CARES Process and Modeling Tools Drive VHA’s Capital Planning Efforts

In developing the model for analyzing VA’s health care demand and  making recommendations for ways to meet that demand, the CARES  process provided VA with a blueprint that drives VHA’s capital planning  process. Using information from  the model, VA could determine current supply and identify current and  future gaps in infrastructure capacity. In addition, the CARES process serves as the foundation  for VHA’s capital budget process. VA continues to use the tools developed through CARES as part of its  capital planning process. According to  VA officials, all capital projects must be based upon the CARES planning  model to advance through VHA’s capital planning process. Range of Alignment Alternatives Considered throughout the CARES Process, and Resulting Decisions Will Result in an Expansion of VA’s Capital Assets

The DNCP, the CARES Commission, and the Secretary considered a range  of capital asset alignment alternatives throughout the CARES process. Although the Secretary tended to agree with the  CARES Commission’s recommendations, the extent to which he agreed  varied by alignment alternative. In particular, the Secretary always agreed  with the commission’s recommendations to build new facilities, enter into  enhanced use leases, and collaborate with DOD and universities, but was  less likely to agree to the CARES Commission’s recommendations to  contract out or close facilities. The  resulting capital alignment alternatives recommended by the CARES  Commission and agreed to by the Secretary will result in an overall  expansion of VA facilities. DNCP, Commission, and VA Secretary Generally Agreed on Alignment Alternatives for VA Facilities, and Decisions Will Result in an Expansion of Assets

Although a range of capital asset alignment alternatives were considered  for VA facilities throughout the CARES process, there was relatively  consistent agreement among the DNCP, the CARES Commission, and the  Secretary as to which were the best alternatives to pursue. These factors include  competing stakeholder interests, facility condition and location, access  issues, established relationships with other health care providers, and  legal restrictions. Some CARES Decisions Implemented, but VA Does Not Use Performance Measures to Assess and Track Their Implementation and Impact

VA has started implementing some CARES decisions and integrating  CARES concepts into its strategic planning process. Specifically, as of  February 2007, VA was in the process of implementing 32 of more than 100  major capital projects that were identified in the CARES process. During this  time, VA put a number of decisions on hold in anticipation of the CARES  decisions. VA has over 100 performance measures that it uses to centrally monitor  agency programs and activities. Thus, VA cannot readily determine whether the  implementation of certain CARES decisions are achieving the intended  results. For  example, VA does not centrally monitor or track the implementation of  CARES decisions, a process that could be used as a performance measure  for CARES. According to officials  in some of the networks we visited, the department does not require them  to track the implementation of CARES decisions. These measures should include both output measures, such as the  implementation status of all CARES decisions, and outcome measures,  such as the degree to which CARES has improved access to medical  services for veterans, and should be explicitly linked to the goals of  CARES. Appendix I: Objectives, Scope, and Methodology

Our overall objective was to determine the extent to which the  Department of Veterans Affairs’ (VA) Capital Asset Realignment for  Enhanced Services (CARES) process has been implemented and how it  has contributed to its overall mission of providing health care services to  veterans. Specifically, our research examined (1) how CARES contributes  to Veterans Health Administration’s (VHA) capital planning process, (2)  the extent to which the CARES process considered alignment alternatives,  and (3) the extent to which VA has implemented CARES decisions and  how this implementation has helped VA carry out its mission. Build a new outpatient clinic and close inpatient services.
Why GAO Did This Study

Through its Veterans Health Administration (VHA), the Department of Veterans Affairs (VA) operates one of the largest health care systems in the country. In 1999, GAO reported that better management of VA's large inventory of aged capital assets could result in savings that could be used to enhance health care services for veterans. In response, VA initiated a process known as Capital Asset Realignment for Enhanced Services (CARES). Through CARES, VA sought to enhance veteran care by the appropriate sizing, upgrading, and locating of VA facilities. GAO was asked to examine the CARES process. Specifically, GAO examined (1) how CARES contributes to VHA's capital planning process, (2) the extent to which the CARES process considered capital asset alignment alternatives, and (3) the extent to which VA has implemented CARES decisions and how this implementation has helped VA carry out its mission. To address these issues, we analyzed CARES documents, interviewed VA officials, and conducted six site visits, among other things.

What GAO Found

The CARES process provided VA with a blueprint that drives VHA's capital planning efforts. As part of the CARES process, VA adapted a model to estimate demand for health care services and to determine the capacity of its current infrastructure to meet this demand. VA continues to use this model in its capital planning process. The CARES process resulted in capital alignment decisions intended to address gaps in services or infrastructure. These decisions serve as the foundation for VA's capital planning process. According to VA officials, all capital projects must be based upon demand projections that use the planning model developed through CARES. A range of capital asset alignment alternatives were considered throughout the CARES process, which adheres to capital planning best practices. There was relatively consistent agreement among the Draft National CARES Plan prepared by VA, the CARES Commission appointed by the VA Secretary to make alignment recommendations, and the Secretary as to which were the best alternatives to pursue. Although the Secretary tended to agree with the CARES Commission's recommendations, the extent to which he agreed varied by alignment alternative. In particular, the Secretary always agreed with the commission's recommendations to build new facilities, enter into enhanced use leases, and collaborate with the Department of Defense and universities, but was less likely to agree to the CARES Commission's recommendations to contract out or close facilities. The decisions that emerged from the CARES process will result in an overall expansion of VA's capital assets. For example, the capital alignment alternatives the Secretary chose to meet future health care demand includes building 3 new medical centers and opening 156 outpatient clinics. In contrast, VA will completely close one facility. A number of factors, including competing stakeholders interests and legal restrictions, shaped and in some cases limited VA's range of alternatives considered during the CARES process. VA has started implementing some CARES decisions, but does not centrally track the implementation of all the CARES decisions or monitor the impact such implementation has had on its mission. VA has begun implementing 32 of the more than 100 capital projects and 32 of the 156 outpatient care centers approved by the Secretary during the CARES process. Although VA has over 100 performance measures to monitor other agency programs and activities, these measures either do not directly link to the CARES goals or VA does not use them to centrally monitor the implementation and impact of CARES decisions. Without this information, VA cannot readily assess the implementation status of CARES decisions, determine the impact such decisions are having on veterans' care, or be held accountable for achieving the intended results of CARES.