VA and IHS Collaboration through Memorandums of Understanding

In 2003, VA and IHS signed an MOU to facilitate collaborative efforts in  serving Native American veterans eligible for health care in both systems. VA and IHS Have Developed Mechanisms to Implement and Monitor the MOU, but Metrics to Monitor Performance Do Not Adequately Measure Progress toward MOU Goals

VA and IHS have documented common goals in their MOU, created   12 workgroups that are tasked with developing strategies to address the  goals of the MOU, and created a Joint Implementation Task Force to  coordinate tasks, develop implementation policy, and develop  performance metrics and timelines—actions that are consistent with those  we have found enhance and sustain agency collaboration. VA and IHS Have Defined Common Goals and Created Mechanisms to Implement the MOU

Consistent with our past work on practices that can enhance and sustain  collaboration, VA and IHS have defined common goals for implementing  the MOU and developed specific strategies the agencies plan to take to  achieve them. VA and IHS have created two mechanisms to implement the MOU— workgroups and a Joint Implementation Task Force. VA and IHS Performance Metrics Do Not Adequately Measure Progress on the MOU Goals

The process developed by the Joint Implementation Task Force to  monitor the implementation of the MOU includes obtaining data on three  performance metrics; however, two of the three metrics do not allow the  agencies to measure progress toward the MOU’s goals. The other two metrics are inadequate because their  connection to a specific goal is not clear and they lack qualitative  measures that would allow the agencies to measure the degree to which  desired results are achieved. The weaknesses we found in these performance metrics could limit the  ability of VA and IHS managers to gauge progress and make decisions  about whether to expand or modify programs or activities, because the  agencies will not have information on how well programs are supporting  MOU goals. VA and IHS Lack Effective Processes to Overcome the Challenges of Consulting with a Large Number of Diverse, Sovereign Tribes

Mainly because of the large number of diverse tribal communities and  tribal sovereignty, VA and IHS face unique challenges associated with  coordinating and communicating to implement the MOU. VA and IHS Face Challenges Implementing the MOU Related to the Large Number of Diverse, Sovereign Tribes

VA and IHS officials told us the large number (566) of federally  recognized tribes and differing customs and policy-making structures  present logistical challenges in widespread implementation of the MOU  within tribal communities. Tribal sovereignty includes the inherent right to govern and protect  the health, safety, and welfare of tribal members. VA and IHS  officials told us that because of tribal sovereignty, tribally operated  facilities may choose whether or not to participate in a particular  opportunity for collaboration related to the MOU, which makes it  challenging to achieve some of the goals of the MOU. VA and IHS Processes in Place to Overcome the Complexities Associated with Consulting with Tribes Do Not Always Ensure Effective Consultation

VA and IHS communicate MOU-related information with the tribes  through written correspondence, in-person meetings, and other steps, as  is consistent with internal controls calling for effective external  communications with groups that can have a serious effect on programs  and other activities; however, according to tribal stakeholders we  interviewed, these methods for consultation have not always met the  needs of the tribal communities, and the agencies have acknowledged  that effective consultation has been challenging. Both VA officials  and members of tribal communities told us that, because tribal leaders  are not always the tribal person designated to make decisions regarding  health care, the “Dear Tribal Leader” letters may not always make their  way to tribal members designated to take action on health care matters. Another specific concern tribal stakeholders that we spoke with  expressed relating to written correspondence was that the agencies  sometimes use the letters to simply inform them of steps the agencies  have taken without consulting the tribes, as called for by the agencies’  tribal consultation policies. In  another example, two tribal stakeholders said they approved of OTGR’s  establishment as an office dedicated to Native American veterans’ issues. However, four tribal stakeholders expressed concerns that, despite the  creation of OTGR, VA still has not always been effective in its efforts to  consult with tribes or be responsive to tribal input provided during  consultation. Agency Comments

We provided draft copies of this report to VA and the Department of  Health and Human Services for review.
Why GAO Did This Study

Native Americans who have served in the military may be eligible for health care services from both VA and IHS. To enhance health care access and the quality of care provided to Native American veterans, in 2010, these two agencies renewed and revised an MOU designed to improve their coordination and resource sharing related to serving these veterans. GAO was asked to examine how the agencies have implemented the MOU.
This report examines: (1) the extent to which the agencies have established mechanisms through which the MOU can be implemented and monitored; and (2) key challenges the agencies face in implementing the MOU and the progress made in overcoming them. To conduct this work, GAO interviewed VA and IHS officials and reviewed agency documents and reports. GAO also obtained perspectives of tribal communities through attendance at two tribal conferences; interviews with tribal leaders and other tribal members, including veterans; and interviews with other stakeholders, such as health policy experts and consultants.

What GAO Found

The Department of Veterans Affairs (VA) and the Indian Health Service (IHS) have developed mechanisms to implement and monitor their memorandum of understanding (MOU); however, the performance metrics developed to assess its implementation do not adequately measure progress made toward its goals. VA and IHS have defined common goals for implementing the MOU and developed strategies to achieve them. They have also created two mechanisms to implement the MOU--12 workgroups with members from both agencies to address the goals of the MOU, and a Joint Implementation Task Force, comprised of VA and IHS officials, to oversee the MOU's implementation. These steps are consistent with practices that GAO has found enhance and sustain agency collaboration. The agencies have also developed three metrics aimed at measuring progress toward the MOU's goals. However, two of the three metrics are inadequate because their connection to any specific MOU goal is not clear and, while they include quantitative measures that tally the number of programs and activities increased or enhanced as a result of the MOU, they lack qualitative measures that would allow the agencies to assess the degree to which the desired results are achieved. The weaknesses in these metrics could limit the ability of VA and IHS managers to gauge progress and make decisions about whether to expand or modify their programs and activities.
VA and IHS face unique challenges associated with consulting with a large number of diverse, sovereign tribes to implement the MOU, and lack fully effective processes to overcome these complexities. VA and IHS officials told us the large number (566 federally recognized tribes) and differing customs and policy-making structures present logistical challenges in widespread implementation of the MOU within tribal communities. They also told us that tribal sovereignty--tribes' inherent right to govern and protect the health, safety, and welfare of tribal members--adds further complexity because tribes may choose whether or not to participate in MOU-related activities. Consistent with internal controls, VA and IHS have processes in place to consult with tribes on MOU-related activities through written correspondence and in-person meetings. However, according to tribal stakeholders GAO spoke with, these processes are often ineffective and have not always met the needs of the tribes, and the agencies have acknowledged that effective consultation has been challenging. For example, one tribal community expressed concern that agency correspondence is not always timely because it is sent to tribal leaders who are sometimes not the tribal members designated to take action on health care matters. Similarly, some tribal stakeholders told GAO that the agencies have not been responsive to tribal input and that sometimes they simply inform tribes of steps they have taken without consulting them. VA and IHS have taken steps to improve consultation with tribes. For example, VA has established an Office of Tribal Government Relations, through which it is developing relationships with tribal leaders and other tribal stakeholders. Additionally, in Alaska, VA has been consulting with a tribal health organization for insight on reaching tribes. However, given the concerns raised by the tribal stakeholders GAO spoke with, further efforts may be needed to enhance tribal consultation to implement and achieve the goals of the MOU.

What GAO Recommends

GAO recommends that the agencies take steps to improve the performance metrics used to assess MOU implementation and to develop better processes to consult with tribes. VA and the Department of Health and Human Services agreed with these recommendations.