Strategic planning provides an important mechanism for HHS to establish long-term goals and strategies to improve the performance of its many health care workforce programs. HHS, as with all executive branch agencies, is required by GPRAMA to engage in performance management tasks, such as setting goals, measuring results, and reporting progress toward these goals. As one of its GPRAMA responsibilities, HHS issues a strategic plan at least every 4 years. HHS’s most recent plan covers fiscal year 2014 through fiscal year 2018 and describes four broad strategic goals: 1. Strengthen health care. 2. Advance scientific knowledge and innovation. 3. Advance the health, safety, and well-being of the American people. 4. Ensure efficiency, transparency, accountability, and effectiveness of HHS programs. Within each strategic goal, the plan presents specific objectives that are linked to a set of strategies for accomplishing that objective, as well as a representative set of performance goals or measures for assessing progress. (See fig. 1.) Annually, HHS releases a performance report that presents progress on the performance measures that contribute to its strategic plan. According to HHS officials, the performance measures included in this performance report are a small but representative subset of HHS’s work as a whole and of the performance measures that HHS tracks annually and publishes through other means. HHS’s strategic planning efforts are led by staff offices that report directly to the Secretary of Health and Human Services. Specifically, the office of the Assistant Secretary for Planning and Evaluation (ASPE) is responsible for the strategic plan, and the office of the Assistant Secretary for Financial Resources (ASFR) is responsible for monitoring performance of HHS’s various efforts and programs. ASPE and ASFR are to coordinate with HHS agencies to facilitate department-wide strategic planning and performance measurement efforts looking across all of HHS’s programs and initiatives, including health-workforce related efforts. These agencies include HRSA, CMS, ACF, the Indian Health Service (IHS), and the Substance Abuse and Mental Health Services Administration (SAMHSA). (See fig. 2.) In addition, HHS has several advisory bodies that make recommendations to the Secretary about several topics. For example, the Council on Graduate Medical Education (COGME), supported by HRSA, provides an ongoing assessment of physician workforce needs, training issues, and financing policies and recommends appropriate federal and private sector efforts to address identified needs. In fiscal year 2014, HHS obligated about $14 billion to 72 health care workforce education, training, and payment programs administered primarily through five of its agencies. HRSA manages the most programs related to health care workforce development, while CMS, ACF, IHS, and SAMHSA also oversee other such programs. HRSA managed 49 of the 72 HHS workforce programs in fiscal year 2014. These programs generally provide financial assistance to students and institutions—in the form of scholarships, loan repayments, or grants—to encourage students to train and work in needed professions and regions. These programs accounted for about 8 percent of HHS’s $14 billion in obligations for workforce development programs. In contrast, CMS managed 3 GME payment programs that together accounted for about 89 percent of this funding. These payments reimburse hospitals for the cost of training medical residents and are calculated, in part, based on the number of residents at the hospital. Some of these payments are included as part of each payment that CMS makes to reimburse hospitals that train residents for care to eligible patients. CMS also manages 1 additional payment program that supports the training of nurses and allied health professionals, which accounts for about 2 percent of total HHS workforce funding. The remaining agencies collectively managed 19 programs, accounting for about 1 percent of total HHS workforce funding. (See fig. 3.) In addition to funding health care workforce programs, HHS examines information about the future demand for health care services, as well as the related supply and distribution of health professionals. Specifically, HRSA periodically publishes health care workforce projections regarding the supply and demand of the health care workforce. We previously found that the agency’s projections had not been updated and recommended that the agency develop a strategy and time frames to update national health care workforce projections regularly. Following that, HRSA awarded a contract to develop a new model, which according to officials has enabled more accurate estimates of workforce projections as well as workforce projections for a wider array of health professions. The agency subsequently issued many of those projections later in 2014 and in 2015. HHS’s current strategic plan lacks specificity regarding how health care workforce programs contribute to its strategic plan goals. Additionally, the performance targets that HHS publicly reports do not comprehensively assess the department’s progress towards achieving its broader strategic plan goals regarding the health care workforce. Finally, the department engages in some coordinated planning, but lacks comprehensive planning and oversight to ensure that its many workforce efforts address identified national needs. HHS’s strategic plan includes broad strategies to which the department’s health care workforce efforts relate, but these strategies do not focus specifically on workforce issues. For example, the current 2014-2018 HHS strategic plan does not have a goal or objective specifically dedicated to health care workforce. Instead, HHS officials stated that workforce development efforts are distributed across various broad access and quality objectives within the plan’s goal of strengthening health care. Specifically, the plan includes seven strategies that contain a health care workforce component and that are distributed among three broad objectives. These strategies generally do not explicitly reference health care workforce training or education, but instead use broad statements that concurrently encompass numerous different components and methods for improving access to and quality of health care. For example, as part of one strategy, HHS seeks to improve access to comprehensive primary and preventative medical services in historically underserved areas and to support federally funded health centers. While not explicit in the plan, HHS officials indicated that developing the health care workforce is one element that contributes to these strategies. (See app. II for more details about the strategic plan.) Past HHS strategic plans included more specific strategies and objectives related to the department’s workforce programs. However, HHS officials told us that the department decided to remove most of workforce-specific language when developing the current plan. The prior HHS strategic plan (2010-2015) included a dedicated goal related to workforce development, with one objective and six corresponding strategies that were specific to health care workforce planning. Further, while an earlier HHS strategic plan (2007-2012) did not have a workforce-specific strategic goal, it also had one objective and corresponding strategies on health care workforce planning, similar to the detailed strategies in the 2010-2015 plan. However, HHS officials told us that in developing the current strategic plan, the department decided to remove most of the workforce-specific language because it determined that workforce development was an intermediate step in achieving the department’s broader strategic goals of improving access to and quality of health care. They also noted that, due to the size of HHS—for fiscal year 2015, HHS spent over $1 trillion through its operating divisions—its strategic plan has to be high level and not too specific about any one topic. Rather than include specificity in HHS’s strategic plan, the department expects that the strategic plans of its agencies will contain additional detail about their health care workforce efforts, as is consistent with their mission, budget, and authorities. However, we found that these agency plans did not always contain this additional detail and were not always updated in a timely manner. For example, while HRSA’s 2016-2018 strategic plan contains a dedicated health care workforce goal with three related objectives and eleven strategies, CMS’s current 2013-2017 plan did not elaborate on any health care workforce issues presented in the HHS strategic plan, nor did it contain other related strategies. Moreover, IHS’s strategic plan was last updated in 2006, and agency officials stated that the agency was not working to update the plan. (See app. III for more details about agency strategic plans.) Consistent with GPRAMA leading practices, for strategic planning to achieve meaningful results on a crosscutting topic like workforce development, it is important that planning efforts across these agencies be coordinated with those of the department. In addition to developing its quadrennial strategic plans, HHS has previously developed other planning documents and workforce development efforts. For example, HHS has published a series of strategic initiatives outlining the Secretary’s priorities. In 2014, one of these priorities was developing the health care workforce. This document identified specific strategies for developing the health care workforce, such as targeting resources to areas of high need and strengthening the primary care workforce. The paper also discussed the need for reform to payment policy to better support emerging health care delivery models. However, as of November 2015, HHS had not released an update to this series of initiatives since the new Secretary assumed office in June 2014. In addition, previous presidential annual budgets have included proposals for improving HHS’s health care workforce programs. Moreover, in conjunction with the President’s fiscal year 2015 budget, HHS released a report in February 2014 providing additional information about the fiscal year 2015 proposals. The report described the challenges to ensuring more diversity among and a better distribution of health care professionals and explained the costs and benefits associated with each of the proposals. HHS has identified a subset of performance measures that are intended to represent the effect that all existing health care workforce programs have on the department’s broader goal of strengthening health care by improving access and quality. Among other places, HHS reports these workforce performance measures in its annual performance plan and report, which indicate progress towards achieving HHS strategic planning goals. From fiscal year 2014 to 2016, the number of healthcare workforce performance measures tracked by HHS within its annual performance report dropped from five to two, and they are focused on a small percentage of programs.