VA generally provides inpatient care at large VA medical facilities owned by the federal government and outpatient care in both federally-owned and leased facilities. Outpatient facilities vary in size, from under 20,000 square feet to more than 200,000 square feet, and include minor leases that cost under $1 million in annual rent and major leases that cost over $1 million in annual rent. VA generally uses build-to-suit lease agreements for its major leases, whereby a developer constructs a facility to VA’s design specifications and leases it to VA, generally for a 20-year term. VA’s use of GSA’s delegated leasing authority requires that VA’s lease terms not exceed 20 years. In 2015, VA had 1,951 leases, of which 1,246 were leased medical space, including 57 major medical facilities. Leased medical space generally consists of outpatient facilities, but also includes mental health clinics, readjustment-counseling centers, research, and other types of clinical spaces. See table 1 for the numbers of VA’s operational leased facilities, including major medical leases, by year from fiscal years 2005 through 2015. VA established its Strategic Capital Investment Planning (SCIP) process for assessing and identifying capital needs, starting with those included in its fiscal year 2012 budget submission. Figure 1 describes the steps in this process, which starts each fiscal year with VA’s assessment of its needs, based on gaps in areas such as providing care to veteran populations and existing facility conditions, and concludes with the identification of capital projects to propose to Congress in VA’s annual budget submission and a long-range capital plan that identifies VA’s capital needs over a 10-year horizon. As of fiscal year 2017, VA estimated that $52 billion to $63 billion would be required over the next 10 years to close gaps identified in VA’s long-range capital plan. VA submits a proposal, known as a prospectus, to certain congressional committees for major medical facility leases. A prospectus should include information on a project’s size and location, and a detailed estimate of the total costs of the medical facility to be leased. Alternatively, as part of its leasing process, VA decides whether to obtain a delegation of authority from the General Services Administration (GSA) in order to award and execute certain leases. According to VA officials, VA does not have authority to enter into multi-year leases or to obligate funds on a year-to- year basis. Consequently, according to VA officials, currently VA applies to GSA for delegations of leasing authority to execute all its leases, which, if approved, enable VA to enter into leases consistent with GSA conditions and obligate funding on a year-to-year basis. Leases executed under GSA’s leasing authority that exceed the prospectus threshold of $2.85 million require GSA to obtain approval from GSA’s authorizing committees. Both GSA’s lease delegation process and VA’s use of it have changed in recent years. In September 2007, we found that GSA’s lease delegation process lacked basic management controls, such as current written policies and procedures, and made recommendations to address these deficiencies that GSA concurred with. In November 2007, GSA issued new guidance to clarify the responsibilities of agencies seeking delegations of authority. In 2013, GSA started using a new system—the GSA Real Estate Exchange (G-REX) system—to review and process applications for delegations of leasing authority, and in 2014, VA started applying for delegation of leasing authority through this system on a lease-by-lease basis. GSA’s review process includes oversight of agencies’ compliance or adherence with conditions and requirements set forth in federal regulations or guidance, such as adherence to guidance from the Office of Management and Budget (OMB) on scoring of capital and operating leases. According to GSA officials, GSA has only granted delegations of leasing authority to VA for operating leases. In 2015, according to GSA, VA applied for 449 delegations of authority, second only to the U.S. Department of Agriculture. In 2009, we issued the GAO’s Cost Estimating and Assessment Guide (Cost Guide), to assist federal agencies in developing reliable cost estimates and also as a tool for evaluating existing cost-estimating procedures. To develop the Cost Guide, GAO cost experts assessed measures applied by cost-estimating organizations throughout the federal government and industry, and considered best practices for the development of reliable cost estimates. While the Cost Guide has a focus on developing cost estimates in the context of government acquisition programs, it outlines best practice steps that are generally applicable to cost estimation in a variety of circumstances. For example, an agency’s cost-estimating procedures can be assessed to determine whether they are likely to produce reliable cost estimates. The Cost Guide identifies 12 best practice steps that, when performed correctly, should produce reliable cost estimates and can be used to determine whether an agency’s procedures meet the four characteristics of a reliable cost estimate. (See appendix I for more information on the 12 cost-estimating best practice steps and how they support the four characteristics). According to the Cost Guide’s four characteristics, a reliable cost estimate is: comprehensive when it accounts for all possible costs associated with a project, is structured in sufficient detail to ensure that costs are neither omitted nor double-counted, and the estimating teams’ composition is commensurate with the assignment; well-documented when supporting documentation is accompanied by a narrative explaining the process, sources, and methods used to create the estimate, and contains the underlying data used to develop the estimate; accurate when it is not overly conservative or too optimistic and is based on an assessment of the costs most likely to be incurred; and credible when it has been cross-checked with independent cost estimates, the level of confidence associated with the point estimate— the best guess at the cost estimate given the underlying data—has been identified, and a sensitivity analysis has been conducted—that is, the project has examined the effect of changing one assumption related to each project activity while holding all other variables constant in order to identify which variable most affects the cost estimate. For each new major project proposed to address SCIP gaps, VA requires an alternatives analysis for contracting out to non-VA providers, new lease, renovation, and new construction options, but VA’s preferred option is often to lease new major medical facilities due to generally shorter project timeframes and flexibility to relocate. VA scores and prioritizes all proposed projects using six major-decision criteria (see table 2). These criteria focus on addressing needs that can demand quick solutions, such as the need to replace an expiring lease that cannot be renewed, and that often change, such as demands for veteran access to care options. As such, according to VA officials, leasing is often VA’s preferred alternative for major medical facilities because it can have shorter project implementation times than if VA were to construct a government-owned facility and can provide flexibility to relocate in the future to meet changes in VA’s needs. We found that VA cited a shorter project timeframe and flexibility to relocate in all 51 of its prospectuses for major medical facility leases submitted to Congress since fiscal year 2015, and that these leases may help address changing and near-term needs. For example, in its fiscal year 2014 submission, VA proposed a new lease to replace an expiring lease in Chattanooga, Tennessee, that would address gaps in federal seismic and accessibility standards, and provide additional space to address projected growth in veteran demand in the area. According to VA, new construction was not preferred because land acquisition would be required, which would extend the project’s implementation timeframe and would not provide flexibility to move in the future should VA’s needs change again. In the fiscal year 2015 submission, VA proposed a new lease in Johnson County, Kansas, to support its finding of growing demand and overcrowding at the Kansas City Veterans Medical Center, and reduce the drive time for a high concentration of veterans in the area to within VA’s 30-minute drive time target. For this proposed lease, VA similarly cited flexibility to relocate in the future and shorter implementation timeframes for preferring a lease to new construction. We also found that VA generally identified leasing as the lowest-cost alternative, but in some cases preferred leasing when other options may have been less costly in order to attain flexibility to relocate in the future and benefit from potentially shorter project timeframes. While VA considers costs when deciding among alternatives, project cost has lower weight among VA’s decision criteria than other criteria, such as increasing veteran access. For example, in fiscal year 2015, VA proposed a new lease in Lafayette, Louisiana, to replace a facility that it had determined was too small and estimated a leased space would have a total life-cycle cost of approximately $259 million, compared to $201 million for construction of a new government-owned facility. According to VA, a federally-owned facility would require a longer timeframe to open than a leased facility and limit VA’s flexibility to adapt to potential changes in the veterans population, demand for services, new technologies, or health care delivery. Leasing may offer VA greater efficiencies and flexibilities with major medical facility projects compared to construction. Specifically, as previously discussed, VA’s use of GSA delegated leasing authority requires that VA’s lease terms not exceed 20 years, and thus VA must vacate a space acquired with this authority at the end of a lease term. This can allow VA to relocate to facilities more aligned with changes in VA’s needs. Construction of federally-owned facilities may not offer this flexibility given the challenges that we have previously identified with renovating and disposing of some federal, including VA, properties due to issues such as competing stakeholder interests. In December 2012, we reported that VA faced challenges renovating its aging properties due to structural limitations, such as floor-to-floor heights and column spacing. Further, construction of a federally-owned facility requires a full upfront funding commitment that can be difficult to attain in the current budgetary environment. In March 2014, we reported federal agencies, including VA, experienced challenges receiving the full upfront project funding for federal real property projects. VA officials added that although VA’s major medical facility lease projects also generally require a lessor to construct a new facility to VA’s specifications, leasing tends to have a shorter project timeframe because it does not require VA to acquire the land on which the facility will be constructed, which can require additional time and resources. In April 2013, we also identified problems, including delays and cost overruns, in VA’s construction of major medical facilities. Although VA justifies leasing its major medical facilities to its department leadership and congressional decision makers based on the flexibility that leasing offers compared to other alternatives, VA does not provide these stakeholders with information on the extent to which it has benefited from that flexibility, nor does VA regularly assess information that would help it do so. In particular, we found that while VA regularly cited future “flexibility,” such as ability to move when needs change, as a justification for the leases included in its annual capital plans, the benefits that VA has experienced from this flexibility with major medical facility leases are not presented to VA stakeholders responsible for selecting projects to present to Congress or to congressional decision makers. VA officials told us that VA’s data systems do not provide VA staff responsible for planning new leases with information on the use of flexibilities with existing major medical facility leases, such as how far VA has moved and why it has moved to new leased locations. In September 2015, a private consulting firm also found that VA did not sufficiently track leases requiring renewal or replacement, potentially requiring costly lease extensions. We and OMB have previously identified the importance of assessing the results of capital decisions and incorporating lessons learned from those assessments into capital decisions. Without transparency on the actual benefits VA has experienced from leasing its major medical facilities, VA and congressional decision makers may lack information to make informed decisions about the need for VA’s major medical facility leases. Further, greater transparency could help decision makers and taxpayers understand the value of leasing in cases in which VA proposes leasing major medical facilities when other alternatives may have a lower cost. As of March 2016, according to VA, 24 major medical facility leases proposed since fiscal year 2015 were yet to be authorized. VA’s cost-estimating procedures for major medical facility leases generally align with 9 of our 12 cost-estimating best practice steps and recent changes may improve the quality of VA’s cost-estimating process for these leases. For a cost-estimating process to support the creation of reliable cost estimates, it should substantially or fully meet each of the four characteristics in GAO’s Cost Guide—comprehensive, well- documented, accurate, and credible—based on the extent to which the procedures incorporate the underlying best practice steps for each characteristic. VA’s overall process incorporates some best practice steps for each of the four characteristics. Specifically, we found that VA’s major medical lease cost-estimating procedures fully met the comprehensive characteristic, substantially met the well-documented characteristic, and partially met the accurate and credible characteristics. (See figure 2.) Because VA’s cost-estimating procedures do not fully incorporate relevant best practices for developing comprehensive, well-documented, accurate, and credible estimates, the cost estimates it produces may be unreliable. Appendix I summarizes our detailed assessment of VA’s procedures. Our conclusion that VA’s cost-estimating process partially met the characteristics for producing reliable cost estimates is based on the following observations from our analysis of VA documentation and interviews with VA officials: Comprehensive: VA’s cost-estimating process fully met the comprehensive characteristic because the procedures incorporate the elements of the two associated best practice steps. The procedures include the best practice step of developing an estimating plan. For example, VA’s procedures outline the timeline for developing, submitting, and reviewing the estimate, as well as who has responsibility for the various aspects of estimate development. VA’s procedures also include the best practice step of determining the estimating structure. For example, the estimate’s inputs are clearly defined, and VA provides detailed guidance to staff on the steps required to estimate those inputs. Well-documented: VA’s cost-estimating process substantially met the well-documented characteristic because the procedures incorporate a large number of related best practice steps. Although VA’s procedures fully include tasks related to the underlying best practice steps of defining the estimate’s purpose, defining the program’s characteristics, documenting the estimate, and presenting the estimate for approval, the procedures substantially met the tasks related to obtaining the data and identifying ground rules and assumptions. For example, the need to fill previously identified gaps in service to veterans defines the purpose of an estimate. The program characteristics are defined during the development of an action plan to design a facility to address those identified needs. The organization-wide system used to develop business plans for major medical facility leases requires documentation of the sources for lease estimates. Last, the same system used to develop business plans for major medical facility leases is the system through which management accesses all the data on these potential leases for review. However, while staff obtain required data internally from VA and external trusted proprietary sources, the data are not uniformly normalized, which can lead to unintended errors in the estimate. For example, five leases’ awarded data was recorded at the fully serviced instead of unserviced rent rates. This could lead to unintended errors in the estimate. In April 2014 we found that changes to the underlying design assumptions for major medical facility lease projects commonly cause variation in VA’s actual first-year lease costs from estimated, prospectus first-year lease costs. We have previously found that better development of assumptions and ground rules can improve cost-estimating procedures. Accurate: VA’s cost-estimating process partially met the accurate characteristic because the procedures incorporate some elements of the two associated best practice steps. The procedures include the best practice step of developing the point estimate and comparing it to an independent estimate, which is based on the market rental rate determined by the market survey conducted during the SCIP process and the cost of specific improvements required for VA’s intended medical purposes. VA applies several standard and variable adjustments to the derived market rate to determine the rental portion of the estimated first-year lease cost to include in its prospectus to Congress. Table 3 below describes the adjustments that VA makes to the market rates it identifies. Although we did not assess these adjustments and how they compare to the private sector, a 2015 independent assessment of VA’s capital planning process found that unique design requirements and limited locations for where VA wants to lease a facility likely contribute to VA’s lease rates exceeding those of private sector medical facilities. This best practice step normally includes comparing the estimate to an independent cost estimate, which VA does not obtain. Because of the standardized nature of the adjustments to the rent rate and pricing for improvements for major medical facility lease cost estimates, obtaining an independent cost estimate for these inputs would likely yield little new information; the rating for this best practice step is substantially met. The procedures also include updating the estimate, another best practice step supporting this characteristic, but VA does not update it with actual costs as the best practice step requires. Estimates are updated during the development process to calculate whether actual costs are likely to rise more than 10 percent above the prospectus estimated cost. If so, VA must notify certain congressional committees and provide an explanation for the increase in authorized costs. Leases executed under a GSA delegation must follow certain requirements for GSA leases. After leases are executed VA does not go back and update the estimate with actual costs. Updating the estimate with actual costs is an identified best practice step because it enables a “lessons learned” analysis, which can strengthen estimates going forward. According to VA officials, the agency plans to conduct a “lessons learned” study, as discussed later, to further understand how actual lease costs compare to estimated costs, which could improve the accuracy of its cost estimates. Credible: VA’s cost-estimating process partially met the credible characteristic because the procedures incorporate some elements of the three associated best practice steps. The best practice steps of conducting sensitivity and risk analyses on the estimate are not directly included in the procedures, but some procedures do address uncertainty and risk. A sensitivity analysis reveals how to assess the potential variability in the estimate by calculating how the estimate is affected by a change in any single underlying assumption. These calculations identify the cost elements that represent the most risk to an estimate. Instead, VA officials said that VA applies an annual escalation rate to adjust for increases in market rental rate and inflationary increases in the cost for tenant improvements over time, two key assumptions supporting the estimate that could cause actual first-year lease costs to fluctuate from the prospectus estimated costs. We found that VA’s use of an escalation rate often did not fully account for variation in lease costs. Specifically, our review of cost data provided by VA for 18 of the 23 most recently completed major medical facility leases activated by the end of fiscal year 2015 shows that actual costs for 15 of the 18 leases varied substantially from adjusted prospectus costs, including 7 leases that were more than 15 percent above VA’s adjusted estimates and 8 that were more than 15 percent below its adjusted estimates. For example, actual first-year lease costs increased about 26 percent over the adjusted estimate for VA’s San Francisco, California, medical facility lease and decreased about 44 percent for its Montgomery, Alabama, facility. Regarding risk analysis, VA does not perform risk analysis on variables affecting the first-year lease cost estimate. The current cost-estimating process does, however, account for some previously determined risks during the action plan development phase. Conducting risk analyses is a best practice because it reveals the effects particular risks can have on the cost estimate. VA recently made a change intended to increase the reliability of its prospectus estimates for major medical facilities and plans to conduct a “lessons learned” study that could further improve how VA estimates its costs. First, VA issued a new standard design guide in January 2016 covering the different types of outpatient clinic facilities and providing guidance on VA activities such as site selection, and delineates minimum federal facility requirements for security, sustainability, and seismic standards. VA officials told us that the new guide was developed to reduce the risk of facility changes and consequent cost changes for lease projects, and that moving forward all authorized major medical facility leases would use this guide. Reducing the potential for design changes after prospectus submission may enable VA to better estimate facility costs because, again, we have found that facility design is a main driver of facility costs. VA officials said that annually VA staff update underlying assumptions in the various major medical facility project cost estimating tools and disseminate updates to field staff to use when developing action plans. This includes basic parameters for lease cost estimating, such as build-out cost per net usable square foot and annual lease rate. Second, VA plans to implement a change to its cost-estimating procedures to improve the process over time. In particular, VA officials told us that the department is planning a “lessons learned” review that would involve updating data used for planning major medical facility leases with actual cost data after the facility is accepted. The intention, the officials added, is to compare actual data with assumptions and estimates to improve the cost-estimation procedures over time. This type of review can improve the cost-estimating process over time by exposing the precise reasons why actual costs differed from the estimate, such as faulty project ground rules and assumptions, and previously unrecognized risks. Both of these steps are in the early stages, and their success will depend on how quickly and successfully VA implements them. In July 2014, VA started requesting delegations of leasing authority on a lease-by-lease basis from GSA to pursue its major medical facility and other leases, and initially experienced challenges meeting GSA’s conditions in order to receive these delegations of authority. VA has taken steps to address these challenges, including developing a management review process for all applications to GSA for delegations of leasing authority, but it is too early to assess the effectiveness of these steps in helping VA to pursue all types of major medical facility leases. In particular, GSA’s process for providing delegations of authority to VA requires that leases be planned according to OMB criteria in order to be considered “operating” leases, which, among other things, requires that the net present value of the proposed lease not exceed 90 percent of the fair market value of the planned facility. This can be challenging with VA’s more costly major medical facility leases given that they must both meet VA’s needs and future needs of the lessor after VA’s lease term ends, as discussed later. Although GSA’s system for processing these applications, known as G- REX, does not maintain records of how many applications did not initially meet GSA’s requirements or why, GSA and VA officials told us that prior to its current practices, VA’s applications in G-REX frequently lacked required information, such as floodplain maps or a justification for why VA would be paying above market rates. Consequently, according to VA, these applications often required multiple corrections and took on average 58 days before GSA approved them and provided delegations of authority. VA officials told us that 58 days was too long and added unacceptable delays to their desired timetables for opening leased facilities. In response, VA took the following three main steps, partly in coordination with GSA, to better align its application process with GSA’s requirements. 1. VA expanded training of its contracting officers to ensure that they were informed about GSA’s requirements for completing requests for delegations of authority. As part of this effort, VA disseminated new guidance to its contracting officers for completing these requests and held training sessions, sometimes with GSA officials. 2. VA implemented an internal management review process, whereby VA officials would review draft applications for delegation of authority prior to submitting them to GSA. As part of this effort, VA developed a lease delegation tracking system for contracting officers to send lease delegation applications to VA management for review and to track the status of the applications once they have been submitted to GSA. According to VA officials, this tracking and reporting system assists in the management of the lease delegation process to ensure compliance to OMB, VA, and GSA requirements from planning through execution. 3. VA increased coordination with GSA, including a weekly GSA-VA meeting to discuss the status of, including any issues with, pending applications. In addition to these steps, in March 2015, VA and GSA entered into a memorandum of understanding governing the request and approval of delegations of leasing authority to VA. As part of the memorandum, GSA agreed that if VA’s applications met GSA requirements, GSA would aim to provide delegations of leasing authority to VA within 30 days for applications not requiring the signature of the GSA administrator (generally those below prospectus level) and within 45 days for those requiring administrator approval. According to VA officials, VA uses its lease delegation tracking system to help monitor progress toward achieving those 30-day and 45-day goals. According to VA’s summary data on lease delegation status, the average processing time for VA’s delegation requests fell from 58 days between July 2014 and February 2015 to 21 days between February 2015 and February 2016. According to GSA officials, VA’s applications have not had any significant problems meeting GSA’s submission requirements since VA implemented the steps above, and regularly include required documentation, such as justifications for paying above market lease rates. GSA officials noted that other agencies that apply for GSA delegated authority may have fewer challenges meeting GSA’s requirements if they took similar steps as those taken by VA. While VA has made progress meeting GSA’s requirements to receive delegations of leasing authority, only 6 of VA’s 572 applications for delegation of leasing authority between July 2014 and January 2016 were above GSA’s current prospectus threshold of $2.85 million in average annual rent. According to VA officials, GSA’s prospectus-level projects can be more difficult to plan as operating leases given their cost and complexity. For example, a lessor has to be willing to lease the facility, often constructed to meet certain VA specifications, to VA for, at most, 90 percent of the fair market value of the facility. Further, while a facility must be configured to meet VA’s needs during the lease term, it must also have a potential use for the lessor beyond VA’s lease term. VA officials added that they had worked with OMB and GSA to develop a methodology for ensuring that these leases would meet those requirements. According to GSA, this new methodology includes a revision of VA’s methods for calculating fair market value and scoring proposed leases to conform to GSA’s methods for leases above GSA’s prospectus level. In January 2016, VA also issued new guidance for leased medical facilities emphasizing that these facilities should only meet minimum VA and federal requirements given that the government cannot own the leased space at the end of the lease term. GSA approved delegations of leasing authority for VA to pursue 5 of the 6 GSA-prospectus-level leases as operating leases. GSA officials added that GSA was awaiting receipt of complete applications for up to 17 additional GSA-prospectus-level leases from VA. As more of these types of leases are reviewed by GSA and executed by VA, a better understanding of VA’s progress meeting GSA’s requirements for them will be possible. VA has made changes to improve its leasing program, including issuing new guidance to introduce more discipline into its cost-estimating process for major medical facility leases and efforts to further understand the factors contributing to actual lease costs compared to those VA identified in its prospectuses. In particular, VA’s new design guidance for major medical facility leases could mitigate design, and thus cost, changes from those included in proposals to Congress. Further, VA’s decision to conduct a “lessons learned” study of actual lease costs compared to estimated costs shows promise for VA to understand the factors that impact cost variance from proposal estimates. Some of these efforts were implemented during our review, and a comprehensive evaluation is not yet possible. While we found that leasing can offer flexibility to address a variety of the department’s and veterans’ needs and help avoid potential challenges with owned properties such as difficulties disposing of them, VA does not assess information to demonstrate to stakeholders how it has benefited from this flexibility. Thus, VA and congressional decision makers may not fully understand the value of leasing these facilities, such as in cases when VA has recommended leasing even when it has determined that other alternatives may be less costly. Although there may be challenges to providing this information given the setup of VA’s data systems, doing so would provide greater transparency to decision makers and taxpayers regarding the need and how best to pay for major medical facilities. To enhance transparency and allow for more informed decision making related to VA’s major medical facility leases, we recommend that the Secretary of Veterans Affairs annually assess how VA has benefited from flexibilities afforded by leasing its major medical facilities and use information from these assessments in its annual capital plans. We provided a draft of this report for review and comment to VA and GSA. VA concurred with our recommendation and provided technical clarifications, which we incorporated as appropriate. GSA provided no comments. VA’s comments are reprinted in Appendix II. As agreed with your offices, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies to the appropriate congressional committees, the Secretary of the Department of Veterans Affairs, and the Administrator of the General Services Administration. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-2834 or shear@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 key contributions to this report are listed in Appendix III. The Cost Guide can be used to assess cost-estimating procedures to determine whether they meet the four characteristics—comprehensive, well-documented, accurate, and credible—for being reliable. Table 1 presents our assessment of VA’s overall cost-estimating process against the four characteristics and related best practices. In addition to the contact named above, Heather MacLeod, Assistant Director; Jennifer Echard; Elke Kolodinski; James Leonard; Josh Ormond; Sarah Sheehan; Delwen Jones; and Crystal Wesco made key contributions to this report.

Summary: VA operates the largest health care network in the United States, with over 2,700 health care sites, including hospitals and outpatient facilities. However, many facilities are outdated, and VA estimates that its capital needs will require up to $63 billion over the next 10 years. In recent years, VA has increasingly leased its facilities, including major medical facilities. These facilities can exceed 200,000 square feet; provide services to veterans such as mental health and other clinical care; are generally built by private developers to meet VA and federal design requirements; and have average annual rent rates in excess of $1 million. VA must submit proposals to Congress and receive authorizations for major medical facility leases. GAO was asked to review VA's leasing program. This report examines: (1) the factors that account for VA's decisions to lease major medical facilities; (2) the extent to which VA's cost-estimating process for leasing these facilities reflects best practices; and (3) steps VA has taken to align its lease process to GSA requirements for delegated leasing authority. GAO analyzed agency documents, VA data on major medical facility leases and lease delegation requests to GSA, compared VA's cost-estimating procedures to best practices in GAO's Cost Guide , and interviewed VA and GSA officials. The Department of Veterans Affairs (VA) leases major medical facilities to benefit from shorter time frames to open a facility and to attain flexibility to relocate. These factors may help VA to meet its needs, such as improving facility compliance with standards and increasing veterans' access to care and services. Unlike owned facilities that can be difficult to dispose of, VA must vacate leased facilities at the end of the lease term, which can allow VA to relocate to space better aligned with its needs. Leases executed under a delegation of authority from the General Services Administration (GSA) can be obligated on an annual basis, whereas owned facilities require full upfront funding that can be difficult to obtain. VA cited flexibility to move as a justification in all 51 of its proposals for these leases since 2015. VA does not, however, assess and provide information to decision makers on how it has benefited from this flexibility. Without transparency on these benefits, VA and congressional decision makers may lack information to understand the need for these leases. GAO and the Office of Management and Budget have reported on the importance of assessing the results of capital decisions in making future decisions. VA's cost-estimating procedures for major medical facility leases generally align with GAO's 12 cost-estimating best practice steps and recent changes in VA's approach may improve the quality of VA's estimates. GAO's review of cost data for these leases since 2006 found that actual costs often varied more than 15 percent above or below the estimates included in their proposals, often due to project design changes. In 2016, VA introduced a design guide for leased medical facilities that delineates VA and federal requirements, such as security and sustainability standards, that may reduce the risk of project, and thus cost, changes from those included in proposals. VA also initiated a lessons-learned effort to evaluate the factors that contribute to differences between actual lease costs and those included in proposals. The success of these steps will depend on how quickly and effectively VA implements them. VA has made progress meeting GSA's requirements to obtain needed delegations of authority to pursue VA leases by expanding training, implementing a management review process, and working more closely with GSA. According to GSA, VA's requests for delegation of authority now regularly include required documentation, such as justifications for paying above market lease rates. As a result, VA has received delegations of authority in about 21 days, down from 58 days when VA first started to apply for delegations in July 2014. However, it is too early to assess the effectiveness of these steps with VA's prospectus-level leases, executed under GSA's delegated authority, that exceed $2.85 million in average annual rent. These leases require authorization from GSA's authorizing committees and can be more difficult to align with GSA's requirements. GAO recommends that VA assess the benefits of major medical facility leasing and use the information in VA's annual capital plans. VA concurred with GAO's recommendation, and GAO incorporated VA's technical comments as appropriate.