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). DOD officials established criteria that COEs must meet to be designated a Defense COE and a uniform process for applicants. VHA’s service offices use a peer review process to designate COEs. However, unlike DOD, VHA has not established criteria for an entity to be designated as a COE. Criteria for designating entities as COEs. In 2011, following our study of one of DOD’s statutorily mandated COEs, DOD leadership determined that it needed to conduct a review of all existing COEs and develop a definition that would be used as criteria for designating entities as Defense COEs. 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. 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.