex-specific care services— mammography, maternity care, and gynecology—under current and  future community care contracts.
Why GAO Did This Study

In 2010, GAO found a number of weaknesses related to care for women veterans at VA medical facilities. GAO was asked to update that study. This report examines (1) the extent that VA medical centers complied with requirements related to the environment of care for women veterans and VHA's oversight of that compliance; (2) what is known about the availability of VHA medical providers who can provide sex-specific care for women veterans at VA facilities; and (3) VHA's efforts to provide and monitor access to sex-specific care for women veterans through Choice. To do this work, GAO reviewed VHA data on environment of care deficiencies; the number, location, and availability of VHA and Choice medical providers; women veteran enrollment; and Choice access-related performance measures. In addition, GAO inspected the environment of care for compliance with VHA policy at a nongeneralizable sample of six VA medical centers, which were selected to achieve variation in different care models, the size of the women veterans' population, and geographical locations. GAO also interviewed VHA Central Office and VA medical center officials.

What GAO Found

The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) does not have accurate and complete data on the extent to which its medical centers comply with environment of care standards for women veterans. VHA policy requires its medical facilities, including VA medical centers, to meet environment of care standards related to the privacy, safety, and dignity of women veterans. VHA Central Office relies on medical centers to conduct regular inspections and to report instances of noncompliance, which are compiled in a VHA database. However, almost all the noncompliance GAO identified through inspections at six VA medical centers it visited had not been reported or recorded in the VHA database, and compliance rates ranged from 65 percent to 81 percent. For example, GAO found a lack of auditory privacy at check-in clerk stations and a lack of privacy curtains in examination rooms, as required by VHA policy. GAO also found weaknesses in VHA's oversight of the environment of care for women, including a lack of thorough inspections and limited verification of facility-reported data which results in inaccurate and incomplete data. As a result, the privacy, safety, and dignity of women veterans may not be guaranteed when they receive care at VA facilities. Federal internal control standards for monitoring call for management to establish activities to monitor the quality of performance over time and promptly resolve any identified issues.
GAO's analysis of VHA data shows that nationally the number of VHA full-time-employee equivalent gynecologists and the number of women's health primary care providers—VHA primary care providers specially trained in women's health care services, such as breast exams—increased by 3 percent and 15 percent respectively, from fiscal year 2014 through fiscal year 2015, and those percentages exceeded the 1 percent growth in women veteran enrollment during the same period. However, about 27 percent of VA medical centers and health care systems lacked an onsite gynecologist and about 18 percent of VA facilities providing primary care lacked a women's health primary care provider, according to VHA data. VHA officials said not all facilities require onsite gynecologists and facilities may authorize gynecological services from non-VA providers. They acknowledged a shortage of at least 675 women's health primary care providers and have a plan to train at least 535 providers by the end of fiscal year 2016.
The Veterans Choice Program (Choice) is a primary option for veterans to receive care from non-VA providers in the community if care cannot be provided at VA facilities. While the number of obstetricians and gynecologists under Choice has increased, some areas lack these providers, according to a VHA analysis. While VHA monitors access-related Choice performance measures (such as timely appointment scheduling) for all veterans, it does not have such measures for women veterans' sex-specific care, such as mammography, maternity care, or gynecology. VHA's data show poor performance on access-related performance measures for all veterans, and GAO found cases where women veterans' maternity care was significantly delayed, suggesting that veterans, including women, face challenges receiving timely access to care. Federal internal control standards for monitoring call for management to establish activities to monitor the quality of performance over time and promptly resolve any identified issues.

What GAO Recommends

GAO recommends that VA (1) strengthen the policies and guidance for its environment of care inspection process and (2) monitor women veterans' access to sex-specific care under current and future community care contracts. VA concurred with GAO's recommendations.