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      Recent Reports
    Veterans Community Care Program: Additional Information on VA Statutory Appointment Timeliness Measurements is NeededGAO-24-105308
      
	Published:  Mar 28, 2024


	Publicly Released: Mar 28, 2024
          Veterans Health Care: Improvements Needed in Patient Tracking for Non-Biological Implantable Medical DevicesGAO-24-106621
      
	Published:  Mar 27, 2024


	Publicly Released: Mar 27, 2024
          Service Members Transitioning to Civilian Life: Agencies Can Improve Warm Handovers for Additional AssistanceGAO-24-106248
      
	Published:  Mar 21, 2024


	Publicly Released: Mar 21, 2024
          VA Health Care: Organization of the Office of Mental Health and Suicide PreventionGAO-24-106023
      
	Published:  Feb 29, 2024


	Publicly Released: Feb 29, 2024
          VA Health Care: Opportunities Exist to Further Meet Student Veterans' Mental Health NeedsGAO-24-106620
      
	Published:  Feb 15, 2024


	Publicly Released: Feb 15, 2024
          Veterans Affairs: Improvements Needed in Estimating Funding for Potential Future Health EmergenciesGAO-24-106359
      
	Published:  Feb 08, 2024


	Publicly Released: Feb 08, 2024
    
    

  
  View More ReportsOpen Recommendations
        Veterans Health: VA Should Improve Its Monitoring of Severe Maternal Complications and Mental Health ScreeningsGAO-24-106209
      
						Jan 16, 2024
              Show
          2Open Recommendations

          Agency Affected
                                                  Recommendation
                                                  StatusDepartment of Veterans Affairs
                                                                                        The Secretary of Veterans Affairs should ensure that as OWH begins monitoring SMM on an ongoing basis, it disaggregates and reviews data on trends in SMM by veteran characteristics, such as race and ethnicity, age, or whether veterans lived in a rural area. (Recommendation 1)
                                                                                        Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.Department of Veterans Affairs
                                                                                        The Secretary of Veterans Affairs should ensure that OWH finalizes the development of and implements a systematic process to compile and review data on MCC screening of veterans for mental health conditions on an ongoing basis. This process should include data on MCCs' completion of required mental health screenings, as well as screening results. (Recommendation 2)
                                                                                        Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
          VA Disability Benefits: Board of Veterans' Appeals Should Address Gaps in Its Quality Assurance ProcessGAO-24-106156
      
						Nov 28, 2023
              Show
          4Open Recommendations

          Agency Affected
                                                  Recommendation
                                                  StatusBoard of Veterans Appeals
                                                                                        The Chairman of the Board of Veterans' Appeals should develop written policies and procedures related to its accuracy rate measure, to require that OAI (1) involves more than one official in the calculation process; (2) documents its calculation of monthly and fiscal year accuracy rates; and (3) manages related error data. (Recommendation 1)
                                                                                        Open
The Board agreed in principle with this recommendation. Board officials stated the recommendation should clarify the Board's need for a policy and procedure to manage data: the loss of data was specific to fiscal years 2019 and 2020. However, we note that the data loss stemmed from not having policies and procedures and without them, these types of data management issues could occur again. We continue to believe that having policies and procedures are an important part of internal control. Without written policies and procedures, the Board could face further challenges such as additional data loss, improperly storing data, or using inconsistent methodologies.Board of Veterans Appeals
                                                                                        The Chairman of the Board of Veterans' Appeals should monitor how veteran law judges choose to incorporate the feedback they receive from the case review process—including whether errors are corrected—and use this data to inform decision making related to the case review process. (Recommendation 2)
                                                                                        Open
The Board agreed with this recommendation. We will monitor the agency's progress to implement it.Board of Veterans Appeals
                                                                                        The Chairman of the Board of Veterans' Appeals should develop and implement an evidence-based decision-making process that includes a plan outlining how it will build evidence to assess the underlying causes for the most common errors identified by the case review process and the most common reasons for CAVC remands. The Board should use this evidence to better target its interventions and assess their results. One option is to fold the development of this process into the Board's planned evaluation. (Recommendation 3)
                                                                                        Open
The Board agreed in principle with this recommendation. We will monitor the agency's efforts to implement it.Board of Veterans Appeals
                                                                                        The Chairman of the Board of Veterans' Appeals should study how to evaluate VLJ adjudicative decisional consistency. One option is to fold the development of this study into the Board's planned evaluation. (Recommendation 4)
                                                                                        Open
The Board disagreed with this recommendation. Board officials stated that it would be inappropriate to force consistency in VLJ decisions in a way that is inconsistent with codes of judicial conduct and other standards applicable to VLJs. They stated that there will and should be variance in how legal authority is applied to the individual facts and circumstances of each case appealed to the Board. Board officials further stated that VLJs should be independent and not subject to pressure and influence. They also stated that, as part of evaluating individual VLJs' adherence to performance standards, the Board evaluates the total number of decisions each VLJ has adjudicated and the manner in which they have adjudicated them, among other things. In addition, Board officials noted that the number of decisions remanded does not demonstrate whether such remands were warranted, and that the number of CAVC remands or reversals does not necessarily correlate with productivity, legal acumen, or even with performance. Finally, they said that the concept of "consistency" of decision-making among individual judges evaluating sets of facts and circumstances of each individual case is a difficult one to address at all levels of adjudication, not only at the Board, but also at CAVC. We acknowledge the importance of judicial independence, that some degree of variance is expected given that independence, and that variation is not necessarily an indicator of poor quality decision-making. In addition, the Board acknowledges that consistency among VLJs in the use of appropriate legal authority is appropriate. However, without studying consistency, the Board will remain unaware of whether systemic inconsistencies in VLJ decision-making exist, and the Board will be unable to target interventions, as appropriate. We continue to believe that the results of systematic study of VLJ adjudicative decisions for consistency could provide a basis for targeting interventions, such as training, to assist VLJs. As such, this recommendation is not intended to "force" consistency in any VLJ decisions, but rather is meant to help the Board assist VLJs. Our recommendation is worded to allow the Board the necessary latitude to implement it in a way that allows for the retention of judicial independence while meeting other goals it deems appropriate.
          VA Disability Benefits: Actions Needed to Address Challenges Reserve Component Members Face Accessing CompensationGAO-24-105400
      
						Oct 30, 2023
              Show
          14Open Recommendations

          Agency Affected
                                                  Recommendation
                                                  StatusDepartment of Veterans Affairs
                                                                                        VA's Under Secretary for Benefits should ensure that VBA develops a mechanism, such as a document that lists known reliability issues with VADIR, to better communicate to federal and non-federal users the limitations of its incomplete data, particularly the unreliable variables on military personnel records from before 1985. (Recommendation 1)
                                                                                        Open
VA agreed in principle with this recommendation. VA plans to work with DOD to produce documentation regarding the scope and limitations of the DOD data contained in VADIR to better communicate this information with federal and non-federal users. We will monitor the progress of these efforts.Department of Defense
                                                                                        The Secretary of Defense should work with the Secretary of Veterans Affairs to develop guidance, such as outreach materials, brochures, or trainings, which: (1) makes reserve component members aware of their potential eligibility for disability compensation under various duty statuses; (2) explains how reporting health conditions when they occur can affect subsequent eligibility for disability compensation; and (3) explains the importance of obtaining and maintaining sufficient documentation of duty status and medical treatment received. (Recommendation 2)
                                                                                        Open
DOD agreed with this recommendation. They will work with VA to develop guidance and outreach materials to ensure that service members have the resources and knowledge to safeguard their rights and benefits. Collaboration will involve the Office of the Under Secretary of Defense of Personnel and Readiness, in consultation with the Military Departments. We will monitor DOD's progress in these efforts.Department of Veterans Affairs
                                                                                        The Secretary of Veterans Affairs should work with the Secretary of Defense to develop guidance such as outreach materials, brochures, or trainings, which: (1) makes reserve component members aware of their potential eligibility for disability compensation under various duty statuses; (2) explains how reporting health conditions when they occur can affect subsequent eligibility for disability compensation; and (3) explains the importance of obtaining and maintaining sufficient documentation of duty status and medical treatment received. (Recommendation 3)
                                                                                        Open
VA agreed with this recommendation. VA will ensure documentation is available that addresses all three components of the recommendation. Once finalized, they will work with DOD to provide this guidance through the interagency structure for the Transition Assistance Program. We will monitor the progress of these efforts.Department of Defense
                                                                                        The Secretary of Defense should ensure that DOD's reserve components make the guidance on reporting and documenting health conditions for the purposes of disability compensation prominently available to reserve component members. (Recommendation 4)
                                                                                        Open
DOD agreed with this recommendation. Once DOD and VA finish collaborating to produce guidance and outreach materials, DOD plans to direct the Secretaries of the Military Departments to make the final products prominently available to their Reserve Component members. We will close this recommendation when this effort is complete.Department of Veterans Affairs
                                                                                        VA's Under Secretary for Benefits should make the guidance on reporting and documenting health conditions for the purposes of disability compensation prominently available to reserve component members. (Recommendation 5)
                                                                                        Open
VA agreed in principle with this recommendation and is committed to making this guidance available. VA stated that, while it has limited access to Reserve Component members to make guidance available to them before they transition from Reserve service, they will work with DOD to provide guidance to promote alignment and implement this recommendation (along with recommendation 3). We will monitor the progress of these efforts.Department of Defense
                                                                                        The Secretary of Defense should ensure the Director of ODEI clarifies policies for military service assessments of their reserve component Military Equal Opportunity programs, to reduce medical bias, which in turn could help improve reserve component members' access to disability compensation. (Recommendation 6)
                                                                                        Open
DOD agreed with this recommendation. ODEI plans to clarify policy in the next revision of DoD Instruction (DoDI) 1350.02 for which the Secretaries of the Military Departments are responsible for ensuring their Reserve MEOs are assessed. ODEI will coordinate with the Military Departments on the frequency of assessment for the Reserve MEO programs. The next revision is expected in Fall 2024. We will monitor DOD's progress to complete this effort.
          VA Equal Employment Opportunity: Increased Attention Needed to Improve Program EffectivenessGAO-23-105429
      
						Sep 12, 2023
              Show
          8Open Recommendations

          Agency Affected
                                                  Recommendation
                                                  StatusDepartment of Veterans Affairs
                                                                                        The Secretary of VA should finalize the I-DEA dashboard and use the data in the dashboard to regularly conduct trend analysis of internal and other data on perceived experiences of discrimination. Such analyses should pinpoint problematic locations, guide preventive efforts, and incorporate available data from VA's All Employee Survey; EEO and Harassment Prevention Program data; and information from other internal and external data collection efforts and assess trends down to the facility level. (Recommendation 1)
                                                                                        Open
VA agreed with this recommendation and noted plans to implement it. We will monitor the agency's efforts to address this recommendation.Department of Veterans Affairs
                                                                                        The Secretary of VA should ensure that the Deputy Assistant Secretary for Resolution Management, Diversity and Inclusion assesses and addresses any potential risks to the independence of the agency's EEO program, including the Harassment Prevention Program. (Recommendation 2)
                                                                                        Open
VA agreed with this recommendation and noted plans to implement it. In April 2024, VA said that the department has an on-going assessment of potential risks to independence including of its EEO functions, the Harassment Prevention Program, and the Alternative Dispute Resolution Program. To implement our recommendation, VA needs to fully review all aspects of its EEO program to determine whether there are potential conflicts including, for example, in reporting structures and job duties.Department of Veterans Affairs
                                                                                        The Secretary of VA should ensure that the Deputy Assistant Secretary for Resolution Management, Diversity and Inclusion assesses the factors that increase the time it takes to implement the terms of final decisions in cases where discrimination is found and develops a plan to ensure these final decisions are implemented in a timely manner. (Recommendation 3)
                                                                                        Open
VA agreed with this recommendation and noted plans to implement it. We will monitor the agency's efforts to address this recommendation.Department of Veterans Affairs
                                                                                        The Secretary of VA should ensure that the Deputy Assistant Secretary for Resolution Management, Diversity and Inclusion develops a strategic workforce plan that incorporates internal stakeholder feedback in order to meet its programmatic functions and goals. (Recommendation 4)
                                                                                        Open
VA agreed with this recommendation and noted plans to implement it. We will monitor the agency's efforts to address this recommendation.Department of Veterans Affairs
                                                                                        The Secretary of VA should ensure that the Deputy Assistant Secretary for Resolution Management, Diversity and Inclusion regularly conducts analyses of VA workforce data to identify barriers to employment in the VA workforce; develop action plans for all identified barriers; and annually report on progress on implementing action plans. (Recommendation 5)
                                                                                        Open
VA neither agreed nor disagreed with this recommendation. VA noted that the culmination of its various analyses will result in findings and an action plan to improve any identified barriers to equal opportunity in the SES, Hispanic/Latino and disability hiring efforts at VA. However, it's not clear that VA's plan includes specific actions, with timeframes and responsible personnel, the agency will take to eliminate the barriers identified in its analysis. VA also did not provide documentation of conducting a barrier analysis for employees with disabilities. Further, VA has lacked a consistent effort to analyze barriers within its workforce, having reported that it did not conduct barrier analyses from fiscal years 2018 through 2020. VA did develop a Barrier Analysis Workgroup, however, VA did not provide clear plans on how to identify and prioritize additional barrier analyses or take the additional needed actions to eliminate identified barriers. We will monitor VA's efforts to take consistent steps to ensure equal access to employment opportunities.Department of Veterans Affairs
                                                                                        The Secretary of VA should ensure that the Assistant Secretary for Human Resources & Administration/Operations, Security and Preparedness collects and analyzes information on facilities' hiring and promotion selection panel processes and addresses any findings from this analysis. This should include action plans with timeframes to address any deficiencies identified and sharing best practices. (Recommendation 6)
                                                                                        Open
VA agreed with this recommendation. In April 2024, VA said that the department is collecting and analyzing information from the VA administrations on hiring and promotion selection panel processes. VA said it will look for deficiencies in the panel processes as well as best practices. VA anticipates this will be completed in fiscal year 2024.
    
    

  
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              Cindy Brown Barnes
            
            Managing Director
      
            brownbarnesc@gao.gov
      
            (202) 512-7215
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              Elizabeth Curda
            
            Director
      
            curdae@gao.gov
      
            (202) 512-7215
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              Shelby S. Oakley
            
            Director
      
            oakleys@gao.gov
      
            (202) 512-4841
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              Sharon M. Silas
            
            Director
      
            silass@gao.gov
      
            (202) 512-7114
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              Andrew Von Ah
            
            Director
      
            VonAha@gao.gov
      
            (213) 830-1011
    John D. Sawyer
      
              John D. Sawyer
            
            Director
      
            sawyerj@gao.gov
      
            (202) 512-7215

            View More Contacts
                                                      MultimediaU.S. Comptroller General Testifies to House on Management Challenges at Veterans Affairs
      
        
        U.S. Comptroller General Testifies to House on Management Challenges at Veterans Affairs
          Tuesday, February 28, 2023Transcript
          Improvements Needed for Veteran Suicide Prevention Outreach
      
        
        Improvements Needed for Veteran Suicide Prevention Outreach
          Monday, December 17, 2018Transcript
          AskGAOLive Chat on Veterans and Higher Education
      
        
        AskGAOLive Chat on Veterans and Higher Education
          Wednesday, May 14, 2014
Podcasts
    
      Hunger Among Military Veterans and Federal Efforts to Address It
    Monday, April 25, 2022
      
            Transcript
          Potentially Ineligible Providers in the Veterans Community Care Program
    Monday, January 17, 2022
      
            Transcript
          VA’s Suicide Prevention Teams Face Increasing Workloads As Demand for Services Grow
    Monday, April 05, 2021
      
            Transcript
Thumbnail
              INTERACTIVE GRAPHICS: Housing for Homeless Veterans through VA's Enhanced-Use Lease Program
        Interactive Graphic
          
            INTERACTIVE GRAPHICS: Housing for Homeless Veterans through VA's Enhanced-Use Lease Program
      
          Wednesday, December 21, 2016
Stock art showing a person wearing military fatigues leaning over a legal notepad with the words "Transition Assistance Program: Day 1" written on it.
          Blog Post
              For Veterans Day—Is A Key Program Meant to Help Veterans Transition to Civilian Life Reaching its Audience?
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					Blog Post
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