In 2011, DOD leadership  delegated responsibility for designating and overseeing Defense COEs to  the Oversight Board. 1). DOD Has Established Criteria for Designating a COE, While VHA Has Not

DOD officials established criteria that COEs must meet to be designated  a Defense COE and a uniform process for applicants. VHA Has Not Developed Criteria for a COE, but Service Offices Use a Peer Review Process to Designate COEs

No criteria for designating entities as COEs. VHA has not developed  consistent criteria for designating an entity as a COE. 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. In  addition, these officials could not provide the criteria that were used to  designate these centers as COEs. Process for designating entities as VHA COEs. VHA service offices  use a peer review process to designate entities as VHA COEs. Both DOD and VHA Lack Written Procedures for Documenting Activities to Oversee COEs

		Defense COE Oversight Board Does Not Have Written Procedures for Documenting Oversight Activities

Our review of the Oversight Board’s charter found that it does not contain  procedures for how oversight of Defense COEs will be documented. Specifically, the Oversight Board charter does not explain (1) how the  Oversight Board will provide and document its feedback to Defense  COEs; (2) how the COEs will respond, if needed, to this feedback; and (3)  how the Oversight Board will determine and document that the COEs’  actions resolved any identified problems. The acting chairman of the  Oversight Board told us the board’s charter gives the board its authority to  conduct oversight of Defense COEs, and if these types of procedures are  needed, the Oversight Board’s charter and meeting minutes will serve this  purpose. The Standards for Internal Control in the Federal Government state that  transactions and events should be promptly documented to maintain their  relevance and value to management in controlling their operations and  helping make decisions. Most VHA Service Offices Lack Written Procedures for Documenting Oversight of COEs

Only one of six VHA service offices has written procedures for  documenting the oversight of its COEs, including providing written  critiques of findings from service office reviews to its COEs and requiring  corrective actions from COEs when needed. Further, the  standards state that significant events, such as in this instance the  identification of problems during oversight and the actions taken to correct  these problems, need to be clearly documented, and the documentation  should be readily available for examination. Federal internal control  standards also state that significant events should appear in management  directives, policies, or operating manuals to help ensure management’s  directives are carried out as intended. Conclusions

Unlike DOD, VHA has not developed standard criteria that entities must  meet in order to be designated a VHA COE. Without defined criteria, VHA  lacks reasonable assurance that its COEs are meeting the agency’s  intended objectives for COEs, such as meeting the needs of veterans and  their families throughout VA’s health care system and operating with  coordinated direction. By not having written procedures that outline how the agencies will  document the activities through which they monitor and oversee the  performance of COEs, both DOD and VHA lack assurance that oversight  activities are performed consistently over time as intended. To help improve VHA’s oversight of its COEs, we recommend that the  Secretary of Veterans Affairs direct the Under Secretary for Health to  require VHA service offices to develop written procedures on how to  document their oversight activities of COEs, including requirements for  documenting feedback, both positive and negative, and documenting the  resolution of identified problems. In its comments, DOD concurred with our  findings and recommendation and explained how it intends to implement  the recommendation. Appendix II: Collaboration Efforts of Centers of Excellence in the Department of Defense and Department of Veterans Affairs

To describe the collaboration efforts of the Defense Centers of Excellence  (COE) in the Department of Defense (DOD) and the Veterans Health  Administration (VHA) COEs in the Department of Veterans Affairs (VA),  we sent a Web-based, structured questionnaire to COE directors,  identified by DOD and VHA officials, to obtain information about how their  COEs collaborate. Table 6 shows the Defense COEs and their reported  collaboration activities.
Why GAO Did This Study

Both DOD and VA's VHA have COEs that are expected to improve certain services throughout both agencies' health care systems. To date, DOD and VHA have designated 7 and 70 COEs, respectively. Congressional hearings have raised questions about DOD's and VHA's oversight of the COEs, including the criteria used to designate them, and whether they are meeting their intended missions.
GAO was asked to review DOD and VHA COEs. GAO (1) examined the criteria and processes DOD and VHA use to designate entities as COEs and (2) assessed how DOD and VHA document the oversight activities related to their agencies' COEs. GAO compared agency criteria against federal internal control standards, and analyzed relevant laws, committee reports, and available agency documents. GAO also analyzed documents from the 7 Defense COEs and from the 6 VHA service offices responsible for the 70 VHA COEs to understand the criteria and processes used to designate them and how oversight activities are documented. GAO interviewed officials from both agencies to obtain additional information about their COEs.

What GAO Found

The Department of Defense (DOD) has developed criteria to designate an entity as a Defense Center of Excellence (COE), but the Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) has not. Health-focused COEs are intended to bring together treatment, research, and education to support health provider competencies; identify gaps in medical research and coordinate research efforts; and integrate new knowledge into patient care delivery. GAO found that DOD leadership and its Defense COE Oversight Board established and refined the definition and criteria for designating entities as Defense COEs. DOD's criteria require its Defense COEs, for example, to achieve improvements in clinical care outcomes and produce optimal value for servicemembers. The Oversight Board developed these criteria in order to have a consistent basis for designating entities as Defense COEs and to limit entities from self-identifying as Defense COEs without meeting the criteria. DOD also developed a uniform process for designating COEs. VHA service offices use a peer review process to designate their COEs. However, unlike DOD, VHA has not developed criteria for designating its COEs. Federal internal control standards 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. Without defined criteria, VHA lacks reasonable assurance that its COEs are meeting the agency's intended objectives for COEs.
The Defense COE Oversight Board and most service offices responsible for overseeing VHA COEs lack written procedures for documenting oversight activities related to their COEs, including requirements for documenting identified problems and their resolution. GAO found that the Oversight Board's charter does not explain how (1) the board will provide and document its feedback, (2) the Defense COEs will respond to this feedback, and (3) the board will document resolution of identified issues. The Oversight Board's acting chairman told GAO the charter gives the board its authority to conduct oversight of Defense COEs and if these types of procedures are needed, the Oversight Board's charter and meeting minutes will serve this purpose. However, GAO's review of the charter and minutes found that they do not contain these types of procedures. Likewise, GAO found that five of six VHA service offices have no written procedures for documenting their findings and the corrective actions taken by COEs. VHA officials told GAO that they do not see a need to develop specific written procedures for documenting oversight of their COEs. Federal internal control standards state that transactions and events should be promptly documented to maintain their relevance and value to management in controlling their operations. Further, significant events, such as the identification of problems and the actions taken to correct them, need to be clearly documented, and these events should appear in management directives, policies or operating manuals to help ensure management's directives are carried out as intended. Absent written oversight procedures, both DOD and VHA lack reasonable assurance that oversight procedures are consistently and routinely performed over time, and that issues raised during oversight are resolved.

What GAO Recommends

GAO recommends that VHA establish criteria for designating entities as COEs. GAO also recommends that DOD and VHA develop written procedures for documenting oversight of their COEs. VA and DOD concurred with GAO's recommendations and provided an action plan for implementing them.