prompt_front: You are given two reports by the government agency.



Question: Write a one-page summary of the report 1.

Report 1: In the United States, both FRA and FTA regulate rail transportation safety  FRA oversees safety of railroads operating on what is known as the general system, a network of standard gage track over which goods may be transported and passengers may travel  This system includes freight railroads, which typically own their own tracks and locomotives, transporting products among states and regions  FRA also oversees safety of intercity passenger and commuter railroads that operate over tracks owned by freight railroads and other entities  FTA oversees safety of rail transit systems that typically serve individual metropolitan areas, using track not shared with freight and other passenger trains  Rail transit includes a variety of modes, such as heavy and light rail, streetcars, automated guideways, cable cars, and others  Rail transit is an important component of the nation’s transportation network, particularly in large metropolitan areas  Rail transit systems provided over 4 4 billion passenger trips in 2016  “Heavy rail” systems in large cities account for much of the total rail transit activity, including 88 percent of passenger trips in 2016  According to FTA, 61 rail transit systems within 28 states, the District of Columbia, and Puerto Rico are subject to safety oversight by one of the 31 agencies in FTA’s state safety oversight program (see fig  1)  The states have long played a central role in conducting safety oversight of rail transit systems  The Intermodal Surface Transportation Efficiency Act of 1991 required, among other things, that states with rail transit operators designate an agency to oversee the safety of those systems, known as a state safety oversight agency  In overseeing state safety agencies, FTA designed the program as one in which FTA, states, and rail transit operators collaborate to ensure the safety and security of rail transit systems  However, limitations have been identified in the state safety oversight program  In 2006, we reported on some state safety agency challenges in overseeing rail transit safety  Specifically, we found many of the state safety agencies lacked enough qualified staff and adequate levels of training to meet their responsibilities  In a 2009 hearing before the Subcommittee on Highways and Transit of the House Committee on Transportation and Infrastructure, then Secretary Ray LaHood of the Department of Transportation discussed some of the weaknesses under the current state safety oversight program and introduced a public transportation safety legislative proposal  In 2010, various bills were introduced in both houses of Congress that would have provided FTA with various enforcement mechanisms and with the authority to issue safety regulations  Additionally, the bills would have required the Secretary to establish a federal certification program for employees and contractors who carry out a state public transportation safety program  In the 112th Congress, the Senate amended a House bill to include a public transportation safety provision, which eventually became section 20021 of MAP-21, the federal public transportation safety program  MAP-21 enhanced FTA’s authority to oversee the safety of rail transit, potentially addressing some of the weaknesses identified by various stakeholders  Specifically, MAP-21 established a comprehensive Public Transportation Safety Program, which continues to rely on state safety agencies to monitor rail transit systems’ safety operations  MAP-21 required that, within 3 years of the effective date of a final state safety oversight program rule, each eligible state have in place a state safety oversight program certified by FTA  An eligible state must, among other things, establish a state safety agency and determine, in consultation with FTA, an appropriate staffing level for this state agency that is commensurate with the number, size, and complexity of the rail transit systems within the state  Additionally, a state safety agency must be financially and legally independent from any rail transit system it oversees and have investigative and enforcement authority with respect to the safety for its rail transit systems, among other things  Each eligible state has until April 15, 2019, to receive FTA approval of its state safety oversight program, or else FTA will be prohibited from obligating certain federal financial assistance to any entity in the state that is otherwise eligible to receive that federal financial assistance  After that approval, state safety agencies will be evaluated for continued compliance with FTA regulations a minimum of once every 3 years through a triennial review process  According to FTA, these requirements represent a dramatic increase in federal expectations for state safety oversight and for the rail transit industry  MAP-21 also established a state safety oversight grant program, offering federal funding to states for their state safety activities  FTA’s Office of Transit Safety and Oversight administers the state safety oversight program  Freight and passenger railroads have played a transformational role in the development of America and continue to be an important part of the economy  The general railroad system consists of a vast network of operations (see fig  2)  The $60 billion freight rail industry is operated by seven Class I, and hundreds of smaller, railroads  In addition, about 40 railroads move passengers, which carry greater than 670 million passengers per year  The federal government has long provided regulatory oversight of railroad safety, both passenger and freight, that operate on the general system  The Interstate Commerce Commission, the first federal regulatory commission in U S  history, was established in 1887 to regulate interstate commerce by rail  The Commission’s safety functions were transferred to FRA, which was created by the Department of Transportation Act in 1966  In its role as federal regulator and overseer of railroad safety, FRA prescribes and enforces railroad safety regulations and conducts research and development in support of improved railroad safety and rail transportation policy  FRA utilizes safety inspectors and specialists, primarily covering five safety disciplines, to review and enforce compliance with these regulations  FRA’s safety disciplines are track, signal, and train control; motive power and equipment; operating practices; and hazardous materials  Following several fatal rail accidents between 2002 and 2008, the Rail Safety Improvement Act of 2008 was enacted, the first authorization of FRA’s safety programs since 1994  This act directed FRA to, among other things, issue new safety regulations for different aspects of railroad safety, such as hours of service requirements for passenger railroad workers, positive train control implementation, track inspection rules, and safety at highway-rail grade crossings  FRA’s Office of Railroad Safety administers the agency’s safety program  Rail transportation is a relatively safe way to transport people and products though serious incidents continue to occur on railroads and rail transit  According to an analysis of DOT’s Bureau of Transportation Statistics data by the American Public Transportation Association, travel by rail transit is far safer than automobile travel  From 2000-2014, for instance, there were 6 53 and 0 33 fatalities per billion passenger-miles traveled in cars or light trucks and rail transit, respectively  Within rail travel, the fatality rates on both railroads and rail transit operators have remained similar in recent years  Further, the rate of accidents and incidents—including collisions and derailments—also do not appear to differ substantially between railroads and rail transit in recent years  Nevertheless, serious incidents continue to occur on railroads and rail transit, posing safety risks to passengers, railroad employees, and the public  For example, in June 2009, two WMATA trains collided, resulting in 52 injuries and 9 deaths  A smoke incident on WMATA’s Metrorail system in January 2015 also resulted in the death of 1 person and injured over 90  In a 10-month period from May 2013 to March 2014, the Metro- North commuter railroad, which serves New York and Connecticut, was involved in five accidents that resulted in the death of 6 people and 126 injured  In June 2016, two BNSF Railway freight trains collided near Panhandle, Texas, resulting in the death of three crew members  Incidents such as these have prompted investigations into both the causes and contributing factors of the specific accidents as well as broader rail safety oversight  FRA has a more centralized safety oversight program for railroads, while FTA is implementing changes to the rail transit oversight program, established in federal statute, which relies on states to monitor and enforce safety  Key characteristics of both programs include: (1) the establishment of safety regulations, (2) inspections and other oversight activities, such as audits and investigations, based on those regulations, and (3) enforcement mechanisms to ensure that safety deficiencies are addressed (see fig  3)  FRA has developed extensive railroad safety regulations over decades  FRA’s railroad safety regulations include requirements governing track design and inspection, grade crossings, signal and train control, mechanical equipment including locomotives, and railroad-operating practices including worker protection rules  For example, FRA’s regulations for track and equipment include detailed, prescriptive minimum requirements, such as formulas that determine the maximum allowable speeds on curved track  Many of FRA’s rail safety regulations establish minimum safety requirements, though railroads can apply for waivers  As FRA updates its safety regulations, it has proposed more performance-based regulations in recent years  Many of FRA’s current safety regulations specify the behavior or manner of compliance that railroads must adopt, such as inspecting each locomotive at least every 92 days  Performance-based regulations, however, specify a desired outcome rather than a behavior or manner of compliance  For example, FRA’s recent rulemaking to amend its passenger equipment safety regulations proposes performance-based crashworthiness and occupant protection requirements, rather than explicit targets or tolerances  According to FRA, establishing performance requirements in these areas would allow a more open rail market that incorporates recent technologies  FTA is currently assessing the need for rail transit safety regulations, having been provided the authority to issue safety regulations in 2012  Since MAP-21 was enacted, FTA has finalized regulations implementing the public transportation safety program authorized by statute  These include regulations that establish rules for FTA’s administration of a comprehensive safety program to improve rail transit safety as well as updated regulations governing state safety oversight of rail transit  In addition to its public transportation safety program regulations, FTA also has regulations governing its drug and alcohol testing program  MAP-21 also authorized FTA, for the first time, to issue rail transit safety regulations, which would establish minimum safety performance requirements for rail transit operators, as part of its requirement to develop a National Public Transportation Safety Plan  FTA initiated a regulatory development effort after the passage of MAP-21, which included a compilation and evaluation of existing transit safety standards, guidance, and best practices from the federal government, states, industry, and other sources  After the evaluation, FTA issued a report that concluded there was limited documentation or evidence of the effectiveness of these existing rail transit safety standards  The report included recommendations that are intended to enable FTA to undertake further data-driven, risk-based analysis of rail transit safety performance and the applicability and effectiveness of the identified safety standards  FTA is also currently analyzing specific focus areas to determine any areas that should be addressed by federal safety regulations  For example, FTA is studying the need for regulations related to rail transit vehicle crashworthiness  Since no federal rail transit safety regulations that establish minimum safety performance requirements for rail transit operators currently exist, rail transit operators are subject to different safety standards, depending largely on what voluntary standards they have chosen to adopt, according to American Public Transportation Association officials we spoke with  The American Public Transportation Association, for instance, has issued a variety of rail transit safety standards, addressing various aspects of the industry including operations, training, and inspections  In addition, states vary in the extent to which they have regulations for rail transit operators  For example, officials from the California Public Utilities Commission noted that it has issued a variety of safety regulations applicable to rail transit operators within the state of California to improve safety of rail operations  Both FRA and FTA have mechanisms to gather the input of stakeholders—including rail operators, labor unions, industry associations, and others—when considering development of safety regulations  In developing most of its safety regulations, FRA seeks input from stakeholders through its Railroad Safety Advisory Committee  In 1996, FRA established this committee to develop new regulations through a collaborative process, with the rail community working together to create mutually satisfactory solutions to safety issues  FTA is collaborating with stakeholders as it assesses the need for rail transit safety regulations  More specifically, FTA’s research partner, the Center for Urban Transportation Research, established a working group to collaborate with industry stakeholders to inform the safety regulations development process  FTA also solicited comments from industry stakeholders on its compilation of existing rail transit safety standards  More broadly, FTA also has a Transit Advisory Committee for Safety, which provides information, advice, and recommendations to FTA on safety matters  FRA fulfills its mission, in part, through safety compliance audits and inspections, and investigations  FRA ensures compliance with its safety regulations through inspections, using a staff of railroad safety experts, inspectors, and other professionals assigned to eight regional offices across the nation  For example, to determine a railroad’s compliance with FRA safety regulations, inspectors examine track, equipment, signal devices, employee actions, and procedures and review maintenance and accident records  Additionally, 31 states have rail safety programs that partner with FRA  Under this approach, FRA enters into agreements with states to allow state inspectors to participate in investigative and surveillance activities concerning federal railroad safety laws  State inspectors who participate in this program submit inspection reports to FRA  More broadly, FRA’s inspections are guided by a risk-based model  Under this approach, FRA focuses its inspections on locations that, according to the data-driven model, are likely to have safety problems  Like other operating administrations within DOT, FRA has relatively few resources for overseeing railroads, compared with the size of the general system  The risk-based model is designed to help FRA target the greatest safety risks  FRA has begun utilizing automated inspections as well  In particular, according to FRA, new imaging technologies have the potential to better inspect track for cracks in the rail that could lead to breakage as well as measure the track’s geometry to ensure that rails are positioned to meet standards  To further promote safety in railroad operations, FRA conducts accident investigations  Separate from investigations conducted by NTSB, FRA investigates select railroad accidents to determine root causation, and any contributing factors, so that railroad properties can implement corrective actions to prevent similar incidents in the future  Resources for railroad safety oversight activities have increased in recent years  FRA was appropriated about $218 million in fiscal year 2017, an increase over the approximately $187 million it received in fiscal year 2015, for safety and operations, which funds FRA’s personnel, including inspectors, and safety programs  According to FRA, Congress provided FRA with increased funding in recent years for the purpose of increasing staffing related to specific safety issues, such as trespasser prevention and passenger rail safety  As part of this effort, FRA has hired additional inspectors, going from 347 inspectors in fiscal year 2013 to over 360 currently, out of the nearly 930 total full-time equivalent staff  FRA officials told us, as we have reported in the past, that it can be difficult to recruit, train, and certify qualified inspectors in a timely manner, especially in certain areas of expertise  Further, according to FRA, its inspectors have the ability to inspect less than 1 percent of the general system annually  Though FTA now has more robust inspection authorities, states will continue to conduct front-line rail transit safety oversight activities  MAP- 21 provided FTA with new authorities to inspect, audit, and investigate practices at rail transit agencies, including safety practices, while also preserving the role of state safety agencies to monitor rail transit systems’ safety operations  According to FTA officials, any federal inspections of rail transit operators are intended to supplement a state safety agency’s oversight activities, except where FTA assumes temporary, direct oversight of a rail transit system from an inadequate state safety agency  FTA officials told us that establishing a nationwide safety inspection program at the federal level is inconsistent with the statutory framework of the state safety oversight program and with congressional intent, which contemplates preserving the primary role of state safety agencies in providing direct safety oversight of rail transit systems  The officials also noted that the state-based approach to rail transit safety oversight is valuable because states are generally closer to, and more familiar with, rail transit operators  To date, FTA has utilized its new inspection authorities only on WMATA’s rail system  As part of oversight activities, some state safety agencies have conducted inspections of the rail transit systems they oversee, though they were not required to do so, according to FTA officials we spoke with  To strengthen states’ abilities to conduct oversight activities, FTA has recommended that state safety agencies develop risk-based inspection programs  Further, to ensure the independence of state safety agencies, these agencies cannot receive funding from the rail transit entities they oversee  Resources for FTA’s rail transit safety oversight administrative expenses have remained relatively stable in recent years, though more are needed, according to FTA  Since fiscal year 2012, FTA’s appropriations for administrative expenses, which funds FTA personnel and support activities including the Office of Transit Safety and Oversight, has increased $14 million, to about $113 million in fiscal year 2017, according to FTA  However, for several years, FTA has averaged about 508 total full-time equivalent staff agency-wide, and a little over 30 safety staff in the Office of Transit Safety and Oversight  According to FTA, the Office of Transit Safety and Oversight has been under-resourced since it was established in response to new safety authority provided in MAP-21  For fiscal year 2018, FTA requested in their submission for the President’s Budget proposal funding to hire up to an additional 20 positions for various lines of safety work  FRA’s and FTA’s oversight activities also include regular audits of, and communication with, the rail operators under their oversight  Given finite resources and large rail networks, FRA and FTA audit rail operators’ own inspections rather than conducting comprehensive federal inspections  More specifically, FRA inspectors, and state safety agencies in FTA’s oversight program, regularly examine records of rail operators’ internal inspections to identify safety deficiencies  Officials from FRA, FTA, and five rail stakeholders we spoke with told us that FRA and FTA rail safety oversight programs also rely on collaboration and communication between rail operators and regulators to ensure safety  For example, regular meetings between FRA and railroad staff to discuss safety trends and industry developments are important to ensuring safety, according to officials we spoke with from FRA and the railroads  FRA specialists and inspectors participate, with representatives of railroad labor and management, in the implementation of voluntary safety programs  For example, FRA sponsors the Confidential Close Call Reporting System, a voluntary, confidential program allowing railroads and their employees to report accident and incident “close calls ” According to FRA officials, voluntary programs such as this increase industry awareness of railroad safety and engagement with it  FTA also collaborates with state safety agencies as rail transit safety issues arise, according to FTA officials, using federal oversight and enforcement authorities as a “back-stop” against the oversight of state safety agencies  Additionally, according to officials we spoke with from FTA and two rail transit operators, state safety agency staff meet with rail transit operators regularly, using knowledge of local operating conditions to help ensure safety  FRA uses a variety of tools, including civil penalties, to resolve safety issues  While some safety issues are resolved informally through discussion and collaboration between FRA and railroads, as noted above, some defects identified during inspections are classified as violations and subject to financial penalties  More specifically, when railroads do not resolve issues in a timely manner or identified defects are serious, FRA has the authority to cite violations and assess civil penalties, against either railroads or individuals  Further, as authorized by law, FRA negotiates settlements with railroads and other entities subject to its safety jurisdiction to resolve claims for civil penalties  In fiscal year 2016, FRA assessed over $11 8 million in civil penalties against railroads  According to FRA, fiscal year 2016 was the second year in a row that it took steps to increase penalty amounts paid by railroads, as part of a continued effort to increase consequences for violations that negatively affect safety  To ensure the safety of rail transit systems, states will continue to be the primary enforcers of safety requirements, according to FTA officials, though FTA now has more enforcement tools  MAP-21 preserved the role of state safety agencies as the primary enforcement body for rail transit  FTA has now required that state safety agencies have enforcement authorities sufficient to compel action from rail transit entities to address safety deficiencies  Though no specific authorities are required, FTA has suggested that a variety of mechanisms could be appropriate, such as the ability to remove deficient equipment from service or assess fines  According to FTA, this requirement is designed to overcome a long- standing vulnerability in state safety oversight, which allowed safety deficiencies to remain for long periods of time  MAP-21 and the FAST Act also provided FTA with more options for enforcement when rail transit operators are found to be out of compliance with safety requirements  In particular, FTA can withhold federal funding for rail transit operators or direct a rail transit operator to use federal funding for a specific purpose  Additionally, after FTA assumes temporary direct oversight of an inadequate state safety agency, FTA can withhold federal funds from the state until the state safety oversight program has been certified  To date, FTA has utilized this authority only with the states responsible for safety oversight of WMATA’s rail system  In February 2017, FTA announced that it would withhold 5 percent of fiscal year 2017 urbanized area formula funds from Maryland, Virginia, and the District of Columbia until a new state safety oversight program is certified for WMATA’s rail system  This action built upon FTA’s determination that WMATA’s state safety agency was ineffective at “providing adequate oversight consistent with prevention of substantial risk of death or personal injury ” FRA and FTA also have the authority to directly intervene in rail operations  In particular, both FRA and FTA can suspend the service of rail operators in response to certain safety concerns  Additionally, FTA can assume direct safety oversight of a rail transit operator if FTA determines the state safety oversight program is not adequate, among other things  In response to safety incidents on WMATA’s rail system, FTA assumed temporary and direct safety oversight of WMATA in October 2015, as previously noted


Report 2:  FRA and FTA’s approaches to their rail safety oversight missions each have strengths and limitations, including how the agencies develop safety regulations, conduct inspections, and carry out enforcement  Compared to FRA’s long-standing role in providing safety oversight over railroads, FTA is in the process of implementing significant changes to its program for rail transit safety oversight after being granted new authorities in MAP- 21 and the FAST Act  With respect to regulations, FRA’s extensive and well-established safety regulations are a strength  FTA has made some progress toward developing appropriate safety regulations, such as identifying subjects for potential regulatory action  With respect to inspections, FRA’s use of a risk-based approach to distributing inspection resources is a strength  FTA has sought to address previously identified deficiencies in state safety oversight by recommending that state safety agencies develop risk-based inspection programs  FTA, though, has not provided states guidance for these efforts  With respect to enforcement, FRA’s use of its enforcement authorities is a strength  FTA is also implementing new statutory requirements that state safety agencies have enforcement authorities but does not have a process or methodology to evaluate the effectiveness of these enforcement practices  Extensive and well-established safety regulations are a strength of FRA’s safety oversight program based on studies we reviewed and discussions with rail operators and stakeholder organizations  According to NTSB, FRA’s railroad safety regulations are an important and effective part of its oversight program  Our previous work reported that according to stakeholders, the Railroad Safety Advisory Committee provides a collaborative environment where stakeholders in the rail community work with FRA to identify issues and proposals for safety standards and regulations that improved the quality of railroads’ safety initiatives and fostered a greater level of compliance with safety regulations  This is consistent with views of stakeholders we spoke with, who characterized FRA’s safety regulations as a strength  An industry association told us that FRA’s regulations promote safety by helping to ensure that no operator falls below a minimum threshold for safe operations, while a rail operator told us that federal regulations help to standardize the operating environment and prevent a patchwork of various state regulations  Four stakeholders also characterized the Railroad Safety Advisory Committee, which plays a large role in crafting FRA’s railroad safety regulations, as effective and inclusive  However, based on studies we reviewed and discussions with rail operators’ and stakeholders’ organizations, FRA faces limitations in its efforts to regulate safety across railroad systems that differ from one another and sometimes change more quickly than the federal regulatory process  Five railroad operators and an industry association told us that some of FRA’s safety regulations do not account for differences in railroads or innovation in safety practices, with three railroad operators stating that this approach requires the extensive use of waivers for particular regulations  Further, two railroad operators and a rail transit operator we spoke with stated that additional federal regulations are needed to provide minimum baseline requirements in specific areas of railroad safety such as medical fitness for duty  In 2014, NTSB also found that FRA needs to do more to regulate particular safety issues including medical fitness for duty and signal protection  FRA officials acknowledged that time and resources are two of the primary challenges that the agency faces when developing safety regulations but also noted additional ways in which the agency can require railroads to adopt safety practices  FRA officials described the process of creating or significantly amending a regulation as involving years of work, even before the agency commences with the process of drafting a rule  The officials also noted that the agency has additional tools to compel railroads to adopt safety practices  For example, FRA officials discussed the use of compliance agreements, in which railroads can have fines reduced in exchange for adopting safety measures that go beyond what FRA regulations require  FRA officials are considering the use of performance-based regulations as they update their safety regulations  As noted above, FRA’s proposed regulations regarding passenger equipment safety incorporates performance -based safety requirements, rather than explicit safety targets or tolerances  FRA has promulgated performance-based regulations about the implementation of positive train control, a communications-based system designed to prevent certain types of train accidents, as well as system safety programs that set general safety parameters and thresholds by which successful performance is governed  FRA’s consideration of performance-based regulations is in line with federal guidance  OMB’s Circular A-4 states that performance standards “are generally superior to engineering or design standards because performance standards give the regulated parties the flexibility to achieve regulatory objectives in the most cost-effective way ” Additionally, under Executive Order 12866, agencies should (to the extent permitted by law and where applicable) identify and assess alternative forms of regulation and specify performance objectives, rather than specifying the behavior or manner of compliance that regulated entities must adopt  However, as the language of OMB’s Circular A-4 and Executive Order 12866 suggest that performance-based regulations are not always feasible, studies of performance-based regulations find that as with any other form of regulation, performance-based standards have trade-offs  FRA officials told us that under certain circumstances, performance- based regulations are appropriate for issues regarding design, maintenance, operation, and technology-driven safety requirements  FRA officials we spoke with did not think performance-based standards are appropriate for areas that require standardization  One example is track safety standards, where the need for different operators to use the same equipment precludes a performance-based approach that allows railroads to meet requirements through different means  FRA officials added that a key aspect of the success of performance-based regulations concerns how railroads demonstrate compliance  This concern is consistent with other studies of performance-based regulations, which find that these regulations are most appropriate when regulators have capacity to measure and monitor performance  Though FTA has made progress assessing the state of rail transit safety standards, a limitation of FTA’s rail transit safety oversight program is the lack of federal rail transit safety regulations, which may contribute to inconsistent safety practices across the rail transit industry, according to studies we reviewed and discussions with rail operators and stakeholder organizations  NTSB reported that the structure of FTA’s oversight process leads to inconsistent practices, inadequate standards, and marginal effectiveness  In addition, a 2016 DOT OIG report found that because FTA’s safety standards are voluntary, they are unenforceable  In 2012, FTA gained the authority to issue safety regulations, though it has not done so yet, and NTSB and other stakeholders we spoke with indicated that the lack of such federal safety regulations is a weakness in federal rail transit safety oversight  Despite differences across rail transit systems, there is value in establishing federal rail transit safety regulations, according to stakeholders from all categories of those we interviewed, including a state safety agency, three rail transit operators, a railroad operator, and two industry associations  Some stakeholders identified specific areas that would benefit from federal rail transit regulations  For example, two rail transit agencies called for federal regulations to address operator fatigue  Some of these officials stated that federal rail transit safety regulations could help ensure safety by establishing clear and consistent minimum standards  Officials from a rail transit entity and an industry association stated that voluntary standards are not enough to ensure that transit entities will adopt appropriate safety measures  According to our analysis, a past study, and stakeholders we spoke with, FTA’s ability to develop and implement performance-based regulations is limited by its lack of capacity to collect and analyze rail safety performance data  In 2017, DOT OIG found that data limitations of FTA’s National Transit Database results in limited safety performance criteria in FTA’s National Public Transportation Safety Plan  Further, two rail transit entities as well as a state safety agency we spoke with stated that they face challenges in analyzing data due to either the size of their systems or their capacity  FTA officials told us that they need more data to inform their decisions regarding whether to establish rail transit safety regulations, and also added that a limitation to their ongoing assessment of potential areas for rail transit safety regulation is the concern about public disclosure of safety data provided to FTA and its potential use in private litigation  According to FTA officials, they need more information to do a comprehensive evaluation of efficacy of current safety standards and practices  As required by the FAST Act, FTA has entered into an agreement with the National Academies of Sciences, Engineering, and Medicine, to conduct a study to evaluate whether it is in the public interest to withhold from federal or state court proceedings any information collected by DOT through its public transportation safety program oversight activities  The National Academies of Sciences is expected to complete this study in 2018  FTA is taking positive steps toward developing safety regulations that may address inconsistent safety practices across rail transit operators  FTA officials stated that the agency is considering issuing rail transit safety regulations and also employs additional tools to compel rail transit entities to adopt safety measures  As noted above, FTA is currently studying whether federal regulations are appropriate for specific areas of rail transit safety  Executive Order 12866 and OMB’s Circular A-4 direct federal agencies to consider performance-based regulations when developing regulations  Further, as the Transportation Research Board recently reported, any decision to use performance-based regulations “must take into account the regulator’s own ability to enforce and motivate compliance (through methods such as auditing and field inspections) as well as the capacity of regulated entities to meet their obligations ” FTA officials noted that they are actively engaged with members of the Transportation Research Board in reviewing and discussing these recent findings related to safety regulations for high-hazards industries  In January 2017, FTA issued its National Public Transportation Safety Plan, which FTA officials noted is one component of their transit safety standard development program  According to FTA officials, the plan identifies a list of issue areas that the agency is currently studying to determine whether national regulations are needed  FTA officials also stated that the plan includes “voluntary standards,” which are intended to put the industry “on notice” that federal safety regulations may be proposed in those areas  FTA officials stated that they view the National Public Transportation Safety Plan as iterative and more easily updated compared with official regulations  Additional tools that FTA officials stated the agency employs in its approach to safety oversight include general directives as well as the requirements associated with FTA grants  Based on our assessment and studies we reviewed, a strength of FRA’s safety oversight program is its risk-based approach to distributing inspection resources, which may serve as an example for FTA and state safety agencies  According to NTSB, FRA’s qualified inspectors are a strength of its oversight program  To help target these inspectors to the areas of highest risk, FRA developed the National Inspection Plan, which includes a quantitative model for allocating inspection resources in a way that tries to minimize railroad accidents  This model utilizes data including: (1) accident and incident data that railroads are required to report, (2) data from FRA inspection activity, and (3) information on railroad activities such as train miles and other data  Based on our assessment of FRA’s model, we believe that it can be an appropriate and useful tool for directing its inspection resources based on risk because it relies on statistical methods commonly used to predict the risk of a violation for regulated entities  While we did not review FRA’s entire modeling process, nor did we validate the results it generates, we do believe that FRA’s approach to using these statistical models as a key part of its inspection program is appropriate  However, a potential limitation of FRA’s inspection program is the flexibility granted to individual inspectors and whether the manner and extent to which inspectors implement this discretion may be inconsistent with the risk-based National Inspection Plan  FRA’s National Inspection Plan provides guidance for inspectors about how much time they should spend inspecting individual railroads  According to FRA officials, FRA inspectors have considerable flexibility to deviate from the National Inspection Plan based on their judgment regarding where to more effectively use their resources  FRA officials stated that situations arise that call for deviations in planned inspections  For example, a particular railroad may experience a serious accident and therefore require more oversight from FRA  According to FRA officials, regional offices make these decisions based on their understanding of emerging issues  Inspectors are expected to know their region and decide which locations to go to, and are in part evaluated based on these decisions  When a region’s record of total inspection time spent on a particular railroad differs from the National Inspection Plan by more than 5 percent, the region’s leadership submits an explanation to FRA’s Office of Railroad Safety  This practice, if not monitored, could allow inspectors to deviate from the data-driven model results in ways that undermine the goal of the National Inspection Plan to deploy FRA’s limited resources efficiently and based on risk  However, FRA officials told us that flexibility for individual inspectors is important, and that FRA is continuously monitoring the model’s performance and making changes as appropriate  Further, OECD’s Best Practice Principles for Regulatory Policy note that it is important to ensure “that sufficient flexibility is left to enforcement and inspection officials to adapt their response in proportion to the facts on the ground ” A strength of FTA’s approach to rail transit safety oversight is that it is working to overcome weaknesses in state oversight of rail transit identified in our prior work and stakeholders we spoke with  For example, FTA has noted that in the past some state safety agencies lacked sufficient oversight authorities  To now be certified by FTA, state safety agencies must demonstrate that they have authority to review, approve and oversee the implementation of rail transit operator’s safety plans  Additionally, we have found, and FTA has also noted, that some state safety agencies would benefit from more training and additional staff  To now be certified by FTA, state safety agencies must be capable of directly hiring and developing staff and contract support, as well as have a training plan for certain staff  Though FTA is seeking to implement stronger safety oversight activities, a limitation of its program is that state safety agencies have not received the guidance and support necessary to develop effective inspection programs  FTA does not currently plan to conduct widespread inspections itself and recommends that state safety agencies develop risk-based inspection programs  According to FTA, states have discretion to establish their inspection programs in accordance with their program standards, and are not required to actually conduct inspections as the method of verifying rail transit operators’ compliance with safety rules  However, direct observation, audits, and performance indicator tracking are useful methods for an oversight agency in assessing a regulated entity’s safety culture  Officials we spoke with from selected state safety agencies say that they have received little guidance from FTA on what their risk-based inspection programs should look like  In the materials FTA provided to states, it said that it intends to provide guidance to states on risk-based inspections but did not provide us with a plan or timeline for doing so  Without guidance from FTA, state safety agencies may not develop effective risk-based inspection programs and thus not use their resources efficiently  Effective risk-based inspection programs are particularly important given state safety agencies’ limited resources  We have reported in the past that some state safety agencies lack sufficient resources, including training and staff  Officials from two rail transit operators and all four industry associations we spoke with stated that state safety agencies continue to have limited resources and capacity  Several state safety agencies we spoke with rely on contractors or employees with other responsibilities besides oversight of rail transit to meet their increased oversight responsibilities and achieve certification from FTA  Federal standards for internal control as well as leading practices for regulatory inspections state that agency objectives, including those related to inspections and enforcement, should be clearly communicated  Specifically, federal standards for internal control require that management communicate the necessary quality information to achieve the agency’s objectives  Additionally, the OECD’s Best Practice Principles for Regulatory Policy recommends that governments ensure clarity of rules and processes for enforcement and inspections and clearly articulate rights and obligations of officials  According to OECD, the frequency of inspections and the resources employed should be proportional to the level of risk  A strength of FRA’s safety oversight program is that the agency has and utilizes clear enforcement authority, according to NTSB and stakeholders we spoke with  As previously discussed, FRA has several enforcement tools available when inspectors find that railroads are noncompliant with applicable regulations, including civil penalties, individual liability, compliance orders, and emergency orders  According to NTSB, this array of specific enforcement tools helps ensure safety deficiencies are addressed by railroads  FRA officials also told us that the process of adjudicating civil penalties provides a forum for FRA and railroad officials to meet to discuss safety issues  Four rail operators also told us that FRA’s authority to issue civil penalties is necessary to ensure railroads’ compliance with regulations  However, a potential limitation of FRA’s approach to enforcement is that it is difficult to quantify the effectiveness of FRA’s civil penalties  FRA has reported that it cannot determine whether observable safety improvements are directly attributable to discrete civil penalties or whether the amount of civil penalties has any effect on safety  We have reported in the past about the challenges of determining the effect of penalties on compliance in tax policy, though we also noted that, despite these challenges, some analyses likely would be useful for better understanding the effect of penalties on compliance  FRA also reported, though, that according to the judgments of its inspectors, issuing civil penalties yields observable improvements in safety practices and compliance with the law  Further, according to FRA, though it does not quantify the impact of civil penalties, FRA monitors railroad responses to its enforcement activity and adjusts its oversight as necessary  More broadly, civil penalties are not meant, by themselves, to ensure railroad safety  Instead, FRA reported that it uses its entire regulatory regime as a whole to try and ensure safety  FRA officials also noted that the agency has additional tools, apart from civil penalties, to compel railroads to adopt safety practices  A strength of FTA’s rail transit safety oversight is that it seeks to improve historically weak state safety agency enforcement authorities, as described in our previous report as well stakeholders we spoke with  FTA requires state safety agencies to adopt enforcement authorities that are sufficient to enable states to compel action from rail transit agencies to address identified deficiencies  FTA has also communicated to states that it is focusing its evaluation of each state’s enforcement authorities in two major areas: ensuring that the state can carry out its primary responsibility for rail transit safety in response to (1) an imminent threat to public safety on the rail transit system and (2) a lack of action or non- compliance from the rail transit operator in carrying out certain safety plans  FTA has provided states with examples of the enforcement authorities and policies state safety agencies could establish to address these specific concerns  Authorities to address imminent safety threats may include the authority to suspend rail transit agencies’ operations, inspect and remove deficient equipment or system infrastructure from service, or issue an order requiring the rail transit agency to correct an unsafe condition prior to placing equipment or infrastructure back into passenger service  FTA has also provided state safety agencies with examples of authorities to address a lack of action or cooperation by the rail transit operator, including the authority to withhold or redirect funds, levy civil or criminal fines or penalties, and a formal citation or ticketing program  Though federal law requires that state safety agencies have enforcement authorities over the safety of the rail transit entities they oversee, a limitation of FTA’s approach is that FTA has not developed a method to evaluate the effectiveness of states’ enforcement practices  Certified state safety agencies will be evaluated for continued compliance with FTA regulations every 3 years  This triennial review process (for rail transit safety) seeks to ensure that states are effectively carrying out their responsibilities  While FTA officials told us that they will evaluate state safety agencies’ enforcement during the triennial reviews, FTA has not developed a process or methodology to evaluate whether state enforcement authorities and practices as a whole are effective  Without a method for determining the effectiveness of state safety agencies’ enforcement, FTA may not have the information needed to identify ineffective safety enforcement  As a result, deficiencies may remain for long periods of time, potentially contributing to safety incidents  Federal standards for internal control maintain that agency managers should perform a range of practices that would facilitate the establishment of a system to monitor the effectiveness of agency activities, which in the context of FTA’s mission includes the effectiveness of its rail transit safety oversight  Agency managers should define objectives clearly to enable the identification of risks, establish activities to monitor performance measures and indicators, and externally communicate the necessary quality information to achieve the entity’s objectives  Internal control standards further stipulate that agency managers should perform monitoring activities regarding their internal control system and evaluate the results  To do so, federal standards for internal control state that agency managers should monitor ongoing operations and effectiveness, evaluate the results of this monitoring, and identify any changes that need to be made to achieve improvement in agency operations  The effectiveness of state safety agency enforcement is especially important because questions have been raised about the efficacy of FTA’s own enforcement mechanisms, including its ability to withhold funds from and assume direct control over safety oversight for a rail transit entity  Rail transit operators and industry association representatives we spoke with stated that FTA’s authority to withhold funding from states is overly punitive, and two stakeholders said the FTA needs more precise tools  Officials from an industry association added that withholding funds can be counterproductive, as most state safety agencies are already underfunded and understaffed  FTA officials pointed to examples in which the agency successfully supported state safety agencies in compelling action from rail transit agencies as evidence that the state safety oversight model, in which FTA backs up state safety agencies, is effective  Additionally, officials from numerous state safety agencies and others questioned whether FTA has the capacity to effectively assume direct safety oversight of rail transit operators  FTA has not assumed direct safety oversight of any rail transit operators outside of WMATA, and FTA officials noted that they intend to continue supporting state safety agencies in their oversight wherever possible  The approaches to rail safety oversight utilized by FRA and FTA each have strengths and limitations  However, FTA’s program is currently in transition as the agency implements new authorities and responsibilities provided in federal law  Though FTA has made progress by evaluating existing rail transit safety standards and providing some guidance to states as part of the certification process, limitations in FTA’s approach may still hinder the success of the state-based rail transit safety oversight program  Given the looming 2019 deadline for state safety oversight programs to achieve FTA certification, FTA can improve its efforts to implement its new rail transit safety oversight program  In particular, without guidance from FTA on how to develop and carry out risk-based inspection programs, state safety agencies may not use limited resources efficiently, risking that important safety issues will go undetected  Further, without a method for how it will monitor the effectiveness of states safety agencies’ enforcement, FTA will lack the information needed to identify ineffective state enforcement, which risks allowing safety deficiencies to remain for long periods of time  By providing this additional guidance and direction to the state safety agencies, FTA would help ensure that states are able to effectively identify and resolve rail transit safety issues  We are making the following two recommendations to FTA: The Office of Transit Safety and Oversight should create a plan, with a timeline, for developing guidance for state safety agencies about how to develop and implement a risk-based inspection program  (Recommendation 1) The Office of Transit Safety and Oversight should develop and communicate a method for how it will monitor the effectiveness of the enforcement authorities and practices of state safety agencies  (Recommendation 2) We provided a draft copy of this report to DOT, NTSB, and WMATA for review and comment  In written comments, reproduced in appendix I, DOT agreed with both our recommendations  DOT also provided technical comments, which we incorporated as appropriate  In e-mails, NTSB and WMATA provided technical comments, which we incorporated as appropriate  NTSB noted that we do not discuss the role of system safety initiatives, such as safety management systems, in the FRA and FTA rail safety oversight programs  We agree with NTSB that system safety concepts are increasingly influencing the FRA and FTA approaches to rail safety oversight but, as NTSB also noted, both FRA and FTA lack finalized regulations codifying their approaches to system safety initiatives  Because the extent of rail entities’ implementation of these initiatives varies and is not complete we did not include an assessment of the strengths and limitations of those initiatives in our scope  As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date  At that time, we will send copies to the Secretary of Transportation, Chairman of NTSB, General Manager of WMATA, and the appropriate congressional committees  In addition, the report will be available at no charge on GAO’s website at http://www gao gov  If you or your staff have any questions about this report, please contact me at (202) 512-2834 or goldsteinm@gao gov  Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report  Individuals who made key contributions to this report are listed in appendix II  In addition to the contact named above, Steve Cohen (Assistant Director); Kyle Browning (Analyst in Charge); Melissa Bodeau; Lacey Coppage; Serena Lo; Sean Miskell; and Josh Ormond made key contributions to this report 

ground_truth: IHS is charged with providing health care to AI/AN people who are members or descendants of 573 tribes. According to IHS, AI/AN people born today have a life expectancy that is 5.5 years less than all races in the United States, and they die at higher rates than other Americans from preventable causes. The ability to recruit and retain a stable clinical workforce capable of providing quality and timely care is critical for IHS. GAO was asked to review provider vacancies at IHS. This report examines (1) IHS provider vacancies and challenges filling them; (2) strategies IHS has used to recruit and retain providers; and (3) strategies IHS has used to mitigate the negative effects of provider vacancies. GAO reviewed IHS human resources data for the provider positions that the agency tracks. GAO also reviewed policies, federal internal control standards, and legal authorities related to providers in federally operated IHS facilities. GAO interviewed IHS officials at the headquarters and area level and at selected facilities. GAO selected facilities based on variation in their number of direct care outpatient visits and inpatient hospital beds in 2014. Indian Health Service (IHS) data show sizeable vacancy rates for clinical care providers in the eight IHS geographic areas where the agency provides substantial direct care to American Indian/Alaska Native (AI/AN) people. The overall vacancy rate for providers—physicians, nurses, nurse practitioners, certified registered nurse anesthetists, certified nurse midwives, physician assistants, dentists, and pharmacists—was 25 percent, ranging from 13 to 31 percent across the areas. IHS officials told GAO that challenges to filling these vacancies include the rural location of many IHS facilities and insufficient housing for providers. Officials said long-standing vacancies have a negative effect on patient access, quality of care, and employee morale. IHS uses multiple strategies to recruit and retain providers, including offering increased salaries for certain positions, but it still faces challenges matching local market salaries. IHS also offers other financial incentives, and has made some housing available when possible. In addition, IHS uses strategies, such as contracting with temporary providers, to maintain patient access to services and reduce provider burnout. Officials said these temporary providers are more costly than salaried employees and can interrupt patients' continuity of care. However, IHS lacks agency-wide information on the costs and number of temporary providers used at its facilities, which impedes IHS officials' ability to target its resources to address gaps in provider staffing and ensure access to health services across IHS facilities. GAO recommends that IHS obtain, on an agency-wide basis, information on temporary provider contractors, including their associated cost and number of full-time equivalents, and use this information to inform decisions about resource allocation and provider staffing. IHS concurred with GAO's recommendation.

prompt_front: You are given two reports by the government agency.



Question: Write a one-page summary of the report 2.

Report 1: IHS was established within the Public Health Service in 1955 to provide health services to members of AI/AN tribes, primarily in rural areas on or near reservations  IHS provides these services directly through a network of hospitals, clinics and health stations, while also providing funds to tribally operated facilities  These federally and tribally operated facilities are located primarily in service areas that are rural, isolated, and underserved  In fiscal year 2017, IHS allocated about $1 9 billion for health services provided by federally and tribally operated facilities  Federally operated IHS facilities, which received over 5 2 million outpatient visits and over 15,000 inpatient admissions in 2016, provide mostly primary and emergency care, as well as some ancillary and specialty services in 26 hospitals, 55 health centers, and 21 health stations  According to IHS, federally operated IHS hospitals range in size from 4 to 133 beds and generally are open 24 hours a day for emergency care needs; health centers offer a range of care, including primary care services and some ancillary services, such as pharmacy, laboratory, and X-ray services, and are open for at least 40 hours a week; and health stations offer only primary care services on a regularly scheduled basis and are open fewer than 40 hours a week  The 12 IHS area offices are responsible for distributing funds to the facilities in their areas, monitoring their operation, and providing guidance and technical assistance (see fig  1)  In addition, five human resources regional offices assist the area offices in the recruitment and hiring of providers  IHS federally operated facilities employ both federal civil service personnel and Commissioned Corps officers  IHS may pay higher salaries for certain federal civil service providers through the development and implementation of special pay tables, which specify the ranges of salaries that these certain providers can receive  According to IHS officials, the Commissioned Corps officers follow the same process for applying for positions at IHS as federal civil service employees  However, the Commissioned Corps officers are uniformed health professionals whose pay and allowances are different  IHS also supplements its workforce capacity with both temporary and long-term contracts with individual physicians or a medical staffing company  IHS downloads information on all funded and active positions from the Capital Human Resource Management System, an HHS data system used for personnel and payment transactions that IHS began using in 2016 to track all employee vacancies  According to IHS officials, the accuracy of the data is verified quarterly by regional human resources officers  As the IHS health care workforce also includes Commissioned Corps officers—who have a separate personnel system—the information on Commissioned Corps officers assigned to IHS are entered into the Capital Human Resource Management System manually, according to IHS officials  According to the National Rural Health Association, the challenges of rural health care delivery are different than those in urban areas  These challenges include those related to more complex patient health status and poorer socioeconomic conditions, as well as physician workforce shortages  According to the Agency for Healthcare Research and Quality, compared with their urban counterparts, residents of rural counties are older, poorer, more likely to be overweight or obese, and sicker  Those living in rural areas also have greater transportation difficulties reaching health care providers, often traveling great distances to reach a doctor or hospital  Exacerbating these challenges is a relative scarcity of medical providers in rural areas compared to urban areas  For example, the National Center for Health Statistics reported the primary care physician- to-patient ratio in rural areas in 2012 was 39 8 physicians per 100,000 people, compared to 53 3 physicians per 100,000 in urban areas  IHS data demonstrate large percentages of vacancies for providers in the 8 areas in which IHS has substantial direct care responsibilities  As of November 2017, the overall percentage of vacancies for physicians, nurses, nurse practitioners, CRNAs, certified nurse midwives, physician assistants, dentists, and pharmacists in these areas was 25 percent, ranging from 13 to 31 percent across the areas  (See fig  2) However, variation in vacancy rates existed among provider types across IHS areas  For example, while the overall percentage of vacancies for physicians, nurses, nurse practitioners, dentists, and physician assistants each exceeded 25 percent, the vacancy rate for pharmacists was less than 25 percent  In addition, for certain provider types in some areas, more than one-third of the positions were vacant  For example, although 29 percent of the total positions for physicians across these 8 areas were vacant, the vacancy rate ranged from 21 percent in the Oklahoma City area to 46 percent in the Bemidji and Billings areas  (See fig  3 ) As another example, although 27 percent of the total positions for nurses across these 8 areas were vacant, the vacancy rate ranged from 10 percent in the Oklahoma City area to 36 percent in the Albuquerque and Bemidji areas  (See fig  4 ) Similarly, across these 8 areas 32 percent of the total positions for nurse practitioners were vacant, ranging from 12 percent in the Oklahoma City area to 47 percent in the Albuquerque area; 27 percent of the total positions for dentists were vacant, ranging from 14 percent in the Phoenix area to 39 percent in the Bemidji area; and 30 percent of the total positions for physician assistants were vacant, and although 4 of the areas had few such positions (the Albuquerque, Bemidji, Oklahoma City, and Portland areas each had 7 or fewer positions), the percentage of vacancies in the 4 areas with 15 or more such positions ranged from 21 percent in the Phoenix area to 40 percent in the Billings area  In contrast, 13 percent of the total positions for pharmacists were vacant, ranging from 3 percent in the Bemidji area to 17 percent in the Albuquerque area  For more information about the vacancies for specific clinical positions, see appendix I  While sizeable vacancies existed across provider types and areas, the majority of positions in all eight areas were occupied by civilians, and about 13 percent were filled by Commissioned Corps officers who are fulfilling assignments with a minimum 2-year term  The percentages of positions by IHS area that were vacant, filled by civilians, and filled by Commissioned Corps officers as of November 2017 are shown in figure 5  IHS officials told us they have experienced considerable challenges in filling vacancies for providers—as well as negative effects on patient care and provider satisfaction when positions are vacant  According to IHS officials, the rural locations and geographic isolation of some IHS facilities create recruitment and retention difficulties  IHS data indicate that 36 of the 102 IHS facilities, including four hospitals, are identified as isolated hardship (ISOHAR) posts  Agency documentation describes ISOHAR posts as ‘‘unusually difficult, which may present moderate to severe physical hardships for individuals assigned to that geographic location,’’ and states that physical hardships may include crime or violence, pollution, isolation, a harsh climate, scarcity of goods on the local market, and other problems  In addition, IHS has reported that insufficient housing, substandard schools, lack of entertainment opportunities, and shopping centers located more than three hours away are all typical not only of ISOHAR posts, but also of many other IHS facility locations  Officials stated that, especially for job candidates and employees with families, these can be critical factors in choosing whether or not to accept or stay in a position  For example, officials from the Portland Area office told us the Colville Service Unit has experienced challenges recruiting physicians because the service unit is 110 miles away from Spokane, and many of the smaller towns nearby have limited amenities—including limited employment opportunities for spouses and school systems that may not meet the expectations of some prospective employees  In addition to hardships generally associated with rural locations, IHS facilities can experience additional challenges specific to recruiting and retaining providers for facilities on tribal lands  For example, Navajo area officials told us that providers who are non-native or are not married to a tribal member generally must go off the reservation to find housing if it is not provided by IHS  According to IHS, the Navajo Nation is one of the largest Indian reservations in the United States, consisting of more than 25,000 contiguous square miles and three satellite communities, and extending into portions of Arizona, New Mexico, and Utah  Living off the reservation can result in long commutes, contributing to a difficult work- life balance  Furthermore, IHS officials noted, public transportation such as buses or trains do not exist in proximity to most IHS facilities  IHS facility staff told us long-standing vacancies have a direct negative effect on patient access to quality health care, as well as employee morale  Officials from multiple facilities we visited told us they have had to cut certain patient services due to ongoing provider vacancies  For example, officials from the Phoenix Area office told us the Nevada Skies Youth Wellness Center, an adolescent substance abuse treatment center, decreased the number of beds available due to staffing vacancies  Similarly, officials from the Rosebud Hospital stated the facility has diverted obstetrics patients to other facilities since July 2016 due to a shortage of physicians, nurses, and nurse anesthetists  During the diversion, those patients were referred to other hospitals in Valentine, Nebraska, and Winner, South Dakota—about 45 miles away  An official from the Sioux San Hospital said that because of vacancies in the diagnostic testing laboratory, the hospital stopped conducting Chlamydia tests in-house and instead sends specimens out to another laboratory for testing  As a result, the official stated it takes about a week longer to get the test results, which can delay treatment  In addition facility staff we interviewed told us the increased stress and fatigue of providers working to make up for staffing shortages results in decreased employee morale  These staff stated that, in some cases, this stress and fatigue has caused providers to leave IHS  One doctor we spoke with described this dynamic of vacancies begetting additional vacancies as a “never-ending cycle” for the facility  In an effort to recruit and retain permanent employees, IHS has used strategies that are similar to strategies used by VHA and tribal facilities in our review  Specifically, IHS has provided financial incentives, professional development opportunities, and some access to housing  The agency has also taken steps to recruit students and connect with potential applicants through webinars, career fairs, and conferences  IHS offers increased special salary rates for certain health care positions, as well as other financial incentives, such as recruitment and retention bonuses  IHS also offers student loan repayments, in return for health professionals’ commitment to work at IHS for a specified period of time  Special salary rates  IHS offers special higher salary rates for physicians, dentists, nurses, CRNAs, certified nurse midwives, nurse practitioners, optometrists, pharmacists, and physician assistants  IHS officials stated that special salary rates are an important recruitment and retention tool for providers, and that without them, federally operated IHS facilities would be at a competitive disadvantage with the private sector, VHA, and tribally operated facilities  In 2015 IHS reported that recruiting and retaining CRNAs was “an ongoing problem for IHS—mostly due to pay,” and the agency rarely had “a sufficient applicant pool ” IHS reported “CRNA services were integral to IHS operations” and without the ability to recruit and retain these providers, IHS was “at risk of having to curtail services to clients ” As a result, according to IHS officials, the agency developed special salary rates for CRNAs, which became effective on December 31, 2015  As of November 2017, IHS had no CRNA vacancies  However, according to IHS officials, the agency has only developed seven national special pay tables and two local special pay tables for Alaska, as of January 2018, due to a lack of human resources personnel trained in this process  Officials told us only one human resources staff person at IHS is experienced with developing special pay tables, which takes a substantial amount of work  However, they stated that this task is only one of her job responsibilities, and she can complete about one special pay table each year  In comparison, according to an official, VHA has developed and regularly revises over 3,000 special salary rates based on local market conditions  For example, IHS officials stated that Phoenix Indian Medical Center cannot offer salaries that are competitive with VHA because salaries for providers in the Phoenix area are relatively high compared to national salaries, and IHS has not developed local salary rates in the Phoenix market  For example, using pay rates effective January 7, 2018, a nurse just starting a career in the Phoenix area could make $63,871 at VHA (local pay table), versus $44,835 at IHS (national pay table)  Although offering increased salaries is an important strategy that IHS uses for recruitment, IHS still experiences challenges in offering competitive salaries  Officials from two area offices told us the maximum amount for a physician salary or certain nursing salaries were not enough for some potential hires, who sought employment elsewhere  While IHS may seek approval from HHS to exceed the maximum salary of certain pay tables, IHS officials said the approval process can be lengthy, which has resulted in the loss of promising candidates—including emergency medicine, general surgery, radiology, and anesthesiologist providers  Similarly, officials from one area office stated that federally operated IHS facilities have experienced challenges competing with other health care systems in recruiting local health care providers, including tribally operated facilities  For example, officials from the Oklahoma City area office told us their area has four of the largest American Indian tribes in the country running their own health systems  According to these officials, in addition to IHS funds, these tribes use money from other sources to pay health care salaries  IHS officials explained that, as a result, tribes can pay higher salaries and may be able to offer other incentives that IHS is unable to provide  Recruitment, relocation, and retention incentives  IHS may offer recruitment, relocation, and retention incentives  Specifically, for positions that are difficult to fill or for individuals who are unlikely to accept the position without an incentive, IHS may offer potential employees a recruitment incentive up to 25 percent of their annual salary  IHS may also pay a relocation incentive for a current employee who must relocate for a position that would otherwise be difficult to fill  In addition, IHS may pay a retention incentive of up to 25 percent of an employee’s current salary if he or she (1) has unusually high or unique qualifications or if there is a special need of the agency, which makes retention essential, or (2) is likely to leave IHS without the retention incentive  Officials from the Phoenix area office told us IHS facilities use the retention bonuses extensively for nursing staff, in particular, to help match the market pay  IHS also analyzed the recruitment and retention of nurses and, as a result of this analysis, requested an exception to the 25 percent limit on recruitment, relocation, and retention incentives, from the Office of Personnel Management (OPM)  In December, 2017, OPM approved IHS’s request to offer incentives up to 50 percent, and IHS officials told us that they are currently reviewing implementation options  Loan repayment  IHS’s Loan Repayment Program pays provider education loans in exchange for an initial two-year service commitment to practice in health facilities serving AI/AN communities  Recipients agree to serve two years in exchange for up to $20,000 per year in loan repayment funding and up to an additional $5,000 per year to offset tax liability, which IHS pays directly to the Internal Revenue Service  Loan repayment recipients can extend their initial two-year contract on an annual basis until their original approved educational loan debt is paid  In fiscal year 2017, a total of 1,267 providers—about 8 percent of the federal IHS workforce—were receiving IHS loan repayments  This included 434 new two-year contracts, 396 one-year extension contracts, and 437 providers starting the second year of their fiscal year 2016 two-year contract  However, IHS’s Loan Repayment Program is not able to pay for the loans of all providers who request it due to limited funding  According to officials in one area office, this has caused providers to either decline a job offer or leave IHS  According to IHS’s fiscal year 2019 budget justification, in fiscal year 2017, 412 providers employed by IHS who applied for loan repayment, did not receive one  An additional 376 applicants either declined a job offer because they did not receive loan repayment funding or were unable to find a suitable assignment meeting their personal or professional needs  Officials in the Billings Area Office told us several physicians stated during exit interviews that they were leaving because they did not receive the loan repayment funding they hoped to receive  According to area office officials, the Billings area lost 5 physicians in 2 weeks because they were not awarded loan repayments  In addition to its own loan repayment program, IHS has worked with HHS’s Health Resources and Services Administration (HRSA) to increase opportunities for providers to apply for loan repayment through the National Health Service Corps  Specifically, IHS worked with HRSA to increase the number of facilities deemed medically underserved and therefore designated Health Professional Shortage Areas  According to IHS, this resulted in 684 health care delivery sites for placement of National Health Service Corps providers, and the number of placements increased to 443 providers as of August 2016  As of January 2018, according to IHS officials, there were 499 providers serving at 797 eligible sites  Applicants cannot receive loan repayment from more than one program concurrently  Officials from several facilities told us they provide access to professional development opportunities for IHS employees as a retention tool  For example, Northern Navajo Medical Facility (Shiprock) officials said they are sending nurse managers and two to three potential future leaders to the American Organization of Nurse Executive trainings  Officials told us this training allows the nurses to network with private executives and look at fellowships  In addition, Chinle Comprehensive Health Care Facility officials told us they paid for a 2-year residency at University of Texas Health Science Center so one of their dentists could obtain additional training in pediatric dentistry  Officials told us that, in return, the dentist agreed to stay at the Chinle Comprehensive Health Care Facility for 6 years  In addition, Shiprock service unit officials told us they have offered their providers, through a partnership with the University of New Mexico, an online Masters of Science in Public Health program in health management  When housing is limited near IHS facilities, IHS has made some housing available to assist with recruitment and retention of providers  Area officials told us federally operated IHS facilities in the Albuquerque, Great Plains, Phoenix, Billings, and Navajo areas provide some government- subsidized housing for providers and their families  At four of the seven facilities we visited—the Kayenta Health Center, Chinle Comprehensive Health Care Facility, Rosebud Hospital, and Pine Ridge Hospital—we observed some staff housing  Kayenta Health Center  Officials from Kayenta Health Center told us that they provide 158 housing units, from 1 bedroom to 4 bedrooms  In addition, the facility has a 19-unit building, similar to a hotel (fully furnished), for temporary contract providers  Officials said they are considering opening units in this building to permanent employees  Chinle Comprehensive Health Care Facility  Officials from Chinle Comprehensive Health Care Facility told us there are 264, 1 to 4 bedroom housing units available for providers both on its campus and nearby  IHS officials also told us they provide access to 19 parking spaces for camping vehicles  Rosebud Hospital  Officials from Rosebud Hospital stated they provide 150 housing units and are also constructing a 19-unit hotel- style building  They said that most, if not all, candidates from outside of the area ask about housing unit availability when deciding whether to accept a position  Pine Ridge Hospital  Officials from Pine Ridge Hospital told us that IHS also provides 105 housing units for its employees  IHS officials explained the housing is a necessity for on-call providers because staff without on-site housing are required to commute extreme distances in very harsh environments to locate housing outside of reservation boundaries  See figure 6 for examples of government-subsidized provider housing near the Kayenta Health Center, Chinle Comprehensive Health Care Facility, Rosebud Hospital, and Pine Ridge Hospital  See appendix II for information about housing provided by one selected tribe  However, there is a greater demand for housing than IHS can provide  During our site visit, Chinle Health Care Facility officials stated that government-subsidized housing availability to meet employee demand is severely limited at all of their three facilities, and the availability of private housing in the community is “non-existent ” As a result, IHS officials from Chinle told us that some providers commute 60 to 90 minutes to work one-way each day  IHS officials told us that, after conducting a needs assessment in 2016, they determined the unmet need for housing at IHS facilities was 1,100 units  According to these officials, the needs assessment also helped them identify some of the greatest needs for housing  The President’s fiscal year 2017 budget proposal for IHS requested $12 million to build new staff housing units “in isolated and remote locations for healthcare professionals to enhance recruitment and retention ” According to agency officials, based on its needs assessment, HHS provided $24 million to build new staff housing units at the Rosebud and Pine Ridge hospitals in the Great Plains area, at the Crownpoint and Chinle health care facilities in the Navajo areas, and at the Supai clinic in the Phoenix area  IHS has also taken steps to recruit future providers by providing scholarships, externships, internships, and residency rotations to health professional students  Scholarships  IHS’s scholarship program provides financial support to qualified AI/AN candidates in exchange for a minimum 2-year service commitment within an Indian health program  Nearly 7,000 AI/AN students have received scholarship awards since the program started in 1978  The awards include (1) scholarships for candidates enrolled in preparatory or undergraduate prerequisite courses in preparation for entry to a health professions school, (2) pre-graduate scholarships for candidates enrolled in courses leading to a bachelor’s degree, including pre-medicine, pre-dentistry, and pre-podiatry, and (3) health professions scholarships for candidates who are enrolled in an eligible health profession degree program  According to IHS, in fiscal year 2017, there were 805 new scholarship applications submitted  After evaluating the applications, 331 applications were deemed eligible for funding, and the program was able to fund 108 new awards  The IHS Scholarship program also reviewed applications from previously awarded scholars who were continuing their education  In fiscal year 2017, 154 continuation awards were funded  In addition to the scholarship program, according to IHS officials, the agency funds two medical students enrolled at the Uniformed Service University of the Health Sciences each year  Each graduate agrees to a 10-year obligation to IHS after medical school graduation and completion of training  In future years, IHS endeavors to fund two additional medical students at the Uniformed Service University of Health Sciences  Externships and internships  IHS provides scholarship recipients with opportunities to receive clinical experience in IHS facilities  In fiscal year 2017, the agency funded 94 students, who were employed for 30 to 120 workdays per calendar year  In addition, IHS provides externships to students temporarily called to active duty as Commissioned Corps officers through the Commissioned Officer Student Training and Extern Program (COSTEP)  IHS officials said that the agency funded about 60-70 students in COSTEP in 2016  IHS also offers a Virtual Internship program through a partnership with the Department of State  Virtual interns spend 10 hours a week from September through May working remotely on their projects, which have included producing bilingual Navajo and English videos for rural health clinics, developing Navajo-specific health education materials on palliative care, improving behavioral health data collection methods, and creating social media strategies and campaigns for health promotion  For the 2017-2018 academic year, about 15 students are participating in virtual internships with IHS  Residency rotations  IHS service units offer rotation opportunities for medical, nursing, optometry, dental, and pharmacy residents as a recruitment tool because research shows students are likely to stay and practice medicine in the area where they studied  For example, the Oklahoma City area has a Memorandum of Agreement with the Oklahoma State College of Medicine, which permits area officials to annually recruit up to two residents from the current year’s residency class to become federal employees while completing their residency program  For every year that IHS sponsors the residents’ position at the university, the resident has a one-year service obligation  In addition, IHS officials from Chinle stated that the service unit participates in educational agreements with numerous universities and residency programs to host medical students, nursing students, and medical residents for rotations  According to officials, recent graduates from residency programs applying for permanent positions with the Chinle Comprehensive Health Care Facility often cite prior rotations at the service unit, or word of mouth from students or residents who have rotated through the service unit, as a reason for applying  The IHS Pharmacy Resident Program is another recruitment program that offers residency training to pharmacists who are willing to serve in high-need locations  Pharmacy residents who are Commissioned Corps officers are required to complete 2 years of service at an IHS federal or tribal facility  Twenty-six Commissioned Corps and civilian pharmacists participate in the Pharmacy Residency Program  See app  II for information on residency programs at tribally operated facilities  IHS officials said they have conducted webinars and career fairs in an attempt to connect with health professional students  For example, in 2016, IHS conducted two informational webinars to recruit Commissioned Corps applicants to facilities in the Great Plains area with critical clinical vacancies  According to IHS officials, approximately 60 applicants attended the two webinars, resulting in 15 nurse hires  In addition, Nashville area officials stated that the area office conducted a marketing campaign at the National Congress of American Indians Conference  Officials explained that the area office provided information about desirable aspects of living in the Nashville area and collected e-mail addresses and areas of interest from potential job candidates  IHS’s Office of Human Resources also partners with HRSA’s Bureau of Health Workforce by participating in nationwide virtual career fairs to promote the National Health Service Corps scholarship and loan repayment opportunities  IHS has also worked with the Office of the Surgeon General to increase the recruitment and retention of Commissioned Corps officers  In May 2017, the Office of the Surgeon General gave IHS priority access to new Commissioned Corps leads—meaning IHS has at least 30 days to make contact with potential applicants to the Commissioned Corps before other agencies have the opportunity to contact them  According to IHS officials, since being given priority access to Commissioned Corps leads, the agency has made 20 direct clinical care selections, of which 15 have entered on duty  In addition to its recruitment and retention strategies, IHS uses strategies to mitigate the negative effects of vacancies by helping to maintain patient access to services, and helping to reduce provider burnout when positions are vacant  Specifically, IHS provides telehealth services; implements alternative staffing models, including hiring nurse practitioners and physician assistants in lieu of physicians; temporarily assigns Commissioned Corps officers to alternate duty stations as needed; and contracts with temporary providers  IHS’s telehealth services include two agency-wide programs that provide teleophthalmology and telebehavioral health services  Teleophthalmology  The IHS Joslin Vision Network (IHS-JVN) Teleophthalmology Program provides annual diabetic eye exams to AI/AN patients in almost all IHS areas with federally operated facilities  According to IHS, patients’ retinal images are scanned locally and sent to a reading center where doctors interpret the images and report back  Officials told us the IHS-JVN program examined 22,000 patients in 2016  Telebehavioral health  The Telebehavioral Health Center of Excellence provides direct care services through video conferencing to patients at remote facilities from providers at IHS facilities that are able to provide the services  These services are provided in all IHS areas with federally operated facilities, and more than 5,800 patient visits occurred in 2016  Additionally, officials told us there are regional telebehavioral health programs, such as in the Oklahoma City area that, combined with the Telebehavioral Health Center of Excellence, saw over 10,000 patients in 2016  IHS officials stated that patients appreciate the telebehavioral services in their communities, because they are the only behavioral health services available in many communities  The IHS psychiatrist who provides services is located in Oklahoma City because, according to IHS officials, it is easier to recruit providers to a more urban location  In addition to these agency-wide telehealth programs, IHS officials identified multiple other local telehealth arrangements that facility staff have developed to help maintain patient access to medical services  For example, there is a diabetes consultant for the Portland area who conducts telenutrition services  There is also a teledermatology program for the Phoenix Area federal facilities operated out of the Phoenix Indian Medical Center  Additionally, several service units—including Pine Ridge Hospital, Rosebud Hospital, and the Sioux San Medical Center—have contracts for emergency department telehealth services  Figure 7 shows telehealth equipment in the Rosebud Hospital emergency department  Staff from multiple facilities told us they have implemented alternative staffing models to focus on hiring for non-physician practitioner positions because these positions are slightly easier to fill  For example, Northern Navajo Medical Center officials told us the facility, facing an emergency department physician shortage, hired physician assistants and nurse practitioners instead  These officials said they converted two physician positions into four physician assistant and nurse practitioner positions  In addition, Chinle officials stated that they added two physician assistants to the urgent care department due to complaints about patient wait times, and patient wait times have decreased as a result  Officials also mentioned dental therapists as an additional type of clinical professional who may be added to the Chinle Health Care Facility staffing model because the service unit has been unable to recruit and retain enough dentists to meet patient need  IHS officials stated that they have worked with the Office the Surgeon General to deploy Commissioned Corps officers, mainly to the Great Plains area, and have also coordinated voluntary temporary duty assignments of Commissioned Corps officers (within IHS and from other agencies) to temporarily fill staffing shortages or meet other mission- critical needs  IHS officials stated that Commissioned Corps officers may also be temporarily assigned to an IHS site to provide services, such as behavioral health support during a suicide cluster  IHS officials from 9 of the 10 geographic areas with federally operated facilities and all seven facilities in our review told us they regularly use temporary contract providers—such as through locum tenens contracts and contracts with university fellowship programs—to maintain patient access to care when positions are vacant  Locum tenens  Officials from the Kayenta Health Center said they contract with temporary providers to compensate for vacancies, and the facility contracts with about 9 providers who rotate to fill 3 vacant emergency department positions  Officials from the Portland area stated that they use temporary providers when there is a staffing shortage with providers  They explained that the Portland area has provider vacancies that have been open for years, and temporary providers fill these vacancies for an extended period of time, usually with a rotating series of providers  Chinle Health Care Facility officials said temporary providers, when of sufficiently high quality, have been recruited to join the permanent corps of civilian service staff  However, they told us locum tenens can cost between $50,000-$200,000 more annually than permanent physicians’ salaries, exclusive of benefits, depending on the specialties and hourly rates associated with the contracts  They said they are finding that increasingly higher hourly rates are needed to ensure a sufficient supply of high-quality temporary providers  IHS officials at all levels of the agency told us they prefer to hire permanent providers, rather than use locum tenens contracts  Facility officials explained that persistent turnover in temporary staff may jeopardize continuity of care  For example, Sioux San Medical Center officials expressed concern about the quality of the care provided by temporary contractors, as well as the consistency of the care provided because the contractors rotate frequently  IHS officials told us that many providers prefer to be on contract due to the higher compensation rates as a contractor, even when taking federal benefits into account  University physicians  IHS officials explained that area offices may also contract with university fellowship programs to provide visiting providers  For example, according to IHS, the Chinle Health Care Facility has entered into long-term contractual agreements with two academic fellowship programs—University of California-San Francisco Health Program and the University of Utah Global Health Fellowship  Officials told us these programs provide U S  residency- trained, board certified physicians interested in global health to work 6-month assignments alternating with another fellow at an international site  In addition, IHS officials stated that the Navajo area office is collaborating with the University of California-San Francisco and its global health fellowship to assign global health fellows to a Navajo Area site for 6 months out of each year  The officials explained that 24 fellows were placed in Navajo-area facilities in 2017 at costs substantially lower than that of locum tenens contracts  According to IHS, the Great Plains area office has collaborated with the University of Washington’s global health fellowship program to assign global health fellows in Internal Medicine to Pine Ridge Hospital for 11- month placements  Agency-wide information on the extent to which facilities use these temporary providers, and the amount spent on them, is not readily available to IHS leadership  While IHS has agency-wide information on vacancies through the Capital Human Resource Management System, IHS delegates the acquisitions process for temporary provider contracts to the head of each area-level Contracting Office  Therefore, agency-wide information on the number of full-time equivalent employees that are temporary providers working at IHS facilities, as well as the cost of these providers, is not readily available  As discussed, officials we spoke with at IHS facilities told us that temporary providers can cost more depending on the specialties and hourly rates  Without agency-wide information on the extent to which such providers are used, IHS is not fully informed about facilities’ reliance and expenditures on temporary providers or their potential effect on patient care, which is inconsistent with federal internal control standards regarding the availability of relevant information to facilitate management decision making and performance monitoring  Specifically, federal internal controls standards state that agency management should obtain, process, and use quality information to make informed decisions and evaluate the agency’s performance in achieving key objectives and addressing risks  IHS’s lack of agency-wide information on the costs and number of temporary providers used at its facilities impedes its ability to make decisions about how best to target its resources to address gaps in provider staffing and ensure that health services are available and accessible across IHS facilities  Maintaining a stable clinical workforce capable of providing quality and timely care is critical for IHS to ensure that comprehensive health services are available and accessible to American Indian/Alaska Native people  However, despite efforts to recruit and retain providers, IHS continues to face considerable challenges to overcome its long-standing struggle to fill sizeable provider vacancies, including geographic isolation and limited amenities  Although IHS is authorized to offer recruitment and retention incentives, such as loan repayments and subsidized housing, the demand for these incentives has been greater than the agency can meet due to resource constraints  However, more complete information on contract providers could help IHS officials make decisions on where to better target its limited resources to address gaps in provider staffing and ensure that health services are available and accessible to American Indian/Alaska Native people across IHS facilities  We are making the following recommendation to IHS: The Director of IHS should obtain, on an agency-wide basis, information on temporary provider contractors, including their associated cost and number of full-time equivalents, and use this information to inform decisions about resource allocation and provider staffing  (Recommendation 1) We provided a draft of this report to HHS and the Department of Veterans Affairs (VA) for review and comment  We received written comments from HHS that are reprinted in appendix III  HHS concurred with our recommendation  In its comments, HHS stated that IHS plans to update its policies by December 2018 to include a centralized reporting mechanism requirement for all temporary contracts issued for providers  HHS also stated that, upon finalization of the policy, IHS will broadly incorporate and implement the reporting mechanism agency-wide and maintain it on an annual basis  HHS also provided technical comments, which we incorporated as appropriate  VA provided comments on a draft of this report in an email, stating that VA officials continue to work to improve recruitment and retention of providers at VHA to ensure that they have the correct number of providers with the appropriate skills  We are sending copies of this report to HHS, the Department of Veterans Affairs, and appropriate congressional committees  In addition, the report will be available at no charge on GAO’s website at http://www gao gov/  If you or your staff have any questions about this report, please contact me at (202) 512-7114 or farbj@gao gov  Contact points for our Office of Congressional Relations and Office of Public Affairs can be found on the last page of this report  Other major contributors to this report are listed in appendix IV  Appendix I: Provider Vacancies with the Indian Health Service (IHS) IHS data collected in November 2017, included the number of positions and vacancies for several types of providers, including physicians, nurses, dentists, pharmacists, nurse practitioners, certified registered nurse anesthetists, certified nurse midwives, and physician assistants  Most of these positions are in the 8 of 12 IHS areas in which IHS has substantial direct care responsibilities  Vacancies for nurse practitioners, nurse midwives, dentists, pharmacists, and physician assistants are provided in this appendix  Nurse practitioners  Nationwide, 97 of 303 positions were vacant in November 2017, and vacancy rates in the 8 areas in which IHS has substantial direct care responsibilities ranged from 12 percent in the Oklahoma City area to 47 percent in the Albuquerque area  (See fig  8) Certified nurse midwives  Nationwide, 8 of 55 positions were vacant in November 2017  See table 1  Dentists  Nationwide, 81 of 306 positions were vacant in November 2017 and vacancy rates in the 8 areas in which IHS has substantial direct care responsibilities ranged from 14 percent in the Phoenix area to 39 percent in the Bemidji area  (See fig  9 ) Pharmacists  Nationwide, 80 of 637 positions were vacant in November 2017 and vacancy rates in the 8 areas in which IHS has substantial direct care responsibilities ranged from 3 percent in the Bemidji area to 17 percent in the Albuquerque area  (See fig  10 ) Physician assistants  Nationwide, 37 of 125 positions were vacant in November 2017  See table 2  Tribal officials from the Chickasaw Nation and Choctaw Nation described their use of strategies to address vacancies, which were very similar to strategies used by the Indian Health Service (IHS)  Like the IHS, one tribe uses the availability of housing units near its medical facility as a recruitment tool for health care providers  Both tribes that described their strategies to recruit and retain providers told us they use their physician residency program in Family Medicine as a recruitment tool  Availability of housing units near the medical facility  Tribal officials from the Choctaw Nation told us the tribe uses housing units—58 housing units that range from studio apartments to multi- room houses—as a recruitment strategy for providers  The provider housing units are occupied by physicians, as well as by physician residents who need housing during their residency or for medical students doing clinical rotations through the facility  According to tribal officials, a factor they considered in making housing units available for providers was the location of its hospital in a rural area of Oklahoma, in a town with a population of about 1,000, which lacks sufficient housing  In September 2017, tribal officials told us all the available housing units were occupied, and the tribe was in the process of constructing at least two 4-bedroom houses  See fig  11 for photos of a completed multi-room house and one under construction  Offering the housing units to provider staff is also part of the tribe’s overall strategy of offering quality-of-life benefits to attract and retain providers  Implementing Accredited Physician Residency Programs  Tribal officials we interviewed noted that they developed physician training programs—specifically graduate medical education, commonly known as residency training—which they use as an important recruitment tool for physicians  One tribe has implemented its Family Medicine residency program, while the other tribe intends for its Family Medicine residency program to be operational in July 2018  Both residency programs are accredited by the American Osteopathic Association, in addition to the American College of Osteopathic Family Practice for one tribe and the American Council for Graduate Medical Education for the other tribe  One program is accredited for 3 resident physicians per year for a total of 9 physician residents at a time, while the other program is accredited for 4 resident physicians per year  We previously found that physicians may practice in geographic areas similar to those where they complete their residency training  Tribal officials with the implemented Family Medicine residency program told us it is successful in that they hired 7 of the 9 residents who completed the residency program  There is also a retention benefit—current providers have the opportunity to stay up-to-date on the latest medical treatment methods by serving as either mentors or as faculty for the residents  In addition to the contact named above, Kathleen M  King (Director), Ann Tynan (Assistant Director), Kelly DeMots (Assistant Director/Analyst-in- Charge), Sam Amrhein, Kristen Anderson, Muriel Brown, Kaitlin Farquharson, Peter Mann-King, Maria Ralenkotter, Lisa Rogers, and Jennifer Whitworth made key contributions to this report 


Report 2: According to NRC’s website, the higher the radiation dose, the sooner the effects of radiation will appear, and the higher the probability of death  Radiation doses such as those received by survivors of the atomic bombs in Japan can cause cancers such as leukemia and colon cancer and, if levels are high enough, acute radiation syndrome  The symptoms of this syndrome range from nausea, fatigue, and vomiting to death within days or weeks  In contrast, the effects of low-dose radiation are more difficult to detect  In particular, below about 100 millisieverts (mSv) (10 rem)—the level below which the National Academies of Sciences, Engineering, and Medicine’s (National Academies) 2006 report on radiation and human health considered radiation to be low dose—data do not definitively establish the dose-response relationship between cancer and radiation exposure  In developing and applying radiation protection requirements and guidance for workers and the public—specifically, limits on dose or increased health risk and guidance levels on exposure—EPA, NRC, DOE, and FDA have generally taken the advice of scientific advisory bodies  In particular, they have relied on the advice of the International Commission on Radiological Protection, the National Council on Radiation Protection and Measurements, and the National Academies’ Nuclear and Radiation Studies Board  This advice includes the use of the linear no-threshold model, which assumes that the risk of cancer increases with every incremental increase in radiation exposure  For example, the National Academies published a report in 2006 stating that the balance of evidence from various types of studies tends to favor a simple proportionate relationship between radiation at low doses and cancer risk  According to the National Academies, the availability of new and more extensive data since the publication of its previous report in 1990 strengthened confidence in the 2006 report’s estimates of cancer risk  The advisory bodies have recognized challenges in accurately estimating cancer risks from very low doses of radiation exposure when using the linear no-threshold model  For example, much of the data on health effects of radiation exposure come from non-U S  populations, such as Japanese atomic bomb survivors  These individuals received a large exposure to radiation over a short period of time (an acute exposure), and there is uncertainty about the extent to which the health effects for these populations can be extrapolated to a U S  population that is regularly (chronically) exposed to low-dose radiation  Nevertheless, NRC officials told us that, in the absence of convincing evidence that there is a dose threshold below which low levels of radiation are beneficial or not harmful, NRC will continue to follow the recommendations of scientific advisory bodies to use the linear no- threshold model  Similarly, officials from EPA told us that they would consider changing the use of the linear no-threshold model as the basis of their requirements and guidance only if there were a strong recommendation from scientific advisory bodies on radiation protection as well as an endorsement of the change by the National Academies  Under this model, federal regulations set dose limits for radiation exposure that are below the level in the National Academies’ 2006 report on radiation and human health for defining low-dose radiation  For example, NRC’s annual dose limit for members of the public (excluding natural, or background, sources of radiation) from operation of nuclear power plants is a hundredth of the level the National Academies considers low dose  NRC based the dose limit on an advisory body recommendation that the cancer risk to the general public from exposure to radiation should be comparable to the public’s risk from everyday activities, such as taking public transportation  The low-dose radiation limits and guidance that federal agencies have developed and applied vary depending on the settings in which exposure can occur  For example, NRC has established limits on occupational dose that apply to nuclear power-plant workers; these limits are higher than NRC’s annual dose limit for members of the public but are still below the level the National Academies considers low dose  In keeping with advisory body recommendations, NRC also applies the principle that doses should be kept as low as reasonably achievable (ALARA)  NRC defines ALARA to mean making every reasonable effort to maintain exposures to radiation as far below dose limits as is practical  At a nuclear power plant we visited as part of our work, representatives told us that under their ALARA plan, the plant set its own dose limit for workers at 40 percent of the NRC’s regulatory limit  Moreover, officials at the plant told us that they have been able to keep exposures below the plant’s own limit by continuously seeking opportunities to reduce unnecessary worker exposure to radiation, such as using robots to perform maintenance work in radiation areas  In contrast to radiation exposure received from nuclear power plants, FDA officials stated that the agency regulates the maximum radiation output of medical equipment, instead of setting limits on the total amount of radiation exposure to patients  According to FDA officials, FDA does not generally have the authority to regulate the total amount of radiation exposure a patient receives from medical imaging equipment  However, in keeping with the principle that radiation exposure should be kept as low as reasonably achievable, FDA encourages voluntary measures by health care providers, such as to investigate and determine whether it is possible to reduce radiation exposure to patients from the use of medical- imaging equipment  From fiscal year 2012 through fiscal year 2016, seven federal agencies obligated $209 6 million for research on the health effects of low-dose radiation, but they did not use a collaborative mechanism to address overall research priorities in this area  DOE and NIH accounted for most of the funding, with DOE obligating $116 3 million and NIH obligating $88 6 million, or about 56 percent and 42 percent of the total, respectively  The five other agencies—NRC, NASA, DOD, EPA, and CDC—obligated the remaining $4 7 million, or about 2 percent of the total  DOE has two offices that have funded research on the health effects of low-dose radiation—the Office of Science and the Office of Environment, Health, Safety and Security—according to funding information DOE provided  The Office of Science established the Low Dose Radiation Research Program in 1998 and funded it through fiscal year 2016  A primary focus of this program was radiobiological research, which examines molecular and cellular responses to radiation exposure  According to DOE’s website for the program, the program provided data and information about the low-dose range of exposure, producing 737 peer-reviewed publications as of March 2012  The Office of Environment, Health, Safety and Security provided funding for epidemiological studies, including studies involving Japanese atomic bomb survivors  NIH has funded and conducted both epidemiological and radiobiological studies on low-dose radiation, according to NIH officials  The officials stated that the studies are conducted through the National Cancer Institute’s internal research program for radiation epidemiology, as well as through NIH’s research programs for external funding of investigator- initiated research  Other institutes of NIH, including the National Institute of Environmental Health Sciences, also fund research related to the health effects of radiation exposure as part of NIH’s overall mission to fund medical research  Among the other agencies that provided some funding to low-dose radiation studies, several provided funding to the Epidemiological Study of One Million U S  Radiation Workers and Veterans (Million Person Study)—an ongoing study headed by the National Council on Radiation Protection and Measurements  DOE also provided funding for this study  In fiscal years 2012 through 2016, the seven agencies who provided funding for research on health effects of low-dose radiation collectively decreased their annual funding obligations in this area by 48 percent, from $57 9 million in fiscal year 2012 to $30 4 million in fiscal year 2016  DOE accounted for a large portion of this overall decrease in annual funding  Specifically, over this 5-year period, DOE reduced its annual funding obligations for this area of research by 45 percent—from $32 6 million in fiscal year 2012 to $18 0 million in fiscal year 2016  According to DOE, the decrease was primarily due to DOE’s reduction in funding for its Low Dose Radiation Research Program  According to DOE officials, decreases in funding for the program reflected a shift toward bioenergy and environmental research  Similarly, over the 5-year period, NIH’s funding for low-dose radiation research decreased by 48 percent—from $23 1 million in fiscal year 2012 to $12 0 million in fiscal year 2016  NIH officials explained that funding levels for a particular disease or research area can fluctuate depending on several factors, including the number and quality of research proposals submitted and the outcome of NIH’s peer reviews of the proposals, as well as the overall research budget  The seven agencies that funded research on health effects of low-dose radiation for fiscal years 2012 through 2016 collaborated on particular research projects through various mechanisms, including joint funding of individual projects, but they did not use a collaborative mechanism to address overall research priorities  As previously noted, the 2016 report of DOE’s Biological and Environmental Research Advisory Committee provided information about research needs in low-dose radiation and found that further research could decrease uncertainty in predicting cancer risk from low-dose radiation  The report stated that other agencies—including NRC, NIH, EPA, DOD, and NASA—could benefit from the reduction in uncertainty that could be obtained by this research  In our September 2017 report, we recommended that the Secretary of Energy lead the development of a mechanism for interagency collaboration to determine roles and responsibilities for addressing priorities related to research on the health effects of low-dose radiation  We made this recommendation because our previous work has shown that collaborative mechanisms can serve multiple purposes, such as leading interagency efforts to develop and coordinate sound science and technology policies across the federal government  Although collaborative mechanisms differ in complexity and scope, they all benefit from certain key features, such as leadership  We directed this recommendation to DOE for several reasons  In the past, DOE took a leading role in advocating for greater communication and coordination between the fields of radiation biology and epidemiology  In addition, DOE is the federal agency that currently has primary responsibility under the Atomic Energy Act of 1954 for research related to the protection of health during activities that can result in exposure to radiation  DOE is well positioned to lead an effort to ensure that federal agencies have a mechanism for interagency collaboration to address overall research priorities related to low-dose radiation health effects because of the agency’s past experience as a leader in this area of research  Such an effort could help DOE and the collaborating agencies determine roles and responsibilities, including leadership when addressing shared research priorities  DOE did not agree with our recommendation  In particular, DOE stated that EPA and NRC also have legal mandates to research low-dose radiation exposure and that these agencies establish their research priorities in accordance with their respective budget authorities and recommendations from independent advisory bodies  DOE stated that as a result, it would not be appropriate for DOE to lead the development of a mechanism for interagency collaboration  We believe that DOE’s concerns stem from a misinterpretation of our recommendation, and we made several changes to our report and our recommendation to clarify DOE’s role  We noted that we did not recommend that a mechanism for interagency collaboration serve as a replacement for agencies’ legal mandates, budget authorities, and recommendations from independent advisory bodies  Instead, this mechanism would help agencies address shared research priorities  In making our recommendation, we did not specify the coordinating mechanism that agencies should use and instead left it to DOE to lead the development of an appropriate mechanism  We continue to believe that an interagency coordination mechanism for low-dose research is needed and that DOE is in the best position to lead agencies in developing the most appropriate mechanism  Chairman Weber, Ranking Member Veasey, and Members of the Subcommittee, this concludes my prepared statement  I would be pleased to respond to any questions that you may have at this time  If you or your staff have any questions about this statement, please contact John Neumann at (202) 512-3841 or neumannj@gao gov  In addition, contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this statement  Individuals who made key contributions to the report on which this testimony is based include Allen Chan, Kendall Childers, Joseph Cook, Richard Johnson, Cynthia Norris, Josie Ostrander, Amber Sinclair, and Jack Wang  This is a work of the U S  government and is not subject to copyright protection in the United States  The published product may be reproduced and distributed in its entirety without further permission from GAO  However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately 

ground_truth: This testimony summarizes the information contained in GAO's September 2017 report, entitled Low-Dose Radiation: Interagency Collaboration on Planning Research Could Improve Information on Health Effects ( GAO-17-546 ). The Department of Energy (DOE), Nuclear Regulatory Commission (NRC), Environmental Protection Agency (EPA), and Food and Drug Administration generally used the advice of scientific advisory bodies to develop and apply radiation protection requirements and guidance for workers and the public in the radiation exposure settings that GAO reviewed. These settings were: (1) the operation and decommissioning of nuclear power plants; (2) the cleanup of sites with radiological contamination; (3) the use of medical equipment that produces radiation; and (4) accidental or terrorism-related exposure to radiation. Specifically, the agencies relied on the advice of three scientific advisory bodies that supported the use of a model that assumes the risk of cancer increases with every incremental radiation exposure. Accordingly, the agencies have set regulatory dose limits and issued guidance to confine exposure to levels that reduce the risk of cancer, while recognizing that scientific uncertainties occur in estimating cancer risks from low-dose radiation. For example, NRC requires nuclear power plants to consider measures for limiting workers' exposure below NRC's regulatory dose limit, such as by using robots for maintenance work in radiation areas. GAO identified seven federal agencies that funded research on low-dose radiation's health effects. In fiscal years 2012 to 2016, DOE, NRC, EPA, and four other federal agencies obligated about $210 million for such research . Although the agencies have collaborated on individual projects on radiation's health effects, they have not established a collaborative mechanism to set research priorities. GAO's previous work has shown that federal agencies can use such mechanisms to implement interagency collaboration to develop and coordinate sound science policies. In the past, DOE took a leading role in this area because DOE provided stable funding and advocated for greater coordination on research on low-dose radiation's health effects. However, since fiscal year 2012, DOE has phased out funding for one of its main research programs in this area. This has created a void in coordination efforts among federal agencies, and no other agency has stepped forward to fill this void. Because of DOE's prior experience as a leader in this area of research and its research responsibility under the Atomic Energy Act of 1954, it could play an important role in helping federal agencies establish a coordinating mechanism for low-dose radiation research. Dollars are in millions and have not been adjusted for inflation Source: GAO analysis of agency data. | GAO-17-546