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Open Recommendations

Veterans Health: VA Should Improve Its Monitoring of Severe Maternal Complications and Mental Health Screenings
GAO-24-106209
Jan 16, 2024
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2 Open Recommendations
Agency Affected Recommendation Status
Department of Veterans Affairs The Secretary of Veterans Affairs should ensure that as OWH begins monitoring SMM on an ongoing basis, it disaggregates and reviews data on trends in SMM by veteran characteristics, such as race and ethnicity, age, or whether veterans lived in a rural area. (Recommendation 1)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.
Department of Veterans Affairs The Secretary of Veterans Affairs should ensure that OWH finalizes the development of and implements a systematic process to compile and review data on MCC screening of veterans for mental health conditions on an ongoing basis. This process should include data on MCCs' completion of required mental health screenings, as well as screening results. (Recommendation 2)
Open
When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

VA Disability Benefits: Board of Veterans' Appeals Should Address Gaps in Its Quality Assurance Process
GAO-24-106156
Nov 28, 2023
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4 Open Recommendations
Agency Affected Recommendation Status
Board of Veterans Appeals The Chairman of the Board of Veterans' Appeals should develop written policies and procedures related to its accuracy rate measure, to require that OAI (1) involves more than one official in the calculation process; (2) documents its calculation of monthly and fiscal year accuracy rates; and (3) manages related error data. (Recommendation 1)
Open
The Board agreed in principle with this recommendation. Board officials stated the recommendation should clarify the Board's need for a policy and procedure to manage data: the loss of data was specific to fiscal years 2019 and 2020. However, we note that the data loss stemmed from not having policies and procedures and without them, these types of data management issues could occur again. We continue to believe that having policies and procedures are an important part of internal control. Without written policies and procedures, the Board could face further challenges such as additional data loss, improperly storing data, or using inconsistent methodologies.
Board of Veterans Appeals The Chairman of the Board of Veterans' Appeals should monitor how veteran law judges choose to incorporate the feedback they receive from the case review process—including whether errors are corrected—and use this data to inform decision making related to the case review process. (Recommendation 2)
Open
The Board agreed with this recommendation. We will monitor the agency's progress to implement it.
Board of Veterans Appeals The Chairman of the Board of Veterans' Appeals should develop and implement an evidence-based decision-making process that includes a plan outlining how it will build evidence to assess the underlying causes for the most common errors identified by the case review process and the most common reasons for CAVC remands. The Board should use this evidence to better target its interventions and assess their results. One option is to fold the development of this process into the Board's planned evaluation. (Recommendation 3)
Open
The Board agreed in principle with this recommendation. We will monitor the agency's efforts to implement it.
Board of Veterans Appeals The Chairman of the Board of Veterans' Appeals should study how to evaluate VLJ adjudicative decisional consistency. One option is to fold the development of this study into the Board's planned evaluation. (Recommendation 4)
Open
The Board disagreed with this recommendation. Board officials stated that it would be inappropriate to force consistency in VLJ decisions in a way that is inconsistent with codes of judicial conduct and other standards applicable to VLJs. They stated that there will and should be variance in how legal authority is applied to the individual facts and circumstances of each case appealed to the Board. Board officials further stated that VLJs should be independent and not subject to pressure and influence. They also stated that, as part of evaluating individual VLJs' adherence to performance standards, the Board evaluates the total number of decisions each VLJ has adjudicated and the manner in which they have adjudicated them, among other things. In addition, Board officials noted that the number of decisions remanded does not demonstrate whether such remands were warranted, and that the number of CAVC remands or reversals does not necessarily correlate with productivity, legal acumen, or even with performance. Finally, they said that the concept of "consistency" of decision-making among individual judges evaluating sets of facts and circumstances of each individual case is a difficult one to address at all levels of adjudication, not only at the Board, but also at CAVC. We acknowledge the importance of judicial independence, that some degree of variance is expected given that independence, and that variation is not necessarily an indicator of poor quality decision-making. In addition, the Board acknowledges that consistency among VLJs in the use of appropriate legal authority is appropriate. However, without studying consistency, the Board will remain unaware of whether systemic inconsistencies in VLJ decision-making exist, and the Board will be unable to target interventions, as appropriate. We continue to believe that the results of systematic study of VLJ adjudicative decisions for consistency could provide a basis for targeting interventions, such as training, to assist VLJs. As such, this recommendation is not intended to "force" consistency in any VLJ decisions, but rather is meant to help the Board assist VLJs. Our recommendation is worded to allow the Board the necessary latitude to implement it in a way that allows for the retention of judicial independence while meeting other goals it deems appropriate.

VA Disability Benefits: Actions Needed to Address Challenges Reserve Component Members Face Accessing Compensation
GAO-24-105400
Oct 30, 2023
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14 Open Recommendations
Agency Affected Recommendation Status
Department of Defense The Secretary of Defense should ensure the Director of ODEI clarifies policies for military service assessments of their reserve component Military Equal Opportunity programs, to reduce medical bias, which in turn could help improve reserve component members' access to disability compensation. (Recommendation 6)
Open
DOD agreed with this recommendation. ODEI plans to clarify policy in the next revision of DoD Instruction (DoDI) 1350.02 for which the Secretaries of the Military Departments are responsible for ensuring their Reserve MEOs are assessed. ODEI will coordinate with the Military Departments on the frequency of assessment for the Reserve MEO programs. The next revision is expected in Fall 2024. We will monitor DOD's progress to complete this effort.
Department of Defense The Secretary of Defense should ensure the Director of ODEI conducts oversight reviews of the military services' Military Equal Opportunity programs, in accordance with DOD policy, to reduce medical bias, which in turn could help improve reserve component members' access to disability compensation. (Recommendation 7)
Open
DOD agreed with this recommendation. ODEI plans to coordinate with the Military Departments to establish a schedule to assess the effectiveness of the Military Services' MEO offices, starting in FY 2025. ODEI also plans to coordinate with the Defense Equal Opportunity Management Institute to develop a standardized assessment methodology to help ensure consistency in the assessment process. We will monitor DOD's progress on these efforts.
Department of the Army The Secretary of the Army should develop and document plans so the Army can implement the new DD Form 214-1 by February 2025. Such plans should fully apply sound planning practices, such as (1) identifying resources; (2) developing activities and timelines; (3) establishing roles, responsibilities, and coordination; (4) conducting a risk assessment; and (5) establishing performance management, such as goals and indicators to measure progress. (Recommendation 8)
Open
DOD agreed with this recommendation. We will monitor DOD's progress to implement it.
Department of the Air Force The Secretary of the Air Force should develop and document plans so the Air Force can implement the new DD Form 214-1 by February 2025. Such plans should fully apply sound planning practices, such as (1) identifying resources; (2) developing activities and timelines; (3) conducting a risk assessment; and (4) establishing performance management, such as goals and indicators to measure progress. (Recommendation 9)
Open
DOD agreed with this recommendation. We will monitor DOD's progress to implement it.
Department of the Navy The Secretary of the Navy should develop and document plans so the Navy can implement the new DD Form 214-1 by February 2025. Such plans should fully apply sound planning practices, such as (1) identifying resources; (2) developing activities and timelines; (3) establishing roles, responsibilities, and coordination; (4) conducting a risk assessment; and (5) establishing performance management, such as goals and indicators to measure progress. (Recommendation 10)
Open
DOD agreed with this recommendation. We will monitor DOD's progress to implement it.
Department of the Navy The Secretary of the Navy should ensure the Commandant of the Marine Corps develops and documents plans so the Marine Corps can implement the new DD Form 214-1 by February 2025. Such plans should apply sound planning practices, such as (1) identifying resources; (2) developing activities and timelines; (3) establishing roles, responsibilities, and coordination; (4) conducting a risk assessment; and (5) establishing performance management, such as goals and indicators to measure progress. (Recommendation 11)
Open
DOD agreed with this recommendation. We will monitor DOD's progress to implement it.

VA Equal Employment Opportunity: Increased Attention Needed to Improve Program Effectiveness
GAO-23-105429
Sep 12, 2023
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8 Open Recommendations
Agency Affected Recommendation Status
Department of Veterans Affairs The Secretary of VA should ensure that the Assistant Secretary for Human Resources & Administration/Operations, Security and Preparedness collects and analyzes information on facilities' hiring and promotion selection panel processes and addresses any findings from this analysis. This should include action plans with timeframes to address any deficiencies identified and sharing best practices. (Recommendation 6)
Open
VA agreed with this recommendation. In April 2024, VA said that the department is collecting and analyzing information from the VA administrations on hiring and promotion selection panel processes. VA said it will look for deficiencies in the panel processes as well as best practices. VA anticipates this will be completed in fiscal year 2024.
Department of Veterans Affairs The Secretary of VA should work with the relevant offices to establish a comprehensive policy for addressing veterans' complaints of discrimination while accessing VA services or participating in VA programs. This policy should include (a) a standardized process for handling veteran complaints of discrimination from intake to final resolution; (b) requirements for communicating with veterans about the status of their complaints; (c) a process for coordinating related efforts across the agency; and (d) a centralized process and requirements for collecting comprehensive data on veterans' complaints, including their resolution. (Recommendation 7)
Open
VA agreed with this recommendation and noted plans to implement it. We will monitor the agency's efforts to address this recommendation.
Department of Veterans Affairs The Secretary of VA should establish a communication strategy to promote veteran awareness of the External Complaint Program and other avenues for filing discrimination complaints. (Recommendation 8)
Open
VA agreed with this recommendation and noted plans to implement it. We will monitor the agency's efforts to address this recommendation.
Department of Veterans Affairs The Secretary of VA should finalize the I-DEA dashboard and use the data in the dashboard to regularly conduct trend analysis of internal and other data on perceived experiences of discrimination. Such analyses should pinpoint problematic locations, guide preventive efforts, and incorporate available data from VA's All Employee Survey; EEO and Harassment Prevention Program data; and information from other internal and external data collection efforts and assess trends down to the facility level. (Recommendation 1)
Open
VA agreed with this recommendation and noted plans to implement it. We will monitor the agency's efforts to address this recommendation.
Department of Veterans Affairs The Secretary of VA should ensure that the Deputy Assistant Secretary for Resolution Management, Diversity and Inclusion assesses and addresses any potential risks to the independence of the agency's EEO program, including the Harassment Prevention Program. (Recommendation 2)
Open
VA agreed with this recommendation and noted plans to implement it. In April 2024, VA said that the department has an on-going assessment of potential risks to independence including of its EEO functions, the Harassment Prevention Program, and the Alternative Dispute Resolution Program. To implement our recommendation, VA needs to fully review all aspects of its EEO program to determine whether there are potential conflicts including, for example, in reporting structures and job duties.
Department of Veterans Affairs The Secretary of VA should ensure that the Deputy Assistant Secretary for Resolution Management, Diversity and Inclusion assesses the factors that increase the time it takes to implement the terms of final decisions in cases where discrimination is found and develops a plan to ensure these final decisions are implemented in a timely manner. (Recommendation 3)
Open
VA agreed with this recommendation and noted plans to implement it. We will monitor the agency's efforts to address this recommendation.
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