HRSA was established in 1982, and its mission is to improve health and achieve health equity through access to quality services, a skilled health workforce, and innovative programs. HRSA’s strategic plan contains four main goals: (1) improve access to quality health care and services, (2) strengthen the health workforce, (3) build healthy communities, and (4) improve health equity. HRSA also has a human capital strategic plan meant to ensure that the agency has the workforce it needs to carry out its mission. That plan contains five main goals: (1) plan for and align the workforce to ensure employees have the right experience and skills to fit the job, (2) support continuous learning, (3) build leadership bench (4) strengthen the performance culture, and (5) improve strength,employee satisfaction. As of September 2013, HRSA was in the process of updating its human capital strategic plan for the 2013 through 2015 timeframe. According to information from HRSA, the agency had appropriations of about $8.1 billion in fiscal year 2013. Since its inception in 1982, HRSA’s appropriations have generally increased in real terms. (See fig.1.) Increases to HRSA’s appropriations since fiscal year 2009 can partially be attributed to ARRA and PPACA. According to HRSA, ARRA provided an additional $2.5 billion to the agency from fiscal years 2009 through 2011. HRSA received approximately $7.8 billion through PPACA from fiscal years 2010 through 2013, and is expecting another $400 million in fiscal year 2014, for a total of about $8.2 billion over the 5 years. According to HRSA, in fiscal year 2012 the agency used over 90 percent of its budget on funding for its programs through grants, cooperative agreements, scholarships and loan repayments, and other forms of programmatic funding. In addition to these funding mechanisms, HRSA uses contracts—award mechanisms used to acquire services or property from a non-federal party for the benefit or use of HRSA—to support its operations and programs. Grants constitute one form of federal assistance consisting of payments in cash or in kind to a state or local government or a nongovernmental recipient for a specified purpose. Cooperative agreements are another form of financial assistance similar to grants, but where the federal agency is more involved with the recipient during the performance of the project. HRSA also has programs that offer scholarships to students and educational loan repayment to health care providers in exchange for a commitment to provide care in underserved areas or for underserved populations. Through these mechanisms, HRSA provides funding and support for a wide variety of programs. HRSA’s programs include a block grant to fund services for maternal and child health across the country, compensation for people injured by vaccines, grants to a national network of health centers to provide primary health care, loan repayment and scholarships for recruiting and training health care providers who practice in underserved communities, and grants to organizations providing services for people living with HIV/AIDS. As a result of ARRA and PPACA, HRSA has expanded some of its programs, and started new programs in recent years. For example, HRSA expanded its Health Center Program and established a Home Visiting Program to improve coordination of services and outcomes for families living in at-risk communities. HRSA’s staff of nearly 1,900 provides oversight, technical assistance, and operational support for the agency’s programs. Its workforce consists of permanent civilian staff, including those within the General Schedule (GS) employment system, the Senior Executive Service (SES), and other HRSA also employs staff from the government pay plans. Commissioned Corps. In addition to permanent civilian and Commissioned Corps staff, HRSA also employs some nonpermanent staff. For example, for its grant review panels, advisory committees, and certain other activities, HRSA may hire individuals for discrete, time- limited activities for which a particular expertise is needed. HRSA has headquarters staff who are assigned to the agency’s headquarters in Rockville, Maryland, and “regional staff” who work in 1 of the agency’s 10 regional offices or 1 of 2 field locations across the United States and Puerto Rico (see fig. 2). The GS system is a classification and pay system for the majority of civilian federal employees. The GS system has 15 grades—GS-1 (lowest) to GS-15 (highest). SES positions are federal employee positions that are classified above GS-15. Other government pay plans for which HRSA has staff include the federal wage system for hourly, blue collar employees and a pay plan for physicians and dentists. HRSA’s organization consists of the Office of the Administrator and 16 other organizational components—7 programmatic bureaus and 9 cross- cutting operational support offices (see fig. 3). HRSA’s Office of the Administrator provides broad leadership and direction to HRSA staff and plans, directs, and interprets major policies, programs, and initiatives for the agency. The Office of the Administrator also makes final decisions about HRSA’s organization, staff allocation, budget, and contracts. The office includes HRSA’s Administrator, Deputy Administrator, and Senior Advisors. HRSA’s seven programmatic bureaus each manage a portfolio of activities dealing with a specific area of health care services, systems, or workforce. Each of HRSA’s bureaus is led by an Associate Administrator and Deputy Associate Administrator, who are generally members of the SES. The bureaus are organized into smaller components called divisions or offices that are led by a director, generally a GS-15, who reports to the bureau’s Associate Administrator. Some of these divisions and offices are further broken down into subcomponents called branches which are led by chiefs who report to the division or office directors. HRSA’s nine operational support offices provide assistance for the agency’s programmatic work and coordination for cross-cutting or agency-wide issues, such as human resources, acquisitions management, and grants administration. (See table 1 for an overview of HRSA’s bureaus and offices and app. I for a list of HRSA programs by bureau.) HRSA’s underlying organizational structure of bureaus and offices has been in place for some time; however, since 2010, the agency has made several organizational changes. These included creating new organizational components, expanding or otherwise changing the functions of some components, and consolidating functions in order to eliminate a component. In addition, HRSA has made minor organizational changes within bureaus, such as realigning branches or shifting oversight responsibility of certain programs, and the staff responsible for them, between or within bureaus. HRSA officials reported that organizational changes were generally made to improve agency efficiency. For example, in 2010, HRSA established the Office of Operations to consolidate three previously separate offices: (1) the Office of Information Technology; (2) the Office of Management; and (3) the Office of Financial Management, which consisted of procurement, budget, policy, and control functions. These offices had formerly each reported directly to the Office of the Administrator. With this restructuring, the Chief Operating Officer— a position created in 2010—gained responsibility for oversight of these functions. In at least one instance, HRSA made a change as a result of a legislative requirement, namely, in October 2011 HRSA made its Office of Women’s Health, which was previously located within its Maternal and Child Health Bureau, a separate office in response to a requirement in PPACA that the office be established within the Office of the Administrator. Most recently, as a result of fiscal circumstances, including the sequester which went into effect in March 2013, and an ongoing hiring freeze in effect since January 2013, HRSA eliminated its Office of Special Health Affairs and distributed most of its functions to other existing bureaus and offices. According to HRSA, the elimination of the Office of Special Health Affairs was made to reduce overhead costs and better utilize staff. HRSA has mechanisms in place to share information important for supporting the agency’s mission across various levels of staff in the agency, including among agency leaders, programmatic bureau and operational support office leaders, and staff. These communication mechanisms include the agency’s operational planning process; cross- cutting workgroups and meetings; and regular communications among the Office of the Administrator, leaders in the bureaus and offices, and agency staff. The mechanisms HRSA has in place are consistent with internal control standards for the federal government, which state that effective communications within organizations should occur in a broad sense with a flow of information down, across, and up the organization. HRSA officials have established an annual operational planning process to facilitate the exchange of information across the agency to plan its budget and allocation of other resources. According to HRSA officials, each bureau and office develops a proposal to request contracts, budget, and other resources for the coming fiscal year. Next, these proposals are shared and discussed among all bureau and office leaders to allow for coordination and to reduce the risk of duplication or overlap of resources. Finally, HRSA’s Administrator makes a determination about resource allocation—such as budgets and contracts for the coming fiscal year— which is documented in a decision memo for each bureau and office. Agency officials told us that this process improves efficiency and reduces the chance for duplication of effort among the bureaus and offices. In addition, HRSA has established 20 active workgroups to coordinate across the agency’s bureaus and offices on cross-cutting topics. For example, according to agency officials, HRSA established a workgroup in April 2010— following the passage of PPACA—to coordinate communications and activities related to the implementation of provisions in the act pertaining to HRSA. The workgroup includes senior leaders from across the agency or their designees. In November 2012, HRSA established a Standard Operating Procedures Workgroup to monitor the implementation of standard operating procedures related to grantee oversight across bureaus, discuss the status of implementation, and to share successful practices regarding their use.