GAO-21-514, COVID-19: Implementation and Oversight of Preparedness Strategies at Veterans Affairs Medical Centers
- Issuer
- Government Accountability Office
- Document type
- Report
- Date
- 2021-06-30
Summary
GAO-21-514, a Government Accountability Office report to congressional addressees dated June 30, 2021, on how the Veterans Health Administration prepared VA medical centers for COVID-19. The report, prepared under a CARES Act oversight provision, describes how four selected medical centers implemented VHA's COVID-19 preparedness strategies and how VHA oversaw that implementation. GAO found that the selected centers used similar approaches, such as screening and testing plans, PPE training, bed expansion planning and PPE counts, and that VHA oversaw them through daily data collection by its Healthcare Operations Center and VHA-wide conference calls. The report notes that VHA received $17.4 billion in supplemental funding in March 2020, and that VA provided one technical comment on the draft.
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United States Government Accountability Office
Report to Congressional Addresses
COVID-19
June 2021
Implementation and
Oversight of
Preparedness
Strategies at Veterans
Affairs Medical
Centers
GAO-21-514
June 2021
COVID-19
Implementation and Oversight of Preparedness
Strategies at Veterans Affairs Medical Centers
Highlights of GAO-21-514, a report to
congressional addresses
Why GAO Did This Study What GAO Found
VHA provides health care to more than Beginning in January 2020, the Veterans Health Administration (VHA) took
10 million veterans each year, offering actions to help the Department of Veterans Affairs medical centers (VAMC)
a range of services at approximately prepare for COVID-19. VHA’s Office of Emergency Management facilitated the
170 VAMCs nationwide. In January development of VHA’s COVID-19 Response Plan, which defined preparedness
2020, components of VHA’s strategies for VAMCs to mitigate the effects of COVID-19. According to VHA,
emergency management system preparedness refers to the development of plans, resources, and capabilities to
began coordinating the agency’s efforts manage and recover from the effects of emergencies. Plans for the safety of staff
to prepare for the COVID-19 pandemic and patients, identification of sufficient supplies and capacity, and coherent
so VAMCs could continue the delivery communication were among the identified strategies.
of services while maintaining the health
and safety of patients and staff. VAMCs began implementing these strategies in February 2020. Officials from
four selected VAMCs reported using similar approaches to implement VHA’s
The CARES Act includes a provision
for GAO to report on its ongoing
preparedness strategies, such as
monitoring and oversight efforts related • developed plans for screening and testing;
to the COVID-19 pandemic. This report • trained staff on personal protective equipment (PPE) use;
describes VHA efforts to prepare for
• identified the capability to expand beds in the event of a patient surge;
COVID-19, including (1) how selected
VAMCs implemented VHA’s COVID-19
• conducted problem solving activities to identify gaps in response capabilities;
preparedness strategies; and (2) the • counted PPE and calculated consumption rates; and
steps VHA took to oversee VAMCs’ • communicated safety information to patients.
implementation of preparedness VHA oversaw VAMCs’ implementation of COVID-19 preparedness strategies by
strategies.
collecting data on the VAMCs’ efforts and holding VHA-wide conference calls.
GAO reviewed VHA plans, policies, VHA’s Healthcare Operations Center (HOC) worked with Veterans Integrated
and guidance related to COVID-19 Service Networks (VISN) to gather data from VAMCs on a daily basis.
preparedness, including VHA’s COVID-
19 Response Plan. GAO interviewed
HOC Data Collection on COVID-19 Preparedness Strategies Implemented at VAMCs
officials at four VAMCs, a
nongeneralizable sample selected
based on hospital complexity and
geographic diversity, as well as officials
from their associated VISNs. GAO also
interviewed officials from VHA’s Central
Office, Office of Emergency
Management, HOC, and other VHA
offices.
GAO provided a draft of this report to
VA. In response, VA provided one The VHA-wide conference calls included officials from VHA Central Office,
technical comment, which was VISNs, and VAMCs, among others, and focused on the data collected. Some
incorporated as appropriate. topics discussed included the number of VAMC staff able to provide PPE training
and VAMC plans to screen staff and patients for COVID-19. VHA-wide calls were
also a way to discuss data collection challenges and for VAMCs and VISNs to
share best practices. In addition to the preparedness issues in this report, GAO
expects to continue examining VHA’s actions to address COVID-19.
View GAO-21-514. For more information,
contact A. Nicole Clowers at (202) 512-7114
or clowersa@gao.gov.
United States Government Accountability Office
Contents
Letter 1
Background 4
Selected VAMCs Used Similar Approaches to Implement VHA’s
COVID-19 Preparedness Strategies 7
VHA Oversaw VAMCs’ Implementation of COVID-19
Preparedness Strategies through Data Collection and
Conference Calls 12
Agency Comments 17
Appendix I GAO Contact and Staff Acknowledgments 20
Tables
Table 1: Selected Components and Functions of VHA’s
Emergency Management System Involved in COVID-19
Preparedness 4
Table 2: Examples of Data Reviewed during Daily VHA-Wide
Conference Calls in March 2020 Concerning VAMCs’
Implementation of COVID-19 Preparedness Strategies 15
Figure
Figure 1: HOC Data Collection on COVID-19 Preparedness
Strategies Implemented at VAMCs 14
Page i GAO-21-514 VA COVID-19 Preparedness
Abbreviations
COVID-19 Coronavirus Disease 2019
HOC Healthcare Operations Center
OEM Office of Emergency Management
PPE personal protective equipment
VA Department of Veterans Affairs
VAMC VA medical center
VHA Veterans Health Administration
VISN Veterans Integrated Service Network
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Page ii GAO-21-514 VA COVID-19 Preparedness
Letter
441 G St. N.W.
Washington, DC 20548
June 30, 2021
Congressional Addressees
Within the Department of Veterans Affairs (VA), the Veterans Health
Administration (VHA) operates one of the nation’s largest health care
systems. VHA provides health care to approximately 10 million enrolled
veterans, including an aging veteran population and a growing number of
younger veterans returning from military operations. Veterans can receive
a range of services at the approximately 170 VA medical centers (VAMC)
throughout the nation, including traditional hospital-based services such
as surgery, critical care, and mental health care. VAMCs, with the support
of VHA, aim to continue the delivery of these services during
emergencies, while maintaining the health and safety of patients
(including both veterans and non-veterans) and staff. 1
VHA began tracking the outbreak of Coronavirus Disease 2019 (COVID-
19) in January 2020. On January 21, 2020, components of VHA’s
emergency management system at the national, regional, and local levels
began coordinating efforts to prepare for COVID-19, which included
developing preparedness strategies for VAMCs. 2 In March 2020, VHA
received $17.4 billion in supplemental funding to support its efforts to
address COVID-19. 3 According to VHA, as of the end of March 2020,
1Non-veterans may be treated in VAMCs, for example, during national emergencies as
part of VA’s mission assignments to provide civilian health care assistance. See 38 U.S.C.
§ 1785.
2In January 2020, VHA began developing its COVID-19 Response Plan that listed six
“strategies to mitigate the effects of COVID-19,” which included preparedness activities
such as training staff and identifying hospital capability requirements. Veterans Health
Administration, Office of Emergency Management, COVID-19 Response Plan, Version 1.6
(Washington, D.C.: Mar. 23, 2020), accessed April 27, 2021,
https://www.va.gov/opa/docs/VHA_COVID_19_03232020_vF_1.pdf.
3Families First Coronavirus Response Act, Pub. L. No. 116-127, div. A, tit. VI, 134 Stat.
178, 183 (2020) ($60M) and the Coronavirus Aid, Relief, and Economic Security (CARES)
Act, Pub. L. No. 116-136, div. B, tit. X, 134 Stat. 281, 583 (2020) ($17.3B). One year later,
in March of 2021, VHA received an additional $14.5 billion from the American Rescue
Plan Act of 2021 for medical care and health needs. Pub. L. No. 117-2, tit. VIII, § 8002,
135 Stat. 4, 112 (2021). For more information on VA’s use and oversight of supplemental
funding from the CARES Act and Families First Coronavirus Response Act, see GAO,
Veterans Affairs: Use of Additional Funding for COVID-19 Relief, GAO-21-379
(Washington, D.C.: May 5, 2021)
Page 1 GAO-21-514 VA COVID-19 Preparedness
VHA had tested roughly 14,900 veterans for COVID-19, and over 1,300
veterans diagnosed with COVID-19 were receiving care through
outpatient and inpatient services at VAMCs.
The CARES Act includes a provision for us to conduct monitoring and
oversight of the authorities and funding provided to address the COVID-
19 pandemic, and the effect of the pandemic on the health, economy, and
public and private institutions of the United States. 4 This report, which is
part of our body of work related to the CARES Act, focuses on VHA’s
preparedness for COVID-19 and describes VHA efforts to mitigate the
effects of COVID-19 on patients and staff, including
1. how selected VAMCs implemented VHA’s COVID-19 preparedness
strategies; and
2. steps VHA took to oversee VAMCs’ implementation of these
preparedness strategies. 5
For both objectives, we reviewed plans, policies, and guidance relating to
VHA’s emergency management system and VHA components’ efforts to
prepare for COVID-19. Specifically, we reviewed VHA’s COVID-19
Response Plan, memos from VHA leadership (such as the Deputy Under
Secretary for Health for Operations and Management), preparedness
exercises created for VAMCs, and other documents about the emergency
management system’s structure and processes. 6
To describe how selected VAMCs implemented VHA’s COVID-19
preparedness strategies, we interviewed officials at a nongeneralizable
sample of four VAMCs and their associated Veterans Integrated Service
One year later, in March 2021, VHA received an additional 14.5 billion from the American
Rescue Plan Act of 2021, for medical care and health needs. Pub. L. No. 117-2, tit. VIII, §
8002, 135 Stat. 4, 112 (2021).
4Pub. L. No. 116-136, § 19010(b), 134 Stat. 281, 580 (2020).
5We regularly issue government-wide reports on the federal response to COVID-19. For
the latest report, see GAO, COVID-19: Sustained Federal Action Is Crucial as Pandemic
Enters Its Second Year, GAO-21-387 (Washington, D.C.: Mar. 31, 2021). Our next
government-wide report will be issued in July 2021 and will be available on GAO’s website
at https://www.gao.gov/coronavirus.
6In July 2020, VHA reorganized its national offices and the title of the Deputy Under the
Secretary for Health for Operations and Management was changed to the Assistant Under
Secretary for Health for Operations.
Page 2 GAO-21-514 VA COVID-19 Preparedness
Network (VISN). 7 We selected the four VAMCs based on variation in
facility complexity level, geographic location, urban/rural designations,
and the number of patients and staff tested or treated for COVID-19. 8 The
four VAMCs and their associated VISNs were: Bath, New York (VISN 2);
Columbia, South Carolina (VISN 7); St. Louis, Missouri (VISN 15); and
Walla Walla, Washington (VISN 20). 9 From each of these VAMCs, we
collected and reviewed plans, policies, trainings, and other documents
related to COVID-19 preparedness. In general, these documents were
created from February 2020 through April 2020. We also reviewed
emergency operation plans and standard operating procedures that were
applicable to COVID-19 preparedness but were in effect prior to the
pandemic. For each of the four VAMCs and their associated VISNs, we
also interviewed leadership officials, emergency managers, and other
officials to learn about how VAMCs prepared for COVID-19 in early 2020.
Information obtained from these interviews and associated document
review cannot be generalized to other VAMCs and VISNs.
To describe steps VHA took to oversee preparedness strategies
implemented at VAMCs, we reviewed the types of data VHA collected on
VAMCs’ implementation of COVID-19 preparedness strategies and
information slides presented during VHA-wide conference calls for the
months of January through March 2020. We also interviewed officials
from VHA’s Central Office, Office of Emergency Management (OEM),
Healthcare Operations Center (HOC), Office of Population Health, and
VISNs for the four selected VAMCs about their roles in VHA’s emergency
management system, including preparing for COVID-19.
We conducted this performance audit from August 2020 to June 2021 in
accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
7VHA organizes its system of care into regional networks called VISNs. Each VISN is
responsible for coordination and oversight of all administrative and clinical activities within
its specified geographic region. Specifically, the 18 VISNs oversee the day-to-day
functions of VAMCs within their geographic regions.
8VHA categorizes VAMCs according to complexity level, which is determined on the basis
of the characteristics of the patient populations served, clinical services offered,
educational and research missions, and administrative complexity. We selected one
VAMC from four out of five complexity levels. We also selected VAMCs to ensure variation
in geographic location.
9In May 2018, VHA approved the integration of the Canandaigua and Bath VAMCs to form
the VA Finger Lakes Healthcare System.
Page 3 GAO-21-514 VA COVID-19 Preparedness
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
VHA relies on its emergency management system to prepare for
Background emergencies, such as COVID-19, with the aim of continuing the delivery
of health care services and maintaining the health and safety of patients
and staff during response and recovery. According to VHA, preparedness
refers to the development of plans, resources, and capabilities to manage
and recover from the effects of emergencies. VHA’s emergency
management system includes components at the national, regional, and
local levels, and they each have functions that include preparedness (see
table 1).
Table 1: Selected Components and Functions of VHA’s Emergency Management System Involved in COVID-19 Preparedness
Component Function
Nationala
Office of Emergency • Coordinates overarching emergency management within VHA including VHA program offices (such as
Management the Office of Population Health), Veterans Integrated Service Networks (VISN), and Department of
Veterans Affairs medical centers (VAMC).b
• Manages national-level workgroups composed of clinical and administrative subject matter experts
from across VHA.
• Provides risk and situational awareness about an emergency to VHA leadership, such as the Assistant
Under Secretary for Health for Operations.
• Coordinates efforts between VHA and other federal, state, and local agencies to share guidance and
resources.
Healthcare Operations • Serves as a centralized information hub providing an operational view of VHA, including VAMC and
Center VISN efforts to prepare for and respond to an emergency.
• Manages recurring and ad-hoc data analysis requests from VHA leadership (such as the Assistant
Under Secretary for Health for Operations) that includes supply chain metrics, best practices, and
facility capacity information, among other data requests.
Regional
VISN Emergency • Coordinates emergency efforts across program offices, including planning, operations, logistics, as
Management Officials well as administrative and financial offices, at the regional and local levels.
• Provides information concerning an emergency at VAMCs to VHA components such as the
Healthcare Operations Center when requested.
Local
VAMC Emergency • Coordinates emergency efforts across program offices within the VAMC to ensure the continuous
Management Officials provision of health care services and safe operations.
• Provides emergency management information to VISN Incident Management Team when requested.
Source: GAO analysis of Veterans Health Administration (VHA) information. | GAO-21-514
Note: VHA organizes its system of care into regional networks called VISNs. Each VISN is
responsible for coordination and oversight of all administrative and clinical activities within its
specified geographic region. Specifically, the 18 VISNs oversee the day-to-day functions of VAMCs
within their regions. VHA has emergency management teams at the national, regional, and local
Page 4 GAO-21-514 VA COVID-19 Preparedness
levels that coordinate the agency’s emergency efforts and include an incident commander; public
information, safety, and liaison officers; and operations, planning, logistics, and finance or
administration chiefs.
a
National emergency management components are housed within VHA’s Office of the Assistant
Under Secretary for Health for Operations. In July 2020, VHA reorganized its national offices and the
title of the Deputy Under the Secretary for Health for Operations and Management was changed to
the Assistant Under Secretary for Health for Operations.
b
The Office of Population Health (located within VHA’s Office of Patient Care Services) manages
programs such as health promotion and disease prevention, health equity, and public health. Through
these programs, the Office of Population Health aims to optimize the health of veterans through, for
example, epidemiology and surveillance, metrics and reporting, education and training, and policy
development.
Beginning in January 2020, VHA’s OEM took the following actions to help
VAMCs prepare for the effects of COVID-19 on patients and staff. 10
• Convened experts. On January 22, 2020, OEM convened eight
national-level workgroups comprised of clinical and administrative
subject matter experts from across VHA. 11 These workgroups
supported various aspects of COVID-19 preparedness, including
updating VHA’s existing plans for infectious disease emergencies,
and generating training and guidance on COVID-19 related issues
such as screening, cleaning, and use of personal protective
equipment (PPE).
• Developed a COVID-19 SharePoint. OEM developed a COVID-19
SharePoint—a web-based platform that centralizes and shares
documents within an agency—where workgroups could make
approved trainings, plans, and guidance available to VHA staff,
including officials at the national, regional, and local levels. The
COVID-19 SharePoint also allowed the workgroups to field questions
from VAMC and VISN staff related to COVID-19 preparedness
strategies.
10OEM coordinates overarching emergency management within VHA, including VHA
program offices. In taking steps to help VAMCs prepare for COVID-19, OEM collaborated
with the Office of Population Health to obtain a perspective that was unique to pandemics
and disease prevention. OEM and Population Health organized VHA’s response into
clinical and emergency management functional operational areas. The Office of
Population Health (located within VHA’s Office of Patient Care Services) manages
programs such as health promotion and disease prevention, health equity, and public
health. Through these programs, the Office of Population Health aims to optimize the
health of veterans through, for example, epidemiology and surveillance, metrics and
reporting, education and training, and policy development.
11The eight workgroups included: diagnostics; communications; veteran/employee triage;
infection control; isolation, quarantine, and treatment; interagency and states; surveillance;
and human resources and fiscal.
Page 5 GAO-21-514 VA COVID-19 Preparedness
• Developed a COVID-19 tabletop exercise. On February 18, 2020,
VHA released a COVID-19 tabletop exercise to VISNs. 12 OEM and
the eight national-level workgroups developed this tabletop exercise
to assist VAMCs with preparing for COVID-19 by identifying strengths,
weaknesses, and gaps associated with response capabilities and
resource availability. (See text box.)
Excerpt from Veterans Health Administration’s (VHA) COVID-19 Tabletop Exercise for Veterans
Affairs Medical Centers (VAMC)
According to the Federal Emergency Management Agency, tabletop exercises are intended to encourage
participants to discuss various issues regarding a hypothetical situation in depth and develop decisions
through slow-paced problem-solving. In February 2020, VHA released a tabletop exercise that was
developed by the agency’s Office of Emergency Management and national-level workgroups of subject
matter experts to assist VAMCs with preparing for COVID-19. This tabletop exercise included the following
scenario:
Scenario: The 2019 Novel Coronavirus, or COVID-19, is a new respiratory virus that spreads in a similar
way that seasonal influenza viruses spread—primarily through the coughs and sneezes of people who are
sick with the virus. Patients with COVID-19 have reported mild to severe respiratory illness with fever,
cough, and difficulty breathing. COVID-19 has been known to cause longer hospital stays for those who
do contract it, and there are currently no preventative or mitigating treatments such as anti-viral
medications or vaccines. Media outlets are reporting several hospitalized cases in your community
diagnosed with the COVID-19 virus. These cases concern medical experts who fear a shortage of
treatment resources will occur. Of specific concern would be seniors, and those who have chronic medical
conditions such as asthma.
Purpose: Assist VAMCs in identifying strengths, weaknesses, and gaps associated with response
capabilities and resource availability when responding to COVID-19. Provide insight into VAMCs’
responses to a public health emergency, including communicating and coordinating with other agencies,
offices, or organizations.
Potential objectives: Explain how VAMCs will screen, isolate, diagnose, and treat patients who present
with COVID-19 symptoms. Identify the availability of required personal protective equipment and
associated equipment required to protect patients and staff during a local outbreak of COVID-19.
Source: GAO analysis of Federal Emergency Management Agency and Department of Veterans Affairs (VA) materials. | GAO-21-514
12VHA’s Deputy Under Secretary for Health for Operations and Management required all
VAMCs to conduct a COVID-19 tabletop exercise. However, VAMCs were not required to
use the COVID-19 tabletop exercise released by VHA, provided any alternative they used
addressed the modules identified in VHA’s COVID-19 tabletop exercise.
Page 6 GAO-21-514 VA COVID-19 Preparedness
• Released VHA’s COVID-19 Response Plan. On March 4, 2020,
VHA circulated a COVID-19 Response Plan among VISN Directors
that outlined a four-phase approach to mitigating the effects of
COVID-19. On March 27, 2020, VHA published the plan on its
website. For phase 1—the preparedness phase—VHA defined 6
strategies to be used by VAMCs. 13 VAMCs began implementing these
strategies in February 2020 while the COVID-19 Response Plan was
being further developed and finalized. 14 Phase 1 defined the following
preparedness strategies for VAMCs:
1. Develop plans, policies, and procedures to protect patients and staff
2. Conduct training on the developed plans, policies, and procedures
3. Conduct a tabletop exercise
4. Identify PPE stock levels and requirements
5. Identify existing hospital capability requirements
6. Develop coherent messaging for patients and staff
Officials from the four selected VAMCs reported taking similar
Selected VAMCs approaches to implement the six preparedness strategies VHA defined in
Used Similar phase 1 of its COVID-19 Response Plan. VHA’s guiding principles for this
phase included protecting patients and staff from COVID-19 infection, and
Approaches to shifting priorities and resources to accommodate a large influx of
Implement VHA’s infectious patients.
COVID-19 Develop plans, policies, and procedures to protect patients and
Preparedness staff. All four selected VAMCs developed or adapted plans to prepare for
COVID-19 that covered the following topics:
Strategies
13Following preparedness, the phases were initial response (phase 2); establishing
alternate sites of care (phase 3); and sustainment and recovery (phase 4).
14According to VHA officials, OEM and the Office of Population Health began developing
its COVID-19 Response Plan in late January 2020 after OEM convened eight national-
level workgroups. While the plan was being developed, VISN and VAMC emergency
managers were receiving guidance from OEM and the eight national-level workgroups on
COVID-19 related issues such as cleaning and use of PPE that informed VAMCs’
implementation of COVID-19 preparedness strategies. Additionally, the COVID-19
tabletop exercise highlighted the actions needed from VAMCs in order to prepare for the
COVID-19 pandemic, which also aligned with the strategies that ultimately appeared in
phase 1 of the plan.
Page 7 GAO-21-514 VA COVID-19 Preparedness
• Cleaning. To convey cleaning and disinfection practices for curtailing
the spread of COVID-19.
• Testing. To conduct and process swabs or other specimen collection
procedures from persons being tested for COVID-19.
• Using PPE. To identify and use PPE for infection prevention and
control to protect staff from COVID-19.
• Screening. To assess individuals for signs, symptoms, and
exposures concerning COVID-19 infection and help ensure the safety
of patients and staff in VAMCs.
Officials noted that they developed these plans to address new and
emergent needs specific to the COVID-19 pandemic that may not have
been covered in pre-existing emergency operation plans or under
standard operating procedures. For example, officials at three selected
VAMCs told us that their COVID-19 screening plans enabled them to
establish separate outdoor screening and testing stations for individuals
arriving at the facility. Screened individuals who were identified as
symptomatic were sent to a dedicated testing area for additional
assessment and potential COVID-19 testing. By physically separating
these testing areas from the facility, the VAMCs were able to limit staff
exposure to potentially infectious individuals and to help mitigate the
spread of COVID-19.
All four selected VAMCs also developed other plans to address the
specific needs of their facility. For example, one VAMC developed plans
for assessing risk and monitoring illness among staff returning from
emergency medical deployments. 15 In addition, two VAMCs developed
traffic flow plans to prevent the spread of COVID-19. These plans helped
VAMCs control the number of individuals and staff that entered and exited
the facility by identifying and monitoring entry points and outdoor areas
15VHA uses its Disaster Emergency Medical Personnel System to deploy clinical and non-
clinical staff to an emergency or disaster for both internal VA missions as well as to
support national, state, and local emergency management, public health, and safety
efforts in times of national crisis. OEM manages VHA’s Disaster Emergency Medical
Personnel System and is responsible for coordinating VHA’s civilian mission assignments.
Between March 2020 and February 2021, VA conducted 117 mission assignments to
provide civilian health care assistance in response to COVID-19. For additional
information on VHA’s emergency medical staff deployment program, see GAO, COVID-19
Pandemic: VA Provides Health Care Assistance to Civilians as Part of the Federal
Response, GAO-21-395 (Washington, D.C.: May 28, 2021).
Page 8 GAO-21-514 VA COVID-19 Preparedness
used for waiting rooms, drive-through pharmacy services, screening, and
testing.
Conduct training on the developed plans, policies, and procedures.
All four selected VAMCs provided trainings on the following topics in
order to prepare staff for the COVID-19 pandemic:
• COVID-19 awareness. Training that generally covered aspects of
COVID-19 symptoms, transmission, prevention, screening, PPE use,
and specimen collection.
• PPE. Training to ensure that PPE users put on and removed PPE
properly. Such training could include identifying PPE; proper usage of
powered air-purifying respirators used for respiratory protection
against aerosolized and airborne droplet virus transmission; and N95
fit-testing to ensure that the respirator’s face piece properly fits the
user’s face.
• Skills refresher. Face-to-face training for nurses to review the skills
needed to perform duties in a department outside their normal station
in the event they needed to be reassigned to support hospital
operations.
• Nasopharyngeal swab specimen collection. Training to instruct
staff on how to collect respiratory specimens for COVID-19 testing
using nasopharyngeal swabs.
VAMC officials noted that these trainings were intended to provide staff
with the information and skills needed to maintain safety and provide care
in the COVID-19 environment. For example, officials at one selected
VAMC described how its COVID-19 screener orientation training helped
ensure consistency in implementation of screening procedures as staff
performing those duties often rotated from other areas (e.g., surgical staff
temporarily assigned to screening due to postponements in elective
surgeries).
All four selected VAMCs also developed other trainings tailored to meet
the specific needs of their facility. For example, one selected VAMC
developed a training for staff that reviewed the VAMC’s emergency
management system, including the roles and relationships of its
emergency management team.
Page 9 GAO-21-514 VA COVID-19 Preparedness
Conduct a tabletop exercise. All four selected VAMCs conducted a
mandatory COVID-19 related tabletop exercise in February 2020. 16
Officials from all four VAMCs reported that shortly after completing the
COVID-19 tabletop exercise, they identified strengths and areas for
improvement. They noted that the COVID-19 tabletop exercise helped
them refine their approaches to implementing other COVID-19
preparedness strategies. For example, officials at one selected VAMC
told us the COVID-19 tabletop exercise highlighted the need to take
precautions with regard to training that went beyond the Centers for
Disease Control and Prevention’s guidance at the time, including
providing additional training for staff on powered air purifying respirator
systems, and fit testing staff for N95 respirators. Officials at another
selected VAMC told us the COVID-19 tabletop exercise enabled them to
consider how the pandemic could affect their entire hospital, not just
inpatient services. These officials reported the COVID-19 tabletop
exercise spurred the development of plans for addressing COVID-19 in
other departments, such as physical therapy and occupational therapy.
Identify PPE stock levels and requirements. All four selected VAMCs
reported that staff manually counted PPE inventory and calculated
consumption rates to identify current stock levels and predict future
needs. All four VAMCs reported they were initially concerned about their
ability to obtain sufficient PPE to meet the predicted stock levels needed
to protect patients and staff during the COVID-19 pandemic. 17 These
officials noted that when they identified the potential for future shortages,
they implemented a number of strategies at the local level to reinforce
16According to OEM officials, all VAMCs completed a COVID-19 tabletop exercise by April
22, 2020, except for five VAMCs who were responding to pandemic-related events (e.g.,
already converting facility spaces to COVID-19 units in order to care for patients with
COVID-19 in their areas). As part of the COVID-19 tabletop exercise, VAMCs complete an
after action report to address ways in which the facility can improve its response
capabilities and resource availability.
17GAO has previously identified longstanding issues with VA’s approach to purchasing
medical supplies. VA supply chain leaders did not have an automated way of tracking the
stock of critical supplies at VAMCs during the COVID-19 pandemic due to VA’s antiquated
inventory management system. Instead, these officials relied on manual tracking reported
by all 170 VAMCs on a daily basis, which limited their ability to have real-time information
on supplies to make key decisions. GAO, VA Acquisition Management: Supply Chain
Management and COVID-19, GAO-20-638T (Washington, D.C.: June 9, 2020), VA
Acquisition Management: COVID-19 Response Strains Supply Chain While Modernization
Delays Continue, GAO-20-716T (Washington, D.C.: Sept. 16, 2020), and VA COVID-19
Procurements: Pandemic Underscore Urgent Need to Modernize Supply Chain,
GAO-21-280 (Washington, D.C.: June 15, 2021).
Page 10 GAO-21-514 VA COVID-19 Preparedness
PPE stock levels, such as purchasing cloth masks, forming sewing circles
to create masks, using expired PPE, and reprocessing N95 respirators.
Officials from all four VAMCs also reported that they coordinated with
their VISNs to identify and obtain needed PPE. For example, officials
from two VAMCs reported VISNs took over tracking PPE so VISNs could
facilitate the redistribution of PPE among VAMCs within their regions to
ensure each had sufficient stock. As we recently reported, VHA also
made changes at the national level to its approach to procuring PPE and
other medical supplies to address the disruptions caused by the
pandemic. 18
Identify existing hospital capability requirements. All four selected
VAMCs developed a surge plan that identified their potential to expand
capacity and ensure the readiness of space, equipment, and staff to
accommodate an increase in COVID-19 patients. These plans generally
identified VAMCs’ options to expand bed capacity, as well as other
flexibilities, such as creating isolation rooms and negative pressure
areas—which contain airborne contaminants and reduce the risk of
disease transmission.
Developing these surge plans required VAMCs to coordinate across
departments in considering different ways to expand hospital capacity.
For example, officials from one VAMC told us they coordinated with a
team of engineers, nurses, and infectious disease staff to construct a
negative pressure ward with entryway designed to protect staff and help
conserve PPE. Officials from another VAMC, which had limited capability
to provide critical care due to the nature of the facility, reported exploring
ways to revamp the facility’s ventilation systems to convert smaller rooms
to negative pressure rooms in the event other medical centers needed
additional support.
Develop coherent messaging for patients and staff. Officials from all
four selected VAMCs reported using the following approaches to keep
patients and staff informed about the COVID-19 pandemic.
18VHA also faces broader challenges in its effort to modernize its medical supply chain.
We recently recommended VHA develop a comprehensive supply chain management
strategy that outlines how VHA’s various supply chain initiatives are related to each other
and to VA-wide initiatives. GAO, VA Acquisition Management: Comprehensive Supply
Chain Management Strategy Key to Address Existing Challenges, GAO-21-445T
(Washington, D.C.: Mar. 24, 2021).
Page 11 GAO-21-514 VA COVID-19 Preparedness
• Call center scripts. Providing appointment schedulers with call
center scripts on COVID-19 safety information, such as masking
requirements, that was disseminated to patients when scheduling
appointments.
• Virtual outreach. Employing a variety of virtual methods to keep
patients informed about COVID-19, such as updating VAMC websites
and conducting outreach via social media and message boards. In
addition to outreach to patients, VAMCs also used virtual methods to
communicate with staff, such as conducting virtual town halls;
disseminating emails from leadership; using text messaging alert
systems; and updating local COVID-19 SharePoint sites.
VAMC officials told us that coherent messaging was important to educate
patients and staff about changes to COVID-19 safety protocols and to
provide transparency regarding VHA operational capacity and policy.
Officials at one VAMC reported that their Veteran Coordinator conducted
outreach about mask requirements and appointment arrival times, as well
as to manage expectations about what services would be available in
person. Officials at another VAMC reported that virtual staff town halls
were an important tool that helped create unity among the staff.
According to officials, during town halls VAMC leadership provided
updates, sought staff feedback, and provided staff the opportunity to ask
questions.
In March 2020, the Healthcare Operations Center (HOC) began collecting
VHA Oversaw data on a daily basis about COVID-19 preparedness strategies
VAMCs’ implemented in VAMCs. HOC officials also facilitated daily discussions
during VHA-wide conference calls based on the collected data.
Implementation of
COVID-19
Preparedness
Strategies through
Data Collection and
Conference Calls
Data Collection HOC collected data on VAMCs’ implementation of the COVID-19
preparedness strategies identified in phase 1 of VHA’s COVID-19
Response Plan (see fig. 1). For example, HOC collected data on the
number of VAMCs that completed the COVID-19 tabletop exercise and
whether VAMCs developed surge plans to expand hospital capacity.
Page 12 GAO-21-514 VA COVID-19 Preparedness
1. HOC distributed a data collection tool to VISNs. In conjunction with
VHA leadership, including the Assistant Under Secretary for Health for
Operations, HOC created a data collection tool to gather information
on VAMCs’ implementation of preparedness strategies. 19 HOC began
distributing the tool to VISN emergency management officials in
March 2020 via SharePoint. 20
2. VISNs collected data needed for the tool from VAMCs. VISN
emergency management officials reported that they obtained data
from VAMC emergency management officials during daily VISN-wide
conference calls. Some VISN emergency management officials also
told us that they obtained data through a chain of emails used to notify
and record required tasks to be completed by VAMCs.
3. VISNs populated and submitted the tool to HOC. VISN emergency
management officials aggregated the data across VAMCs and
populated the tool in SharePoint. VISN emergency management
officials told us they updated the tool on a daily basis for HOC’s
review.
19HOC officials told us that they updated the data collection tool frequently, sometimes
daily, based on COVID-19 developments and at the direction of leadership. From March
2020 through May 2020, the data collected via this tool provided VHA with daily
information related to VAMC preparedness strategies, among other things. Due to the
evolving nature of the pandemic, the type of data HOC collected with this tool changed
over time and therefore the data collected using this tool did not allow for longitudinal
analyses.
20Prior to uploading the data collection tool via SharePoint, HOC officials had emailed the
tool to VISNs daily.
Page 13 GAO-21-514 VA COVID-19 Preparedness
Figure 1: HOC Data Collection on COVID-19 Preparedness Strategies Implemented at VAMCs
Conference Calls HOC officials told us that they facilitated daily VHA-wide conference calls
based on the data collection tool submitted by the VISNs. VHA officials
reported that staff from VHA Central Office, OEM, HOC, VISNs, and
VAMCs could attend the calls. 21 Specifically, on the daily calls, officials
did the following:
Reviewed data on VAMCs’ preparedness strategies. Using reporting
templates, HOC officials told us they facilitated discussion on VAMC
implementation of each of the preparedness strategies in phase 1 of
VHA’s COVID-19 Response Plan. See table 2 for examples of the data
reviewed during these calls in March 2020.
21For several years, HOC stated that they routinely held calls with VHA leadership to
provide updates concerning VHA operations. According to HOC officials, these calls
became longer and more frequent during the early months of the pandemic. HOC officials
also told us that, as a way to connect entities and share information across VHA, VHA
leadership began including OEM, VISN, and VAMC officials on these calls in March 2020.
HOC developed a data collection tool to gather data that informed these discussions and
assisted VHA in its oversight of VAMCs’ implementation of COVID-19 preparedness
strategies. HOC officials reported that VHA-wide calls became less frequent in May 2020,
due to the decrease in COVID-19 cases during the summer months.
Page 14 GAO-21-514 VA COVID-19 Preparedness
Table 2: Examples of Data Reviewed during Daily VHA-Wide Conference Calls in March 2020 Concerning VAMCs’
Implementation of COVID-19 Preparedness Strategies
Preparedness strategies Examples of the types of data reviewed
Develop plans, policies, and procedures • Whether VAMCs developed plans to establish areas for screening patients and staff
to protect patients and staff for COVID-19.
Conduct training on the developed plans, • The number of VAMC staff capable of providing personal protective equipment (PPE)
policies, and procedures training.
• The number of PPE trainings conducted at VAMCs within each VISN.
Conduct a tabletop exercise • The number of VAMCs that completed a COVID-19 tabletop exercise.
• Weaknesses and gaps associated with response capabilities identified during the
COVID-19 tabletop exercise.
Identify PPE stock levels and • The projected weekly PPE stock levels for VAMCs within each VISN.
requirements • Supply chain issues occurring within VISNs.
Identify existing hospital capability • Whether VAMCs developed surge plans to expand hospital capacity and ensure the
requirements readiness of space, supplies, equipment, and staff at VAMCs.
• The number of VAMCs where COVID-19 affected staffing.
Develop coherent messaging for patients • Whether VAMCs were using call center COVID-19 scripts to ensure coherent
and staff messaging when communicating information related to COVID-19 to patients.
Source: GAO analysis of interviews with Veterans Health Administration (VHA) and Veterans Affairs medical center (VAMC) officials and VHA documents. | GAO-21-514
Note: VHA’s Healthcare Operations Center (HOC) officials told us they facilitated daily VHA-wide
conference calls that were based on data that each Veterans Integrated Service Networks (VISN)
gathered from their VAMCs. On a daily basis, VISNs aggregated data collected from VAMCs and
entered it into a tool that HOC created to facilitate the review of specific information related to COVID-
19 preparedness. Due to the evolving nature of the pandemic, the type of data collected with this tool
changed over time and therefore the tool did not allow for longitudinal data analyses.
In addition to facilitating their efforts to oversee VAMCs’ implementation
of the preparedness strategies, VHA officials told us that discussing the
data submitted by VISNs during these conference calls also helped to
inform VHA-wide decisions. For example, upon learning that some
VAMCs potentially needed to expand intensive care unit bed availability
to treat COVID-19 patients, VHA temporarily shut down outpatient
services and postponed elective procedures to provide VAMCs with
additional beds for intensive care unit conversions. In addition, due to
staffing shortages related to COVID-19 and the projected need for surge
staffing, VHA officials said that the agency increased hiring efforts by
launching national hiring announcements using dual compensation
Page 15 GAO-21-514 VA COVID-19 Preparedness
waivers to hire retired federal employees, and worked with the Office of
Personnel Management to expedite hiring processes. 22
Addressed challenges with the data collection tool. HOC officials also
used the conference calls to address challenges concerning the data
collection tool. Officials from one selected VISN told us they found some
of the terms used in the tool to be confusing. For example, for screening
and testing of patients and staff, terms such as “persons under
investigation” did not clarify if the person was tested for COVID-19 and
awaiting results, or if they were asymptomatic with a COVID-19
diagnosis. Both VISN and HOC officials told us that after discussions,
HOC created a data dictionary to clarify terms used in the reporting
templates, which helped provide consistency in the data reported across
VAMCs.
Shared best practices. The conference calls were also a way for
VAMCs and VISNs to share best practices that provided solutions to local
challenges related to the implementation of COVID-19 preparedness
strategies among the facilities, including the following examples: 23
• VAMC and VISN emergency management officials told us they used
shared solutions, such as 3-D printing to produce additional masks,
face shields, and testing supplies, to address challenges related to
supply chain issues.
• One VISN officials also told us that some VAMCs incorporated shared
best practices, such as the use of tents and drive-through screening
facilities, into local plans for screening patients and staff.
22In March 2020 the Office of Personnel Management authorized the use of excepted-
service, temporary appointments under 5 C.F.R. § 213.3102(i)(3) to address the need for
hiring additional staff in response to COVID-19. Consistent with this guidance, VHA
waived or postponed certain pre-employment requirements until after individuals were
hired, such as physicals, credentialing, and fingerprints. Dual compensation or salary-
offset waivers allow federal agencies to hire retired federal employees during a military
threat, natural disaster, or unforeseen occurrence. Retired federal employees who are
rehired under the dual compensation waiver can earn both sick and annual leave, but are
not eligible for additional retirement coverage (other than Social Security coverage).VHA
hired 16,202 new hires between March 29, 2020, and May 27, 2020, which included
registered nurses, respiratory therapists, housekeepers, supply technicians, among
others.
23HOC officials told us that many of the best practices shared during these calls were
distributed via VHA’s COVID-19 SharePoint. VAMC and VISN officials could also attend a
call hosted by OEM that occurred several times a week and VISN officials could attend a
morning conference call with VHA leadership and HOC officials.
Page 16 GAO-21-514 VA COVID-19 Preparedness
HOC officials told us that states—such as New York that experienced
COVID-19 surges during the early months of the pandemic—shared best
practices concerning clinical staff training, as well as procedures used to
convert spaces to negative pressure rooms to expand hospital capability.
In addition to the preparedness issues in this report, we expect to
continue examining VHA’s actions to address COVID-19.
We provided a copy of this draft report to VA for review and comment. VA
Agency Comments provided us with one technical comment, which we incorporated as
appropriate.
We are sending copies of this report to the appropriate congressional
committees and the Secretary of Veterans Affairs. In addition, the report
is available at no charge on the GAO website at https://www.gao.gov.
If you or your staff have any questions about this report, please contact
me at (202) 512-7114 or clowersa@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made key contributions to this
report are listed in appendix I.
Nicole Clowers
Managing Director, Health Care
Page 17 GAO-21-514 VA COVID-19 Preparedness
List of Addressees
The Honorable Patrick Leahy
Chairman
The Honorable Richard Shelby
Vice Chairman
Committee on Appropriations
United States Senate
The Honorable Ron Wyden
Chairman
The Honorable Mike Crapo
Ranking Member
Committee on Finance
United States Senate
The Honorable Patty Murray
Chairwoman
The Honorable Richard Burr
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate
The Honorable Gary C. Peters
Chairman
The Honorable Rob Portman
Ranking Member
Committee on Homeland Security and Governmental Affairs
United States Senate
The Honorable Rosa L. DeLauro
Chairwoman
The Honorable Kay Granger
Ranking Member
Committee on Appropriations
House of Representatives
Page 18 GAO-21-514 VA COVID-19 Preparedness
The Honorable Frank Pallone, Jr.
Chairman
The Honorable Cathy McMorris Rodgers
Ranking Member
Committee on Energy and Commerce
House of Representatives
The Honorable Bennie G. Thompson
Chairman
The Honorable John Katko
Ranking Member
Committee on Homeland Security
House of Representatives
The Honorable Carolyn B. Maloney
Chairwoman
The Honorable James Comer
Ranking Member
Committee on Oversight and Reform
House of Representatives
The Honorable Mark Takano
Chairman
Committee on Veterans’ Affairs
House of Representatives
The Honorable Richard Neal
Chairman
The Honorable Kevin Brady
Ranking Member
Committee on Ways and Means
House of Representatives
The Honorable Julia Brownley
Chairwoman
Subcommittee on Health
Committee on Veterans’ Affairs
House of Representatives
Page 19 GAO-21-514 VA COVID-19 Preparedness
Appendix I: GAO Contact and Staff
Appendix I: GAO Contact and Staff
Acknowledgments
Acknowledgments
A. Nicole Clowers, (202) 512-7114 or clowersa@gao.gov
GAO Contact
In addition to the contact named above, Debra A. Draper (Director),
Staff Hernán Bozzolo (Assistant Director), Courtney Liesener (Analyst-in-
Acknowledgments Charge), Caitlin Scoville, and Kelly Turner made key contributions to this
report. Also contributing were Cathleen Hamann, Sandra Mansour, and
Ethiene Salgado-Rodriguez.
(104451)
Page 20 GAO-21-514 VA COVID-19 Preparedness
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