Defense Centers of Excellence: Limited Budget and Performance Information on the Center for Psychological Health and Traumatic Brain Injury
Published: 2011-06-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The National Defense Authorization Act for Fiscal Year 2008 established the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCOE) in January 2008 to develop excellence in prevention, outreach, and care for service members with psychological health (PH) conditions and traumatic brain injury (TBI). DCOE consists of six directorates and five component centers that carry out a range of PH- and TBI-related functions. GAO was asked to report on (1) DCOE's budget formulation process; and (2) availability of information to Congress on DCOE. GAO reviewed budget guidance, budget requests and performance data. GAO reviewed Department of Defense (DOD) reports submitted to Congress on PH and TBI and interviewed DOD officials.
section_title: What GAO Found
paragraphs: DCOE's role in the DOD budget formulation process is limited. For fiscal year 2012, DCOE's role in budget formulation was limited to consolidating component center budget requests and providing budget requests to the TRICARE Management Activity (TMA). Further, the budget requests DCOE provided to TMA did not have complete narrative justifications. Office of Management and Budget Circular A-11 specifies that the basic requirements for a justification include a description of the means and strategies used to achieve performance goals. At the time of GAO's review, prior-year funding and obligations data and funding received by component centers from sources external to DCOE were not readily available. The absence of these data indicates that TMA and DCOE did not have benefit of this data to inform budget formulation decisions. Also, quarterly reviews conducted by DCOE that collect data on performance and resources do not include component centers. Expansion of reviews and greater access to performance information could provide DCOE an opportunity to collect information that links component center performance with resources and better informs budget decision making. DCOE's mission and funding have not been clearly defined to Congress. At a congressional hearing, Members expressed differing visions of DCOE's mission and voiced concern about the amount of time needed to establish DCOE and achieve results. Moreover, in four congressional subcommittee testimonies, DCOE's first director and the Assistant Secretary of Defense for Health Affairs characterized DCOE as DOD's "open front door for all concerns related to PH and TBI." These statements suggest a divergent understanding of DCOE's role and bolster the importance of clear communication on DCOE's mission, funding, and activities. Because DCOE is a relatively small entity primarily funded through the larger Defense Health Program appropriation, it falls below the most detailed level that is presented in congressional budget presentation materials. In addition, at Congress's request DOD provides mandated and ad hoc reports on PH and TBI expenditures. While these reports present information on activities and accomplishments for PH and TBI, DOD does not--and is not required to--report separately on DCOE.
section_title: What GAO Recommends
paragraphs: To enhance visibility and improve accountability, GAO recommends that the Secretary of Defense direct the Director of TMA work with the Director of DCOE to develop and use additional narrative in budget justifications, to regularly collect and review data on funding and obligations, and expand its review and analysis process. DOD concurred with GAO's recommendations. GAO understands that the expanded review and analysis process would not include realigned component centers. GAO agrees that ensuring entities external to TMA comply with regular collections of funding and obligations data could be a limitation.

section_title: Letter
paragraphs: As of June 2011, approximately 44,000 U.S. military service members have  been wounded in action in conflicts in Afghanistan and Iraq. Due to  improved battlefield medicine, those who might have died in past conflicts  are now surviving, many with multiple serious injuries-—such as  amputations, burns, and traumatic brain injuries—that require extensive  outpatient rehabilitation. Congress passed the National Defense  Authorization Act for Fiscal Year 2008, which directed the Department of  Defense (DOD) to create centers of excellence on traumatic brain injury  (TBI) and post-traumatic stress disorder and other psychological health  (PH) conditions to develop excellence in the prevention, outreach, and  care for those with PH and TBI conditions. In fiscal year 2010 DOD  allotted $638 million in operations and maintenance funding for PH and  TBI activities; of these funds, the Defense Centers of Excellence for  Psychological Health and Traumatic Brain Injury (DCOE) and its  component centers received about $168 million. Congressional  committees have expressed concerns about how DCOE formulates its  budget.
This is the second report we are issuing about DCOE’s establishment and  ongoing development. We issued a report in February 2011 examining  DCOE’s strategic planning and financial management. In that report we  recommended the Secretary of Defense direct DCOE to improve its  strategic plan by aligning daily activities in support of goals and improving  performance measures to enable DCOE to determine if achievement of  each measure fully supports attainment of its associated goal. In addition,  we recommended that the Director of the TRICARE Management Activity  (TMA)—under which DCOE operates—develops, updates, and maintains  written procedures for proper classification and recording of DCOE  obligations. DOD concurred with our recommendations.
For this report, we were asked to examine DCOE’s budget formulation  process and the availability of its funding and performance information to  Congress. In particular, we addressed the following objectives:  1.  Describe and evaluate DCOE’s budget formulation within the broader  DOD-wide budget process for PH and TBI and the information used to  make budget decisions.  2.  Evaluate the information available to Congress on DCOE’s funding and  activities.
To achieve these objectives, we reviewed DCOE’s budget formulation for  operations and maintenance funding for fiscal years 2008 through 2012. To  understand DCOE’s budget formulation process and the data used to  inform budget requests, we reviewed documentation relevant to its budget  formulation process and interviewed knowledgeable DOD officials. To  understand DCOE’s structure, history, and funding, we gathered and  analyzed information on the creation and organization of DCOE. We also  reviewed the legislative history of DCOE, DOD appropriations acts, and  accompanying committee reports. We interviewed officials at Health  Affairs, TMA, the Uniformed Services University of the Health Sciences  (USUHS), DCOE, and DCOE’s component centers about the budget  formulation process, and the information used in budget decision making.  We reviewed DCOE’s mission, strategic goals, and performance measures.
Also, we reviewed budget request and justification documents for DCOE  and its component centers. To understand how DCOE participates in DOD  budget formulation processes, we reviewed DOD budget formulation  guidance, including guidance specifically affecting DCOE or PH and TBI.
To determine what information is available to Congress on DCOE’s  funding and activities we reviewed the President’s budget requests and  DOD justification documents for relevant years and reports requested by  Congress on DOD’s effort to address PH and TBI. To identify  congressional direction on information requirements, we reviewed DOD  appropriations acts, accompanying committee reports, and congressional  hearing records.
We conducted this performance audit from June 2010 through June 2011 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.
subsections: section_title: Background
paragraphs: The National Defense Authorization Act for Fiscal Year 2008 (NDAA)  directed DOD to establish centers of excellence for traumatic brain injury  and post-traumatic stress disorder. Although the NDAA described  responsibilities for the centers, it did not specify where the centers should  be located within the DOD organization. Instead, it directed the Secretary  of Defense to ensure that to the maximum extent practicable centers  collaborate with governmental, private, and nonprofit entities. Senior-level  DOD officials convened representatives from the Army, Navy, Air Force,  Marines, and Department of Veterans Affairs to determine how to  establish the centers. Informally, this group was known as the “Red Cell”  and its primary mission was to address recommendations related to PH  and TBI. Rather than establishing separate centers of excellence for  traumatic brain injury and post-traumatic stress disorder, a combined  center for both PH and TBI was created. According to one representative,  the Red Cell also debated how funding would be divided between PH and  TBI and across the military services. The military services, TMA, and  DCOE receive PH and TBI funding through the Defense Health Program  (DHP) appropriation account.
subsections: section_title: DOD Organizational Structure and the DCOE Network
paragraphs: Organizationally the services are led by Secretaries who have a direct  relationship with the Secretary of Defense. As shown in figure 1, DCOE  reports directly to the Assistant Secretary of Defense for Health  Affairs/Director of TMA within the Office of the Secretary of Defense.
DCOE consists of a central office and six directorates. The central office  conducts multiple functions such as leadership and resource management  and is responsible for DCOE’s budget formulation process. The six  directorates carry out a range of activities related to PH and TBI, including  operating a call center, disseminating information on DOD training  programs, developing clinical practice guidelines related to PH and TBI,  and identifying PH and TBI research needs. The DCOE network also  includes five component centers that provide an established body of  knowledge and experience related to PH and TBI. The component centers  are the Defense and Veterans Brain Injury Center (DVBIC), Deployment  Health Clinical Center (DHCC), Center for the Study of Traumatic Stress  (CSTS), Center for Deployment Psychology (CDP), and the National  Center for Telehealth and Technology (T2).
section_title: PH and TBI Funding and Allotments
paragraphs: Over time, PH and TBI funding evolved from DHP amounts directed  specifically for PH and TBI to funding support being incorporated into the  broader DHP appropriation. In fiscal year 2007, Congress appropriated  approximately $600 million specifically for TBI and post-traumatic stress  disorder treatment. In fiscal year 2008, Congress specifically appropriated  $75 million for PH and TBI activities. In fiscal year 2009, funding for PH  and TBI was not appropriated a specific amount, rather funding was  drawn from DHP’s general operation and maintenance funds—DOD had  discretion over the amount and distribution of funds internally allotted.  Beginning in fiscal year 2010, PH and TBI funding was included in the base  budget request for the DHP, which established a longer-term funding  stream for PH and TBI.
As shown in figure 2, in fiscal year 2010 a total of $638 million in DHP  operations and maintenance funding was allotted for PH and TBI across  the military services, TMA Financial Operations Division (TMA FOD), and  DCOE. The Army received the largest portion of funds, about $279 million  or 44 percent, while DCOE received approximately $168 million or 26  percent. Of all PH and TBI funding allotted, $96 million or 15 percent was  suballoted to component centers within the DCOE network.
section_title: DOD Budget Formulation Process
paragraphs: Budget formulation for DOD occurs as part of the Planning, Programming,  Budgeting and Execution Process, which projects near-term defense  spending. The system is intended to provide defense decision makers with  the data they need to make trade-offs among potential alternatives; thus  resulting in the best possible mix of forces, equipment, and support to  accomplish DOD’s mission. Specifically, DOD budget formulation occurs  in the programming phase of the Planning, Programming, Budgeting and  Execution Process, and begins with the development of a program  objective memorandum (POM). The POM reflects decisions about  resource allocations and proposed budget estimates and is used to inform  the development of the President’s Budget and DOD Congressional  Justifications. Because DCOE is only one, relatively small entity receiving  funds through the broader DHP appropriation, it is not visible in DOD  budget presentation materials. The POM covers six fiscal years and is  developed in even fiscal years, for example fiscal year 2008 and fiscal year  2010. DOD develops the POM approximately 18 months in advance of the  first fiscal year the POM covers.
section_title: While DCOE’s Role in the Budget Formulation Process Is Limited, More Complete Information Would Be Helpful
subsections: section_title: DCOE Does Not Make PH and TBI Budget Formulation Decisions, and Its Input to the Process Is Limited
paragraphs: DCOE had a limited role in budget decision making for the fiscal year 2012  POM process. Ultimately, senior DOD officials, including the Health  Affairs Deputy Assistant Secretaries of Defense, decided to fund 1 of 18  PH and TBI requests, which did not include DCOE’s. For this POM, DCOE  headquarters solicited and received budget requests from component  centers. Ultimately, DCOE accepted and incorporated all component  center requests into its budget request. However, in some instances DCOE  officials said they requested additional justification from component  centers. PH and TBI budget requests from across DOD, including DCOE,  were collected for consideration in the fiscal year 2012 POM. A working  group of PH and TBI subject matter experts within DOD reviewed and  prioritized requests for funding above the fiscal year 2010 base budget  from across the department. According to a DCOE official, DCOE’s  interests were represented by TMA officials who contributed to the  prioritization of these requests; however, the final decisions were not  formally communicated to DCOE.
DCOE had a limited role in budget formulation for the fiscal year 2010  POM because it was still in its first year of operation. According to a  senior DOD official, no limits were imposed on PH and TBI budget  requests and no trade-off decisions were made. Nevertheless, this year was  significant because it was the first year that DCOE’s budget was  considered in the DHP baseline budget request. According to DCOE  officials, because DCOE had only recently been established, it had limited  staff. In addition, component centers were still being realigned under  DCOE and both the relationship between component centers and DCOE  and the missions of two component centers, T2 and the National Intrepid  Center of Excellence (NICOE), were unclear. For the fiscal year 2008 POM  process, the newly established DCOE had no role in budget formulation.  Instead, the Red Cell convened to determine how the centers of excellence  would be implemented and provided recommendations on DCOE’s  original budget, which the Senior Oversight Committee approved.  Because the POM process occurred on a biannual basis in even fiscal  years, DOD did not have a budget formulation process in fiscal years 2009  and 2011.
section_title: DCOE’s Budget Request Did Not Have Complete Narrative Justification
paragraphs: For the fiscal year 2012 POM, DCOE provided limited narrative support for  its budget justification. TMA requested that DCOE complete and submit a  spreadsheet template with cost estimates and narrative for resource  requests above the prior-year baseline. The narrative portion asked for  four elements: (1) background, (2) requirements summary, (3) impact to  other programs, and (4) the risk if not funded. DCOE and its component  centers did not provide this template in a complete manner. Not all of the  requested narrative elements were provided. For example, the impact to  other programs was not discussed for half the requests DCOE submitted.  In addition, the DCOE headquarters request was calculated with a 3.5  percent inflation factor versus the 1.7 percent prescribed in POM  guidance, but DCOE did not explain why it needed to use a higher inflation  rate.
Two years earlier, for the 2010 POM, DCOE provided no narrative support  for its budget justification. TMA requested that DCOE provide completed  spreadsheets that did not include a narrative component. For this POM,  DCOE differentiated the amounts it requested by PH or TBI strategic  initiatives and by commodity, but did not provide narrative justifications  for these amounts. Guidance contained in OMB Circular A-11 specifies  that the basic requirements for a justification include a description of the  means and strategies used to achieve performance goals. Means can  include human resources, information technology, and operational  processes. Strategies may include program, policy, management,  regulatory, and legislative initiatives and approaches and should be  consistent with the agency’s improvement plans. According to OMB, a  thorough description of the means and strategies to be used will promote  understanding of what is needed to achieve a certain performance level  and increase the likelihood that the goal will be achieved. To develop a  comprehensive departmentwide budget submission to OMB, a thorough  description of means and strategies in justifications is needed at all levels  within an agency.
DCOE already collects information that could improve its budget  justifications. DCOE requests that both directorates and component  centers prepare “fact sheets,” which contain detailed information  including mission, activities, relevant legislation, staffing, performance  metrics, and resource requirements. Information like that in the fact  sheets provides an expanded discussion of performance information.  DCOE and TMA could leverage this existing information to improve  budget justifications and resulting decisions.
section_title: Key Information Was Not Readily Available to Inform Budget Formulation
paragraphs: Decision making for DCOE’s budget formulation could be facilitated by  key information, such as funding and obligations data, additional non- DCOE funding received by its component centers, and performance  information resulting from internal reviews. This information could also  help DCOE justify and prioritize its budget requests. However, DOD  required more than 3 months to query numerous sources and provide us  with prior-year data on funding and obligations for DCOE and its  component centers. The absence of readily available, comprehensive  historical funding and obligations data indicates that TMA and DCOE did  not have benefit of these data to inform budget formulation. Furthermore,  DCOE and TMA FOD do not have access to systems that track funds  authorized for execution on behalf of the DCOE component centers  because component center budget execution is conducted at multiple sites  that maintain separate financial systems. According to TMA and DCOE  officials, DCOE has limited responsibility for budget execution activities.  TMA FOD and DCOE must request and compile obligations data for funds  administrated by budget execution sites. For example, as shown in figure  3, once DCOE requests that TMA FOD authorize funding for T2, the funds  are provided to T2’s host entity, Madigan Army Medical Center. At this  point, TMA and DCOE can no longer monitor the execution of T2’s funds  through TMA’s financial reporting systems and must request that  information. TMA FOD’s financial system contains data on spending it  administrates for DCOE headquarters and component centers. DCOE and  TMA should use comprehensive historical funding and obligations data to  inform budget formulation and justify requests. OMB Circular A-11 directs  agencies to present prior-year resource requirements in budget  justification materials.
Prior to our review, DCOE did not collect information on the sources and  amounts of funds component centers received in addition to allotments  from DCOE, and therefore did not have benefit of these data to help  inform budget decision making. In some cases, component centers  receive significant amounts of non-DCOE funding. For example,  Deployment Health Clinical Center received about $8.3 million in funding  from DCOE in fiscal year 2010, while it was awarded about $3.3 million  from external sources. Standards for internal control in the federal  government state that information should be recorded and communicated  to management and others within the entity who need it. Without  information on non-DCOE funding, when DCOE and TMA make trade-off  decisions, they cannot consider all the resources available to component  centers. While DCOE has begun collecting information on component  centers’ non-DCOE funding, it has not had an opportunity to use that data  to inform budget formulation and requests because the fiscal year 2012  POM process already occurred.
Additionally, DCOE could obtain more performance information to better  prioritize and justify its budget requests. In the middle of fiscal year 2010,  DCOE began to hold quarterly meetings to evaluate directorates’  performance and reallocate resources used for DCOE’s daily activities.  However, component centers are not included in this process. A DCOE  official said component centers are excluded because DOD is reviewing  the governance structure of all DOD centers of excellence, and this could  affect the organizational structure of DCOE. But if DCOE included the  component centers in this process, it could collect information that links  component center performance with resources and enhance future budget  decision making.
section_title: Limited Information Is Available on DCOE’s Mission, Funding, and Activities
paragraphs: DCOE’s mission has not been clearly defined to Congress. For example, in  one hearing of the House Committee on Armed Services, Members  expressed differing visions of DCOE’s mission. One Member expressed  frustration that DCOE had not become an “information clearinghouse” and  the “preeminent catalogue of what research has been done,” as had been  envisioned. A second Member described his vision of DCOE being an  overarching body that “coordinates, inspects, and oversees the  tremendous amount of good work being done across the nation.” Members  also voiced concern about the amount of time needed to establish DCOE  and achieve results. In four congressional subcommittee testimonies,  DCOE’s first director and the Assistant Secretary of Defense for Health  Affairs characterized DCOE as DOD’s “open front door for all concerns  related to PH and TBI.” These statements suggest a divergent  understanding of DCOE’s role and bolster the importance of clear  communication on DCOE’s mission, funding, and activities.
DCOE is a relatively small entity and it does not typically appear in DOD  DHP budget presentation materials and falls below the most detailed level  that is presented—the Budget Activity Group level. DCOE has only  appeared in DOD’s budget presentation materials for fiscal year 2010,  when PH and TBI funding was first included in the DHP base budget  request. In the request, DOD did not specify that DCOE’s individual  budget request for 2010 was only about $168 million of the $800 million  requested. Specifically, the request stated “$0.8B to fund operations of the  Defense Center of Excellence (DCoE) for Psychological Health and  Traumatic Brain Injury, and to ensure that critical wartime medical and  health professionals are available to provide needed mental health  services by improving hiring and retention bonuses and offering targeted  special pay.”
DOD provides supplemental reporting on PH and TBI expenditures  through reports mandated in the National Defense Authorization Act for  Fiscal Year 2008, as well as ad hoc reports at Congress’s request. While  these reports present activities and accomplishments by strategic  initiative, DOD is not required to separately report on DCOE in its annual  reports. Thus, while PH and TBI information is reported to congressional  decision makers, DCOE specific funding and activities are not visible. The  Government Performance Results Act (GPRA) Modernization Act of 2010  further requires agencies to consult with the congressional committees  that receive their plans and reports to determine whether they are useful  to the committee. Table 1 summarizes selected mandated and ad hoc  reports DOD provided to Congress.
section_title: Conclusions
paragraphs: DCOE faces numerous challenges, such as recruiting staff and shaping  relationships with its component centers and military services.  Nonetheless, DCOE could take additional steps to make better informed  budget decisions and justify resource requests. DCOE lacks key  information, such as comprehensive funding and obligations data for  component centers and does not make full use of performance data. Better  leveraging of such information could enhance DCOE’s ability to influence  component centers’ progress towards achievement of positive outcomes  for wounded service members. For DCOE to achieve its mission and goals  it must have access to and consider information needed to prioritize its  activities and communicate its role to stakeholders. As DOD reviews the  governance structure of its centers of excellence, such as DCOE, it has an  opportunity to ensure that these centers have the tools needed to promote  success.
section_title: Recommendations for Executive Action
paragraphs: To enhance visibility and improve accountability, we recommend that the  Secretary of Defense direct the Director of TMA to work with the Director  of DCOE on the following three actions:  1.  develop and use additional narrative, such as that available in  component center fact sheets, in budget justifications to explain the  means and strategies that support the request.  2.  establish a process to regularly collect and review data on component  centers’ funding and obligations, including funding external to DCOE.  3.  expand its review and analysis process to include component centers.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to the Secretary of the Department of  Defense for official review and comment. The Assistant Secretary of  Defense of Health Affairs and Director of TRICARE Management Activity  provided us with written comments, which are summarized below and  reprinted in appendix III. DOD also provided technical comments that  were incorporated into the report as appropriate. DOD concurred with all  of our recommendations. Specifically, DOD concurred with our  recommendation that the Director of TRICARE Management Activity  (TMA) work with the Director of the Defense Centers of Excellence for  Psychological Health and Traumatic Brain Injury (DCOE) to develop and  use additional narrative, such as that available in component centers’ fact  sheets and budget justifications. DOD also concurred with our  recommendation to establish a process to regularly collect and review  data on component centers’ funding and obligations, including funding  external to DCOE. However, DOD stated that one limitation in executing  this recommendation is ensuring entities external to TMA comply with the  request to regularly report funding and obligations data. We agree that this  limitation presents challenges for DCOE’s and TMA’s oversight of  obligations and funding data. However, a complete understanding of this  information is important to fully review the resources that affect DCOE’s  operations.
DOD stated that DCOE is appropriately informed of budget execution data  through formal systems, as well as informal coordination and managerial  reporting. In addition, TMA stated that it executes a majority of the total  operations and maintenance funding that DCOE and its component  centers receive and that TMA, DCOE, and the Services have instituted  numerous internal controls to monitor planned and actual expenditures.  Despite the level of oversight described by DOD, it was not readily able to  provide us with disaggregated information on DCOE’s funding and  obligations. Although TMA does execute and oversee the majority of  operations and maintenance funding for DCOE and its component centers,  additional funding remains outside of its oversight, including  approximately 18 percent of operations and maintenance funding.
The data provided for fiscal year 2010 remain incomplete and the  information provided has not been sufficient to confirm its accuracy or  reliability. Furthermore, DOD was unable to describe the process used to  identify and resolve errors in source data from multiple financial systems,  and TMA stated that it could not confirm the accuracy of data from  financial systems it does not administrate. This raises questions about  DCOE and TMA’s oversight and use of these data to inform budget  formulation. Lastly, DOD agreed with the recommendation to expand its  review and analysis process to include component centers, but that it did  not plan to include two component centers, the Center for the Study of  Traumatic Stress and the Center for Deployment Psychology, which are in  the process of formally aligning under the Uniformed Services University  of the Health Sciences.
We are sending copies of this report to the Secretary of Defense and  appropriate congressional committees. In addition, the report is available  at no charge on the GAO Web site at http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  Denise M. Fantone at (202) 512-6806 or fantoned@gao.gov. Contact points  for our Offices of Congressional Relations and Public Affairs may be found  on the last page of this report. GAO staff who made major contributions to  this report are listed in appendix IV.
section_title: Appendix I: Scope and Methodology
paragraphs: We reviewed the Defense Centers of Excellence for Psychological Health  and Traumatic Brain Injury (DCOE) budget formulation for fiscal years  2008 through 2012. To understand DCOE’s budget formulation process and  the data used to inform budget requests, we reviewed documentation  relevant to its budget formulation process and interviewed knowledgeable  Department of Defense (DOD) officials. To understand DCOE’s structure,  history, and funding, we gathered and analyzed information on the  creation and organization of DCOE, such as the report on the outcomes of  the Red Cell, and memorandums of agreement between DCOE and  component centers. We also reviewed the legislative history of DCOE,  DOD appropriations acts from fiscal years 2007, 2008, 2009, and 2010, and  accompanying committee reports.
Initially, we sought to obtain funding and obligations data from fiscal years  2007 through 2011; however, DOD was unable to provide these data in a  timely manner, and ultimately provided data that we determined were not  sufficiently reliable for presenting funding and obligations figures. As a  result, the team reduced the scope of our data request to only include  fiscal year 2010. Through interviews and responses to written questions,  DOD provided additional information about the process used to generate  and validate this data. However, as of May 5, 2011, the data provided for  fiscal year 2010 remain incomplete, and the information provided has not  been sufficient to confirm the accuracy or reliability of all detailed funding  and obligations data. Because such data are necessary to fully understand  the budget process for psychological health (PH) and traumatic brain  injury (TBI), the team decided to present these data, but to note that we  have not confirmed their accuracy.
We reviewed DCOE’s mission, strategic goals, and performance measures.  Also, we reviewed budget request and justification documents for DCOE,  and its component centers for fiscal years 2010 and 2012, and documents  that support the development of budget requests, such as component  center fact sheets. To understand how DCOE participates in DOD budget  formulation processes we reviewed DOD budget formulation guidance,  including TRICARE Management Activity (TMA) and Program Objective  Memorandum (POM) guidance for fiscal year 2010 and 2012 that  specifically affects DCOE. The Defense Health Program appropriation  includes three accounts, Operations and Maintenance, Procurement, and  Research, Development, Test and Evaluation (RDT&E). We focused our  review on the budget formulation process for Operations and Maintenance  funding because DCOE and DCOE component centers do not receive any  baseline funding for Procurement and RDT&E, which are obtained  through separate budget processes. We interviewed officials at Health  Affairs, Force Health, Protection and Readiness, TMA, the Uniformed  Services University of the Health Sciences (USUHS), DCOE, and DCOE’s  component centers about the budget formulation process, and the  information used in budget decision making.
To determine what information is available to Congress on DCOE’s  funding and activities, we reviewed the President’s budget requests and  DOD’s justification documents for fiscal years 2010, 2011, and 2012. In  addition, we reviewed reports mandated by the 2008 National Defense  Authorization Act on PH conditions and TBI, and reports requested by the  Senate Appropriations Committee on PH and TBI expenditures. To  identify congressional direction on information requirements, we reviewed  DOD appropriations acts from fiscal years 2007, 2008, 2009, and 2010,  accompanying committee reports, and congressional hearing records.
We conducted this performance audit from June 2010 through June 2011 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.
section_title: Appendix II: Description of Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury Directorates and Component Centers
paragraphs: Six directorates carry out a range of activities related to psychological  health (PH) conditions and traumatic brain injury (TBI).
Strategic Communications Directorate—To strategically inform  and disseminate to multiple audiences and stakeholders; providing  relevant and timely information, tools, and resources for warriors,  families, leaders, clinicians, and the community that empowers them,  supports them, and strengthens their resilience, recovery, and  reintegration.
Psychological Health Clinical Standards of Care Directorate— To promote optimal clinical practice standards to maximize the  psychological health of warriors and their families.
Research Directorate—To improve PH and TBI outcomes through  research; quality programs and evaluation; and surveillance for our  service members and their families.
Resilience and Prevention Directorate—Assist the military  services and the DOD to optimize resilience; psychological health; and  readiness for service members, leaders, units, families, support  personnel, and communities.
Education Directorate—To assess training and educational needs in  order to identify, and promote effective instructional material for  stakeholders resulting in improved knowledge and practice of PH and  TBI care.
Traumatic Brain Injury Clinical Standards of Care  Directorate—To develop state of the science clinical standards to  maximize recovery and functioning and to provide guidance and  support in the implementation of clinical tools for the benefit of all  those who sustain traumatic brain injuries in the service of our  country.
The Defense Centers of Excellence for Psychological Health and  Traumatic Brain Injury (DCOE) network also includes five component  centers that provide an established body of knowledge and experience  related to PH and TBI. Component centers include:    Defense and Veterans Brain Injury Center (DVBIC)—With a  focus on TBI, DVBIC was created as a collaboration between DOD and  Department of Veterans Affairs that serves military personnel,  veterans, and their families by providing clinical care, conducting  research, and providing education and training to DOD providers.
Deployment Health Clinical Center (DHCC)—Focused on  deployment-related health concerns, including PH, DHCC serves  military personnel, veterans, and their families by providing outpatient  care, conducting research, leading the implementation of a primary  care screening program for post-traumatic stress disorder and  depression, and information to military health system providers.
Center for the Study of Traumatic Stress (CSTS)—By addressing  a wide scope of trauma exposure that includes the psychiatric  consequences of war, deployment, disaster, and terrorism, CSTS  serves DOD, and collaborates with federal, state, and private  organizations. Activities include conducting research, providing  education and training to military health system providers, and  providing consultation to government and other agencies on  preparedness and response to traumatic events.
Center for Deployment Psychology (CDP)—Covering both PH and  TBI, CDP trains military and civilian psychologists and other mental  health professionals to provide high quality deployment-related  behavioral health services to military personnel and their families.
National Center for Telehealth and Technology (T2)— Addressing both PH and TBI, T2 serves military personnel, veterans,  and their families by acting as the central coordinating agency for DOD  research, development, and implementation of technologies for  providing enhanced diagnostic, treatment, and rehabilitative services.
section_title: Appendix III: Comments from the Department of Defense
subsections: section_title: GAO Comments
paragraphs: The following GAO comments on the Department of Defense’s letter dated  June 3, 2011, supplement those that appear in the text of the report. 1.  While DOD stated that DCOE is appropriately informed of budget  execution data through formal systems, as well as informal  coordination and managerial reporting, DOD was not readily able to  provide us with basic information on funding and obligations.  Furthermore, the data provided for fiscal year 2010 remain incomplete  and the information provided has not been sufficient to confirm its  accuracy and reliability. This raises questions about DCOE and TMA’s  oversight and use of these data to inform budget formulation. Accurate  and reliable status of funding data should be used as the starting point  to inform, justify, and prioritize future budget requests. Although DOD  stated that funding data provided to us on February 15, 2011, should be  reported on, we continue to believe that these data do not reflect  specific psychological health and traumatic brain injury funding that  DCOE provided to component centers. Service-level data provided on  that date were not subsequently revised. However, data for DCOE and  its component centers were revised multiple times after receiving  initial data on February 15, 2011. We continued to work with DCOE  and TMA to address inconsistencies, incorporate new data, and  establish a common understanding of budget terminology, such as  allotments and obligations. Moreover, DOD provided numerous  revisions to data provided after February 15, 2011, and continued to do  so even in comments to the draft of this report. While DOD believes  that the data provided are reliable, DOD was unable to describe the  process used to identify and resolve errors in source data from  multiple financial systems, and TMA stated that it could not confirm  the accuracy of data from financial systems it does not administrate.
section_title: Appendix IV: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the individual listed above, Carol M. Henn, Assistant  Director; Erinn L. Sauer; Michael Aksman; Alexandra Edwards; Robert  Gebhart; Jyoti Gupta; Chelsa Gurkin; Felicia Lopez; and Steven Putansu  made major contributions to this report.