Saturday, June 24, 2017

GAO-17-480, VA Health Care: Improvements Needed in Data and Monitoring of Clinical Productivity and Efficiency, May 23, 2017

What GAO Found

In 2013, the Department of Veterans Affairs (VA) implemented clinical productivity metrics to measure physician providers' time and effort to deliver procedures. VA also developed statistical models to track clinical efficiency at VA medical centers (VAMC). Data collected under the metrics and models are used to identify sub-optimal clinical productivity and inefficiency at VAMCs. GAO found that contrary to federal internal control standards for information, VA's metrics and models may not provide quality information because the information is incomplete and may not accurately reflect clinical productivity and efficiency. GAO identified limitations with VA's metrics and models that limit VA's ability to assess whether resources are being used effectively. Specifically,

  • Productivity metrics are not complete because they do not account for all providers or clinical services. Due to data systems limitations, the metrics do not capture all types of providers who deliver care at VAMCs, including contract physicians and advanced practice providers, such as nurse practitioners, serving as sole-providers. In addition, the metrics do not capture providers' workload evaluating and managing hospitalized patients.
  • Productivity metrics may not accurately reflect the intensity of clinical workload. A 2016 VA audit shows that VA providers do not always accurately code the intensity of—that is, the amount of effort needed to perform— clinical procedures or services. As a result, VA's productivity metrics may not accurately reflect provider productivity, as differences between providers may represent coding inaccuracies rather than true productivity differences.
  • Productivity metrics may not accurately reflect providers' clinical staffing levels. Officials at five of the six selected VAMCs GAO visited reported that providers do not always accurately record the amount of time they spend performing clinical duties, as distinct from other duties.
  • Efficiency models may also be adversely affected by inaccurate workload and staffing data. To the extent that the intensity and amount of providers' clinical workload are inaccurately recorded, some of VA's efficiency models examining VAMC utilization and expenditures may also be inaccurate. For example, the model that examines administrative efficiency requires accurate data on the amount of time VA providers spend on administrative tasks; if the time providers allocate to clinical, administrative, and other tasks is incorrect, the model may overstate or understate administrative efficiency.

GAO found that VA Central Office has taken steps to help VAMCs monitor provider productivity by developing a comprehensive analytical tool VAMCs can use to identify the drivers of low productivity. While VAMCs are required to monitor VA's productivity metrics, GAO found that VA does not require VAMCs to monitor VA's efficiency models. Further, VA does not systematically oversee VAMCs' efforts to monitor clinical productivity and efficiency. As a result, VA cannot systematically identify best practices to address low productivity and inefficiency as well as determine the factors VAMCs commonly identify as contributing to low productivity and inefficiency. This approach is inconsistent with federal standards for internal control related to monitoring.

Why GAO Did This Study

VA has faced challenges managing its budget and ensuring veterans' access to health care, generating congressional interest in asking GAO to examine VA's use of its productivity and efficiency metrics.

This report assesses (1) whether VA's clinical productivity metrics and efficiency models provide complete and accurate information on provider productivity and VAMC efficiency, and (2) VA's efforts to monitor and improve clinical productivity and efficiency.

GAO reviewed VA documentation, such as policies and guidance, and 2015 data on clinical productivity and efficiency, the most recent data available. GAO also interviewed VA Central Office officials about VA's metrics and models and monitoring efforts. GAO visited six VAMCs and their corresponding Veterans Integrated Service Networks, selected based on geographic diversity, variation of facility complexity, and differences in productivity and efficiency levels. GAO examined VA's efforts to monitor and improve clinical productivity and efficiency in the context of federal standards for internal control related to information and monitoring.

What GAO Recommends

GAO is making four recommendations to improve the completeness and accuracy of VA's productivity metrics and efficiency models and to strengthen VA's oversight of VAMCs' use of these metrics and models. VA concurred or concurred in principle with GAO's recommendations and described its plans to implement them.

For more information, contact Randall B. Williamson at (202) 512-7114 or

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