The Joint  Commission,  an organization that accredits medical centers and other  hospitals throughout the country, has developed standards that require  medical centers to undertake several actions that relate to engineering,  environmental management, and safety including: maintaining the patient environment by ensuring that a suitable  temperature is maintained, that areas are clean and appropriately  lighted, and furnishings and equipment are in good repair; managing utility systems to ensure operational reliability; and minimizing fire hazards and providing a safety system in case of fire. In addition to the environment of care inspections, VHA uses other  inspections to help execute and oversee facility operations and  maintenance functions. Figure 1 below details the process used to identify and address  deficiencies, as outlined in VHA guidance. Challenges in Addressing Identified Deficiencies

The buildings that VHA manages are, on average, 55 years old, and  many have substantial capital repair and improvement needs. For example, according to  VHA’s data for fiscal year 2017, medical centers reported conducting  about 11,000 weekly inspections, during which more than 128,000  deficiencies were identified. Most deficiencies were closed within 14  business days, as required by VHA policy, but nearly 30,000 deficiencies  across all medical centers had not been addressed within 14 days or had  been addressed through a plan for future work. For  example at one medical center officials told us that in some cases,  correcting deficiencies found on an environment of care inspection is a  temporary solution for issues related to aging structures that need  extensive repairs and renovations. Additionally, VHA’s aging information technology systems exacerbate the  administrative workload. Officials from all six medical centers said that while they endeavor to  address all environment of care deficiencies in accordance with the  inspection requirements, these vacancies affected their ability to perform  maintenance and repair functions. VHA Takes Steps to Help Medical Centers Comply with Inspection Requirements but Does Not Have Goals or Measures to Determine Program Effectiveness

While VHA provides guidance and oversight to ensure medical centers  implement the environment of care inspection process, it lacks  performance goals, objectives, and measures that would enable it to  assess how well it is achieving its policy of a clean, safe, and functional  environment. To help medical centers achieve compliance with the  inspection requirements, VHA does the following: develops guidance for medical center and VISN staff on their roles  and responsibilities in conducting inspections and compliance  monitoring, and on how to use the Environment of Care inspections  database software; oversees the deployment and maintenance of the Environment of  Care inspections database software, which medical centers use to  track deficiencies and staff attendance at inspections, among other  things; and provides summary reports from inspections data on deficiencies,  closure status, and staff attendance rate at inspections to officials at  the medical center and VISN-level for program management purposes  To monitor a medical center’s compliance with environment of care  requirements, VHA tracks three measures, which, according to VHA  officials, were established to ensure that medical centers were meeting  requirements related to the inspections process, such as having relevant  staff present for the inspections. Nor do these  performance measures provide useful information on the actual condition  of facilities or desired outcomes. VHA has stated it intends to create goals and objectives for the  Environment of Care Program, along with performance measures to  assess whether the goals and objectives are being achieved, but it has  not yet done so. This standard can be a challenge given the  substantial capital repair and improvement needs in many of these  facilities. However, absent clear goals, objectives, and  performance measures, and a timeline for developing them, VHA will  continue to be limited in its ability to assess how effective the program is  at ensuring a safe, clean, and functional environment. VA also provided technical comments, which we  incorporated as appropriate. Additionally, VA provided general comments on our report.
Why GAO Did This Study

VHA oversees one of the largest health care systems, serving approximately 9-million veterans at numerous health care facilities, including 170 medical centers. To ensure a safe environment for veterans and employees, VHA must keep its facilities clean and well maintained.
GAO was asked to examine (1) how VHA medical centers identify maintenance and repair needs and challenges they face in addressing those needs, and (2) to what extent VHA provides oversight to ensure medical centers are providing a safe, clean, and functional environment.
GAO reviewed VHA's procedures and standards related to facility operations and maintenance functions at medical centers and interviewed VHA's administrative office officials regarding oversight of these functions. GAO also interviewed VHA officials from three regional offices and six medical centers selected based on factors such as geographic location and veteran population served, and conducted site visits at four of these medical centers.

What GAO Found

Veterans Health Administration's (VHA) medical centers conduct regular inspections of the settings in which patients receive health care services, called the “environment of care”, to identify maintenance and repair needs. These inspections also help ensure compliance with accreditation standards requiring, among other things, that utility systems operate properly and that areas are clean and in good repair. The main three steps in the process associated with these inspections are shown below. In addition to the environment of care inspections, VHA conducts other periodic assessments of facilities' major systems, such as plumbing and air conditioning.
VHA inspections routinely identify deficiencies reflective of an aging infrastructure—VHA's buildings are on average 55 years old. This situation in turn is leading to workload and staffing challenges in addressing maintenance and repair needs. For example, according to VHA's 2017 data, medical centers reported conducting approximately 11,000 total inspections for the year that resulted in about 128,000 identified deficiencies. Most of these deficiencies were closed within 14 business days, as required by VHA. However, nearly 30,000 of them were not closed or had been addressed through a plan for future work. Medical center officials added that correcting deficiencies may only be a temporary solution for issues related to aging structures that need extensive repairs and renovations. In addition, VA headquarters and field officials said that staff vacancies are common and can affect the efficiency and speed of maintenance and repairs.
VHA provides guidance and selected oversight to ensure medical centers implement the process for environment of care inspections. However, VHA lacks performance goals, objectives, and measures that would enable it to provide effective oversight, address challenges, and assess how well it is achieving a clean, safe, and functional environment. As part of ensuring compliance with the inspection process, VHA measures whether medical centers meet certain requirements, such as having appropriate staff present for inspections. VHA does not, however, have measures that enable it to assess how well medical centers are achieving desired outcomes. Although it has stated its intent to develop such measures, VHA has not yet committed to a time frame for doing so.

What GAO Recommends

GAO recommends that VHA set a timeline for defining goals, objectives, and outcome-oriented performance measures that can address challenges and help achieve a clean and safe care environment. VA concurred with the recommendation and provided general and technical comments, which GAO incorporated as appropriate.