	Background

Over the last decade, VHA has increasingly provided care on an  outpatient basis, including primary care and mental health care services. Of the 733 CBOCs in fiscal year 2016, 210  were classified by VHA as multi-specialty, and nearly all of these (206)  were VHA-operated. 3.) VHA Has Not Fully Implemented Policy Requirements, and Inaccurate Information Limits Its Oversight of CBOC Quality of Care VHA Has Not Fully Implemented CBOC Oversight Policy Requirements

We found that VHA has implemented certain oversight requirements, but  not others described in Directive 1229—its policy that outlines VHA’s  oversight responsibilities for outpatient sites of care, including CBOCs. Officials from the three VHA  offices with responsibility for collaborating to develop guidelines for  monitoring the quality and comprehensiveness of care in CBOCs, as  required in the policy, told us that they are not currently developing  these guidelines and they have no plans to do so. However, VHA may miss clinic performance problems that  are not identifiable in the VISN-level data. We  found that three of the four VISNs in our review largely delegated  oversight of the CBOCs to the VAMCs, rather than conducting  continuous quality monitoring as required in the policy. Specifically,  officials from these VISNs said that they largely focus their oversight  on the VAMCs and do not separately review the performance of every  CBOC unless the VAMC informs them of a quality problem at a  particular clinic. Of the remaining two VISNs,  officials at one VISN reported only having mid-year and year-end  meetings with VHA central office at which they did not specifically  discuss the CBOCs, and officials from the other VISN said they did  not have any regular quarterly performance reviews with VHA central  office. This lack of consistent oversight poses the risk that VHA is not  providing one, high quality standard of care to veterans across  CBOCs. We found that 22 percent of sites were incorrectly  classified as CBOCs, based on the site classifications in VAST. Because the site classifications in the  CBOC Report are based, in part, on officials’ judgment in addition to  the classifications in VAST, the report does not present accurate  information on CBOCs across VHA and is of limited usefulness to  VHA as a tool to ensure that VHA-operated and contracted CBOCs  are providing the same standard of care that is of high quality. Missing CBOCs. No guidance or training for use of the CBOC Report. VHA central  office officials do not provide guidance or training specific to the  CBOC Report to assist VISNs and VAMCs in using it to oversee  CBOCs. In our  review of the CBOC Report from the first quarter of fiscal year 2017,  we found that in several places in the report, shorthand text and  acronyms were used, but not defined. Several VAMC and VISN officials stated that guidance or training that  is specific to understanding the CBOC Report would be helpful. Officials  from the office of the Deputy Under Secretary for Health for  Operations and Management said that VISNs and VAMCs are  expected to use the report as part of their CBOC oversight; however,  we found there is no requirement that they do so. We found that  officials from three of the four VISNs and three of the four VAMCs in  our review were not regularly using the CBOC Report. If  VISN and VAMC officials do not use the report as a part of their  oversight, they may be missing opportunities to compare VHA- operated and contracted CBOCs and ensure they are providing one  standard of care that is of high quality. Conclusions

CBOCs are an integral part of VHA’s health care delivery system, and  VHA requires that such clinics, whether VHA-operated or contracted,  provide the same standard of care to veterans that is of high quality. The CBOC Report, as  VHA’s only report comparing clinical quality of care across both VHA- operated and contracted clinics, could be an important part of those  guidelines. However, as it currently stands, the report is inaccurate and  incomplete and VISNs and VAMCs are not trained on or required to use  it; thus, it is of limited use to VHA, including the VISNs and VAMCs that  have responsibility for CBOC oversight. (Recommendation 1)
Establish a process for regularly updating the CBOC Report to ensure it  contains an accurate and complete list of CBOCs that is consistent with  VHA’s established site classifications. (Recommendation 2)
Ensure that VISNs and VAMCs receive guidance or training on how to  use the CBOC Report. In its  written comments, VA concurred with all four of the report’s  recommendations, and identified actions it is taking to implement them.
Why GAO Did This Study

In fiscal year 2016, VHA's 733 CBOCs provided care to more than 3 million veterans at a cost of $5.3 billion. Although most of these clinics are VHA-owned and -operated, 101 are operated through contracts with non-VHA organizations. VHA policy states that CBOCs, whether VHA-operated or contracted, must provide one standard of care that is of high quality.
GAO was asked to review VHA's use of contracts to carry out core functions. This report examines, among other issues, the extent to which VHA oversees CBOC operations.
To conduct this work, GAO reviewed VHA's policies and CBOC Report. GAO also interviewed officials from VHA's central office and from a nongeneralizable sample of eight CBOCs and their four respective VAMCs and VISNs. The CBOCs were selected for variation in factors such as contract status and geographic area.

What GAO Found

Community-based outpatient clinics (CBOC) are an important part of the Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) health care delivery system. These clinics are geographically separate from VA medical centers (VAMC) and provide outpatient services, including primary care and mental health care. GAO found weaknesses in VHA's oversight of CBOCs:
Incomplete policy implementation. VHA has not implemented certain CBOC oversight requirements as outlined in its policy. Specifically, VHA has not developed guidelines for monitoring the quality and comprehensiveness of care in CBOCs and officials said they have no plans to do so. Officials told GAO they believe the requirement was met as part of their regular oversight of Veterans Integrated Service Networks (VISN)—regional networks responsible for oversight of VAMCs and CBOCs. However, VHA may miss CBOC performance problems that are not identifiable in VISN-level data. Further, although policy requires VHA central office officials to review CBOC performance as part of quarterly VISN performance reviews, officials said they do not specifically do so unless the VISN identifies a problem. Officials from three of the four VISNs in GAO's review said they largely delegate CBOC oversight to VAMCs, and do not separately review clinic performance unless a VAMC identifies a problem.
An inaccurate and incomplete CBOC Report. VHA's CBOC Report is prepared by VHA central office and distributed to VISNs and VAMCs quarterly and at year-end. The CBOC Report could be useful to compare clinical quality of care between VHA-operated and contracted CBOCs, but it is inaccurate and incomplete. Specifically, VHA officials have used their judgment to classify certain sites as CBOCs in the report, rather than use the official classifications in policy. GAO found that 22 percent of sites were incorrectly classified as CBOCs when they were other types of sites, including VAMCs. As a result, the report is of limited usefulness to VHA as an oversight tool.
Lack of guidance or training on the CBOC Report. VHA central office officials do not provide guidance or training specific to understanding the CBOC Report to assist VISNs and VAMCs in their oversight of CBOCs. GAO found that in several places in the report, shorthand text and acronyms were used, but not defined. In addition, several VISN and VAMC officials stated that guidance or training would be helpful.
No requirement to use the CBOC Report. VHA officials told GAO that VAMCs and VISNs are expected to use the CBOC Report as an oversight tool, but GAO found that VHA lacks a requirement that they do so. Officials from three of the four VISNs and three of the four VAMCs in GAO's review were not using the report.
These weaknesses potentially lead to inconsistent oversight and create a risk that VHA is not providing one standard of care that is of high quality to veterans across VHA-operated and contracted CBOCs.

What GAO Recommends

GAO recommends that VHA (1) implement oversight requirements that align with existing policy; (2) establish a process to ensure the CBOC Report is accurate and complete; (3) provide guidance or training to VISNs and VAMCs on how to use the CBOC Report; and (4) require use of the CBOC Report as an oversight tool. VA concurred with all of GAO's recommendations and identified actions it is taking to implement them.