Centers of Excellence: DOD and VA Need Better Documentation of Oversight Procedures
Published: 2015-12-02T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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 servicemembers. 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.
section_title: What GAO Recommends
paragraphs: 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.

section_title: Letter
paragraphs: 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. 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 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. 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  self-identify as COEs without meeting any criteria.
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  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.  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. 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. 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 compared DOD’s and VHA’s available oversight documentation with  the Standards for Internal Control in the Federal Government.
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.
subsections: section_title: Background
paragraphs: The Assistant Secretary of Defense for Health Affairs leads the MHS and  is ultimately responsible for the Defense COEs. In 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.
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. 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).
section_title: DOD Has Established Criteria for Designating a COE, While VHA Has Not
paragraphs: 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.
subsections: section_title: DOD Has Established Criteria for Defense COEs and Has a Uniform Process for Approving COE Applicants
paragraphs: 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. 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  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. 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 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.
section_title: VHA Has Not Developed Criteria for a COE, but Service Offices Use a Peer Review Process to Designate COEs
paragraphs: 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. A  good internal control environment requires that the agency’s  organizational 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.  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.”  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. 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  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.
section_title: Both DOD and VHA Lack Written Procedures for Documenting Activities to Oversee COEs
subsections: section_title: Defense COE Oversight Board Does Not Have Written Procedures for Documenting Oversight Activities
paragraphs: 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.
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.
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.
section_title: Most VHA Service Offices Lack Written Procedures for Documenting Oversight of COEs
paragraphs: 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.
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.  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.
section_title: Conclusions
paragraphs: 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  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.
section_title: Recommendations for Executive Action
paragraphs: 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.
section_title: Agency Comments
paragraphs: 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.
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.
section_title: Appendix I: List of Veterans Health Administration Centers of Excellence and Their Focus
paragraphs: 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.
subsections: section_title: VHA’s Office of Patient Care Services
paragraphs: 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. 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.
section_title: VHA’s Office of Research and Development
paragraphs: 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.
section_title: VHA’s Office of Academic Affiliations
paragraphs: VHA’s Office of Academic Affiliations has eight COEs that were  departmentally designated, according to VHA officials. 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.
section_title: Appendix II: Collaboration Efforts of Centers of Excellence in the Department of Defense and Department of Veterans Affairs
paragraphs: 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. 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. 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.
subsections: section_title: Defense COEs
paragraphs: Defense COEs report using written agreements or other tools to  collaborate. Table 6 shows the Defense COEs and their reported  collaboration activities.
section_title: VHA’s Office of Patient Care Services
paragraphs: 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  Geriatric and Extended Care Services. 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.
section_title: VHA’s Office of Research and Development
paragraphs: 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.
section_title: VHA’s Office of Academic Affiliations
paragraphs: 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 Patient- Centered 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.
section_title: Appendix III: Comments from the Department of Veterans Affairs
section_title: Appendix IV: Comments from the Department of Defense
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact:
section_title: Staff Acknowledgments
paragraphs: 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.