Accessible Version

CENTERS OF 

EXCELLENCE

DOD and VA Need 

Better Documentation 

of Oversight 

Procedures

Report to Congressional Requesters

December 2015

GAO-16-54

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-16-54, a report to 

congressional requesters

December 2015

CENTERS OF EXCELLENCE

DOD and VA Need Better Documentation of Oversight 

Procedures 

Why GAO Did This Study

Both DOD and VA’s VHA have COEs 

that are expected to improve certain 

services throughout both agencies’ 

health care systems. To date, DOD 

and VHA have designated 7 and 70 

COEs, respectively. Congressional 

hearings have raised questions about 

DOD’s and VHA’s oversight of the 

COEs, including the criteria used to 

designate them, and whether they are 

meeting their intended missions. 

GAO was asked to review DOD and 

VHA COEs. GAO (1) examined the 

criteria and processes DOD and VHA 

use to designate entities as COEs and 

(2) assessed how DOD and VHA 

document the oversight activities 

related to their agencies’ COEs. GAO 

compared agency criteria against 

federal internal control standards, and 

analyzed relevant laws, committee 

reports, and available agency 

documents. GAO also analyzed 

documents from the 7 Defense COEs 

and from the 6 VHA service offices 

responsible for the 70 VHA COEs to 

understand the criteria and processes 

used to designate them and how 

oversight activities are documented. 

GAO interviewed officials from both 

agencies to obtain additional 

information about their COEs.

What GAO Recommends

GAO recommends that VHA establish 

criteria for designating entities as 

COEs. GAO also recommends that 

DOD and VHA develop written 

procedures for documenting oversight 

of their COEs. VA and DOD concurred 

with GAO’s recommendations and 

provided an action plan for 

implementing them.

What GAO Found

The Department of Defense (DOD) has developed criteria to designate an entity 

as a Defense Center of Excellence (COE), but the Department of Veterans 

Affairs’ (VA) Veterans Health Administration (VHA) has not. Health-focused 

COEs are intended to bring together treatment, research, and education to 

support health provider competencies; identify gaps in medical research and 

coordinate research efforts; and integrate new knowledge into patient care 

delivery. GAO found that DOD leadership and its Defense COE Oversight Board 

established and refined the definition and criteria for designating entities as 

Defense COEs. DOD’s criteria require its Defense COEs, for example, to achieve 

improvements in clinical care outcomes and produce optimal value for service 

members. The Oversight Board developed these criteria in order to have a 

consistent basis for designating entities as Defense COEs and to limit entities 

from self-identifying as Defense COEs without meeting the criteria. DOD also 

developed a uniform process for designating COEs. VHA service offices use a 

peer review process to designate their COEs. However, unlike DOD, VHA has 

not developed criteria for designating its COEs. Federal internal control 

standards provide that management should have a control environment that 

provides management’s framework for planning, directing, and controlling 

operations to achieve agency objectives, such as VHA’s objectives for how 

COEs are to operate and what COEs are supposed to achieve. Without defined 

criteria, VHA lacks reasonable assurance that its COEs are meeting the agency’s 

intended objectives for COEs.

The Defense COE Oversight Board and most service offices responsible for 

overseeing VHA COEs lack written procedures for documenting oversight 

activities related to their COEs, including requirements for documenting identified 

problems and their resolution. GAO found that the Oversight Board’s charter 

does not explain how (1) the board will provide and document its feedback, (2) 

the Defense COEs will respond to this feedback, and (3) the board will document 

resolution of identified issues. The Oversight Board’s acting chairman told GAO 

the charter gives the board its authority to conduct oversight of Defense COEs 

and if these types of procedures are needed, the Oversight Board’s charter and 

meeting minutes will serve this purpose. However, GAO’s review of the charter 

and minutes found that they do not contain these types of procedures. Likewise, 

GAO found that five of six VHA service offices have no written procedures for 

documenting their findings and the corrective actions taken by COEs. VHA 

officials told GAO that they do not see a need to develop specific written 

procedures for documenting oversight of their COEs. Federal internal control 

standards state that transactions and events should be promptly documented to 

maintain their relevance and value to management in controlling their operations. 

Further, significant events, such as the identification of problems and the actions 

taken to correct them, need to be clearly documented, and these events should 

appear in management directives, policies or operating manuals to help ensure 

management’s directives are carried out as intended. Absent written oversight 

procedures, both DOD and VHA lack reasonable assurance that oversight 

procedures are consistently and routinely performed over time, and that issues 

raised during oversight are resolved.

View GAO-16-54. For more information, 

contact Randall B. Williamson at (202) 512-

7114 or williamsonr@gao.gov.
Letter 1

Page i GAO-16-54 Centers of Excellence

Background 4

DOD Has Established Criteria for Designating a COE, While VHA 

Has Not 8

Both DOD and VHA Lack Written Procedures for Documenting 

Activities to Oversee COEs 14

Conclusions 16

Recommendations for Executive Action 17

Agency Comments 17

Appendix I: List of Veterans Health Administration Centers of Excellence and Their Focus 19

Appendix II: Collaboration Efforts of Centers of Excellence in the Department of Defense and Department of 

Veterans Affairs 28

Appendix III: Comments from the Department of Veterans Affairs 37

Appendix IV: Comments from the Department of Defense 40

Appendix V: GAO Contact and Staff Acknowledgments 42

GAO Contact: 42

Staff Acknowledgments 42

Appendix VI: Accessible Data 43

Agency Comment Letter 43

Tables

Table 1: Composition of the Military Health System Defense 

Centers of Excellence Oversight Board (May 2015) 5

Table 2: Defense Centers of Excellence and Their Origins, as of 

September, 2015 10

Table 3: Veterans Health Administration (VHA) Office of Patient 

Care Services Centers of Excellence (COE), Location, 

Origin, and Areas of Focus; by Type of Service (August 

2015)20

Table 4: Veterans Health Administration (VHA) Office of Research 

and Development Centers of Excellence (COE), Location, 

Origin, and Areas of Focus (August 2015) 24

Contents
Table 5: Veterans Health Administration (VHA) Office of Academic 

Affiliations Centers of Excellence (COE), Locations, 

Origins, and Areas of Focus; by Area of Education 

(August 2015) 27

Table 6: Defense Centers of Excellence Responses to GAO 

Questionnaire on Collaboration Activities (December 2014 

– January 2015) 29

Table 7: Veterans Health Administration (VHA) Office of Patient 

Care Services: Mental Health Services Centers of 

Excellence Responses to GAO Questionnaire on 

Collaboration Activities (December 2014 – January 2015) 30

Table 8: Veterans Health Administration (VHA) Office of Patient 

Care Services: Specialty Care Services Centers of 

Excellence Responses to GAO Questionnaire on 

Collaboration Activities (December 2014 – January 2015) 31

Table 9: Veterans Health Administration (VHA) Office of Patient 

Care Services: Geriatrics and Extended Care Services: 

Geriatric Research Education Clinical Centers (GRECC) 

Centers of Excellence Responses to GAO Questionnaire 

on Collaboration Activities (December 2014 – January 

2015)33

Table 10: Veterans Health Administration (VHA) Office of 

Research and Development: Rehabilitation Research and 

Development Centers of Excellence Responses to GAO 

Questionnaire on Collaboration Activities (December 2014 

– January 2015) 34

Table 11: Veterans Health Administration (VHA) Office of 

Academic Affiliations: Primary Care Education and 

Patient-Centered Specialty Care Education Centers of 

Excellence Responses to GAO Questionnaire on 

Collaboration Activities (December 2014 – January 2015) 36

Figure

Page ii GAO-16-54 Centers of Excellence

Figure 1: Department of Veterans Affairs (VA) Veterans Health 

Administration (VHA) Program and Service Offices with 

Centers of Excellence (COE) 7
Page iii GAO-16-54 Centers of Excellence

Abbreviations

COE center of excellence

CONOPS concept of operations

DOD Department of Defense

GRECC Geriatric Research Education Clinical Center

MHS Military Health System

MIRECC Mental Illness Research, Education, and Clinical Center

PADRECC Parkinson’s Disease Research, Education, and Clinical 

Center

PTSD post-traumatic stress disorder

VA Department of Veterans Affairs

VHA Veterans Health Administration

VISN Veterans Integrated Service Network

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Page 1 GAO-16-54 Centers of Excellence

441 G St. N.W.

Washington, DC 20548

December 2, 2015

The Honorable Johnny Isakson

Chairman

Committee on Veterans’ Affairs

United States Senate

The Honorable Jeff Miller

Chairman

Committee on Veterans’ Affairs

House of Representatives

The Honorable Richard Burr

United States Senate

Both the Department of Defense (DOD) and the Department of Veterans 

Affairs (VA) have established centers of excellence (COE) that are 

expected to improve certain services throughout the DOD and VA health 

care systems. Health-focused COEs are intended to bring together 

treatment, research, and education to support health care provider 

competencies, identify gaps in medical research and coordinate research 

efforts, and integrate new knowledge into patient care delivery. DOD and 

VA COEs have been established in a number of specialty areas, including 

Parkinson’s disease; multiple sclerosis; trauma; and loss of an extremity, 

vision, or hearing. The COEs’ goals vary depending on their specific 

missions and are generally intended to improve patient health outcomes 

by integrating knowledge gained through research. Health-focused COEs 

have been established in DOD and VA’s Veterans Health Administration 

(VHA) in two ways—in response to statutory mandates and through 

departmental designation.1 One of the COEs created in response to statutory 

mandates was required to be jointly operated by both DOD and VA. To date, 

DOD and VHA have designated 7 and 70 COEs, respectively. See appendix I for 

 

1VHA within VA is responsible for health-related issues, including COEs. For the purposes of this 

report, VHA and GAO treat the COEs created pursuant to congressional direction during 

the legislative process as being statutorily mandated. For example, VHA established three 

COEs because they were mentioned in a House conference report, which we characterize 

as “statutory language” for purposes of this report. (H.R. Rep. No. 109-305, at 39 (2005)) 

accompanying Pub. L. No.109-114, 119 Stat. 2372 (Nov. 30, 2005).

Letter
information we collected from VHA officials on the number of COEs and 

whether the COE is statutorily mandated or departmentally designated.

Congressional hearings have raised questions about DOD and VA COEs 

and the criteria these agencies use to designate entities as COEs and 

oversee them in order to assess whether they are meeting their intended 

missions of providing better clinical outcomes to servicemembers and 

veterans through improved patient care delivery.

Page 2 GAO-16-54 Centers of Excellence

2 Additionally, in the health 

care community in general, the term COE has been widely used, sometimes 

without official designation or mandate. Some providers of care proclaim 

to be COEs without reference to specific criteria that would demonstrate 

excellence in research, education, or clinical services. Various groups 

have raised concerns about the definition of this term because it is 

applied broadly and inconsistently by hospitals and health care systems. 

These groups believe the term can cause confusion among consumers of 

health care because they may believe the entity classified as a COE has 

undergone some type of rigorous review or certification. A New York 

State Department of Health study, for example, found that the term is 

used by many without official designation, and some providers selfidentify as COEs without meeting any criteria.3

You asked us to examine DOD’s and VHA’s health-related COEs. In this report, 

we

1. examine the criteria and processes DOD and VHA use to designate entities 

as COEs within their respective agencies, and

2. assess how DOD and VHA document the oversight activities related to the 

agencies’ COEs.

To examine the criteria and processes that DOD and VHA use to 

designate entities as COEs within their respective agencies, we collected 

and analyzed federal laws and committee reports that required DOD and 

 

2

See House Committee on Veterans’ Affairs, Subcommittee on Oversight and Investigations, The

Vision Center of Excellence: What Has Been Accomplished in Thirteen Months?, Hearing 

by the House of Representatives, 111 Congress, First Session, March 17, 2009; House 

Committee on Armed Services, Subcommittee on Military Personnel, Department of 

Defense Medical Centers of Excellence, Hearing by the House of Representatives, 111 

Congress, Second Session, April 13, 2010.

3Commission on Health Care Facilities in the 21st Century-New York State Department of Health, 

Quality Health Care (New York, 2007). 
VHA to establish certain COEs. We also obtained and reviewed DOD and 

VHA policies, procedures, and other documents that explain how their 

COEs are defined and designated. These documents include applications 

and requests for proposals to be designated a COE, and reviews of COE 

applications. We interviewed DOD and VHA officials about the criteria 

and processes the agencies use to designate entities as COEs. We 

assessed the criteria DOD and VHA each use to designate entities as 

COEs against Standards for Internal Control in the Federal Government.

Page 3 GAO-16-54 Centers of Excellence

4

Internal controls are an integral component of an organization’s management that 

provides reasonable assurance that program objectives are being achieved.

To assess how DOD and VHA document oversight of their respective COEs, we 

collected and analyzed available DOD and VHA policies, procedures, and 

other documents related to the oversight of COEs.5 We interviewed DOD 

and VHA officials to confirm our understanding of their methods of 

documentation of oversight activities. For DOD, we interviewed the acting 

chair of the Military Health System (MHS) Defense COE Oversight Board 

(Oversight Board) to understand how DOD documents its oversight of 

COEs. For VHA, we interviewed officials from VHA’s six service offices 

that have responsibility for overseeing VHA COEs to learn how they 

document their oversight activities of COEs.6 For two of the six service 

offices, Mental Health Services and Specialty Care Services, we limited our 

scope to one type of COE in each of these service offices. We reviewed the 

Mental Illness Research, Education, and Clinical Center (MIRECC) COEs 

in the Mental Health service office because MIRECCs make up the 

majority of COEs in this service office. In addition, we reviewed the 

Parkinson’s Disease Research, Education, and Clinical Center 

(PADRECC) COEs in the Specialty Care service office because 

PADRECCs make up the majority of COEs in this service office. We 

 

4

See GAO, Standards for Internal Control in the Federal Government, 

GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999). 

5We focused on the performance oversight conducted by DOD and VHA’s six service 

offices for their respective COEs.

6VHA also has another service office, the Rehabilitation and Prosthetic Care Services, that 

provides VHA staff to DOD to support its COEs, but does not manage any VHA COEs. Therefore, 

this service office is not included in our review of VHA COEs. In this review, we include 

these COEs under the Defense COEs. 
compared DOD’s and VHA’s available oversight documentation with the 

Standards for Internal Control in the Federal Government.

Page 4 GAO-16-54 Centers of Excellence

7

In addition, we used a Web-based, structured questionnaire to obtain additional 

information about DOD and VHA COEs, such as the basis upon which they were 

designated and how they collaborate with other COEs within and outside their

agencies. We administered the questionnaire between December 2014 

and January 2015, to COE directors identified by DOD and VHA officials. 

See appendix II for information we collected from COE directors on DOD 

and VHA COE collaboration efforts.

We conducted this performance audit from June 2014 through December 

2015 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

The Assistant Secretary of Defense for Health Affairs leads the MHS and 

is ultimately responsible for the Defense COEs.8In 2011, DOD leadership 

delegated responsibility for designating and overseeing Defense COEs to the 

Oversight Board. The Oversight Board includes members appointed by the 

Surgeons General of the Army, the Navy, and the Air Force; VA; and other 

components within DOD, as shown in table 1.

 

7GAO/AIMD-00-21.3.1.

8The MHS is a complex system that provides resources and oversees health care delivery, 

medical education, public health, and research. See DOD Directive Number 5136.01, 

Assistant Secretary of Defense for Health Affairs, Sept. 30, 2013.

Background
Table 1: Composition of the Military Health System Defense Centers of Excellence 

Page 5 GAO-16-54 Centers of Excellence

Oversight Board (May 2015)

Chairperson Deputy Assistant Secretary of Defense for 

Health Services Policy and Oversight

Oversight board members Deputy Assistant Secretary of Defense, Health 

Readiness Policy and Oversight

Deputy Assistant Secretary of Defense, Health 

Resources Management and Policy

Army Representativea

Navy Representativea

Air Force Representativea

Marine Corps Representativeb

Uniformed Services University of the Health 

Sciences Representative

Defense Health Agency Representative

Department of Veterans Affairs Representative

Joint Staff Surgeon Representative

Source: Department of Defense. | GAO-16-54.

a

The military branch Surgeon General appoints member.

b

The Commandant of the Marine Corps appoints member.

The Oversight Board’s charter, which was signed by the Assistant 

Secretary of Defense for Health Affairs, delegates oversight of Defense 

COEs to the Oversight Board. The charter lists the Oversight Board’s 

responsibilities and activities, and the quarterly meeting minutes provide 

documentation of the Oversight Board’s activities, procedures, and 

decisions. For example, the Oversight Board’s charter requires the Board 

to conduct periodic reviews of Defense COEs’ performance and to review 

and recommend applicants for Defense COE designation. The charter 

was originally signed in September 2011 by the Assistant Secretary of 

Defense for Health Affairs, and updated and signed again in May 2015. 

The updated charter clarified responsibilities for the Oversight Board 

related to overseeing COEs, such as validating that a Defense COE is 

meeting objectives for which it was established and that the return from 

its work merits continued investment.

For VA, VHA’s Under Secretary for Health is ultimately responsible for 

VHA COEs. Three program offices within VHA—the Office of Patient 

Care Services, the Office of Research and Development, and the Office 

of Academic Affiliations—have COEs. These three program offices 

delegate responsibility for their COEs to service offices within their 

organizational structures. The Office of Patient Care Services has three 

service offices with COEs—Mental Health Services, Specialty Care 
Services, and Geriatric and Extended Care Services.

Page 6 GAO-16-54 Centers of Excellence

9 The Office of 

Research and Development has one service office with COEs—Rehabilitation 

Research and Development Service—and the Office of Academic Affiliations 

has two service offices with COEs, referred to as coordinating centers—

Primary Care Education and Patient-Centered Specialty Care Education. 

(See fig. 1).

 

9VHA also has another service office, the Rehabilitation and Prosthetic Care Services, which

provides VHA staff to DOD to support its COEs, but does not manage any VHA COEs. 

Therefore, this service office is not included in our review of VHA COEs. In this review, we 

include these COEs under the Defense COEs. 
Figure 1: Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Program and Service Offices with 

Page 7 GAO-16-54 Centers of Excellence

Centers of Excellence (COE)

Note: Dotted lines indicate an indirect organizational relationship.

a

VHA’s Office of Patient Care Services also has another service office, Rehabilitation and Prosthetic 

Care Services, which provides VHA staff to DOD to support its COEs, but does not manage any VHA 

COEs. Therefore, this service office is not included in our review of VHA COEs. In this review, we 

include these COEs under the Defense COEs.

b

The Vision COE is organizationally aligned under VHA’s Specialty Care Services. VHA does not 

manage this COE, but provides staff to DOD for the COE. In this review, we include this COE under 

the Defense COEs.
DOD officials established criteria that COEs must meet to be designated 

a Defense COE and a uniform process for applicants. VHA’s service 

offices use a peer review process to designate COEs. However, unlike 

DOD, VHA has not established criteria for an entity to be designated as a 

COE.

Criteria for designating entities as COEs. In 2011, following our study 

of one of DOD’s statutorily mandated COEs, DOD leadership determined 

that it needed to conduct a review of all existing COEs and develop a 

definition that would be used as criteria for designating entities as 

Defense COEs.

Page 8 GAO-16-54 Centers of Excellence

10 MHS leadership developed a definition for Defense COEs, 

and the COE Oversight Board members refined and approved the criteria 

contained in this definition. Only entities that meet the criteria in the 

Oversight Board-approved definition can be given the designation of a 

Defense COE.

The definition approved by the Oversight Board states that Defense 

COEs will focus on an associated group of clinical conditions and achieve 

improvement in outcomes through clinical, educational, and research 

activities. The criteria require Defense COEs to provide the entire clinical 

spectrum of care for a patient—from the prevention of diseases and 

treatment of clinical conditions through rehabilitation and transition to 

civilian life; for example, by developing clinical practice guidelines and 

educational materials and identifying research priorities and strategies for 

improving access to care. In addition, the Oversight Board developed 

other criteria that entities applying for Defense COE designation have to 

meet, such as clearly defining their mission, developing metrics to 

quantitatively assess their progress in meeting their mission, and 

determining whether the research they plan to conduct is needed 

because of existing research gaps.

The Oversight Board acting chairman said the board developed criteria 

for a Defense COE because it is important for the board, as well as MHS 

leadership, to apply consistent criteria when designating entities as 

Defense COEs. The acting chairman said not having clear and consistent 

criteria could make it easier for entities to self-identify as a Defense COE 

 

10See GAO, Defense Health: Management Weaknesses at Defense Centers of 

Excellence for Psychological Health and Traumatic Brain Injury Require Attention,

GAO-11-219 (Washington, D.C.: Feb. 28, 2011).

DOD Has Established 

Criteria for 

Designating a COE, 

While VHA Has Not

DOD Has Established 

Criteria for Defense COEs 

and Has a Uniform 

Process for Approving 

COE Applicants
without meeting rigorous requirements. In addition, the criteria may 

facilitate coordination among COEs to meet the agency’s intended 

objectives for them—which is to improve the health of servicemembers, 

veterans, their families, and ultimately the military readiness of 

servicemembers.

Approval process for Defense COEs. The Oversight Board established 

a uniform process that requires applicants to present consistent 

information when applying for Defense COE designation. Applicants are 

required to describe why the designation as a Defense COE is important 

to them and how they meet the criteria of a Defense COE. The Oversight 

Board, after considering the applications from potential COEs, 

subsequently determines whether a Defense COE applicant passes the 

preliminary review. Applicants that do not pass the preliminary review are 

instructed to provide additional information or clarify the information 

presented for reconsideration. There is no limit on the number of times 

they can resubmit their application. Those that pass this preliminary 

review are instructed to develop a concept of operations (CONOPS) and 

a briefing for the Oversight Board. A CONOPS is a document that is 

designed to give an overall picture of the operation of the proposed 

Defense COE, explaining what the applicant intends to accomplish and 

how it will be done using available resources. The CONOPS includes a 

description of the value that the applicant brings to the MHS and a brief 

description of MHS needs and gaps that the applicant will address. The 

Oversight Board developed a CONOPS template to ensure that during 

required briefings information is consistently presented to the Board by 

applicants seeking Defense COE status. The applicant’s briefing to the 

Oversight Board is intended to provide an overview of the mission and 

goals of the applicant COE, including how the applicant meets the 

Defense COE criteria, as established by the Oversight Board.

After reviewing documentation from applicants, Oversight Board 

members make recommendations about Defense COE designation to the 

Assistant Secretary of Defense for Health Affairs, who makes the final 

decision.

Page 9 GAO-16-54 Centers of Excellence

11 According to DOD officials, in 2012, after the Oversight Board 

reviewed the briefings and CONOPS for the four statutorily mandated COEs and 

made its recommendations, the Assistant Secretary of Defense for Health 

 

11The recommendation of the Oversight Board is determined by a majority vote. Applicants for 

Defense COE designation are notified in writing of the decision reached by the Assistant 

Secretary of Defense for Health Affairs. 
Affairs designated these applicants as Defense COEs. Subsequently, the 

Oversight Board reviewed and approved three other applicants as 

Defense COEs, according to these officials. The seven Defense COEs 

are listed in table 2 along with the origin of the Defense COE—that is, 

whether the Defense COE was statutorily mandated or departmentally 

designated. 

Table 2: Defense Centers of Excellence and Their Origins, as of September, 2015

Page 10 GAO-16-54 Centers of Excellence

Defense Centers of Excellence (COE)

Statutorily 

mandated

Department of 

Defense designated

Defense Centers of Excellence for 

Psychological Health and Traumatic Brain 

Injuryb

Yes No

Vision Center of ExcellencebYes No

Hearing Center of ExcellencebYes No

Extremity Trauma and Amputation Center 

of Excellencea

Yes No

Comprehensive Cancer Center No Yes

Joint Trauma System No Yes

Consortium for Health and Military 

Performance

No Yes

Source: Department of Defense. | GAO-16-54.

aCOE established by statute as a joint Department of Defense and Department of Veterans Affairs 

(VA) COE.

b

VA provides staff to these Defense COEs.

No criteria for designating entities as COEs. VHA has not developed 

consistent criteria for designating an entity as a COE. VHA officials told 

us they believe the term COE is “a term of art” and does not lend itself to 

standard and consistent criteria. Furthermore, officials said they never 

considered a need for these criteria.

Standards for Internal Control in the Federal Government provide that 

management should have a control environment that provides 

management’s framework for planning, directing, and controlling 

operations to achieve agency objectives, such as VHA’s objectives for 

how COEs are to operate and what COEs are supposed to achieve.12 A 

good internal control environment requires that the agency’s organizational 

 

12GAO/AIMD-00-21.3.1. 

VHA Has Not Developed 

Criteria for a COE, but 

Service Offices Use a 

Peer Review Process to 

Designate COEs
structure clearly define key areas of authority and responsibility for operating 

activities. The organizational structure encompasses the operational 

processes needed to achieve management’s objectives. Without VHA 

developing criteria to establish, execute, control, and assess COEs, VHA 

management risks not meeting its objectives for COEs.

The lack of standard and consistent criteria for designating COEs hinders 

VHA’s ability to carry out the following functions.

· VHA cannot provide both a basis for determining whether COEs are 

meeting the agency’s intended objectives for COEs and a coordinated 

direction for its COEs. These objectives include meeting the needs of 

veterans and their families, conducting pertinent research, and 

promoting innovative approaches to care delivery by VHA clinicians, 

according to VHA officials.

· VHA officials might not be able to determine the precise number of 

COEs within the agency as a basis for planning, directing, and 

controlling operations to achieve agency objectives. VHA officials 

reported to us that the agency has 70 COEs, with the largest number 

located within VHA’s Office of Patient Care Services. The Office of 

Patient Care Services reported that it has 49 COEs—39 statutorily 

mandated and 10 VHA designated. The Rehabilitation Research and 

Development Service, under VHA’s Office of Research and 

Development, reported it has 13 VHA-designated COEs, and VHA’s 

Office of Academic Affiliations reported 8 VHA-designated COEs.

Page 11 GAO-16-54 Centers of Excellence

13

However, VHA’s Office of Patient Care Services Chief of Financial 

Operations could not confirm this number, telling us he could not provide us 

with a definite number of COEs because there were no criteria for him to 

use to identify entities designated as COEs. Other VHA officials have 

also had difficulty identifying the universe of VHA’s COEs. For 

example, VHA officials initially omitted listing the 20 Geriatric 

Research Education Clinical Centers (GRECC) as VHA COEs until 

we told these officials that GRECC officials told us they were 

designated as VHA COEs.

In addition, confusion exists within VHA about statutorily mandated COEs 

because of the lack of criteria. For the COEs that VHA officials said were 

statutorily mandated, the statutory language often uses the term “center.” 

 

13The Office of Academic Affiliations, Patient-Centered Specialty Care Education, recently added 

a COE that is not included in this count.
VHA decided to designate some of these centers as COEs, even though 

the statutory language was the same or similar for many centers that VHA 

did not designate as COEs. For example, the National Center for 

Preventive Health has statutory language similar to the language 

establishing the National Center for Post-Traumatic Stress Disorder 

(PTSD); however, the National Center for PTSD is considered a VHA 

COE while the National Center for Preventive Health is not.

Page 12 GAO-16-54 Centers of Excellence

14 Officials 

from VHA and VA’s Office of General Counsel were unable to explain why 

some centers listed in statutory language are designated as COEs, while other 

centers with similar language are not designated as COEs. In addition, these 

officials could not provide the criteria that were used to designate these 

centers as COEs.

Process for designating entities as VHA COEs. VHA service offices 

use a peer review process to designate entities as VHA COEs. In 

general, a peer review process is often used by government agencies to 

determine the merit of proposals submitted by researchers applying for 

grants or some type of funding.

VHA service offices typically solicit applications or proposals from entities 

interested in being designated a COE, and interested entities complete an 

application or submit a proposal. Each application or proposal for COE 

designation may differ depending on the condition, disease, or specific 

health-related area being studied. For example, applications or proposals 

for a mental health COE designation may require applicants to address 

how their research will focus on bipolar disorder, borderline personality 

disorder, or schizophrenia, while applications or proposals for an 

educational COE may require applicants to address how they will develop 

and test innovative approaches for curricula related to patient-centered 

care or study new approaches and models of collaboration among health 

care professionals.

Within each of the six service offices, applications or proposals are 

reviewed by a panel of subject matter experts who prioritize the 

applications based on the strengths and weaknesses of the proposals or 

on the proposals with the highest merit rating. The service office peer 

review panel may be made up of experts from VHA entities or from 

 

14VHA opened the National Center for Preventive Health in 1995 at the Durham, North Carolina 

VA medical center and named the center the VHA National Center for Health Promotion 

and Disease Prevention.
entities external to VHA, according to VHA officials. Generally, the 

experts review information such as the focus of the planned research and 

available staffing and funding. Once the experts identify the best 

applicants, they forward this information to the appropriate service office 

officials. If the service office staff agrees with the list of best applicants, 

some service offices forward this list to the Under Secretary for Health, 

who ultimately makes the final decision with respect to designating an 

entity as a VHA COE, while other service offices forward the list to their 

program director, who makes the final decision.

While all six service offices use a peer review process to review, approve, 

and designate entities as COEs, the processes may differ in several 

respects. First, the content of submitted applications or proposals may 

differ among service offices. This is due, in part, to the lack of consistent 

and standard criteria within VHA that applicants must meet to be 

designated a VHA COE, such as how the applicant will meet the needs of 

veterans and their families and ensure that pertinent research is 

conducted to meet these needs—VHA’s intended objectives for its COEs, 

according to VHA officials. Second, the types and levels of review within 

service offices vary. For example, to help prioritize the best applicants, 

two VHA service offices developed a numerical scoring system to rate 

each application based on scientific and technical merit, typically based 

on the requirements contained in the solicitation for applications or 

proposals. For instance, if the solicitation for applications or proposals 

requires an evaluation plan that contains specific evaluation criteria, such 

as proposed outcome measurements, reporting methodology, expected 

findings, and potential implications for VHA and the community, 

applicants can be awarded up to 10 points for including these items. 

Other service offices do not include a scoring system as part of their 

approval process. Third, four of VHA’s six service offices conduct a site 

visit to the highest rated applicants’ facilities as part of their approval 

process; the other two do not, according to VHA officials. An official from 

one service office told us the staff members that conduct the visits have 

seen many potential COEs, and such on-site inspections can help to 

determine the applicant’s potential viability as a COE.

Page 13 GAO-16-54 Centers of Excellence
Page 14 GAO-16-54 Centers of Excellence

Our review of the Oversight Board’s charter found that it does not contain 

procedures for how oversight of Defense COEs will be documented. 

Specifically, the Oversight Board charter does not explain (1) how the 

Oversight Board will provide and document its feedback to Defense 

COEs; (2) how the COEs will respond, if needed, to this feedback; and (3) 

how the Oversight Board will determine and document that the COEs’ 

actions resolved any identified problems. The acting chairman of the 

Oversight Board told us the board’s charter gives the board its authority to 

conduct oversight of Defense COEs, and if these types of procedures are 

needed, the Oversight Board’s charter and meeting minutes will serve this 

purpose.

The Oversight Board’s acting chairman said the board’s minutes 

document its activities and decisions, including the procedures followed 

when conducting COE oversight reviews and any problems identified. 

However, our review of the Oversight Board’s minutes, from its inception 

in 2011 to April 2015, shows that the minutes did not indicate the 

procedures followed when conducting COE reviews and did not explain 

how the Oversight Board documented and resolved identified problems.15

The Standards for Internal Control in the Federal Government state that 

transactions and events should be promptly documented to maintain their 

relevance and value to management in controlling their operations and helping 

make decisions. Further, the standards state that significant events, such as 

in this instance the identification of problems during oversight and the 

actions taken to correct these problems, need to be clearly documented, 

and the documentation should be readily available for examination. 

 

15In its June 2015 minutes, the latest minutes available at the time of our review, the Oversight 

Board documented the feedback it provided to its Defense COEs.

Both DOD and VHA 

Lack Written 

Procedures for 

Documenting 

Activities to Oversee 

COEs

Defense COE Oversight 

Board Does Not Have 

Written Procedures for 

Documenting Oversight 

Activities
Federal internal control standards also state that significant events should 

appear in management directives, policies, or operating manuals to help 

ensure management’s directives are carried out as intended. Once 

established, federal internal control standards state that management 

should monitor and assess over time the quality of performance, including 

monitoring the policies and procedures to ensure that the findings of 

reviews are promptly resolved.

Page 15 GAO-16-54 Centers of Excellence

16

Oversight Board officials told us that feedback to Defense COEs from 

oversight reviews conducted by the board is typically provided verbally 

and has not been documented. Therefore, documentation of feedback, 

both positive and negative, is not always available. Officials said that 

negative feedback may be documented in the Oversight Board’s minutes; 

however, if the Oversight Board identifies problems with the Defense 

COEs, the board’s charter and meeting minutes do not require that the 

Defense COEs provide written corrective action plans. As a result, there 

will not be a record of the corrective action taken by a Defense COE and 

whether the action resolved the problem identified by the Oversight 

Board. Absent specific procedures for how oversight should be conducted 

and how findings and corrective actions should be documented, DOD 

leadership lacks assurance that the Oversight Board has identified all 

problems and has taken appropriate action to determine that the 

problems have been resolved.

Only one of six VHA service offices has written procedures for 

documenting the oversight of its COEs, including providing written 

critiques of findings from service office reviews to its COEs and requiring 

corrective actions from COEs when needed. The other five service offices 

do not have written procedures for documenting oversight activities. While 

most service offices do not have written procedures that require them to 

document their COE oversight, several currently provide written feedback 

to their COEs on the results of the service offices’ reviews. Specifically,

three of the five service office directors provide written feedback to their 

COEs on the findings from the service office reviews. However, only one 

of these three service office directors requests that his COEs provide 

written corrective action plans.

 

16GAO/AIMD-00-21.3.1

Most VHA Service Offices 

Lack Written Procedures 

for Documenting Oversight 

of COEs
Officials from three service offices told us they believe the process they 

currently have works fine because they provide written feedback to the 

COEs on the results of their reviews. However, if these directors leave the 

service offices, another director might not request written documentation 

of the oversight that is conducted because the documentation procedures 

are not written. The Standards for Internal Control in the Federal 

Government state that transactions and events should be promptly 

documented to maintain their relevance and value to management in

controlling their operations and helping make decisions. Further, the 

standards state that significant events, such as in this instance the 

identification of problems during oversight and the actions taken to correct 

these problems, need to be clearly documented, and the documentation 

should be readily available for examination. Federal internal control 

standards also state that significant events should appear in management 

directives, policies, or operating manuals to help ensure management’s 

directives are carried out as intended. Once established, federal internal 

control standards state that management should monitor and assess over 

time the quality of performance, including monitoring the policies and 

procedures to ensure that the findings of reviews are promptly resolved.

Page 16 GAO-16-54 Centers of Excellence

17

Without written procedures for documenting oversight activities, VHA 

leadership lacks assurance that its service offices are identifying and 

correcting all problems. Leadership also does not have evidence that the 

service offices conducted a review and do not have documentation of 

past and present problems to identify potential patterns and take action 

quickly to minimize the effects of these problems.

Unlike DOD, VHA has not developed standard criteria that entities must 

meet in order to be designated a VHA COE. Without defined criteria, VHA 

lacks reasonable assurance that its COEs are meeting the agency’s 

intended objectives for COEs, such as meeting the needs of veterans and 

their families throughout VA’s health care system and operating with 

coordinated direction.

By not having written procedures that outline how the agencies will 

document the activities through which they monitor and oversee the 

performance of COEs, both DOD and VHA lack assurance that oversight 

activities are performed consistently over time as intended. Written 

 

17GAO/AIMD-00-21.3.1

Conclusions
procedures would better ensure a common understanding of oversight 

activities among staff and enhance clear communication, especially as 

normal turnover occurs among the staff responsible for monitoring and 

providing feedback to COEs. Having systematic procedures for 

documenting oversight activities is necessary to better ensure that the 

agencies’ COEs are accountable for accomplishing the agencies’ 

objectives for them, such as meeting the health care needs of 

servicemembers and veterans.

To help ensure that COEs are meeting VHA’s intended objectives for 

them, we recommend that the Secretary of Veterans Affairs direct the 

Under Secretary for Health to establish clear, consistent standard criteria 

that entities must meet to receive COE designation, and require all 

existing VHA COEs, as well as new applicants for COE status, to meet 

these criteria.

To improve documentation of the activities DOD undertakes to oversee 

the Defense COEs, we recommend that the Secretary of Defense direct 

the Assistant Secretary of Defense for Health Affairs to require the MHS 

Defense COE Oversight Board to develop written procedures on how to 

document oversight activities of Defense COEs, including requirements 

for documenting feedback, both positive and negative, and documenting 

the resolution of identified problems.

To help improve VHA’s oversight of its COEs, we recommend that the 

Secretary of Veterans Affairs direct the Under Secretary for Health to 

require VHA service offices to develop written procedures on how to 

document their oversight activities of COEs, including requirements for 

documenting feedback, both positive and negative, and documenting the 

resolution of identified problems.

VA provided written comments on a draft of this report, as well as an 

action plan for implementing our recommendations. We have reprinted 

VA’s comments and action plan in appendix III. In its comments, VA 

generally agreed with our conclusions and concurred with our 

recommendations. VA stated that a team of VHA subject matter experts 

will develop standards to be used in designating COEs and overseeing 

their performance.

Page 17 GAO-16-54 Centers of Excellence

Recommendations for 

Executive Action

Agency Comments
DOD also provided written comments on a draft of this report, which we 

have reprinted in appendix IV. In its comments, DOD concurred with our 

findings and recommendation and explained how it intends to implement 

the recommendation. DOD also provided technical comments, which we 

have incorporated in the report as appropriate.

We are sending copies of this report to appropriate congressional 

committees; the Secretary of Defense; the Secretary of Veterans Affairs; 

and other interested parties. We will also make copies 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 williamsonr@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. Key contributors to this report are listed in 

appendix V.

Randall B. Williamson

Director, Health Care

Page 18 GAO-16-54 Centers of Excellence
Appendix I: List of Veterans Health 

Administration Centers of Excellence and 

Their Focus

The Veterans Health Administration (VHA) within the Department of 

Veterans Affairs has three program offices—the Office of Patient Care 

Services, the Office of Research and Development, and the Office of 

Academic Affiliations—that have centers of excellence (COE). These 

three program offices delegate responsibility for their COEs to six service 

offices within their organizational structure. The Office of Patient Care 

Services has three service offices with responsibility for VHA COEs—

Mental Health Services, Specialty Care Services, and Geriatric and 

Extended Care Services. The Office of Research and Development has 

one service office with COEs—Rehabilitation Research and Development 

Service—and the Office of Academic Affiliations has two service offices 

with COEs, referred to as coordinating centers—Primary Care Education 

and Patient-Centered Specialty Care Education.

VHA’s Office of Patient Care Services has all 39 of the COEs that were 

statutorily mandated, as well as 10 COEs that were departmentally 

designated. This office has three service offices that are responsible for 

these COEs: Mental Health Services, Specialty Care Services, and 

Geriatrics and Extended Care Services.

Page 19 GAO-16-54 Centers of Excellence

1 Table 3 lists each COE in the Office 

of Patient Care Services and groups the COEs by their specific service office, as 

well as indicating their location. The table also indicates the origin of the 

COE—whether the COE was statutorily mandated or departmentally 

designated—and provides a brief description of the COE’s research, 

clinical, and/or educational focus, as provided by VHA.

 

1VHA also has another service office, Rehabilitation and Prosthetic Care Services, which provides 

VHA staff to DOD to support its COEs, but does not manage any VHA COEs. Therefore, 

this service office is not included in our review of VHA COEs. In this review, we include 

these COEs under the Defense COEs. 

Appendix I: List of Veterans Health 

Administration Centers of Excellence and 

Their Focus

VHA’s Office of Patient 

Care Services
Appendix I: List of Veterans Health 

Administration Centers of Excellence and 

Their Focus

Table 3: Veterans Health Administration (VHA) Office of Patient Care Services Centers of Excellence (COE), Location, Origin, 

Page 20 GAO-16-54 Centers of Excellence

and Areas of Focus; by Type of Service (August 2015) 

COE Name and Location

Statutorily 

mandated

Departmentally 

designated COE Focus

Mental Health Services (17 COEs)

National Center for Post-Traumatic Stress 

Disorder (PTSD), Executive Division (White River 

Junction, Vermont) 

Yes No Advance the science and promote the 

understanding of traumatic stress in order to 

improve the wellbeing and understanding of 

American veterans.

Veterans Integrated Service Network (VISN) 1 

Mental Illness Research, Education, and Clinical 

Center (MIRECC) (West Haven, Connecticut)

Yes No Improve care for veterans with co-occurring 

substance use disorders and mental illnesses, 

as well as related issues, such as VAcompensated disabilities, homelessness, 

criminal justice histories, and medical comorbidities.

VISN 3 MIRECC (Bronx, New York) No Yes Enhance the recovery of veterans with 

diagnoses of schizophrenia, bipolar disorder and 

borderline personality. 

VISN 4 MIRECC

(Philadelphia and Pittsburgh, Pennsylvania)

No Yes Focus on the study and implementation of 

measurement based mental health care.

VISN 5 MIRECC

(Baltimore, Maryland)

No Yes Maximize the recovery and community 

functioning of veterans with serious mental 

illnesses.

VISN 6 MIRECC

(Durham, North Carolina)

No Yes Implement a translational medicine center for 

assessment and treatment of post deployment 

mental illness with a special focus on traumatic 

brain injury, identifying biomarkers, and 

assessing needs of women veterans and 

families.

VISN 16 MIRECC

(Houston, Texas)

No Yes Promote equity in engagement, access, and 

quality of mental health care for veterans facing 

barriers to care, especially rural veterans.

VISN 19 MIRECC

(Denver, Colorado and Salt Lake City, Utah)

No Yes Reduce suicidal ideation and behaviors among 

veterans by identifying cognitive and 

neurobiological underpinnings of self-directed 

violence.

VISN 20 MIRECC

(Seattle, Washington and Portland, Oregon)

Yes No Improve the quality of life and functioning of 

veterans by developing, evaluating, and 

promoting the implementation of effective 

treatments for military PTSD and its complex comorbidities.

VISN 21 MIRECC

(Palo Alto, California)

No Yes Build an integrated system of clinical, research, 

and educational efforts designed to improve the 

clinical care of veterans with dementia and with 

PTSD.

VISN 22 MIRECC

(San Diego and Long Beach, California)

Yes No Improve functional outcomes of veterans with 

psychotic disorders.
Appendix I: List of Veterans Health 

Administration Centers of Excellence and 

Their Focus

Page 21 GAO-16-54 Centers of Excellence

COE Name and Location

Statutorily 

mandated

Departmentally 

designated COE Focus

Suicide Prevention COE

(Canandaigua, New York)

Yes No Integrate surveillance with intervention 

development through research for 

implementation of effective veteran suicide 

prevention strategies.

Research on Returning War Veterans 

(Waco, Texas)

Yes No Promote research on post-deployment 

adjustment and development of treatments for 

veterans with post-war problems in functioning.

Stress and Mental Health

(San Diego, California)

Yes No Investigate stress and its related medical and 

psychiatric problems in veterans and active duty 

personnel.

Center for Integrated Healthcare

(Syracuse and Buffalo, New York)

No Yes Improve the quality of veterans’ health care by 

supporting the national integration of mental and 

behavioral health services into patient aligned 

care teams.

Substance Abuse Treatment and Education 

(Philadelphia, Pennsylvania) 

No Yes Develop, implement, and evaluate substance 

use disorder treatment and provide evidencebased educational initiatives. Substance Abuse Treatment and Education 

(Seattle, Washington)

No Yes

Specialty Care Services (12 COEs)

Parkinson’s Disease Research, Education, and Clinical Centers (PADRECC)

Northwest PADRECC

(Portland, Oregon and Seattle, Washington)

Yes No Evaluate cognitive decline, prevention of 

dyskinesia and gait impairment, as well as 

neurodegeneration and regeneration in animal 

models and related neurodegenerative disease.

Southwest PADRECC

(Los Angeles, California)

Yes No Implement and evaluate VISN 22-wide nurse-led 

care coordination program built on the disease 

indicators and guided by identified gaps in care. 

Southeast PADRECC

(Richmond, Virginia)

Yes No Track eye movements as a unique biomarker for 

various movement disorders. 

Philadelphia PADRECC

(Philadelphia, Pennsylvania)

Yes No Evaluate non-motor symptoms, biomarkers, and 

pathophysiology of the disease; and the 

relationship of traumatic brain injury to the 

development of the disease.

Houston PADRECC

(Houston, Texas)

Yes No Evaluate differential effects of two deep brain 

stimulation sites on motor, autonomic and 

neuropsychological aspects of the disease, 

utility of diffusion tensor imaging in the disease,

sleep architecture and sleep disorders and 

studies focused on energy expenditure in 

patients with the disease. 

San Francisco PADRECC

(San Francisco, California)

Yes No Investigate deep brain stimulation and 

pharmacologic therapies and studies of motor 

and non-motor symptoms, as well as biomarkers 

of the disease and its etiology pathogenesis and 

progression. 

Epilepsy COEsa
Appendix I: List of Veterans Health 

Administration Centers of Excellence and 

Their Focus

Page 22 GAO-16-54 Centers of Excellence

COE Name and Location

Statutorily 

mandated

Departmentally 

designated COE Focus

Northeast Region Epilepsy COEa

(Baltimore, Maryland)

Yes No Evaluate and treat psychogenic non-epileptic 

seizures, and provide epilepsy evaluations for 

the Richmond VA polytrauma center.

Southeast Region Epilepsy COEa

(Durham, North Carolina)

Yes No Specialize in informatics and telemedicine, 

including store and forward 

electroencephalogram technology, and provide 

epilepsy evaluations for the Tampa VA 

polytrauma center. 

Northwest Region Epilepsy COEa

(Madison, Wisconsin)

Yes No Specialize in basic science investigations 

regarding epilepsy and store and forward 

electroencephalogram services, and provide 

epilepsy evaluations for the Minneapolis VA 

polytrauma center. 

Southwest Region Epilepsy COEa

(Los Angeles, California)

Yes No Specialize in telemedicine, education and 

invasive intracranial recordings and epilepsy 

surgery, and provide epilepsy evaluations for the 

Palo Alto VA polytrauma center.

Multiple Sclerosis COEsb

Multiple Sclerosis COEb

(Baltimore, Maryland)

Yes No Develop policy for multiple sclerosis care 

procedures. Provide consultative direction on 

the management of complex aspects of multiple 

sclerosis care. Collaborate on pre-clinical and 

clinical research relating to the health needs of 

veterans with multiple sclerosis. Leverage 

informatics expertise to elucidate the 

emergence, natural history, consequences and 

demography of multiple sclerosis.

Multiple Sclerosis COE

b

(Portland, Oregon and Seattle, Washington)

Yes No

Geriatrics and Extended Care Services (20 COEs)

Ann Arbor Geriatric Research, Education, and 

Clinical Center (GRECC)

(Ann Arbor Veterans Affairs (VA) Medical Center)

Yes No Specialize in pathogenesis of age-related 

neurodegenerative disease, infectious diseases 

in long-term care, and gait and balance in the 

elderly.

Baltimore GRECC

(VA Maryland Health Care System)

Yes No Reduce risk factors for cerebrovascular and 

cardiovascular disease in the elderly, poststroke neuromuscular 

rehabilitation/regeneration, and lipemic and 

glycemic controls in the elderly. 

Birmingham/Atlanta GRECC

(Birmingham and Atlanta VA Medical Centers)

Yes No Specialize in incontinence in the elderly, mobility 

in the elderly, and end of life care.

Bronx/New York Harbor GRECC

(Bronx VA Medical Center)

Yes No Specialize in health services utilization in the 

elderly, models of non-institutional extended 

care, end of life care, and rural health geriatric 

education strategies.

Cleveland GRECC

(Cleveland VA Medical Center)

Yes No Specialize in infectious diseases in the elderly, 

and inpatient behavioral management 

strategies. 
Appendix I: List of Veterans Health 

Administration Centers of Excellence and 

Their Focus

Page 23 GAO-16-54 Centers of Excellence

COE Name and Location

Statutorily 

mandated

Departmentally 

designated COE Focus

Durham GRECC

(Durham VA Medical Center)

Yes No Specialize in osteoporosis management, viral 

disease in the elderly, and polypharmacy in the 

elderly.

Eastern Colorado GRECC

(Eastern Colorado VA Health Care System -

Denver)

Yes No Specialize in obesity in the elderly, gender 

differences in geriatric care, and rural health.

Gainesville GRECC

(North Florida/South Georgia Veterans Health 

System-Gainesville)

Yes No Specialize in endocrinological controls in aging, 

and patient safety.

Greater Los Angeles GRECC

(Greater Los Angeles VA Healthcare System)

Yes No Specialize in preventive approaches to 

dementia, sleep in the elderly, and geriatric 

models of care.

Little Rock GRECC

(Central Arkansas VA Healthcare System)

Yes No Specialize in activity in institutionalized elders, 

rural health, and substance abuse in the elderly.

Madison GRECC

(Madison VA Medical Center)

Yes No Specialize in epidemiology and neuroradiology 

of dementia, swallowing disorders in the elderly, 

and transitions of care.

Miami GRECC

(Miami VA Medical Center)

Yes No Specialize in bone and cartilage metabolism, 

diabetes and cardiovascular risk factors, and 

simulation strategies for teaching geriatric care.

Minneapolis GRECC

(Minneapolis VA Health Care System)

Yes No Specialize in pathogenesis of Alzheimer’s and 

Parkinson’s diseases, and models of dementia 

outpatient care.

New England GRECC

(Bedford VA Medical Center and Boston VA 

Health Care System)

Yes No Specialize in pathogenesis and models of 

institutional care of dementia, and delirium 

surveillance and prevention.

Palo Alto GRECC

(Palo Alto VA Health Care System)

Yes No Specialize in biomarkers of dementia, natural 

language processing of electronic health 

records, and bone and joint disease in the 

elderly.

Pittsburgh GRECC

(VA Pittsburgh Healthcare System)

Yes No Specialize in strokes in the elderly and speech 

rehabilitation post-stroke.

Puget Sound GRECC

(Puget Sound VA Health Care System-Seattle)

Yes No Specialize in genetic and glycemic basis and 

correlates of dementia, pharmacodynamics and 

drug biotransport in the elderly, advanced care 

planning and adrogeny. 

Salt Lake City GRECC

(VA Salt Lake City Health Care System)

Yes No Specialize in vascular dynamic changes in 

advanced age, metadata analysis in geriatrics, 

and glycemic determinants of dementia onset. 

San Antonio GRECC

(South Texas VA Health Care System)

Yes No Specialize in glycemic control in advanced age, 

and dementia pathogenesis.
Appendix I: List of Veterans Health 

Administration Centers of Excellence and 

Their Focus

Page 24 GAO-16-54 Centers of Excellence

COE Name and Location

Statutorily 

mandated

Departmentally 

designated COE Focus

Tennessee Valley GRECC

(Tennessee Valley VA Health Care SystemNashville)

Yes No Specialize in outcomes and implementation 

research in geriatrics, delirium assessment and 

management in critical care, and epidemiology 

of geriatric diseases.

Source: VA | GAO-16-54.

a

The COE coordinates epilepsy care for a specific region of the country. Regional VA medical center 

sites provide in-patient epilepsy monitoring and telemedicine services.

b

The Baltimore multiple sclerosis COE focuses on VISNs 1-11, and coordinates clinical, educational 

and research activity for 32 consortium sites. The Portland and Seattle multiple sclerosis COE 

focuses on VISNs 12-23, and coordinates clinical, educational and research activity for 46 consortium 

sites.

VHA’s Office of Research and Development has 13 COEs that were 

departmentally designated, according to VHA officials. This office has one 

service office—Rehabilitation Research and Development—that is 

responsible for these COEs. Table 4 lists each COE in this service office 

and provides the location of the COE, as well as a brief description of the 

COE’s research, clinical, and/or educational focus, as provided by VHA.

Table 4: Veterans Health Administration (VHA) Office of Research and Development Centers of Excellence (COE), Location, 

Origin, and Areas of Focus (August 2015)

COE Name and Location

Statutorily 

mandated

Departmentally 

designated COE Focus

Rehabilitation Research and Development (13 COEs)

Translational Research Center for Traumatic 

Brain Injury and Stress Disorders

(Boston, Massachusetts)

NO Yes Promote multidisciplinary research aimed at 

improving our understanding of the complex 

cognitive and emotional problems faced by

Operation Enduring Freedom and Operation Iraqi 

Freedom veterans. Focus on innovations in the 

diagnosis of mild traumatic brain injury and in the 

development of treatments that target the 

combined effects of traumatic brain injury and 

stress-related disorders. 

Center of Neurorestoration and 

Neurotechnology

(Providence, Rhode Island)

No Yes Strive to advance and translate neurotechnology 

to restore lost function. Seek to develop, test, and 

implement new therapies and technologies that 

can restore function in disorders of the nervous 

system that impair movement, emotion, or 

cognition in the veteran population.

VHA’s Office of Research 

and Development
Appendix I: List of Veterans Health 

Administration Centers of Excellence and 

Their Focus

Page 25 GAO-16-54 Centers of Excellence

COE Name and Location

Statutorily 

mandated

Departmentally 

designated COE Focus

Restoration of Nervous System Function

(West Haven, Connecticut)

No Yes Develop new therapeutic approaches that will 

improve function and quality of life of veterans with 

injuries of the nervous system. Focus on spinal 

cord injury, multiple sclerosis, and nerve injury, 

and neuropathic pain after traumatic nerve injury 

and traumatic limb amputation, and pain after 

injuries such as burn.

Medical Consequences of Spinal Cord Injury

(Bronx, New York)

No Yes Study the use of anabolic pharmaceuticals, 

including anabolic steroids, to treat secondary 

disabilities of spinal cord injury. 

Wheelchairs and Associated Rehabilitation 

Engineering Human Engineering Research 

Laboratories

(Pittsburgh, Pennsylvania)

No Yes Improve the mobility and function of people with 

disabilities through advanced engineering in 

clinical research and medical rehabilitation.

Center of Visual and Neurocognitive 

Rehabilitation

(Decatur, Georgia)

No Yes Foster the health and well-being of veterans 

through uniquely synergistic research impacting 

visual and/or neurocognitive function.

Brain Rehabilitation Research Center

(Gainesville, Florida)

No Yes Develop and test treatments that harness 

neuroplasticity to substantially improve or restore 

impairments of motor, cognitive, and emotional 

functions that have been caused by neurologic 

disease or injury.

Maryland Exercise and Robotics Center of 

Excellence

(Baltimore, Maryland)

No Yes Develop and test new rehabilitation therapies to 

improve physical function, fitness, and 

cardiovascular health for veterans with stroke and 

other neurological disability conditions. 

Functional Electrical Stimulation

(Cleveland, Ohio)

No Yes Investigate functional electrical stimulation, a 

technology that relies on controlled electrical 

current to activate paralyzed muscles to return full 

or partial physical function to individuals with 

disabilities.

Advanced Platform Technology

(Cleveland, Ohio)

No Yes Develop advanced technologies that serve the 

clinical needs of veterans with motor and sensory 

deficits and limb loss to provide clinicianresearchers within the VA with new tools for 

rehabilitation, treatment and scientific inquiry that 

lead to independence and enhanced societal 

participation.

National Center for Rehabilitative Auditory 

Research

(Portland, Oregon)

No Yes Address the needs of veterans with hearing and 

auditory system disorders through research 

focused on diagnosis and assessment, 

rehabilitation, and prevention.

Limb Loss Prevention and Prosthetic 

Engineering

(Seattle, Washington)

No Yes Unite investigators in diverse fields in basic and 

clinical research to improve the quality of life and 

functional status of veteran amputees and 

veterans who are at risk for amputation.
Appendix I: List of Veterans Health 

Administration Centers of Excellence and 

Their Focus

Page 26 GAO-16-54 Centers of Excellence

COE Name and Location

Statutorily 

mandated

Departmentally 

designated COE Focus

Prevention and Treatment of Visual Loss

(Iowa City, Iowa)

No Yes Focus on early detection of potential blinding 

disorders of the veteran and general population, 

including retinal disease, glaucoma, and traumatic 

brain injury. 

Source: VA. | GAO-16-54.
Appendix I: List of Veterans Health 

Administration Centers of Excellence and 

Their Focus

VHA’s Office of Academic Affiliations has eight COEs that were 

departmentally designated, according to VHA officials.

Page 27 GAO-16-54 Centers of Excellence

2 This office has two 

service offices, referred to as coordinating centers—Primary Care Education and 

Patient-Centered Specialty Care Education—that are responsible for COEs.

Primary Care Education has five COEs and Patient-Centered Specialty 

Care Education has three COEs. Table 5 lists each COE by service office 

and gives the location of the COE and a brief description of the research, 

clinical, and/or educational focus of the respective COEs.

Table 5: Veterans Health Administration (VHA) Office of Academic Affiliations Centers of Excellence (COE), Locations, 

Origins, and Areas of Focus; by Area of Education (August 2015)

Veterans Affairs (VA) facility where COE assigned

Statutorily 

mandated

Departmentally 

designated COE Focus

Primary Care Education (5 COEs)

Boise Veterans Affairs (VA) Medical Center No Yes Foster transformation of clinical 

education by preparing graduates of 

health professional programs to work 

in and lead patient-centered 

interprofessional teams. Develop and 

test innovative approaches for 

curricula related to patient-centered 

care and study new approaches and 

models of collaboration.

Cleveland VA Medical Center No Yes

San Francisco VA Medical Center No Yes

VA Puget Sound Health Care System- Seattle No Yes

VA Connecticut Healthcare System-West Haven No Yes

Patient-Centered Specialty Care Education (3 COEs)

Atlanta VA Medical Center No Yes Foster the transformation of clinical 

education and patient care by 

preparing graduates of health 

professional schools and programs to 

work in and lead patient-centered 

interdisciplinary and/or 

interprofessional teams providing 

specialty care in the primary care 

setting.

Cleveland VA Medical Center No Yes

VA Salt Lake City Health Care System No Yes

Source: VA. | GAO-16-54.

 

2The Office of Academic Affiliations, Patient-Centered Specialty Care Education, recently 

added a COE that is not included in this count.

VHA’s Office of Academic 

Affiliations
Appendix II: Collaboration Efforts of Centers of 

Excellence in the Department of Defense and 

Department of Veterans Affairs

To describe the collaboration efforts of the Defense Centers of Excellence 

(COE) in the Department of Defense (DOD) and the Veterans Health 

Administration (VHA) COEs in the Department of Veterans Affairs (VA), 

we sent a Web-based, structured questionnaire to COE directors, 

identified by DOD and VHA officials, to obtain information about how their 

COEs collaborate.

Page 28 GAO-16-54 Centers of Excellence

1 We sent the questionnaire to the COE directors between 

December 2014 and January 2015. The questionnaire asked COE directors to 

describe the extent to which Defense and VHA COE staff collaborate 

internally—with other staff from within their agencies, and externally—with 

staff from other federal agencies and academic organizations. The 

questionnaire also asked the COE directors if they use certain tools, such 

as written agreements, staff participation in committees, working groups, 

councils, or task forces; or other tools or mechanisms to coordinate or 

collaborate.2 All 7 Defense COE directors responded to the questionnaire, and 

60 of VHA’s 70 COE directors, or 86 percent, responded to the collaboration 

section of the questionnaire. Tables 6 through 11 provide information about 

Defense and VHA COE collaboration efforts.

Defense COEs report using written agreements or other tools to 

collaborate. Table 6 shows the Defense COEs and their reported 

collaboration activities.

 

1We use the term “collaboration” broadly to refer to any joint activity that is intended to produce 

more public value than could be produced when an organization acts alone. The term 

collaboration includes activities that others have defined as cooperation, coordination, 

integration, or networking. See GAO, Results-Oriented Government: Practices That Can 

Help Enhance and Sustain Collaboration among Federal Agencies, GAO-06-15 

(Washington, D.C.: Oct. 21, 2005).

2

See GAO, Managing for Results: Key Considerations for Implementing Interagency Collaborative 

Mechanisms, GAO-12-1022 (Washington, D.C.: Sept. 27, 2012).

Appendix II: Collaboration Efforts of Centers 

of Excellence in the Department of Defense 

and Department of Veterans Affairs

Defense COEs
Appendix II: Collaboration Efforts of Centers of 

Excellence in the Department of Defense and 

Department of Veterans Affairs

Table 6: Defense Centers of Excellence Responses to GAO Questionnaire on Collaboration Activities (December 2014 –

Page 29 GAO-16-54 Centers of Excellence

January 2015)

Defense Center of Excellence 

(COE)

COE reports 

collaborating with 

Defense COEs with 

similar missions or 

other Department of 

Defense (DOD) staff not 

affiliated with this COE

COE reports 

collaborating with 

Veterans Health 

Administration (VHA)a

COE reports 

collaborating 

with other 

federal 

agenciesa

COE reports 

collaborating 

with academic 

organizations

Defense Centers of Excellence for 

Psychological Health and Traumatic 

Brain Injuryc

COE reported some level 

of collaboration 

COE reported some level 

of collaboration 

COE reported 

some level of 

collaboration 

COE reported 

some level of 

collaboration 

Hearing Center of Excellencec COE reported some level 

of collaboration 

COE reported some level 

of collaboration 

COE reported 

some level of 

collaboration 

COE reported 

some level of 

collaboration 

Extremity Trauma and Amputation 

Center of Excellenceb

COE reported some level 

of collaboration 

COE reported some level 

of collaboration 

COE reported 

some level of 

collaboration 

COE reported 

some level of 

collaboration 

Vision Center of Excellencec COE reported some level 

of collaboration 

COE reported some level 

of collaboration 

COE reported no 

collaboration

COE reported 

some level of 

collaboration 

Consortium for Health and Military 

Performance

COE reported some level 

of collaboration 

COE reported some level 

of collaboration 

COE reported 

some level of 

collaboration 

COE reported 

some level of 

collaboration 

Comprehensive Cancer Center COE reported some level 

of collaboration 

COE reported some level 

of collaboration 

COE reported 

some level of 

collaboration 

COE reported 

some level of 

collaboration 

Joint Trauma System COE reported some level 

of collaboration 

COE reported some level 

of collaboration 

COE reported 

some level of 

collaboration 

COE reported 

some level of 

collaboration 

aCOEs responding affirmatively on the questionnaire to any of the collaboration questions related to 

VHA and other federal agencies are noted in the table as collaborating.

bCOE established by statute as a joint Department of Defense and Department of Veterans Affairs 

(VA) COE.

c

VA provides staff to these Defense COEs.

VHA’s Office of Patient Care Services has three service offices that have 

established 49 COEs, with 39 of them statutorily mandated and 10 

departmentally designated, according to VHA officials. The service offices 

are the Mental Health Services, the Specialty Care Services, and the 

VHA’s Office of Patient 

Care Services
Appendix II: Collaboration Efforts of Centers of 

Excellence in the Department of Defense and 

Department of Veterans Affairs

Geriatric and Extended Care Services.

Page 30 GAO-16-54 Centers of Excellence

3 The COEs that responded to the 

collaboration section of the questionnaire report using written agreements or 

other tools to collaborate. Tables 7, 8 and 9 provide information on the 

collaboration activities of the three service offices within the Office of 

Patient Care Services that have COEs.

Table 7: Veterans Health Administration (VHA) Office of Patient Care Services: Mental Health Services Centers of Excellence 

Responses to GAO Questionnaire on Collaboration Activities (December 2014 – January 2015)

Center of excellence (COE) and location

COE reports 

collaborating with 

VHA COEs with 

similar missions or 

other VHA staff not 

affiliated with this 

COE

COE reports 

collaborating with 

Department of 

Defensea

COE reports 

collaborating 

with other 

federal 

agenciesa

COE reports 

collaborating 

with academic 

organizations

National Center for Post-Traumatic Stress 

Disorder, Executive Division (White River 

Junction, Vermont)

reported some level 

of collaboration 

reported some level 

of collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Veterans Integrated Service Network (VISN) 

1 Mental Illness Research, Education, and 

Clinical Center (MIRECC)

(West Haven, Connecticut)

reported some level 

of collaboration 

reported some level 

of collaboration 

reported no 

collaboration

reported some 

level of 

collaboration 

VISN 3 MIRECC (Bronx, New York) reported some level 

of collaboration 

reported some level 

of collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

VISN 4 MIRECC (Philadelphia and 

Pittsburgh, Pennsylvania)

reported some level 

of collaboration 

reported no 

collaboration

reported some 

level of 

collaboration 

no response or didn’t 

know

VISN 5 MIRECC (Baltimore, Maryland) reported some level 

of collaboration 

reported no 

collaboration

reported no 

collaboration

reported some 

level of 

collaboration 

VISN 6 MIRECC (Durham, North Carolina) reported some level 

of collaboration 

reported some level 

of collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

VISN 16 MIRECC (Houston, Texas) reported some level 

of collaboration 

reported no 

collaboration

reported no 

collaboration

reported some 

level of 

collaboration 

 

3VHA also has another service office, the Rehabilitation and Prosthetic Care Services, 

which provides VHA staff to DOD to support its COEs, but does not manage any VHA 

COEs. Therefore, this service office is not included in our review of VHA COEs. In this 

review, we include these COEs under the Defense COEs.
Appendix II: Collaboration Efforts of Centers of 

Excellence in the Department of Defense and 

Department of Veterans Affairs

Page 31 GAO-16-54 Centers of Excellence

Center of excellence (COE) and location

COE reports 

collaborating with 

VHA COEs with 

similar missions or 

other VHA staff not 

affiliated with this 

COE

COE reports 

collaborating with 

Department of 

Defensea

COE reports 

collaborating 

with other 

federal 

agenciesa

COE reports 

collaborating 

with academic 

organizations

VISN 19 MIRECC (Denver, Colorado and 

Salt Lake City, Utah)

reported some level 

of collaboration 

reported some level 

of collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

VISN 20 MIRECC (Seattle and Tacoma, 

Washington and Portland, Oregon)

reported some level 

of collaboration 

reported some level 

of collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

VISN 21 MIRECC (Palo Alto, California) reported some level 

of collaboration 

reported some level 

of collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

VISN 22 MIRECC, (Los Angeles, San Diego 

and Long Beach, California)

reported some level 

of collaboration 

reported no 

collaboration

reported no 

collaboration

reported some 

level of 

collaboration 

Substance Abuse Treatment and Education 

(Seattle and Tacoma, Washington)

reported some level 

of collaboration 

reported no 

collaboration

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Substance Abuse Treatment and Education 

(Philadelphia, Pennsylvania)

reported some level 

of collaboration 

reported some level 

of collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Stress and Mental Health (San Diego, 

California) 

reported some level 

of collaboration 

reported some level 

of collaboration 

no response or 

didn’t know

reported some 

level of 

collaboration 

Suicide Prevention (Canandaigua, New 

York)

reported some level 

of collaboration 

reported some level 

of collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Research on Returning War Veterans 

(Waco, Texas)

reported some level 

of collaboration 

reported some level 

of collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Center for Integrated Healthcare (Syracuse 

and Buffalo, New York)

reported some level 

of collaboration 

reported some level 

of collaboration 

reported no 

collaboration

reported some 

level of 

collaboration 

aCOEs responding affirmatively on the questionnaire to any of the collaboration questions related to 

the Department of Defense and other federal agencies are noted in the table as collaborating.

Table 8: Veterans Health Administration (VHA) Office of Patient Care Services: Specialty Care Services Centers of Excellence 

Responses to GAO Questionnaire on Collaboration Activities (December 2014 – January 2015)

Center of excellence (COE) and location, by area 

of expertisea

COE reports 

collaborating with

VHA COEs with 

similar missions 

or other VHA staff 

not affiliated with 

this COE

COE reports 

collaborating 

with

Department of 

Defenseb

COE reports 

collaborating 

with ther 

federal 

agenciesb

COE reports 

collaborating 

with academic 

organizations
Appendix II: Collaboration Efforts of Centers of 

Excellence in the Department of Defense and 

Department of Veterans Affairs

Page 32 GAO-16-54 Centers of Excellence

Center of excellence (COE) and location, by area 

of expertisea

COE reports 

collaborating with

VHA COEs with 

similar missions 

or other VHA staff 

not affiliated with 

this COE

COE reports 

collaborating 

with

Department of 

Defenseb

COE reports 

collaborating 

with ther 

federal 

agenciesb

COE reports 

collaborating 

with academic 

organizations

Parkinson’s Disease Research, Education, and Clinical Centers (PADRECC)

Northwest PADRECC (Portland, Oregon and Seattle, 

Washington)

reported some 

level of 

collaboration 

reported no 

collaboration

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

San Francisco PADRECC (San Francisco, California) reported some 

level of 

collaboration 

reported no 

collaboration

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Philadelphia PADRECC (Philadelphia, Pennsylvania) reported some 

level of 

collaboration 

reported no 

collaboration

reported no 

collaboration

reported some 

level of 

collaboration 

Southwest PADRECC (Los Angeles, California) reported some 

level of 

collaboration 

reported no 

collaboration

reported no 

collaboration

reported some 

level of 

collaboration 

Southeast PADRECC (Richmond, Virginia) reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

reported no 

collaboration

reported some 

level of 

collaboration 

Epilepsy

Northeast Region Epilepsy COE (Baltimore, 

Maryland)

reported some 

level of 

collaboration 

reported no 

collaboration

reported no 

collaboration

reported some

level of 

collaboration 

Northwest Region Epilepsy COE (Madison, 

Wisconsin)

reported some 

level of 

collaboration 

reported no 

collaboration

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Southwest Region Epilepsy COE (Los Angeles, 

California)

reported some 

level of 

collaboration 

reported no 

collaboration

reported no 

collaboration

reported some 

level of 

collaboration 

Multiple Sclerosis

Multiple Sclerosis COE (Baltimore, Maryland) reported some 

level of 

collaboration 

reported no 

collaboration

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Multiple Sclerosis COE (Portland, Oregon and 

Seattle, Washington)

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

aCOEs not listed in the table did not complete the collaboration section of the questionnaire.

bCOEs responding affirmatively on the questionnaire to any of the collaboration questions related to 

the Department of Defense and other federal agencies are noted in the table as collaborating.
Appendix II: Collaboration Efforts of Centers of 

Excellence in the Department of Defense and 

Department of Veterans Affairs

Page 33 GAO-16-54 Centers of Excellence

Table 9: Veterans Health Administration (VHA) Office of Patient Care Services: Geriatrics and Extended Care Services: 

Geriatric Research Education Clinical Centers (GRECC) Centers of Excellence Responses to GAO Questionnaire on 

Collaboration Activities (December 2014 – January 2015) 

Center of excellence (COE) and locationa

COE reports 

collaborating with

VHA COEs with 

similar missions 

or other VHA staff 

not affiliated with 

this COE

COE reports 

collaborating 

with

Department of 

Defenseb

COE reports 

collaborating 

with other 

federal 

agenciesb

COE reports 

collaborating 

with academic 

organizations

Birmingham/Atlanta GRECC, (Birmingham and 

Atlanta Veterans Affairs (VA) Medical Centers) 

Birmingham, Alabama and Atlanta, Georgia

reported some level 

of collaboration 

reported no 

collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Durham GRECC (Durham VA Medical Center) 

Durham, North Carolina

reported some level 

of collaboration 

reported no 

collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Eastern Colorado GRECC (Eastern Colorado VA 

Health Care System) Denver, Colorado

reported some level 

of collaboration 

no response or 

didn’t know

no response or 

didn’t know

reported some 

level of 

collaboration 

Gainesville GRECC (North Florida/South Georgia 

Health System) Gainesville, Florida

reported some level 

of collaboration 

no response or 

didn’t know

no response or 

didn’t know

reported some 

level of 

collaboration 

Little Rock GRECC (Central Arkansas VA Health 

Care System) Little Rock, Arkansas

reported some level 

of collaboration 

reported no 

collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Madison GRECC, (Madison VA Medical Center) 

Madison, Wisconsin

reported some level 

of collaboration 

no response or 

didn’t know

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Miami GRECC, (Miami VA Medical Center) Miami, 

Florida

reported some level 

of collaboration 

no response or 

didn’t know

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Minneapolis GRECC (Minneapolis Health Care 

System) Minneapolis, Minnesota

reported some level 

of collaboration 

reported no 

collaboration 

no response or 

didn’t know

reported some 

level of 

collaboration 

Palo Alto GRECC (Palo Alto VA Health Care 

System), Palo Alto, California

reported some level 

of collaboration 

reported no 

collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Pittsburgh GRECC, (Pittsburgh Healthcare System) 

Pittsburgh, Pennsylvania

reported some level 

of collaboration 

reported no 

collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Salt Lake City GRECC, (Salt Lake City Health Care 

System) Salt Lake, Utah

reported some level 

of collaboration 

reported no 

collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 
Appendix II: Collaboration Efforts of Centers of 

Excellence in the Department of Defense and 

Department of Veterans Affairs

Page 34 GAO-16-54 Centers of Excellence

Center of excellence (COE) and locationa

COE reports 

collaborating with

VHA COEs with 

similar missions 

or other VHA staff 

not affiliated with 

this COE

COE reports 

collaborating 

with

Department of 

Defenseb

COE reports 

collaborating 

with other 

federal 

agenciesb

COE reports 

collaborating 

with academic 

organizations

San Antonio GRECC, (South Texas VA Health 

Care System) San Antonio, Texas

reported some level 

of collaboration 

reported no 

collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Tennessee Valley GRECC, (Tennessee Valley VA 

Health Care System) Nashville, Tennessee

reported some level 

of collaboration 

reported no 

collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

aCOEs not listed in the table did not complete the collaboration section of the questionnaire.

bCOEs responding affirmatively on the questionnaire to any of the collaboration questions related to 

the Department of Defense and other federal agencies are noted in the table as collaborating.

VHA’s Office of Research and Development has one service office that 

has COEs—the Office of Rehabilitation Research and Development 

Service. This service office reports they have 13 COEs, all departmentally 

designated, that focus on a selected area of research relevant to veterans 

with disabilities. The COEs report using written agreements or other tools 

to collaborate. Table 10 indicates the collaboration activities of the COEs.

Table 10: Veterans Health Administration (VHA) Office of Research and Development: Rehabilitation Research and 

Development Centers of Excellence Responses to GAO Questionnaire on Collaboration Activities (December 2014 – January 

2015) 

Center of excellence (COE) and location

COE reports 

collaborating with 

VHA COEs with 

similar missions or 

other VHA staff not 

affiliated with this 

COE

COE reports 

collaborating 

with 

Department of 

Defensea

COE reports 

collaborating 

with Other 

federal 

agenciesa

COE reports 

collaborating 

with academic 

organizations

Translational Research Center for Traumatic Brain 

Injury and Stress Disorders (Boston, 

Massachusetts)

reported some level 

of collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Center of Neurorestoration and Neurotechnology 

(Providence, Rhode Island)

reported some level 

of collaboration 

reported some 

level of 

collaboration 

reported no 

collaboration 

reported some 

level of 

collaboration 

Restoration of Nervous System Function (West 

Haven, Connecticut)

reported some level 

of collaboration 

reported no 

collaboration 

no response or 

didn’t know

reported some 

level of 

collaboration 

Medical Consequences of Spinal Cord Injury 

(Bronx, New York)

reported some level 

of collaboration 

reported no 

collaboration

reported no 

collaboration 

reported some 

level of 

collaboration 

VHA’s Office of Research

and Development
Appendix II: Collaboration Efforts of Centers of 

Excellence in the Department of Defense and 

Department of Veterans Affairs

Page 35 GAO-16-54 Centers of Excellence

Center of excellence (COE) and location

COE reports 

collaborating with 

VHA COEs with 

similar missions or 

other VHA staff not 

affiliated with this 

COE

COE reports 

collaborating 

with 

Department of 

Defensea

COE reports 

collaborating 

with Other 

federal 

agenciesa

COE reports 

collaborating 

with academic 

organizations

Wheelchairs and Associated Rehabilitation 

Engineering Human Engineering Research 

Laboratories (Pittsburgh, Pennsylvania)

reported some level 

of collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Center of Visual and Neurocognitive Rehabilitation 

(Decatur, Georgia)

reported some level 

of collaboration 

reported no 

collaboration 

reported no 

collaboration 

reported some 

level of 

collaboration 

Brain Rehabilitation Research Center (Gainesville, 

Florida)

reported some level 

of collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Maryland Exercise and Robotics COE, (Baltimore, 

Maryland)

reported some level 

of collaboration 

reported no 

collaboration 

reported no 

collaboration 

reported some 

level of 

collaboration 

Functional Electrical Stimulation (Cleveland, Ohio) reported some level 

of collaboration 

no response or 

didn’t know

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Advanced Platform Technology (Cleveland, Ohio) reported some level 

of collaboration 

reported no 

collaboration 

reported no 

collaboration 

reported some 

level of 

collaboration 

National Center for Rehabilitative Auditory 

Research (Portland, Oregon)

reported some level 

of collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

Limb Loss Prevention and Prosthetic Engineering 

(Seattle, Washington)

reported some level 

of collaboration 

reported some 

level of 

collaboration 

reported no 

collaboration 

reported some 

level of 

collaboration 

Prevention & Treatment of Visual Loss (Iowa City, 

Iowa)

reported some level 

of collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

reported some 

level of 

collaboration 

aCOEs responding affirmatively on the questionnaire to any of the collaboration questions related to 

the Department of Defense and other federal agencies are noted in the table as collaborating.

VHA’s Office of Academic Affiliations reports that it has eight COEs and 

all were departmentally designated. This office has two service offices, 

referred to as coordinating centers: Primary Care Education and PatientCentered Specialty Care Education. Primary Care Education has five 

COEs and Patient-Centered Specialty Care Education has three. The 

Primary Care Education and Patient-Centered Specialty Care Education 

COEs that responded to the collaboration section of our questionnaire 

indicated that they use written agreements or other tools to collaborate. 

Table 11 shows the collaboration activities of the COEs that responded to 

our questionnaire.

VHA’s Office of Academic 

Affiliations
Appendix II: Collaboration Efforts of Centers of 

Excellence in the Department of Defense and 

Department of Veterans Affairs

Table 11: Veterans Health Administration (VHA) Office of Academic Affiliations: Primary Care Education and Patient-Centered 

Page 36 GAO-16-54 Centers of Excellence

Specialty Care Education Centers of Excellence Responses to GAO Questionnaire on Collaboration Activities (December 

2014 – January 2015) 

Centers of excellence (COE) and 

location, by area of educationa

COE reports 

collaborating 

with VHA COEs 

with similar 

missions or 

other VHA staff 

not affiliated 

with this COE

COE reports 

collaborating 

with 

Department of 

Defenseb

COE reports 

collaborating 

with other 

federal 

agenciesb

COE reports 

collaborating 

with 

academic 

organizations

Primary Care Education Boise Veterans Affairs (VA) 

Medical Center (Boise, Idaho)

reported some 

level of 

collaboration 

reported no 

collaboration 

reported no 

collaboration 

reported some 

level of 

collaboration 

Cleveland VA Medical Center 

(Cleveland, Ohio)

reported some 

level of 

collaboration 

reported no 

collaboration 

no response 

or didn’t know

reported no 

collaboration 

San Francisco VA Medical Center 

(San Francisco, California)

reported some 

level of 

collaboration 

reported no 

collaboration 

reported no 

collaboration 

reported some 

level of 

collaboration 

VA Puget Sound Health Care 

System (Seattle, Washington)

reported some 

level of 

collaboration 

reported no 

collaboration 

reported 

some level of 

collaboration 

reported some 

level of 

collaboration 

Patient-Centered Specialty 

Care Education

Atlanta VA Medical Center 

(Atlanta, Georgia)

reported some 

level of 

collaboration 

reported no 

collaboration 

reported no 

collaboration 

reported some 

level of 

collaboration 

Cleveland VA Medical Center 

(Cleveland, Ohio)

reported some 

level of 

collaboration 

reported no 

collaboration 

no response 

or didn’t know

reported some 

level of 

collaboration 

VA Salt Lake City Health Care 

System (Salt Lake City, Utah)

reported some 

level of 

collaboration 

reported no 

collaboration 

reported no 

collaboration 

reported some 

level of 

collaboration 

aCOEs not listed in the table did not complete the collaboration section of the questionnaire.

bCOEs responding affirmatively on the questionnaire to any of the collaboration questions related to 

the Department of Defense and other federal agencies are noted in the table as collaborating.
Appendix III: Comments from the Department 

of Veterans Affairs

Page 37 GAO-16-54 Centers of Excellence

Appendix III: Comments from the 

Department of Veterans Affairs
Appendix III: Comments from the Department 

of Veterans Affairs

Page 38 GAO-16-54 Centers of Excellence
Appendix III: Comments from the Department 

of Veterans Affairs

Page 39 GAO-16-54 Centers of Excellence
Appendix IV: Comments from the Department 

of Defense

Page 40 GAO-16-54 Centers of Excellence

Appendix IV: Comments from the 

Department of Defense
Appendix IV: Comments from the Department 

of Defense

Page 41 GAO-16-54 Centers of Excellence
Appendix V: GAO Contact and Staff 

Acknowledgments

Randall B. Williamson (202) 512-7114 or williamsonr@gao.gov

In addition to the contact named above, Marcia A. Mann, Assistant 

Director; Mary Ann Curran Dozier; Martha Fisher; Carolyn Fitzgerald; 

Carolina Morgan; and Jacquelyn Hamilton made key contributions to this 

report.

Page 42 GAO-16-54 Centers of Excellence

Appendix V: GAO Contact and Staff 

Acknowledgments

GAO Contact:

Staff 

Acknowledgments
Appendix VI: Accessible Data

Page 43 GAO-16-54 Centers of Excellence

DEPARTMENT OF VETERANS AFFAIRS 

WASHINGTON DC 20420

November 16, 2015

Mr. Randall Williamson 

Director

Health Care

U.S. Government Accountability Office

441 G Street, NW

Washington, DC 20548 

Dear Mr. Williamson:

The Department of Veterans Affairs (VA) has reviewed the Government 

Accountability Office's (GAO) draft report, "CENTERS OF EXCELLENCE: 

DOD and VA Need Better Documentation of Oversight Procedures" 

(GA0-16-54). VA generally agrees with GAO's conclusions and concurs 

with GAO's recommendations to the Department.

The enclosure specifically addresses GAO's recommendations and 

provides an action plan. VA appreciates the opportunity to comment on 

your draft report.

Appendix VI: Accessible Data

Agency Comment 

Letter

Text of Appendix III: 

Comments from the 

Department of Veterans 

Affairs

Page 1
Appendix VI: Accessible Data

Sincerely,

Robert L. Nabors II

Chief of staff 

Enclosure

Department of Veterans Affairs (VA) Comments to

Government Accountability Office (GAO) Draft Report

"CENTERS OF EXCELLENCE: DOD and VA Need Better Documentation 

of Oversight Procedures"

(GA0-16-54)

GAO Recommendation 1: To help ensure the COEs are meeting VHA's 

intended objectives for them, GAO recommends that the Secretary of 

Veterans Affairs direct the Under Secretary for Health to establish clear, 

consistent standard criteria that entities must meet to receive COE 

designation, and require all existing VHA COEs, as well as new 

applicants for COE status, to meet these criteria.

VA Comment: Concur. Specialized Centers of Excellence (COE) are 

essential components of the Department of Veteran Affairs' response to 

meeting the health care needs of Veterans. COEs share a singular 

mission to improve the health and well-being of Veterans through world 

class, cutting-edge science, education, and the enhancement of clinical 

care.

The concept of COEs is unique in combining education, research, and 

clinical care into a single program with the purpose of dramatically 

reducing the time from scientific discovery to implementation. Over time, 

research and clinical innovations by COEs have had a profound effect on 

enhancing health care delivery to Veterans.

Page 44 GAO-16-54 Centers of Excellence

Page 2
Appendix VI: Accessible Data

To ensure Veterans Health Administration (VHA) has instituted clear and 

consistent criteria that entities must meet to receive and maintain the 

COE designation, a team of VHA subject matter experts will develop 

standards to be used in the establishment, continuance, and compliance 

expectations required to receive and maintain COE status. If the COE is 

required or authorized by a specific statutory authority, the requirements 

of that authority will apply. The standards developed by VHA will be 

applied to the extent they are consistent with any applicable statutory 

provisions.

Target Completion Date: December 31, 2016

GAO Recommendation 2: To help improve VHA's oversight of its COEs, 

GAO recommends that the Secretary of Veterans Affairs direct the Under 

Secretary for Health to require VHA service offices to develop written 

procedures on how to document their oversight activities of COEs, 

including requirements for documenting feedback, both positive and 

negative, and documenting the resolution of identified problems.

VA Comment: Concur. To ensure VHA has instituted written procedures 

on how to document their oversight activities of COEs, a team of VHA 

subject matter experts will develop these written procedures on how to 

document oversight activities of COEs.

The written procedures will include requirements for documenting 

feedback, both positive and negative, and documenting the resolution of 

identified problems.

Target Completion Date: December 31, 2016

Page 45 GAO-16-54 Centers of Excellence

Page 3

Text of Appendix IV: 

Comments from the 

Department of Defense
Appendix VI: Accessible Data

THE ASSISTANT SECRETARY OF DEFENSE

1200 DEFENSE PENTAGON

WASHINGTON, DC 20301-1200

NOV 17 2015

Mr. Randy Williamson 

Director, Health Care

U.S. Government Accountability Office

441 G Street, NW, Washington, DC 20548

This is the Department of Defense (DoD) response to the GAO Draft 

Report, GA0-16- 54, "CENTERS OF EXCELLENCE: DOD and VA Need 

Better Documentation of Oversight Procedures," dated October 20, 2015 

(GAO Code 291210).

Thank you for the opportunity to review and comment on the draft report. 

After careful review, we concur with the draft report findings and 

recommendation for the Military Health System Defense Center of 

Excellence (CoE) Oversight Board. The Oversight Board will develop the 

written procedures on how to document oversight activities of Defense 

COEs by March 2016. My specific comments to the report's 

recommendation are enclosed.

My points of contacts for this issue are Mr. Edmund Chan (Functional) 

who can be reached (703) 681-1709 or at edmund.m.chan.civ@mail.mil 

and Mr. Gunther Zimmerman (Audit Liaison) at (703) 681-4360 or at 

gunther.j.zimmemran.civ@mail.mil.

Jonathan Woodson, M.D

Enclosures: As stated

Page 46 GAO-16-54 Centers of Excellence

Page 1
Appendix VI: Accessible Data

GAO Draft Report Dated October 20, 2015 

GA0-16-54 (GAO CODE 291210)

"CENTERS OF EXCELLENCE: DOD AND VA NEED BETTER 

DOCUMENTATION OF OVERSIGHT PROCEDURES"

DEPARTMENT OF DEFENSE COMMENTS TO THE GAO 

RECOMMENDATION

RECOMMENDATION: To improve documentation of the activities DoD 

undertakes to oversee the Defense Center of Excellence (COEs), the 

GAO recommends that the Secretary of Defense direct the Assistant 

Secretary of Defense for Health Affairs to require the Military Health 

System Defense COE Oversight Board to develop written procedures on 

how to document oversight activities of Defense COEs, including 

requirements for documenting feedback, both positive and negative, and 

documenting the resolution of identified problems.

DoD RESPONSE: The Department concurs. The Oversight Board will 

develop written procedures on how to document oversight activities of 

Defense COEs, including requirements for documenting feedback, both 

positive and negative, and documenting the resolution of identified 

problems by March 2016.

Page 47 GAO-16-54 Centers of Excellence

Page 2

(291210)
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