Veterans Affairs Secretary David Shulkin delivered his diagnosis of the department Wednesday.

VA’s prognosis? A long road toward recovery.

Shulkin is, after all, a doctor, and he offered a fact-filled assessment on the “State of VA,” outlining 13 areas where the department needs to improve and the legislative and administrative fixes it needs in order to see progress.

Shulkin said he and his team have reviewed 137 different studies on the department from outside sources, as well as the 2016 Commission on Care report and VA’s own internal assessments.

President Donald Trump said veterans reform is one of his top domestic priorities, and he’s reminded Shulkin of the importance of staying transparent as VA begins to make changes.

“It is important that we be open and candid and transparent about where the problems are,” he told reporters May 31. “As a business man, the only way to fix the issues in an organization is if you come out and you talk about what those problems are. As you know I’m a doctor, and I like to diagnose things, assess them and treat them. What you’re going to hear today is a candid assessment of where things are in VA.”

Accountability

Shulkin was blunt in his assessment of the current accountability procedures Congress authorized when it passed the Veterans Access, Choice and Accountability Act of 2014. Again, he encouraged Congress to pass new legislation.

Under current disciplinary procedures, it takes the department 51 days from the day VA management proposes to suspend or remove an employee until the date the action actually takes effect, Shulkin said.

“Because of the way judges review these cases, they can force us to take terrible managers back who have been fired for poor performance,” he said. “We recently saw that in one of our executives in San Juan, [Puerto Rico]. Just last week, we were forced to take back an employee after they were convicted no more than three times for [a] DUI and had served a 60-day jail sentence.”

VA currently has 1,500 disciplinary actions pending. The department did recently fire the medical center directors of the Washington, D.C. and Shreveport, Louisiana, VA hospitals.

“Our accountability processes are clearly broken,” Shulkin said. “We had to wait more than a month to fire a psychiatrist watching pornography using his iPad while seeing a veteran. The expedited senior executive removal authority that was given to us in the Choice Program isn’t working.”

The Senate VA Committee recently passed the VA Accountability and Whistleblower Protection Act, which would eliminate the Merit Systems Protection Board as an avenue for senior executives to appeal disciplinary cases.

The House has already passed its own accountability legislation.

Staffing

VA has long bemoaned the lengthy hiring process and the difficulties it’s had to recruit and retain top talent, particularly in the medical professions.

The department has roughly 49,000 vacancies, with most in the Veterans Health Administration.

VA currently lacks a position management system, so the department can’t often track which jobs are open.

Shulkin said he will stand up a new Management Manpower Office by December, which he described as the first tangible step in setting up such a system to track open positions.

Regardless, the department also lacks the incentives Shulkin said it needs to attract new talent. For example, the mean salary for a biomedical engineer in the United States is $85,620, but the VA can pay, on average, only $65,677 for the same position.

Once VA has the right talent, it takes too long get new employees in their seats and working. It takes 110 days to onboard a new nurse and 177 days for a new nurse practitioner, Shulkin said.

Access

Since wait time scandals at the Phoenix, Arizona, VA hospital and others across the country were first made public in 2014, the department has made some improvements.

All 168 VA medical centers now offer same-day medical and mental health care services.

But veterans are waiting 60 days or more for new appointments in primary care or mental health at 30 VA locations, Shulkin said.

The department will present its plan to redesign the Veterans Choice Program before the Senate VA Committee next week. Shulkin has already hinted what he wants the new Choice program to look like. Generally, the goal is to consolidate the several different ways veterans can access private sector care into one, more manageable system.

“This is not a privatization of VA,” he said. “This is not deluding the impact of VA. Every day I am in this job I am more and more convinced that veterans and America need a strong VA. It’s essential for national security. It’s essential to honor our commitment. I will not allow our policies to weaken the VA. Our policies will strengthen the VA, but working with the private sector is the way to do that.”

Paying providers

VA’s 500,000 community care providers are increasingly frustrated by how long it takes for the department to reimburse them for the health care services they’ve already provided to veterans, Shulkin said.

It takes the department more than 30 days to process 20 percent of its “clean” provider claims, and VA currently has more than $50 million in outstanding outpatient bill charges that are more than six months old.

Community care

VA currently has eight separate programs veterans can use to access health care from community providers.

But the rules are so complicated that VA rejects one out of every five community care claims, Shulkin said.

VA is also looking to add more Defense Department facilities to its network of participating places where veterans can access health care. Currently, three DoD facilities participate in the VA Choice network.

Quality

The department recently launched a new website that tracks wait time and quality data about each VA medical center and clinic.

According to Shulkin, 14 VA facilities have one star ratings — information that’s available on the department’s new website.

“That’s not acceptable to us,” he said of the 14 facilities. “We’re deploying teams and implementing performance plans for each of those facilities.”

Shulkin said the revamped Choice program will allow veterans who would typically visit a low-performing hospital go to another facility instead.

Disability claims and appeals

VA had made some progress in cutting down its backlog of disability claims in recent years.

But the department has 90,000 claims that take more than 125 days to process. Shulkin said he wants to cut that number in half over the next two years.

VA will also introduce decision-ready claims nationwide by Sept. 1. It’s an option that veterans can take to move their claims through the process more quickly.

The department expects all Veterans Benefits Administration offices will be paper-less by mid-2018.

VA has said it would need “billions of dollars in additional appropriations” to work through the 470,000 appeals that are now pending in the Veterans Benefits Administration and Board of Veterans Appeals as of April 1.

The House recently passed the VA Appeals Improvement and Modernization Act, which would help the department address new appeals more quickly, but the legislation doesn’t address the backlog of pending appeals.

IT

About 75 percent of the department’s IT spend goes toward maintaining old VA systems.

Shulkin said that’s having an impact on how quickly VA doctors and nurses can get their hands on the medical equipment they need.

“This is what we saw in the Washington, D.C.. VA several weeks ago,” he said.

VA is in the process of replacing its financial management and appointment scheduling systems, but both projects will take years to finish.

Shulkin also committed to making a decision by July 1 on which direction he’ll take in modernizing VA’s electronic health record.

Without funding to update the VA Loan Electronic Reporting Interface, the department will have to revert to using a paper-based system to process veterans’ loan applications.

The department services 90,000 veterans annually in this area now, but paper would force VA to help only 12,000 in a year, Shulkin said.

Capital assets

VA’s recent facility condition assessment of its own assets found that it needs $18 billion to fix or upgrade old buildings.

The department currently has 400 vacant buildings and 735 under-utilized facilities, and it costs VA $25 million a year to maintain them, Shulkin said.

Nearly 450 of VA’s buildings date back to the Revolutionary and Civil Wars.

Shulkin said he has no plans at the moment to close specific buildings, but he wants to work with Congress to develop a “national alignment strategy” to modernize VA infrastructure.

“What I’m looking to do in this national realignment strategy is to make sure that we’re using our current resources most effectively,” he said. “That’s why when I’m spending money on vacant and under utilized buildings that aren’t helping veterans, I want to realign that to help invest back into our facilities that need capital repairs.”

Construction

The department currently has 11 major construction projects on hold because VA and the Army Corps of Engineers are struggling to work through a complicated acquisition process, Shulkin said.

The department is waiting on congressional approval on a joint proposal that would authorize those projects moving forward.

Those projects together are worth about $1.4 billion.

Bureaucracy

Shulkin reiterated his belief that the department’s central office is too large and unwieldy. He said he’ll keep the hiring freeze in place at VA’s corporate offices as it consolidates 140 different program offices.

He’s also directing VA headquarters to begin cutting burdensome regulations and requirements from the rule book, and he’s actively encouraging the department to pursue more shared services solutions.

The goal, Shulkin said, is to reduce overhead costs at VA headquarters by 10 percent.

In addition, VA will soft-launch the White House veterans complaint hotline on June 1. The hotline was one of the president’s specific priorities for the department.

VA plans to test the hotline system over the next few months, with the goal of having it fully operational by Aug. 15.

Waste, fraud and abuse

VA prevented about $27 million in fraudulent and $24 million in duplicative payments from going out in fiscal 2016, but Shulkin said he’d like to see that number in increase in the coming years.

He’s currently identifying members to serve on the new Fraud, Waste and Abuse Prevention Advisory Committee, which the department will stand up by July.

VA announced in April it would also launch a task force to investigate waste, fraud and abuse within the department.

According to the Government Accountability Office, VA’s improper payment estimate totaled at least $5.5 billion in 2016. Yet that estimate may not be entirely accurate. VA has at least four programs that are highly susceptible to risk and were not included in the department’s total improper payment estimate.

Veterans suicide

Combating veterans suicide is VA’s top clinical priority, which he called a “public health crisis.

According to the department’s most recent estimate, at least 20 veterans a day commit suicide in the United States.

Shulkin said VA will launch the “Getting to Zero” initiatives later this summer, which will codify the department’s efforts to eliminate veterans suicide.

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