While VHA’s handbook for the program provides general  information on the responsibilities of patient advocacy program staff, it  does not specify the VAMC department to which patient advocates should  report to help ensure VAMCs meet these expectations. In the absence of an updated document, VAMCs are  still expected to follow the outdated handbook. In light of the limited and outdated guidance on the governance of the  program, patient advocacy program staff at most of our selected VAMCs  noted that the VAMC department to which patient advocates report can  have a direct effect on the ability of staff to resolve veterans’ complaints. VHA Has Provided Limited Guidance to VAMCs on Staffing the Patient Advocacy Program

VHA has provided limited guidance to VAMCs on the number and type of  patient advocacy program staff needed to ensure that complaints from  veterans are addressed in a convenient and timely manner. Officials at all but one of the selected VAMCs stated that program staff at  their VAMCs had more work to do than they could handle. The lack of guidance on staffing may impede VAMCs’ efforts to ensure  that they have the appropriate number and type of staff to administer the  patient advocacy program. Until actions to address the  weaknesses we found are completed, the lack of guidance for VAMCs on  determining the appropriate number and types of staff will put the patient  advocacy program at risk of being unable to address veterans’ complaints  in a convenient and timely manner. VHA Has Recommended Training for Patient Advocates, but Has Not Developed an Approach to Routinely Assess Their Training Needs or Monitored Training Completion

		VHA Has Developed a Recommended Training List for Patient Advocates, but Has Not Developed an Approach to Assess Their Training Needs on a Routine Basis

VHA has recently developed a list of recommended training for patient  advocates. Rather, OPCC&CT  officials stated that they relied on VAMC and VISN staff to conduct these  assessments. Monitoring training  completion would also be consistent with federal standards for internal  control related to control activities. Without  monitoring training completion, there is an increased risk that patient  advocates have not received the training they need to effectively fulfill  their responsibilities such as advocating on behalf of veterans and  consistently using PATS to document and resolve complaints. VHA Has Not Monitored Patient Advocacy Data-Entry Practices or Reviewed Patient Advocacy Data to Assess Program Performance and Identify System-Wide Improvements

		VHA Has Not Monitored Whether Complaints Were Always Entered into PATS and Issue Codes Assigned Consistently

VHA officials have not monitored PATS data-entry practices to ensure  complaints were always entered into PATS and issue codes were  assigned consistently to ROCs. OPCC&CT officials stated that they relied on VISN-level coordinators to  monitor coding practices because VHA’s handbook for the program states  that these coordinators should develop VISN-wide consistent approaches  for entering complaints into PATS. We also found inconsistencies in how VAMC officials coded specific  veterans’ feedback. OPCC&CT officials stated that they did not conduct systematic reviews of  PATS data because VISN and VAMC officials were primarily responsible  for these analyses. According to VHA officials, OPA is in the process of identifying the data it  needs to review on a routine basis, and directed its National Strategic  Workgroup to identify program data that could be reviewed to assess  program performance and identify potential system-wide improvements  by the spring of 2018. This is especially  important given concerns about veterans’ ability to receive timely and  quality care. (Recommendation 1) assess and provide guidance to VAMCs on appropriately staffing the  patient advocacy program, including guidance on how to determine  the appropriate number and type of staff. (Recommendation 2) develop an approach to routinely assess the training needs of patient  advocates. VA did not provide technical comments. Appendix II: Patient Advocate Tracking System (PATS) Data Entry and Management

Patient advocacy program staff, such as patient advocates or service- level advocates who are designated to respond to veterans’ feedback,  enter feedback from veterans or their representatives in the Veterans  Health Administration (VHA) Patient Advocate Tracking System (PATS)  by creating a report of contact (ROC). The Comprehensive Addiction and Recovery Act of 2016 (CARA),  includes a provision for every VAMC to display the purpose of the  program, along with the contact information of a patient advocate at the  facility, in as many prominent locations as deemed appropriate to be seen  by the largest percentage of veterans. Appendix III: Approaches to the Governance and Staffing of the Patient Advocacy Program

The eight Department of Veterans Affairs (VA) medical centers (VAMC)  selected for our review used a variety of approaches to govern the patient  advocacy program, resulting in differences in the number of positions for  patient advocates and service-level advocates and the title of the  positions.
Why GAO Did This Study

VHA has designated patient advocates at each VAMC to receive and document feedback from veterans or their representatives, including requests for information, compliments, and complaints. In recent years, the importance of a strong patient advocacy program has taken on new significance given concerns with VHA's ability to provide veterans timely access to health care, among other issues.
The Comprehensive Addiction and Recovery Act of 2016 included a provision for GAO to review VHA's patient advocacy program. This report examines the extent to which VHA has (1) provided guidance on the governance of the program; (2) provided guidance on staffing the program; (3) assessed the training needs of patient advocates and monitored training completion; and (4) monitored patient advocacy program data-entry practices and reviewed program data. GAO reviewed VHA and VAMC documents, including summaries of program data. GAO interviewed VHA officials about the program, as well as officials from a non-generalizable selection of eight VAMCs and five VISNs selected based on the volume of veteran complaints and other factors. GAO also compared VHA policies and practices to federal internal control standards.

What GAO Found

The Veterans Health Administration (VHA) provided limited guidance to Department of Veterans Affairs (VA) medical centers (VAMC) on the governance of its patient advocacy program and its guidance, a program handbook, has been outdated since 2010. VAMCs are still expected to follow the outdated handbook, which does not provide needed details on governance, such as specifying the VAMC department to which patient advocates should report. Officials from most of the VAMCs that GAO reviewed noted that the VAMC department to which patient advocates report can have a direct effect on the ability of staff to resolve veterans' complaints. The lack of updated and complete guidance may impede the patient advocacy program from meeting its expectations, to receive and address complaints from veterans in a convenient and timely manner.
VHA also has provided limited guidance to VAMCs on staffing the patient advocacy program. VHA's handbook states that every VAMC should have at least one patient advocate and appropriate support staff; however, it did not provide guidance on how to determine the number and type of staff needed. Officials at all but one of the eight VAMCs in GAO's review stated that their patient advocacy program staff had more work to do than they could accomplish. This limited guidance on staffing could impede VAMCs' efforts to ensure that they have the appropriate number and type of staff to address veterans' complaints in a timely manner.
Further, VHA has recommended training for patient advocates, but it has not developed an approach to routinely assess their training needs or monitored training completion. VHA officials stated that they relied on VAMC and Veterans Integrated Service Network (VISN) staff to conduct these activities. However, GAO found that for the eight VAMCs in its review, the training needs of patient advocates were not routinely assessed, and training completion was not always monitored. Without conducting these activities, VHA increases its risk that staff may not be adequately trained to advocate on behalf of veterans.
Finally, VHA has not monitored patient advocacy program data-entry practices or reviewed the data to assess program performance. VHA officials stated that they relied on VISN and VAMC officials to ensure that all complaints were consistently entered into VHA's Patient Advocate Tracking System (PATS). However, GAO identified inconsistencies in the extent to which VAMC officials did so. VHA's lack of monitoring may pose a risk that not all complaints are entered into this tracking system—a goal of the program. Additionally, VHA officials stated they did not systemically review data in the system to assess program performance and identify potential system-wide improvements because VHA considered this the responsibility of VAMCs. As a result, VHA officials may miss opportunities to improve veterans' experiences.
VHA is beginning to address many of these governance, staffing, training, and data issues, including directing a workgroup to provide recommendations by spring of 2018. However, because the recommendations will be advisory, and because program deadlines have slipped in the past, the nature and timing of the actions needed to resolve these issues remain unclear.

What GAO Recommends

GAO is making 6 recommendations to improve guidance for and oversight of the patient advocacy program, focusing on governance, staffing, training, and PATS data entry and assessment. VA concurred with GAO's recommendations.