I'll be very quick.
All hospitals have to go through an accreditation program where they basically undergo a quality assurance evaluation. Veterans Affairs is in charge of funding and even providing medical treatment, assessment and so on, yet there's no quality assurance program there.
Again, back in that original committee I was on, we had a professor and that's what she did. The idea would be to hire somebody who is an expert in this and then implement a system where the department is reviewed on a regular basis, just like a hospital has to be reviewed on a regular basis in order to maintain its accreditation.
That would be a good first step, because it would give veterans, family members and caregivers an ability to provide useful feedback and hopefully to be able to implement change.