1.) The Executive Agreement defines  the relationship between VA and DOD for establishing and operating the  FHCC, in accordance with the NDAA for Fiscal Year 2010, and contains  provisions in 12 integration areas regarding specific aspects of FHCC  operations. Some provisions relate to establishing and operating  the FHCC and have designated deadlines, such as implementing IT  strategies. The Executive Agreement also includes 15 integration benchmarks that  VA and DOD plan to use to determine the integration’s success. FHCC Officials Have Made Progress Implementing VA and DOD’s Executive Agreement, but Challenges May Impact Further Implementation Progress

FHCC officials (including both VA and DOD officials) have made progress  implementing the provisions of the 12 Executive Agreement integration  areas. Governance structure. In addition, the advisory bodies described in the Executive Agreement are  in place. In the workforce management  and personnel integration area, the NDAA for Fiscal Year 2010  authorized a transfer from DOD to VA of the positions and personnel  necessary to operate the FHCC. Quality assurance. Lack of MTF Designation Has Presented Challenges for FHCC Operations and Health Care Providers

According to DOD policy, an MTF is a military treatment facility owned  and operated by DOD that is established for the purpose of furnishing  medical and/or dental care to eligible individuals. VA and DOD Use Integration Benchmarks to Assess Provision of Care and Operations at the FHCC, but the Performance Reporting Plan May Not Yield Transparent, Meaningful, and Accurate Results

VA and DOD, through FHCC staff, are using the 15 integration  benchmarks set forth in the Executive Agreement (and their  corresponding performance measures) to assess the provision of care  and operations at the FHCC. The plan is to report on these performance  measures using a tool developed by FHCC staff—a scorecard that  generates a monthly summary score. However, the summary score does  not account for data collection variation, FHCC staff have not specified  what target score(s) would indicate successful performance, and the  scorecard initially contained an error, all of which raise concerns about  the FHCC’s ability to report transparent, meaningful, and accurate  performance results. 2. The summary score lacks a set target score(s) to indicate success. Conclusions

The FHCC is a 5-year demonstration project that has the potential to be a  model for future VA and DOD integration efforts. To ensure that the plan to report on FHCC performance results is  transparent and provides meaningful information that can assist VA and  DOD leadership and Congress in decision making with regard to the  future of the FHCC or other VA/DOD integration efforts, we recommend  that the Secretaries of Veterans Affairs and Defense direct FHCC  leadership to conduct further evaluation of the scorecard reporting tool  and its methodology and make revisions that will better ensure the  transparency and accuracy of the information reported. DOD agreed with our finding that the lack of an MTF designation for the  FHCC has posed some challenges and confusion; however, the  department did not concur with our recommendation to the Secretary of  Defense to seek a legislative change to designate the FHCC as an MTF.
Why GAO Did This Study

The National Defense Authorization Act (NDAA) for Fiscal Year 2010 authorized the Departments of Veterans Affairs (VA) and Defense (DOD) to establish a 5-year demonstration project to integrate VA and DOD medical care into a first-of-its- kind Federal Health Care Center (FHCC) in North Chicago, Illinois. Expectations for the FHCC are outlined in an Executive Agreement signed by VA and DOD in April 2010. The NDAA for Fiscal Year 2010 also directed GAO to annually evaluate various aspects of the FHCC integration. This report examines (1) what progress VA and DOD have made implementing the Executive Agreement to establish and operate the FHCC and (2) what plan, if any, VA and DOD have to assess FHCC provision of care and operations. GAO reviewed FHCC documents and conducted visits to the site; interviewed VA, DOD, and FHCC officials; and reviewed related GAO work.

What GAO Found

FHCC officials have made progress implementing provisions of the Executive Agreement's 12 integration areas. For some areas, all provisions have been addressed, including establishing the facility's governance structure and patient priority system. Progress continues to be made in other areas, such as workforce management and personnel and quality assurance. However, as previously reported by GAO, there have been delays implementing the information technology provisions, which present challenges for operating the FHCC as a fully integrated facility. In addition, while some workarounds are in place, the lack of an military treatment facility (MTF) designation that other DOD medical facilities have presents challenges for efficient FHCC operations and results in uncertainty regarding access to preferred drug prices and provider authority to sign medical readiness forms for active duty Navy servicemembers. Although VA and DOD are assessing the provision of care and operations at the FHCC, their plan to report on performance lacks transparency and may not provide a meaningful and accurate measure of success. Specifically, VA and DOD, through FHCC staff, are using 15 integration benchmarks set forth in the Executive Agreement to assess the integration. From these benchmarks, FHCC staff identified 38 corresponding performance measures to assess the integration's success. While FHCC staff plan to report on these performance measures through a reporting tool they developed--a scorecard that calculates a monthly summary score--the tool lacks transparency and may not provide a meaningful indicator of performance. The scorecard does not account for data collection variation, there is no designated target score(s) to indicate successful integration performance, and the scorecard initially contained a calculation error, all of which raise concerns about its ability to provide transparent, meaningful, and accurate information.

What GAO Recommends

GAO recommends that DOD seek a legislative change to designate the FHCC as a MTF--a DOD facility providing medical or dental care to eligible individuals, and that VA and DOD direct FHCC leadership to further evaluate its integration performance reporting tool. DOD did not agree with the recommendation regarding the MTF designation, but GAO continues to believe such designation is important. VA and DOD agreed with GAO's recommendation regarding the scorecard reporting tool.