Warfighter Support: Actions Needed to Improve Explosive Ordnance Disposal Forces Planning

EOD forces are a high demand, critical asset that support DOD's ability to execute military operations. DOD increased the number of EOD forces by more than 70 percent from 2002 to 2012 because of increased demand. When not deployed, EOD forces provide support to civil authorities. One of these missions is protecting U.S. and foreign dignitaries—also referred to as VIP support missions.

House Report 115-200 included a provision for GAO to review matters related to EOD capabilities and requirements. This report assesses the extent to which (1) the military services consider all combatant command EOD requirements, including DSCA, in determining the number of EOD personnel needed, and (2) DOD evaluates the effect of VIP support missions on the military preparedness of EOD forces. GAO reviewed relevant guidance, analyzed EOD data, and interviewed EOD and manpower officials. This is a public version of a sensitive report that GAO issued in July 2019. Information that DOD deemed sensitive has been omitted.

The military services' processes for determining the necessary number of explosive ordnance disposal (EOD) personnel are based on combat-related missions. However, these processes do not fully consider some defense support of civil authority (DSCA) missions that EOD forces conduct. Demand for EOD forces for DSCA missions can be manpower-intensive and frequent. For example, EOD forces' workload for protecting U.S. and foreign dignitaries—also referred to as Very Important Person (VIP) support missions—increased from about 248,000 to over 690,000 man-hours in fiscal years 2007 to 2017 (figure). However, according to officials, the services do not consider DSCA missions in determining the number of EOD personnel needed, instead focusing on combat-related missions. Unless the Department of Defense (DOD) ensures that the services update guidance to consider the total EOD force required to support both missions, decision makers cannot accurately assess the EOD forces' sufficiency.

DOD guidance specific to VIP support missions does not include a requirement for the services to report on the effect of VIP support missions on military preparedness. According to officials, military preparedness is degraded when the services' EOD forces are unable to concurrently complete predeployment tasks such as training for combat. Per DOD guidance, Secret Service support requests are to be evaluated based on their effects on military preparedness. Without this information, decision makers are precluded from understanding the risk to EOD forces' military preparedness resulting from the routine VIP support missions. Decision makers need this information to ensure efficient and effective accomplishment of both VIP support missions and preparation for combat-related missions for affected combatant commands.

GAO is making four recommendations including that DOD (1) update the appropriate service guidance to ensure that all EOD missions, including DSCA missions, are considered in determining the required number of EOD forces, and (2) incorporate into appropriate guidance a requirement for the military services to notify the Joint Staff and combatant commands when VIP support missions negatively affect the military preparedness of EOD units. DOD did not provide comments on the draft of this report.

Military doctrine describes explosive ordnance disposal (EOD) as a high  demand, critical capability essential for the success of military  operations. Combatant commands rely on EOD to accomplish their  missions. The Department of Defense (DOD) increased its EOD forces  by more than 70 percent from 2002 to 2012 because of increased  demand for these forces. EOD forces execute a variety of duties during  operations including countering improvised explosive devices and  collecting and evaluating captured explosive-related enemy materiel.  However, demand for EOD forces is not limited to wartime duties.  According to officials, when not deployed to combat or on combat-related  missions, EOD forces also provide support to civil authorities (referred to  as defense support of civil authorities (DSCA) missions). One of these  DSCA missions is to provide support to agencies that protect U.S.  dignitaries worldwide and foreign dignitaries visiting the United States.  These Very Important Person (VIP) support missions can be manpower-  intensive. For example, a three-city, 5-day visit to the United States by a  foreign dignitary generated a request for nearly 800 of DOD’s EOD  technicians in support of the U.S. Secret Service (Secret Service).

In prior work, we reported that EOD forces had operated jointly in Iraq  and Afghanistan to fulfill battlefield requirements, and that the services  had jointly developed guidance on tactics, techniques, and procedures for  EOD forces. However, DOD had not fully institutionalized joint EOD  doctrine in the form of a joint publication. We recommended that DOD  develop joint EOD doctrine that would guide combatant commanders’  planning and clarify joint operational roles and responsibilities. In 2016,  DOD published its joint EOD doctrine providing an authoritative  description of EOD activities for the combatant commands and military  services.

In House Report 115-200, which accompanied a bill for the National  Defense Authorization Act for Fiscal Year 2018, the House Armed  Services Committee expressed concern about the degree to which EOD  requirements and capabilities have been integrated into operational  plans. The report included a provision for us to assess matters related to  the sufficiency of EOD capabilities to address combatant command  requirements. In this report, we assess the extent to which (1) the  military services consider all combatant command EOD requirements,  including defense support of civil authorities (DSCA) missions, in  determining the number of EOD personnel needed and (2) DOD  evaluates the effect of Very Important Person (VIP) support missions on  the military preparedness of EOD forces.

This report is a public version of a sensitive report that we issued in July  2019. DOD deemed some of the information in our July report to be  sensitive, which must be protected from public disclosure. Therefore, this  report omits sensitive information about specific examples of the effect of  recent VIP support missions on EOD forces’ military preparedness. This  report addresses the same objectives as the sensitive report and uses the  same methodology.

For our first objective, we assessed the extent to which the Army, Navy,  Marine Corps, and Air Force manpower processes determine and meet  combatant command requirements for EOD, including combat-related  missions and DSCA missions. We reviewed relevant DOD guidance  documents. We collected data on the amount of time EOD forces spent  on VIP support missions from 2007 to 2017 to provide an 11-year  overview and to identify any trends. Based on U.S. Northern Command’s  (NORTHCOM) response to our data reliability questionnaire and  supporting documentation the command provided, we determined that the  data we obtained were sufficiently reliable for the purpose of reporting  EOD program information.

We met with EOD officials from each service including officials from the  Naval Surface Warfare Center, Indian Head, Explosive Ordnance  Disposal Technology Division to discuss their respective service’s EOD  responsibilities and force structure. We interviewed officials from  NORTHCOM and the U.S. Indo-Pacific Command, Joint Staff, and  service headquarters to understand their perspectives on the sufficiency  of EOD forces as well as gaps, shortfalls, and redundancies associated  with existent force structures. Additionally, we met with officials from the  Navy’s and Army’s EOD force providers to understand the services’  processes for responding to combatant command requirements. Finally,  we met with manpower officials to discuss each service’s procedures and  processes used to determine manpower for addressing combatant  command needs.

For our second objective, we assessed the extent to which DOD  evaluates the impact of VIP support missions on the military  preparedness of EOD forces. We specifically examined the processes  used to provide EOD forces to VIP support missions to understand the  extent to which these missions entail risk to military preparedness.  Additionally, we discussed these processes with the responsible DOD  officials. We reviewed VIP support missions because, according to  officials, it is the most frequently occurring and manpower-intensive EOD  DSCA mission. We reviewed DOD, service, and Joint Staff guidance  related to the use of EOD forces in support of other federal agencies and  joint doctrine discussing risk management in the context of joint  operational planning. We collected data on the Army’s combat-related  and DSCA demands for its EOD forces because the Army has the largest  EOD force of all four military services. Based on the Army’s results from  our data reliability questionnaire and supporting documentation provided,  we determined that the data that we obtained concerning missions and  availability of EOD forces were sufficiently reliable for the purpose of  reporting EOD program information.

We met with EOD officials from each service to discuss the demand and  effects of the VIP support mission on EOD forces. We also met with  representatives of NORTHCOM, Joint Force Headquarters-National  Capital Region, Joint Staff, service headquarters, the Office of Assistant  Secretary of Defense for Homeland Defense and Global Security, the  Office of the Under Secretary of Defense for Personnel and Readiness,  and the Office of the Deputy Assistant Secretary of Defense for Stability  and Humanitarian Affairs.

The performance audit upon which this report is based was conducted  from September 2017 through July 2019 in accordance with generally  accepted government auditing standards. Those standards require that  we plan and perform the audit to obtain sufficient, appropriate evidence to  provide a reasonable basis for our findings and conclusions based on our  audit objectives. We believe that the evidence obtained provides a  reasonable basis for our findings and conclusions based on our audit  objectives. We subsequently worked with DOD in August and September  2019 to prepare this unclassified version of the original sensitive report for  public release. This public version was also prepared in accordance with  these standards.

Background Types of Missions Conducted by EOD Forces

The military services – Army, Navy, Air Force, and Marine Corps – have  highly trained EOD personnel to eliminate explosive hazards in support of  a variety of events and activities, ranging from major combat operations  and contingency operations overseas to assisting the Secret Service in its  protection of the President of the United States (see fig.1). EOD forces  are dispersed worldwide to meet combatant commanders’ operational  requirements related to these missions. Although the services’ EOD  forces support combatant commanders, NORTHCOM’s Joint Force  Headquarters-National Capital Region coordinates EOD force support of  land-based homeland defense and DSCA missions.

EOD forces conduct combat-related and DSCA missions that support  national military objectives. EOD combat-related missions include  preparations for combat such as training and exercises, and the wartime  execution of EOD missions. EOD forces play a major role in all phases of  combat operations. For example, these forces contribute to information  gathering during operations and serve to enable the safe conduct of  operations within an operational area. Additionally, EOD forces support  freedom of maneuver and force protection. Further, they may directly  support missions such as counterterrorism, deterring and defeating  aggression, and countering weapons of mass destruction, among others  across the spectrum of operations. Officials from each service stated that  EOD forces prepare for these combat-related missions during  predeployment in-garrison periods.

EOD forces also conduct DSCA missions when they are not engaged in  combat-related missions. DOD provides EOD forces when requested in  advance by specific federal agencies and approved by the appropriate  DOD official. Officials stated that generally, EOD forces undertake VIP  support missions during in-garrison periods, just after returning from  combat-related deployments or while preparing for the next deployment.

DOD Guidance and Processes Related to EOD Manpower and Risks

The military services collectively have more than 6,300 EOD positions to  fulfill combatant command missions, and demand for EOD manpower and  expertise is high. Each service determines the number of EOD  technicians it needs based on its respective requirements, which consider  combatant commanders’ wartime missions and plans. According to a  DOD official, the services take into account the long lead times—up to 3  years in one service—that can be necessary to produce qualified and  experienced EOD specialists.

In accordance with DOD policy, when considering EOD wartime  requirements, service officials should make certain that national military  objectives can be accomplished using a minimum of manpower that  produces maximum combat power. DOD policy also states that a formal  validated process is to be used to determine wartime manpower  requirements. Generally, manpower requirements are the amount of  personnel needed to accomplish a job, mission, or program. Joint  doctrine outlines mission tasks associated with EOD units. Once a  service determines the tasks required of a particular community (such as  EOD), the service then sizes its forces (i.e., determines the manpower  requirement) according to the demand for those tasks among the  combatant commands.

Risk is the effect of uncertainty on objectives with the potential for either a  negative outcome or a positive outcome or opportunity. In the military,  accurately appraising risk allows leaders and staffs to manage and  communicate risk effectively to inform decisions across disparate  processes. Joint doctrine describes a planning process that aligns  resources and military activities, and enables leaders to examine risks,  among other factors, to determine a preferred course of action to achieve  an objective. Planning for EOD involves military manpower systems that  accurately determine the required EOD forces and decision makers who  decide how much risk is acceptable if or when there is a shortfall of EOD  forces.

According to DOD doctrine on joint planning, regardless of the efforts to  mitigate it, some level of risk will remain and should be identified to senior  leaders so there is a common understanding of the decisions required  and the potential effects of those decisions. Commanders must include a  discussion of risk in their interaction with DOD senior leaders and that  discussion must be in concrete terms that enable and support decision-  making. In the context of strategic and military risk evaluation during joint planning, combatant commanders and DOD’s senior leaders work  together to reach a common understanding of risk, decide what risk is  acceptable, and minimize the effects of accepted risk by establishing  appropriate risk controls.

Military Services’ Processes for Determining EOD Manpower Levels Focus on Combat- Related Missions, but Do Not Consider the Increasing Demand for Some DSCA Missions

The military services’ processes for determining EOD manpower levels  are based on combat-related missions and, accordingly, do not fully  consider DSCA missions. However, DOD provides EOD resources for  various DSCA missions such as: aiding in the protection of the President of the United States and  dignitaries through VIP support missions; providing assistance to law enforcement agencies and other civil  authorities in the United States and its territories when necessary to  save lives under DOD’s immediate response authority; and  rendering safe military munitions when requested by civil authorities  (see fig. 2).

EOD and manpower officials from each of the military services explained  that, in practice, their respective services focus on combat-related  missions and do not consider DSCA missions in determining the number  of EOD personnel needed. Specifically:

According to Army officials, the Total Army Analysis process that is  used to size Army forces considers core functions for combat  operations and warfighting requirements. They explained that this  process does not consider DSCA requirements in determining the  number of EOD forces needed. In Army guidance, manpower is  based on wartime missions and wartime requirements for sustained  combat operations, among other types of information. Due in part to  force structure adjustments and the drawdown of EOD forces, since  2014, according to information provided by the Army, the Army has  reduced more than 800 EOD positions, the equivalent of two EOD  battalions and 13 EOD companies.

According to Navy officials, the Navy makes manpower decisions with  a focus on wartime requirements by analyzing required operational  capabilities against the projected operational environment. In Navy  manpower guidance, this analysis is critical to developing fleet  manpower requirements for units such as EOD forces. Navy officials  explained that the process does not consider the DSCA mission in  determining EOD manpower.

The Air Force’s EOD manpower standard, which has been updated  through 2013, is based on in-garrison needs and wartime  requirements. In Air Force manpower guidance, manpower is  described as a critical resource that enables combat capability; the  guidance further notes that manpower requirements are identified and  resources are subsequently allocated for peacetime and wartime  missions. However, Air Force officials stated that the process  focuses on results for combat-related missions and does not  specifically include DSCA requirements.

According to Marine Corps officials, the Marine Corps’ EOD forces are  sized to support Marine Expeditionary Forces for deployment for  overseas combat operations. The Marine Corps’ manpower guidance  describes a force structure process designed to identify and provide  the capabilities, including personnel and equipment, necessary to  accomplish mission essential tasks. Marine Corps officials stated  that the service does not receive additional EOD manpower  specifically for DSCA missions.

Although service manpower calculations do not reflect DSCA missions,  one of the DSCA missions—VIP support—is manpower intensive and  occurs frequently. Specifically, the workload for VIP support can be  substantial and has increased from about 248,000 man-hours in fiscal  year 2007 to over 690,000 man-hours in fiscal year 2017. According to  a NORTHCOM official, this rise is due to an increase in the different types  and complexity of threats requiring more EOD personnel to sufficiently  support civil authorities. Figure 3 below illustrates the increase in the  amount of time the EOD forces have spent on VIP support missions.

The military services have a long-standing practice of providing support to  civil authorities, including EOD support. DOD support to civil authorities is  grounded or reflected in statute and DOD guidance. For example, the  Presidential Protection Assistance Act of 1976 requires executive  agencies, including DOD, to assist the Secret Service on a temporary  basis in protecting the President, the Vice President and other persons—  such as visiting foreign dignitaries (see fig.4). In addition, the National  Military Strategy and current homeland defense strategy prioritize  defending the homeland and providing support to civil authorities.

Moreover, DOD guidance addresses DSCA generally as well as specific  support to the Secret Service, Department of Homeland Security, and law  enforcement. Further, the Secretary of Defense approved a Joint Staff  standing execute order (EXORD) which is used to execute routine VIP  support missions related to the protection of dignitaries on short notice.  This order authorizes NORTHCOM to provide EOD support to the Secret  Service and U.S. Department of State within the NORTHCOM area of  operations, and to coordinate that support at locations worldwide. Joint  doctrine for EOD also lists DSCA as one of nine military missions that  EOD forces may directly support, and states that the majority of EOD  DSCA missions will be in support of law enforcement or emergency  support agencies. Finally, the military services’ Inter-Service  Responsibilities for Explosive Ordnance Disposal lists several common  responsibilities of the military services’ EOD assets that include providing  support to civilian agencies such as the Secret Service.

While the DSCA mission is emphasized in departmental guidance and  support of civil authorities has placed increasing and significant demands  on EOD forces, the military services do not fully consider these factors in  determining the appropriate number of EOD forces. According to EOD  officials, this is because the primary mission of EOD forces is to conduct  combat missions in support of combatant commanders and meet  operational plans. Service officials stated that DSCA missions are not  priority missions when it comes to sizing their respective forces, and that  they do not routinely increase EOD manpower in order to provide support  to other federal agencies.

Standards for Internal Control in the Federal Government state that  management should design control activities to achieve objectives and  respond to risks. Specifically, management should ensure policies and  procedures are relevant and effective in achieving an entity’s objectives.  In addition, the standards state that management should use quality  information to make informed decisions and evaluate the entity’s  performance in achieving key objectives. Quality information is  information that is appropriate, current, complete, accurate, accessible,  and provided on a timely basis. DOD manpower policy states that  manpower management shall be flexible, adaptive to program changes,  and responsive to new management strategies, and that existing policies,  procedures, and structures shall be periodically evaluated to ensure  efficient and effective use of manpower resources.

However, the military services’ current processes for determining the  appropriate amount of EOD manpower do not fully account for the  increase in DSCA missions requiring EOD support. While it is  understandable that the services prioritize combat missions when  determining EOD requirements, they are not considering all available  information in their decision-making process. This lack of consideration  limits their ability to efficiently and effectively achieve their objectives and  manage risks. Accounting for the increase in EOD manpower demand  may not necessarily result in an increase in manpower; however, the  services will be better prepared to understand the demand on existing  EOD forces and evaluate any resulting risks. Ultimately, unless the  military services update appropriate guidance to ensure that they  consider the total EOD force required to support combat-related and  DSCA missions, decision makers cannot accurately assess the  sufficiency of EOD forces to meet both missions and the associated risks.

DOD Cannot Evaluate the Effects of VIP Support Missions on Military Preparedness Because the Services Are Not Required to Notify Decision Makers

DOD cannot evaluate the effects of VIP support missions on military  preparedness because current VIP support mission guidance does not  require the military services to notify the Joint Staff and appropriate  combatant commands when military preparedness is negatively affected  by these missions. According to officials from the military services, the  execution of VIP support missions introduces risk that threatens the  services’ abilities to execute combat-related missions. Specifically,  military preparedness is degraded when the services’ EOD forces are  unable to concurrently complete predeployment tasks, such as training for  combat, because the forces are called upon to execute routine VIP  support missions. Officials told us that EOD forces can only conduct  these VIP support missions during the time period when EOD forces are  scheduled to conduct predeployment tasks and accomplish training. As a  result, according to officials, VIP support missions can deleteriously affect  military preparedness for EOD forces.

In multiple instances, missions supporting civil authorities have stressed  the Army’s EOD capabilities, resulting in missed training and the inability  to participate in exercises and activities supporting combat-related  missions, according to statements and data provided by the Army.  Furthermore, fulfilling VIP support missions can be particularly difficult  because short-notice demand for EOD teams often exceeds the planned  VIP support demand that can be supported. As a result, Army EOD teams  are sometimes dispatched at the expense of military preparedness for  combat-related missions in support of combatant commands, according  to Army officials. Specific details of the effect recent VIP support missions  have had on the Army’s EOD capabilities are included in our July 2019  restricted report.

Officials from other services also acknowledged that undertaking routine  VIP support missions comes at the expense of training for combat-related  missions because of the high demand for and limited number of EOD  forces. According to a senior Navy official, that service has sometimes  refused mission requests to protect dignitaries because of its inability to  meet operational demands, such as deployments and training for its EOD  forces and support missions to protect dignitaries simultaneously. When  this occurs, however, NORTHCOM will ask another service to accept the  mission, thereby putting increased demand on that other service’s EOD  forces that, in turn, may conflict with their scheduled training and  preparations for combat missions, according to military service officials.  Because NORTHCOM has few permanently assigned forces to conduct  VIP support missions, it must instead rely on EOD forces from each of the  military services that are in-garrison and preparing for but not currently  deployed to a combat-related mission.

According to DOD guidance, DOD’s ability to grant Secret Service  requests for support is to be evaluated based on a number of factors, one  of which is the effect on military preparedness. For example, DOD  Directive 3025.18, Defense Support of Civil Authorities (DSCA), specifies  that requests from civil authorities for assistance shall be evaluated for  several factors, including the impact on DOD’s ability to perform its other  primary missions. The guidance also provides that the Chairman of the  Joint Chiefs of Staff is responsible for advising the Secretary of Defense  on the effects of requests for civil support on national security and military  readiness.

According to joint doctrine, a commander’s tasks associated with the  function of command and control include managing risk—such as that  arising from EOD support for other agencies protecting dignitaries—as  well as communicating and ensuring the flow of information across the  staff and joint force, and to higher authorities. Additionally, in the context  of evaluating strategic and military risk during joint planning, combatant  commanders and senior DOD leaders work together to reach a common  understanding of risk, decide what risk is acceptable, and minimize the  effects of accepted risk. The Standards for Internal Control in the  Federal Government also addresses the importance of an entity using  quality information to achieve its objectives. Specifically, management  should use quality information to make informed decisions and evaluate  the entity’s performance in achieving key objectives and addressing risks.

As previously mentioned, the Joint Staff has issued a Secretary of  Defense-approved EXORD that provides guidance for the military to  provide EOD support to the Secret Service and Department of State for  routine VIP support missions. However, this EXORD does not specify a  requirement for the services to notify DOD stakeholders regarding the  effect on military preparedness for combat missions. As a result, the  military services are not advising the Joint Staff or NORTHCOM when  these VIP support missions are adversely affecting EOD military  preparedness for combat-related missions. Regarding military  preparedness, the absence of a notification requirement precludes  decision makers from understanding the risk to EOD forces’ ability to  perform their primary mission. Decision makers need this information to  carry out their responsibilities and assess risk to ensure efficient and  effective accomplishment of both VIP support missions and preparation  for combat-related missions for combatant commands.

The military services’ EOD forces provide the combatant commanders  necessary capabilities for combat and combat-related missions. They  also provide capabilities through their DSCA missions that are important  to supporting U.S. law enforcement agencies and other federal, state, and  local civil authorities. DOD has manpower processes that result in careful  consideration of the requirements of the combatant commander for  combat-related missions. However, those manpower processes do not  fully consider DSCA missions, such as the VIP support mission and its  accompanying substantial workload. Until DOD processes begin to  consider the demand for EOD support for both types of missions, decision  makers cannot know the complete manpower requirement for EOD.  Consequently, the extent to which the services’ EOD forces are sufficient  or insufficient to meet national military objectives cannot be fully known.  Furthermore, DOD lacks a requirement in guidance specific to the VIP  support mission to notify stakeholders regarding the effects of such  missions on military preparedness for combat-related missions. As a  result, DOD may not be fully considering risks associated with the use of  EOD forces for VIP support on the preparation and training of those  forces for combat-related missions.

We are making the following four recommendations to DOD.

The Secretary of the Army should update Army manpower guidance, or  other guidance as appropriate, to ensure that all missions conducted by  EOD forces, including DSCA missions, are considered in determining the  required number of EOD forces. (Recommendation 1)

The Secretary of the Air Force should update Air Force manpower  guidance, or other guidance as appropriate, to ensure that all missions  conducted by EOD forces, including DSCA missions, are considered in  determining the required number of EOD forces. (Recommendation 2)

The Secretary of the Navy should update Navy and Marine Corps  manpower guidance, or other guidance as appropriate, to ensure that all  missions conducted by EOD forces, including DSCA missions, are  considered in determining the required number of EOD forces.  (Recommendation 3)

The Secretary of Defense should ensure that the Chairman of the Joint  Chiefs of Staff, in collaboration with the combatant commands,  incorporate into the appropriate guidance a requirement that the military  services notify the Joint Staff and the affected combatant commands  when the execution of VIP support missions negatively affects the  preparedness of EOD units for combat-related missions.  (Recommendation 4)

We provided a draft of this report to DOD for review and comment. DOD  did not provide comments.

We are sending copies of this report to the appropriate congressional  committees, the Secretary of Defense, and the Secretaries of the Army,  Navy, and Air Force. In addition, the report is available at no charge on  the GAO website at http://www.gao.gov.

If you or your staff have questions about this report, please contact me at  (202) 512-5431 or russellc@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made key contributions to this report are  listed in appendix I.

Appendix I: GAO Contact and Staff Acknowledgments

In addition to the contact named above, Guy LoFaro, (Assistant Director),  Ben Atwood, Naba Barkakati, Christopher Gezon, Amie Lesser, Dennis  Mayo, Paulina Reaves, Michael Silver, Michael Shaughnessy, Stephen  Woods, and Lillian Yob made contributions to this report.

Forces trained in explosive ordnance disposal are critical to DOD military operations. From 2002–2012, DOD added more than 70% more of these forces to meet increasing demand.

When not deployed, these forces are also used to protect U.S. and foreign dignitaries. From 2007–2017 their use for such “VIP” missions more than doubled. DOD said that routine VIP missions affect these forces’ preparation for deployment. But DOD doesn’t consider the requirements of both types of missions when determining how many explosive ordnance disposal forces it needs.

We recommended that DOD consider VIP missions when determining how many personnel it needs.


VA Health Care: Goals and Related Measures Needed to Better Assess the Impact of Same-Day Services

In 2014, a series of congressional testimonies highlighted problems with veterans' access to care after significant appointment wait times at VA medical centers reportedly resulted in harm to veterans. In response, VHA implemented several initiatives, including same-day services at its medical centers and outpatient clinics.

GAO was asked to review the same-day services initiative and VHA's related oversight activities. This report (1) describes how VHA designed and how selected medical centers implemented the same-day services initiative; and (2) examines VHA's efforts to assess the impact of the same-day services initiative on veterans' access to care.

GAO reviewed VHA documents, including policies, guidance, and requirements related to same-day services and interviewed VHA officials regarding implementation and oversight. GAO visited six VA medical centers selected for the complexity of services offered, range of wait times, and geographic variation, among other factors. GAO interviewed officials from (1) the six VA medical centers and affiliated outpatient clinics, (2) VHA's networks with oversight responsibility, and (3) two veterans service organizations.

The Department of Veterans Affairs' (VA) Veterans Health Administration (VHA) introduced its same-day services initiative in primary and mental health care in April 2016, and used a five-pronged approach for its design: it defined same-day services, developed guidance, updated its mental health policies, offered training, and assessed VA medical center readiness to implement the initiative. Officials from all six VA medical centers GAO visited said they already were providing same-day services prior to the initiative and generally relied on previous approaches to implement VHA's same-day-services initiative. However, these officials told GAO that some of VHA's guidance and updated policies were difficult to implement due to long-standing challenges of staffing and space constraints, among others. For example, one medical center official stated that the medical center did not have the appropriate providers readily available to complete the initial mental health assessments of new patients in a timely manner—a new requirement under VHA's updated policies.

VHA officials stated that the objectives of the same-day services initiative are to improve veterans' access to care and customer service. However, VHA has not documented these objectives in a directive or developed and documented performance goals that, with associated performance measures, would monitor progress. Although VHA does monitor patient experience scores and the number of same-day appointments, these measures are not tied to specific performance goals. For example, VHA has not specified targets for the number of same-day appointments medical centers should provide. Furthermore, monitoring the number of same-day appointments does not capture all of the ways VA medical centers provide same-day services, such as renewing prescriptions. VHA officials acknowledged the intitiative was quickly developed in response to the 2014 access crisis, and developing new policies or processes, which could include documenting objectives and developing performance goals, was not the priority. Without performance goals and related measures, VHA will continue to be limited in its ability to determine, how, if at all, the same-day services initiative has improved veterans' access to care.

GAO recommends that VA document objectives and develop performance goals and related performance measures to facilitate the periodic assessment of the impact of same-day services on veterans' access to care. VA agreed with GAO's recommendation.

The Veterans Health Administration (VHA), within the Department of  Veterans Affairs (VA), operates the nation’s largest integrated health care  system, providing care to more than 9 million enrollees at its 172 VA  medical centers. In recent years, we and others have raised questions  about VHA’s ability to provide health care services in a timely manner. In  2014, a series of congressional testimonies highlighted serious problems  with veterans’ access to care after well-publicized events drew national  attention to appointment wait times at VA medical centers. In some  cases, delays in care reportedly resulted in harm to veterans. Due to  these and other challenges, we added VHA health care to our High Risk  List in 2015, with status updates in 2017 and 2019.

In response to the critical access-to-care problems highlighted by  congressional hearings in 2014, VHA proceeded to implement reforms  intended to address deficiencies identified across the system. In April  2016, VHA introduced the MyVA Access Declarations, a set of  expectations for veterans’ care across VA medical centers, which  included an initiative focusing on providing same-day services in primary  and mental health care. VHA specified that its expectation for the same- day services initiative was that VA medical centers would either address  veterans’ health care needs that day or schedule appropriate follow-up  care, depending on the urgency.

You asked us to review VHA’s implementation and oversight of the same- day-services initiative. This report  (1) describes how VHA designed and how selected medical centers  implemented the same-day services initiative, and  (2) examines VHA’s efforts to assess the impact of the same-day services  initiative on veterans’ access to care.

For both objectives we interviewed officials involved with providing and  overseeing same-day services in primary and mental health care from six  selected VA medical centers, one community-based outpatient clinic  (CBOC) affiliated with each of the medical centers, and the Veterans  Integrated Service Networks (VISN) that oversee each of the selected VA  medical centers. We selected three of the six VA medical centers based  on (1) VHA’s assessment of their access performance at the start of the  same-day services initiative, (2) current new patient wait times in primary  care and mental health, and variation in (3) geographic distribution and  complexity level. We selected the remaining three VA medical centers  because they had reportedly developed unique approaches to same-day  service implementation. We identified one of these three VA medical  centers by speaking with VHA officials, and two of the three by reviewing  their most recent annual reports. For each of the six selected VA medical  centers, we interviewed officials at one associated CBOC. See table 1 for  a list of VA medical centers we selected. The information and  perspectives we obtained from officials from the six VA medical centers,  six CBOCs, and four VISNs in our review cannot be generalized.

For both objectives we interviewed VHA officials responsible for  developing guidance for the same-day services initiative, training, and  performance measures from the offices of veterans access to care,  primary care services, and mental health services. To gain additional  insights, we interviewed officials from two veterans service organizations;  one that had published a report on VA challenges with providing timely  access, including same-day services, and one that an official stated they  asked their members about the same-day services initiative: the  American Legion, and Iraq and Afghanistan Veterans of America.

To describe how VHA designed the same-day services initiative and how  VA medical centers implemented it, we reviewed VHA guidance  documents to assist VA medical centers in same-day service  implementation. Specifically, we reviewed VHA’s MyVA Access  Implementation Guidebook, which identifies implementation solutions for  VA medical centers. We also reviewed VHA-developed training for VA  medical center staff on implementing the same-day services initiative. In  addition we reviewed medical center same-day services self-certification  surveys to understand what process VHA used to determine which  medical centers were providing same-day services.

To examine VHA’s efforts to assess the impact of the same-day services  initiative and its impact on veterans’ access to care, we reviewed VHA- developed guidance and trainings related to providing same-day services,  including guidance provided to VA medical centers on how to use access  data and same-day services performance measures to monitor the  initiative. We evaluated the information we obtained against federal  standards for internal control related to ensuring accountability through  documentation. We also compared VHA’s performance measurement  efforts against key practices we have identified in our past work.

We conducted this performance audit from April 2018 to August 2019 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

In response to the 2014 access crisis, VA launched the MyVA initiative,  which was designed to transform the health care experience of veterans.  In concert with the MyVA initiative, VA introduced the MyVA Access  Declarations in April 2016 with the goal of improving access by providing  veterans more control as to how they receive their health care. The MyVA  Access Declarations was a list of nine “access declarations” that were  intended to serve as the foundational principles for improving and  ensuring access to care. Two of these “access declarations” required  providing timely primary and mental health care and included same-day  services.

VHA had policies in place for same-day services in primary and mental  health care clinics for several years prior to the same-day-services  initiative. In primary care, the 2014 Patient-Aligned Care Team (PACT)  handbook required all primary care providers and registered nurses to  ensure they provide same-day access (unless it is too late in the day as  determined by the individual facility) for face-to-face encounters,  telephone encounters and, when required by VHA guidance or policy,  other types of encounters. The PACT handbook was supplemented by a  2015 VHA memo on unscheduled patient walk-ins. The memo states that  if an unscheduled patient presents at a PACT clinic with a clinical  concern, the patient cannot be turned away without evaluation by a  clinical member of the team, regardless of clinic hours, resource  availability, or eligibility/enrollment status.

VHA also had previously developed policies stating that veterans are  entitled to timely access to mental health care. Specifically, a 2007 VHA  memo required that all veterans requesting or referred for mental health  care or substance abuse treatment receive an initial evaluation within 24  hours. VHA’s 2015 Uniform Mental Health Services handbook also  noted that all new patients requesting or referred for mental health care  services must receive an initial evaluation within 24 hours and a more  comprehensive diagnostic and treatment planning evaluation within 30  days.

Additionally, since 2008, VHA has required the integration of primary care  and certain mental health care services at VA medical centers serving a  veteran population greater than 5,000. This care model, known as  Primary Care–Mental Health Integration (PC-MHI), integrates mental  health staff into each primary care PACT clinic, allowing veterans to  receive services for depression, anxiety, post-traumatic stress disorder,  and substance use without needing to obtain a separate referral to  providers in the mental health care clinic. According to VHA guidance,  PC-MHI has been shown to improve access to same-day mental health  care and reduce no-show rates to appointments.

VHA’s veterans access to care office was created in 2016 as the national  oversight office for VHA access-to-care issues. Additionally, each VISN is  responsible for overseeing the VA medical centers within their designated  regions. This oversight includes oversight of access issues and the  implementation of initiatives such as the same-day service initiative. VA  medical center directors are responsible for ensuring local policies are in  place for the effective operation of their primary and mental health care  clinics, including affiliated CBOCs.

VHA Used a Five- Pronged Approach to Design Its Same-Day Service Initiative; Selected VA Medical Centers Relied on Previous Approaches to Implement It

VHA Used a Five-Pronged Approach to Design and Set Up the Same-Day- Services Initiative

VHA used a five-pronged approach to design its same-day services  initiative: VHA (1) defined same-day services, (2) developed guidance, (3)  updated its mental health policies, (4) offered training, and (5) assessed  VA medical center readiness to implement the initiative.

VHA defined same-day services. As an initial step, VHA leadership  developed the following definitions of same-day services in primary and  mental health care:

Same-day services in primary care: “When a veteran requires  primary care services right away, during regular business hours, he or she will receive services the same day at a VA medical center. If a  veteran calls after normal business hours, he or she will receive care  the next business day.”

Same-day services in mental health: “If a veteran is in crisis or has  another need for mental health care right away, he or she will receive  immediate attention from a health care professional at a VA medical  center.”

VHA also identified a variety of ways in which veterans can receive same- day services, including: (1) providing a face-to-face visit; (2) returning a  phone call; (3) arranging a telehealth or video care visit; (4) responding to  a secure email; or (5) scheduling a future appointment.

VHA developed guidance for the same-day service initiative. To help  VA medical centers implement its definition of same-day services, in April  2016, VHA developed written guidance—the MyVA Access  Implementation Guidebook. The guidebook provides a variety of  solutions to help VA medical centers meet the intent of the same-day  service initiative. The guidebook includes specific solutions for VA  medical centers struggling to provide same-day services in primary or  mental health care for veterans with urgent care needs:  Implementing open access in primary and mental health care:  Open access aims to balance the supply of (for example, available  appointments) and demand for (for example, the number of patients  assigned to a provider and annual visits per patient) services to  increase patient access. Achieving open access requires  implementing specific strategies including achieving full staffing,  planning for contingencies such as clinical staff absences or  vacancies and managing the number of times patients see a provider  each year, among other strategies.

Implementing primary care-mental health integration: In order to  complete the implementation of PC-MHI across the VA system, the  guidebook suggests facilities address staffing vacancies, develop a  PC-MHI implementation plan, and choose an open access scheduling  model (for example, full open access where there are no scheduled  appointments and patients are seen on a first come, first served  basis), among other things.

Utilizing same-day referrals to mental health for suicide  prevention: This solution reiterates many of the mental health policy  changes that VHA introduced in conjunction with the same-day  service initiative such as implementing an initial screening evaluation,  developing a process for same-day care for established patients with  an urgent need, and deploying open access scheduling, among other  things.

The guidebook states that all of the solutions were chosen because they  were used successfully at other VA medical centers; can be quickly  implemented; and have a high impact on veterans’ access to care. The  guidebook also notes that flexibility is a key element when choosing  solutions and explains that VA medical centers should select and modify  solutions as needed. The guidebook does not make any of the solutions  mandatory; however, several of the mental health solutions were  introduced to facilities through separate VHA memos and are required.

VHA updated mental health policies. VHA updated certain mental  health policies to facilitate the implementation of the same-day services  initiative. Specifically, in April 2016 VA issued a memo updating its mental  health policy to require that any veteran new to mental health services  requesting or referred for care in person be seen the same day by a  licensed independent provider to screen for and address immediate care  needs. This was a change from the previous timeframe of 24 hours for  an initial evaluation. The memo also created new processes for VA  medical centers to assess same-day services in mental health care  clinics, including a medical chart review and a one-time review of  standard operating procedures to ensure that the new guidelines are  being followed. VHA also distributed other memos that either sought to  clarify existing guidance or expand same-day services into other areas of  mental health care, such as substance abuse. Additionally, VHA  provided a memo to VA network directors and mental health leads about  scheduling models for mental health care that all VA medical centers  needed to implement for the same-day service initiative.

VHA provided training on the same-day-services initiative. VHA  provided voluntary training for same-day services some of which  discussed the solutions from the guidebook and the updated mental  health policy. The trainings began in February 2016 for primary care and  in May 2016 for mental health. The trainings consisted of national  telephone calls (often with slide presentations) that any VA medical  center staff member could join, and the presentation materials were  posted to VHA’s internal website. The telephone trainings generally  occurred twice a month in primary care and every week in mental health  care.

VHA assessed VA medical center same-day service readiness.  Beginning in January 2017, VHA provided technical assistance around  same-day services to VA medical centers. VHA reviewed several aspects  of same-day services, including how VA medical centers were able to  provide same-day services and identified any approaches that may have  needed improvement. Generally, low-performing VA medical centers  received continuous on-site support; moderate performing VA medical  centers received a combination of virtual and on-site support; and, high  performing VA medical centers primarily received virtual support.

To determine the progress that VA medical centers were making in  providing same-day services, VHA conducted surveys that required  medical center directors to self-certify—and, in some cases, VISN  directors to validate—that their VA medical centers (including affiliated  CBOCs) were able to provide same-day services. In the event that a  VISN director could not validate medical center survey information, VHA  followed up with the medical center and VISN director to create an action  plan to mitigate any issues that were delaying validation. These surveys  were conducted in 2016 and 2017; focused on either primary care, mental  health care or both; and varied in the information collected to determine  how VA medical centers were providing same-day services (See Table 2  for information on the same-day-services readiness assessment surveys  used by VHA).

According to VHA, all VA medical centers were offering same-day  services in primary and mental health care by December 2016. In  January 2018, VHA announced that same-day services in primary and  mental health care had been achieved in all VA medical centers and  CBOCs (more than 1,000 facilities).

Selected VA Medical Centers Generally Relied on Previous Approaches to Implement the Same- Day-Services Initiative

Officials we spoke with from all six VA medical centers in our review told  us they were providing same-day services in primary and mental health  care prior to the same-day service initiative, an assertion supported by  VHA survey data. For example, in a VHA survey conducted in May 2016,  around the same time as the launch of the same-day service initiative,  142 out of 165 officials (86 percent) that responded to the survey said that  their medical centers offered same-day appointments “always” or “very  frequently” in primary care for urgent concerns.

We found that the VA medical centers in our review used a variety of  approaches in providing same-day services in primary and mental health  care, most of which were in existence before the initiative. As noted  earlier, VHA did not require the implementation of any specific solutions in  the guidebook and afforded VA medical centers the flexibility to choose  appropriate local solutions for the same-day service initiative. Many VA  medical centers used this flexibility to continue providing same-day  services as they had prior to the initiative often because that is what their  resources allowed them to do or, in the case of mental health, because it  was built into the foundation of their service line. VHA officials noted that  mental health services—particularly PC-MHI—were built around same- day services so VHA’s guidance was familiar to them. The approaches  used by the selected VA medical centers included using “float providers”  who had not already been assigned specific patients to assist those who  requested same-day services; carving out specific appointment times in  the schedule for walk-ins; overbooking appointments in providers’  schedules, and offering walk-in clinics.

VHA suggested that certain solutions should be prioritized if VA medical  centers were struggling to provide same-day services and, in particular  for mental health, created new requirements around same-day services.  However, officials at selected VA medical centers noted that some of the  suggested solutions in the guidebook—particularly open access—and  requirements in updated mental health policies were difficult to implement  because of longstanding challenges with staffing, space, or competing  VHA policies. For example, VHA’s guidebook suggests the  implementation of open access in primary and mental health care in such  situations. However, officials at four of the six VA medical centers we  visited noted that open access was difficult to implement because of the  long-standing challenges mentioned above. In addition, VHA updated its  mental health policy to include that any veteran new to mental health  services requesting or referred for care in person be seen the same day  by a licensed independent provider to screen for and address immediate  care needs. However, one medical center official noted that they had  designed their mental health clinic processes around registered nurses,  who are responsible for completing the initial assessments of new  patients. The official added that the medical center did not have licensed  independent providers readily available at certain facilities to help  complete the assessments in a timely manner.

Officials at all six medical centers we visited noted that implementation  was also sometimes challenging as veterans’ expectations shifted with  the same-day-services initiative, with veterans’ expecting more immediate  access to care from physicians for a variety of conditions. For example,  one medical center official noted that veterans are presenting for care and  wanting to see a provider because it is these veterans’ understanding that  they could get care immediately for any condition including chronic, less  urgent issues. Additional officials at the same facility echoed this concern  and noted that they are not certain that this was the policy’s intent.  Another medical center official noted that several medical center officials  asked VHA to change the name “same-day service” because it gives the  impression that veterans would always be able to see their provider  immediately. This official added that there is some confusion for both staff  and veterans about what are same-day services. Additionally, according  to one veterans service organization official that we spoke with, a small  number of veterans reported that the availability of same-day services  varied by facility (VA medical center versus CBOC) and location (urban  versus rural). Another medical center official noted that same-day  services are not sustainable if the definition is immediate care by a  provider for any condition, especially non-urgent issues.

VHA officials told us that the same-day service initiative was a response  to the 2014 access crisis and they wanted facilities to use the resources  available to them rather than waiting on new policies and strategies. They  stated that their main concern was that veterans’ needs were met, not  necessarily how they were met. As such, VHA officials told us that they  found VA medical centers’ implementation of same-day services  acceptable. The VHA officials added that the guidebook is still the  foundational document for same-day services. VHA officials told us that it  is important for VA medical centers to educate patients on the appropriate  use of same-day services. They added that in fiscal year 2019 they are  (1) developing a more precise definition of same-day services; (2)  developing a website to better explain the purpose of the initiative; and (3)  requiring on-demand trainings to provide a clearer explanation about what  same day services are available and what staff roles and responsibilities  are, among other things. The training is expected to be completed no  later than the first quarter of fiscal year 2020.

VHA Has Not Documented Objectives or Developed Performance Goals and Related Measures to Assess the Impact of Same- Day Services on Veterans’ Access to Care

VHA is limited in its efforts to assess the impact of same-day services due  to its lack of documented objectives, developed performance goals and  related performance measures. Our previous work has shown the benefit  of fully connected objectives and performance goals with measurable  targets. Objectives state the longer term desired impact or outcome to  be achieved, while performance goals communicate the target the agency  seeks to achieve within a certain timeframe. Performance measures are  indicators of the progress the agency is making towards a goal or target  within a particular time frame.

VHA officials told us that the overall objectives of same-day services are  to improve veterans’ access to care and customer service while having  minimal impact on medical centers’ existing workflows. However, VHA  has not documented these objectives—for example, in a directive. In  addition, VHA has not developed and documented performance goals  that, with associated performance measures, would facilitate monitoring  of progress towards the desired outcome of the same-day services  initiative. VHA officials stated that the same-day-services initiative was  developed quickly in response to the 2014 access crisis, and noted that at  the time, their focus was “to get something out quickly” instead of taking  time to standardize the initiative around specific policies and procedures,  which could include documenting objectives and developing performance  goals. VHA officials acknowledged that their decision to focus on quickly  implementing the initiative without documenting objectives and  developing performance goals and associated performance measures  makes assessing the impact of the same-day services initiative more  challenging.

VHA has taken some steps to collect data on same-day services. For  example, VHA officials stated that they primarily rely on two measures to  assess the impact of the same-day services initiative: patient experience  scores and the number of same-day appointments. However, without  performance goals these measures do not provide VHA with a means to  monitor progress and provide limited information on same-day services’  impact.

Patient experience score: VHA uses the Survey of Healthcare  Experiences for Patients (SHEP) to measure veterans’ perceptions of  their experience at VA medical centers. For same-day services,  VHA monitors responses to two questions. According to VHA officials,  the key measure is based on the survey question that asks “in the last  6 months, when you contacted this provider’s office to get an  appointment for care you needed right away, how often did you get an  appointment as soon as you needed?” While SHEP scores provide  some data related to customer service and access to care, VHA has  not developed performance goals that sets targets for these or other  aspects of the same-day services initiative that would benefit from  monitoring. Such goals would better enable VHA to identify gaps in  performance and plan any needed improvements; ensure balance  between agency priorities, such as customer service and access; and  identify unintended effects, such as disruption to clinic workflows. For  example, officials at one medical center told us that focusing on  customer service creates issues with respect to routine care in that  veterans’ definition of customer service is based on what makes them  happy, while providers are focused on providing the best treatment.  Officials added that these two definitions do not always align. In  addition, officials at another medical center stated that implementing  same-day services impacted their providers’ schedules and the  resulting changes to their processes created chaos.

Number of same-day appointments: VHA measures the number of  same-day appointments, which, according to a VHA official, are  identified in VHA data as appointments completed on the same day  they are created in VHA’s scheduling system. According to a VHA  training document, VA completed 12 million same-day appointments  in fiscal year 2018. However, without performance goals with clear  targets for same-day appointments, an official from one VISN said she  was unclear how many same-day appointments medical centers  should be scheduling. Additionally, same-day services performance  goals may afford VHA the opportunity to monitor other key  measures—such as those that capture services that do not require an  appointment—which could provide VHA with important information on  the impact of same-day services on access to care. Moreover,  performance goals and additional performance measures may help  prevent unintended consequences, such as an over-emphasis on  same-day appointments as the way to provide same-day services,  which VHA officials stated they are working to curb. For example,  officials at two selected medical centers also noted that measuring the  number or proportion of same-day appointments does not capture all  the ways medical centers provide same-day services. Officials at  two other selected medical centers noted they can meet veterans’  same-day needs through multiple avenues, such as a registered  nurse providing patient education or by renewing a prescription, that  do not require an appointment and therefore, would not be counted in  the number of same-day appointments. VHA officials stated that the  impact of the same-day services on access to care is difficult to  measure and additional measures would help properly measure the  impact.

VHA’s lack of documented objectives and developed performance goals  and related measures is inconsistent with our prior work on effective  management practices and federal internal control standards.  Specifically, we have previously reported that performance measures  benefit from certain key practices, such as breaking down of broad long-  term objectives into specific near-term performance goals with  measurable targets and time frames, and key attributes, such as balance  to prevent skewed incentives over-emphasizing certain goals.  Additionally, Standards for Internal Control in the Federal Government  states that documentation provides a means to retain organizational  knowledge and mitigate the risk of having that knowledge limited to a few  personnel. Without clearly documented objectives, performance goals,  and related performance measures, VHA is hindered in its efforts to  define success for its same-day service initiative and measure progress  achieving it.

VHA officials stated they rely on VISN and VA medical center officials to  oversee same-day services; however, we found that without performance  goals and related performance measures, VISNs and VA medical centers  found it challenging to oversee the same-day services initiative.  Specifically, officials at five of the six medical centers and two of the four  VISNs we visited stated that it is difficult to measure same-day services;  which in turn makes assessing the initiative’s impact on veterans’ access  to care difficult. Officials at one medical center explained that the  challenge stems from the fact that that VHA has not defined what  outcome it wants to achieve. In addition, officials at another VA medical  center stated that they have a number of access measures available to  them, but it was unclear to them which measures they should be  prioritizing as part of their oversight of the same-day services initiative.

Further, absent performance goals, we found that VISNs and medical  centers, which operate in a decentralized environment, varied in their  oversight strategies. For example, one VISN required all medical centers  to complete a self-assessment of their access capacity and sustainability,  and collected information on a number of key open access elements,  including Patient-Aligned Care Team staffing levels and provider panel  sizes, among others. However, oversight by other VISNs was reportedly  less robust. For example, at one VISN, officials stated it is difficult to audit  access broadly and described their oversight of same-day services as  “fairly minimal.”

At the medical center level, oversight also varied as officials tried to  develop their own oversight solutions. Officials at one medical center we  visited used a feature within the outpatient appointment scheduling  system that allowed them to count the specific services, such as  pharmacy refills, that veterans seeking same-day mental health care had  requested. According to these officials, the tool provided additional data  not found in existing VHA access-related reports and allowed them to  better understand veterans’ demand for specific same-day services and  utilize resources more efficiently. These officials added that they  developed this solution because they had not received guidance from  VHA on how they should measure demand, and they had skilled staff with  the ability to develop their own measures. However, not all VA medical  centers we visited had the skilled staff to develop similar solutions.  Developing performance goals and related performance measures would  better position VHA to obtain useful, comparable information on the  impact of same-day services on access to care across VISNs and  medical centers.

Moving forward, VHA is planning to conduct a “mystery shopper”  evaluation of same-day services to assess the impact of same-day  services. The mystery shopper evaluation will consist of various scenarios  in which veterans, engaged through a contractor, will attempt to access  same-day care at a variety of clinics in VA medical centers. As described  in a VHA planning document, the evaluation is intended to provide VHA  with information on veterans’ experience in obtaining same-day services  and will attempt to understand variations in how same-day services are  provided. However, VHA officials have not determined if the evaluation  will be ongoing. VHA officials stated that in addition to the mystery  shopper evaluation, they are considering additional measures to better  assess the impact of same-day services beyond their current measures,  such as the number of pharmacy refills completed the same day they  were requested. However, as of May 2019, VHA had not developed  specific performance goals to align these measures to, or set timeframes  for their creation. Without overall performance measures that are tied to  documented performance goals, VHA will continue to be limited in its  ability to assess the impact of same-day services on veterans’ access to  care.

VHA’s same-day services initiative for primary and mental health care is  one of several efforts by VHA to help improve veterans’ access to care in  the 5 years since access issues garnered national attention. VHA’s stated  objectives for the same-day-services initiative are to improve veterans’  access to care and customer service while having minimal impact on  medical centers’ existing workflows. However, VHA has not documented  these objectives or developed performance goals and related measures  that provide for monitoring towards the desired outcomes. VHA primarily  relies on veteran satisfaction scores and the number of same-day  appointments to monitor the same-day-services initiative, but these  measures alone do not enable an assessment of the impact of same-day  services on access to care. Without documented objectives, and  performance goals and related measures tied to these goals, VHA will  continue to be limited in its ability to determine, how, if at all, the same- day-services initiative has improved veterans’ access to care.

The Under Secretary for Health should document same-day services  objectives and develop performance goals and related performance  measures to facilitate the periodic assessment of the impact of same-day  services on veterans’ access to care. (Recommendation 1)

We provided a draft of this report to VA for review and comment. In its  written comments, which are reproduced in appendix I, VA concurred in  principle with our recommendation. VA stated that its Office of Veterans  Access to Care will clarify objectives, develop performance goals, and  explore the options for reliable performance measures. VA noted that  identifying options for performance measures will take approximately 9  months and that additional time may be needed for development, testing  and refinement. VA provided a target completion date of April 2020.

We are sending copies of this report to the appropriate congressional  committee and the Secretary of Veterans Affairs. In addition, the report  will be available at no charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or at DraperD@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix II.

Appendix I: Comments from the Department of Veterans Affairs

Appendix II: GAO Contact and Staff Acknowledgments

In addition to the contact named above, Ann Tynan (Assistant Director),  Dan Klabunde (Analyst-in-Charge), Jennie F. Apter, and Q. Akbar Husain  made key contributions to this report. Also contributing were Muriel  Brown, Jacquelyn Hamilton, Ethiene Salgado-Rodriguez, and Merrile  Sing.

Congressional hearings in 2014 highlighted complaints that veterans were facing long wait times to get care at Veterans Affairs medical centers. One of VA’s responses was an initiative to provide same-day services.

We found VA launched this initiative without documenting its goals or objectives. We recommended that VA do so to better assess if veterans are getting timely care.

Also, VA officials at 6 centers told us they were providing same-day services. However, longstanding problems such as staff and space shortages made it hard to deliver the services according to policy and guidance.

VA health care has been on our High Risk List since 2015.