I spent my career designing and planning Department of Veterans Affairs (VA) buildings and health care delivery strategies Here are some specific VA reforms needed. The principles underlining these could be also applied to other Departments.
1. Make requests for VA Construction Funding a part of each VA Administration’s budget request, not a part of a separate Construction request. Project priorities should be reevaluated for each budget submission by the respective Administration. This would put responsibility for the content of project submissions squarely on the using Administration.
2. Once Congress approves funding for a project, the project’s VA Administration (Veterans Health Administration, Veterans Benefit Administration or National Cemetery Administration) should hold the funds and be responsible for budget management. Currently Office of Construction and Facility Management (OCFM) holds the funds and the using Administration is not a part of budget management. This is roughly analogous to letting your car dealer decide which car you should have and how much you should pay.
3. Require all VA organizational elements to use the same geographic alignments. Require all boundaries to align with State lines. Currently VHA, VBA, NCA, OIT, OCFM etc. divide the country differently. This would make it easier to define needs and coordinate internally and externally. It would also make it possible to see how much money is sent to each State and Congressional District.
4. Require VA buildings housing programs needed to back up DoD in war to be government-owned and designed to DoD security standards. All other VA buildings, owned and leased, should be designed to the standards of the community. Currently VA has its own construction and physical security standards which are expensive and not uniformly applied. There is no reason to hold VA outpatient care and administrative functions to a higher physical security standard than the private sector. The physical security standards are one of the reasons for extremely expensive VA construction and leases.
5. Interstitial mechanical floors should not be included in VA buildings. While an interesting engineering solution, interstitial mechanical floors are extremely expensive to build. Maintenance and future renovation savings do not offset the costs—in some cases they actually complicate future work. Since these floors are semi-conditioned space, they also result in higher energy costs than an equally well-built and insulated conventional building. There are other VA building standards that needlessly drive up costs—these should also be reviewed and eliminated.
6. Require VA contracts and services to be procured solely through consideration of cost, quality, and time. Any costs associated with meeting other goals must be paid for with funds appropriated for those purposes. For example, if a building to house Veteran health care programs could be constructed for $100,000,000 but the proposed contract includes an additional $200,000 to meet a small business goal and an additional $2,000,000 to meet a “Green” building goal that exceeds what is typical for the building type, then those additional costs, of $2,200,000, must come from funds appropriated for those other goals. If such funds are not available, then the small business and “Green” requirements must be deleted.
7. For Nonrecurring Maintenance (NRM) projects, budget authorizations must be worded to allow carryover to future fiscal years. Something must be done to stop the intense pressure to quickly obligate and spend NRM program funds. In my office, we referred to the annual NRM program plan as our “burn plan”. The only meaningful metric was getting the funds obligated.
8. Medical Center Directors should be operating officers responsible for the day-to-day care of Veterans. Decisions on where to spend capital funds must be made at the Veterans Integrated Service Network (VISN) level and above. Currently strong Medical Center Directors make decisions that are in conflict with where the real needs are. This happens at small rural facilities and also at large ones. Medical Centers do need adequate maintenance funding and the ability to keep facilities safe and functional, but large investments should be decided based on the overall needs of Veterans in the entire market, state, VISN and nation.
9. Access to care metrics must include consideration of the workload capacities of each point of care. In other words, a Veteran within 30 minutes of a point of care with no appointments for 6 months does not have acceptable access. Access distances and times must not be seen as absolutes. What is needed first is high quality care.
10. Continue the VA Integrated Planning Process which compares a market driven ideal VA benefits and care solution to the status quo, and develops a process for improvement.
During my VA career there were numerous efforts to fix, realign, or transform VA. In every case it seemed that the effort to transform was pushed without a real understanding of how the bureaucracy was organized or worked. This lack of understanding allowed the bureaucracy to react like a living thing to defend itself. Transformation efforts usually zeroed in on an issue without coordinating with related functions or offices. By not coordinating these efforts, the overall bureaucracy was able to avoid accountability, maintain compartments of deniability to allow spreading the blame in case of (inevitable) failure, and confine any damage to only a part of itself. The transformation ideas themselves were nearly always good. When a new scandal in the 4th Branch of government is confirmed the first response should be to immediately reduce the responsible organization’s funding. The bureaucracy will respond by cutting programs that may be unrelated to the scandal but are highly visible. The correct response is to further cut the budget and hold the managers accountable for making sure that the important things still get done.