Native American Youth: Information on Involvement in Justice Systems and Grant Programs to Help Address Juvenile Delinquency

This testimony summarizes the information contained in GAO's September 2018 report, entitled Native American Youth: Involvement in Justice Systems and Information on Grants to Help Address Juvenile Delinquency ( GAO-18-591 ).

GAO's analysis of available data found that the number of American Indian and Alaska Native (Native American) youth in federal and state and local justice systems declined across all phases of the justice process—arrest, adjudication, and confinement—from 2010 through 2016. During this period, state and local arrests of Native American youth declined by almost 40 percent from 18,295 in 2010 to 11,002 in 2016. The vast majority of Native American youth came into contact with state and local justice systems rather than the federal system.

However, more Native American youth were involved in the federal system than their percentage in the nationwide population (1.6 percent). For example, of all youth arrested by federal entities during the period, 18 percent were Native American. According to Department of Justice (DOJ) officials, this is due to federal jurisdiction over certain crimes involving Native Americans. Comprehensive data on Native American youth involvement in tribal justice systems were not available for analysis. GAO's analysis showed several differences between Native American and non-Native American youth in the federal justice system. For example, the majority of Native American youths' involvement was for offenses against a person, such as assault and sex offenses. In contrast, the majority of non-Native American youths' involvement was for public order offenses (e.g., immigration violations) or drug or alcohol offenses. On the other hand, in state and local justice systems, the involvement of Native American and non-Native American youth showed many similarities, such as similar offenses for each group.

DOJ and the Department of Health and Human Services (HHS) offered at least 122 discretionary grants and cooperative agreements (grant programs) from fiscal years 2015 through 2017 that could be used to address juvenile delinquency among Native American youth. DOJ and HHS made approximately $1.2 billion in first-year awards to grantees during the period, of which the agencies awarded approximately $207.7 million to tribal governments or Native American organizations. Officials from the agencies, tribal governments, and Native American organizations identified factors they believe affect success in applying for grant programs. For example, some tribal governments and Native American organizations found being able to call or meet with federal officials during the application process helpful but found that short application deadlines are a challenge.

I am pleased to be here today to discuss our recently completed report on  American Indian and Alaska Native (Native American) youth involvement  in federal, state and local, and tribal justice systems, and federal grant  programs available to help address issues of delinquency among Native  American youth.

In particular, I will highlight our findings pertaining to (1) what available  data show on the number and characteristics of Native American youth in  federal, state and local, and tribal justice systems; and (2) selected  federal discretionary grants and cooperative agreements (grant  programs) that could help prevent or address delinquency among Native  American youth, and tribal governments and Native American  organizations’ access to them.

According to recent reports and agency research, several risk factors  make some Native American youth susceptible to becoming involved with  justice systems at the federal, state and local, and tribal levels.  These risk factors include exposure to violence; substance abuse; poverty;  limited job market skills; and tribal communities’ limited funding for mental  health, education, housing, and other services.

Native American youth who commit offenses can enter one or more  justice systems at the federal, state and local, and tribal levels. Although  these justice systems have unique characteristics, youth generally  proceed through certain phases, including arrest, prosecution and  adjudication, and in some instances, placement and confinement in a  detention facility.

When a Native American youth enters the federal criminal justice system,  the Department of Justice (DOJ) and Department of the Interior (DOI),  among others, have responsibility for investigating and prosecuting his or  her act of delinquency or crime. Additionally, federal agencies including  DOJ and the Department of Health and Human Services (HHS) provide  funding through grant programs that grantees could use to help prevent  or address juvenile delinquency.

Outside Indian country, a state generally has jurisdiction to proceed  against a youth who has committed a crime or act of juvenile  delinquency. Federal law limits federal jurisdiction over youth if a state  has jurisdiction over the youth and has a system of programs and  services adequate for their needs. State and local justice systems have  specific courts—often at the county or city level—with jurisdiction over  youth alleged to have committed an act of juvenile delinquency or a crime. Inside Indian country, youth (and adults) may fall under federal,  state, or tribal jurisdiction depending on several factors. These factors  include the nature of the crime, the status of the alleged offender and  victim—that is, whether they are Indian or not—and whether jurisdiction  has been conferred on a particular entity by statute. The Major Crimes  Act, for example, grants the federal government criminal jurisdiction over  Indians in Indian country charged with serious, felony-level offenses  enumerated in the statute, such as murder, manslaughter, kidnapping,  burglary, and robbery. State jurisdiction in Indian country is generally  limited to two instances: when both the alleged offender and victim are  non-Indian, or when a federal statute confers, or authorizes, a state to  assume criminal jurisdiction over Indians in Indian country. Otherwise,  only the federal and tribal governments have jurisdiction in Indian country.

For our September 2018 report, we analyzed federal, state and local, and  tribal arrest, adjudication, and confinement data from 2010 through 2016 (the most recent available) from DOJ and DOI. We also analyzed DOJ  and HHS grant program award documentation from fiscal years 2015  through 2017, and application information for a sample of the grant  programs chosen based on the amount of funding awarded and other  factors. Additionally, we also interviewed officials from DOJ, HHS, and 10  tribal governments or Native American organizations chosen to include  successful and unsuccessful applicants to the grant programs, among  other things. Additional information on our scope and methodology can  be found in our September 5, 2018 report. For specific information about  the different databases from which we gathered our data, see appendix I.  Our work was performed in accordance with generally accepted  government auditing standards.

Available Data Indicate Native American Youth Involvement in Justice Systems Declined from 2010 through 2016 and Differed in Some Ways from That of Non-Native American Youth

In our September 2018 report, we found that from 2010 through 2016 the  number of Native American youth in federal and state and local justice  systems declined across all phases of the justice process—arrest,  adjudication, and confinement—according to our analysis of available  data. At the federal level, arrests by federal agencies dropped from 60  Native American youth in 2010 to 20 in 2016, and at the state and local  level, arrests of Native American youth declined by almost 40 percent  from 18,295 arrested in 2010 to 11,002 in 2016.

Our analysis also found that the vast majority of these Native American  youth came into contact with state and local justice systems, not the  federal system. For example, from 2010 through 2016, there were  105,487 total arrests of Native American youth reported by state and local  law enforcement agencies (LEAs). In contrast, there were 246 Native  American youth held in federal custody by the U.S. Marshals Service due  to arrest by federal LEAs during the same period.

We also found a number of similarities between Native American and  non-Native American youth in state and local justice systems. For  example, the offenses that Native American youth and non-Native  American youth were arrested, adjudicated, and confined for were  generally similar. In contrast, our analysis also showed a number of  differences between Native American and non-Native American youth in  the federal justice system. For example, our analysis showed variation in  the types of offenses committed by each group. From fiscal years 2010  through 2016, the majority of Native American youth in the federal justice  system were arrested, adjudicated, or confined for offenses against a  person, with the top two specific offenses being assault and sex  offenses. In contrast, the majority of involvement of non-Native  American youth in the federal system during the same period was due to  public order or drug and alcohol offenses at all three stages, with the top  two specific offenses being drug and immigration related. Our  September 2018 report contains additional information on the differences  between Native American and non-Native American youth involved with  the federal justice system.

Further, we found that the percent of Native American youth involved in  most state and local systems was generally similar to their representation  in the youth populations in those states. For example, our analysis found  that the majority (about 75 percent) of Native American youth arrested by  state and local LEAs from calendar years 2010 through 2016 were  located in 10 states: Alaska, Arizona, Minnesota, Montana, New Mexico,  North Dakota, Oklahoma, South Dakota, Washington, and Wisconsin.  These 10 states had among the highest percent of Native Americans in  their states’ overall youth populations, according to 2016 U.S. Census  estimates we reviewed. In 2016, the largest number of arrests by state  and local LEAs occurred in Arizona and South Dakota.

In contrast, we found that representation of Native American youth  arrested, referred for adjudication, and confined at the federal level during  the period reviewed was greater (13 to 19 percent) than their  representation in the nationwide youth population (1.6 percent).

DOJ officials told us that the population of Native Americans in the federal  justice system has historically been higher than their share in the  nationwide population, and they attributed this and other differences  shown by our analysis to federal government jurisdiction over certain  crimes in Indian country, as well as the absence of general federal  government jurisdiction over non-Native American youth. According to  DOJ officials, this jurisdiction requires the federal government to  prosecute offenses that would commonly be prosecuted by states if  committed outside of Indian country. According to DOJ officials, a small  handful of federal criminal statutes apply to all juveniles, such as  immigration and drug statutes, but the federal government has been  granted greater jurisdiction over Native American youth than non-Native  American youth by federal laws that apply to crimes committed in Indian  Country, such as the Major Crimes Act. For example, one DOJ official  noted that the Major Crimes Act gives the federal government exclusive  jurisdiction over crimes such as burglary and sex offenses committed in  Indian country. This differs from the treatment of non-Native American  youth, who are not prosecuted in the federal system for the same types of  offenses, because the federal government does not have jurisdiction over  those youth for such offenses. Non-Native American youth are instead  subject to the general juvenile delinquency jurisdiction of state and local  courts.

Additionally, DOJ officials stated that tribal justice systems are often  underfunded and do not have the capacity to handle Native American  youths’ cases. Therefore, they stated that when both federal and tribal justice systems have jurisdiction, the federal system might be the only  system in which the youth’s case may be adjudicated. For these reasons,  the percentage of Native American youth offenders in the federal justice  system is higher than non-Native American juveniles in accordance with  population size, according to DOJ officials.

Representatives from four of the five Native American organizations we  interviewed, whose mission and scope of work focus on Native American  juvenile justice issues and that have a national or geographically specific  perspective, noted that federal jurisdiction is a key contributor to the  higher percentage of Native American youth involved at the federal justice  level. Additionally, representatives from all five organizations noted,  similarly to DOJ officials, that federal jurisdiction over crimes in Indian  country is typically for more serious offenses (specifically under the Major  Crimes Act), such as offenses against a person.

Comprehensive data from tribal justice systems on the involvement of  Native American youth were not available. However, we identified and  reviewed a few data sources that provided insights about the arrest,  adjudication, and confinement of Native American youth by tribal justice  systems. See appendix II for a summary of our analysis of data from  these sources.

DOJ and HHS Offered at Least 122 Grant Programs; Tribal Governments or Native American Organizations Were Eligible for Almost All but in a Sample of Applications We Reviewed, Applied Primarily for Programs Specifying Native Americans

In our September 2018 report, we identified 122 discretionary grants and  cooperative agreements (grant programs) offered by DOJ and HHS from  fiscal years 2015 through 2017 that could help prevent or address  delinquency among Native American youth. DOJ and HHS made  approximately $1.2 billion in first-year awards through the 122 programs  over the period, of which the agencies awarded about $207.7 million to  tribal governments or Native American organizations. A list of the 122  programs, which focus on a range of issues such as violence or trauma,  justice system reform, alcohol and substance abuse, and reentry and  recidivism, can be found in our September 2018 report.

The 122 DOJ and HHS grant programs we identified included 27  programs that specified tribes or Native Americans as a primary  beneficiary and 95 programs that did not specify these populations but  could include them as beneficiaries. For example, the Department of  Justice’s Office of Juvenile Justice and Delinquency Prevention offered  the Defending Childhood American Indian/Alaska Native Policy Initiative:  Supporting Trauma-Informed Juvenile Justice Systems for Tribes  program for funding in fiscal year 2016. The goal of this program— increasing the capacity of federally recognized tribes’ juvenile justice and  related systems to improve the life outcomes of youth who are at risk or  who are involved in the justice system and to reduce youth exposure to  violence—explicitly focused on tribal communities. On the other hand, the  Sober Truth on Preventing Underage Drinking Act grant program, which  HHS’s Substance Abuse and Mental Health Services Administration  offered for funding in fiscal year 2016 to prevent and reduce alcohol use  among youth and young adults, is an example of a program that did not  specify tribes or Native Americans as a primary beneficiary but could  include them as beneficiaries.

We found that tribal governments and Native American organizations  were eligible for almost all of the grant programs we identified.  Specifically, they were eligible to apply for 70 of 73 DOJ programs and 48  of 49 HHS programs. However, although tribal governments and Native  American organizations were eligible to apply for almost all of the  programs, we found in a non-generalizable sample of applications we  reviewed that they applied primarily for the programs that specified tribes  or Native Americans as a primary beneficiary. For example, we reviewed  applications for 18 DOJ grant programs and found that tribal governments  and Native American organizations accounted for over 99 percent of the  applications for the 5 grant programs within the sample that specified  tribes or Native Americans as a primary beneficiary. However, tribal  governments and Native American organizations accounted for about 1  percent of the applications for the 13 programs in the sample that did not  specify tribes or Native Americans as a primary beneficiary.

We interviewed officials from DOJ’s Office of Justice Programs (OJP) and  seven HHS operating divisions to obtain their perspectives on why tribal  governments and Native American organizations might not apply for grant  programs that do not specify them as a primary beneficiary. They  identified various reasons, including that tribal governments and Native  American organizations might not be aware that they are eligible to apply  for certain grant programs; might believe that their applications to grant  programs that do not specify tribes or Native Americans as a primary  beneficiary will not be competitive with other applications; or might prefer  to apply for those grant programs that specify tribes or Native Americans  as a primary beneficiary.

We also interviewed representatives from 10 tribal governments and  Native American organizations, who provided perspectives on whether or  not a grant program’s focus on tribes or Native Americans as a primary  beneficiary affected their decision to apply for the program. Officials  from 6 of 10 tribal governments and Native American organizations  indicated that they would consider any grant program that met the needs  of their communities, while the remaining 4 indicated that a grant  program’s focus or lack thereof on tribes or Native Americans could affect  their ability to apply for it.

Officials from the 10 tribal governments and Native American  organizations also identified various federal practices they found helpful  or challenging when applying for grant programs related to preventing or  addressing delinquency among Native American youth. When asked  what federal practices, if any, were particularly helpful when applying to  receive federal funding, they most frequently responded that they found it  particularly helpful to be able to call or meet with federal officials if they  had questions about or needed help on their applications. Regarding the  biggest challenges, they cited short application deadlines, difficulties  collecting data for grant program applications, and a scarcity of grant  writers and other personnel needed to complete a quality application.

In addition, DOJ OJP and HHS officials provided perspectives on why  some tribal governments and Native American organizations might be  more successful in applying for federal funding than others. The officials  stated, among other things, that larger and better-resourced tribal  governments and Native American organizations were more successful at  applying for federal funding and that previously successful grant program  applicants were more likely to be successful again.

More detailed information on the perspectives from tribal governments,  Native American organizations, and agency officials regarding the factors  they believe affect the ability of tribal governments and Native American  organizations to apply successfully for federal grant programs can be  found in our September 2018 report.

Chairman Hoeven, Vice Chairman Udall, and Members of the Committee,  this completes my prepared statement. I would be pleased to respond to  any questions you may have at this time.

Appendix I: Data Sources for Federal, State and Local, and Tribal Justice Systems by Phase of the Justice Process

For our September 2018 report, we obtained and analyzed record-level  and summary data from federal, state and local, and tribal justice systems  from 2010 through 2016. Figure 1 illustrates the data sources we  included in our report for each phase of the justice process (arrest,  adjudication, and confinement) in each justice system (federal, state and  local, and tribal). Generally, state and local entities include those  managed by states, counties, or municipalities.

Appendix II: GAO Findings Regarding American Indian and Alaska Native Youth Involvement with Tribal Justice Systems

Comprehensive data from tribal justice systems on the involvement of  American Indian and Alaska Native (Native American) youth were not  available. However, in our September 2018 report, we identified and  reviewed a few data sources that can provide certain insights about the  arrest, adjudication, and confinement of Native American youth by tribal  justice systems. The following is a summary of our analysis of data from  these sources.

Arrests. Although comprehensive data on the number of tribal law  enforcement agency (LEA) arrests were not available, we obtained and  reviewed admission records from three juvenile detention centers in  Indian country managed by the Department of the Interior’s Bureau of  Indian Affairs (BIA). Based on those records, at least 388 Native  American tribal youth were admitted to these three facilities in 2016, as  shown in table 1. In the Northern Cheyenne facility, for which we obtained  records for 5 years, the number of youth admitted increased yearly  between 2012 and 2016, from 14 to 204.

According to BIA officials, this growth in the number of youth admitted to  the Northern Cheyenne facility likely reflects an increase in admissions of  Native American youth from surrounding tribes. Specifically, because the  Northern Cheyenne facility is centrally located, the officials said that the  facility admits youth from other tribes, which have grown accustomed to  sending their youth to the facility. BIA officials also noted that the  Northern Cheyenne facility services an area where there is a high rate of  delinquency among youth, and because the facility works well with Native  American youth struggling with delinquency issues, many tribes elect to  send their delinquent youth to the facility. Further, since 2012, the  Northern Cheyenne facility increased its bed space and staff, thus  increasing its capacity to admit more youth, according to BIA officials.

Even though comprehensive tribal arrest data were not available, we  reported in September 2018 that the Department of Justice’s (DOJ)  Bureau of Justice Statistics (BJS) was undertaking an effort to increase  collection of arrest data from tribal LEAs. Specifically, this data collection  activity is the Census of Tribal Law Enforcement Agencies. This  collection activity, which BJS plans to conduct in 2019, is to capture  information including tribal LEA workloads and arrests, tribal LEA access  to and participation in regional and national justice database systems,  and tribal LEA reporting of crime data into FBI databases.

Adjudication. Comprehensive data were not available to describe the  extent to which tribal courts processed Native American youth or found  them guilty. However, BJS concluded a tribal court data collection effort— the National Survey of Tribal Court Systems—in 2015. Through this  survey, BJS gathered information from more than 300 tribal courts and  other tribal judicial entities on their criminal, civil, domestic violence, and  youth caseloads, and pretrial and probation programs, among other  things. DOJ officials told us that BJS has analyzed the data, and plans to  release results in the future.

Confinement. According to data published by BJS, the number of youth  in Indian country jails declined from 190 in 2014 to 170 in 2016 (about an  11 percent decrease).

If you or your staff have any questions about this testimony, please  contact Gretta L. Goodwin, Director, Homeland Security and Justice at  (202) 512-8777 or goodwing@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this statement. GAO staff who made key contributions to this testimony  are Tonnye’ Conner-White, Assistant Director; Steven Rocker, Analyst-in- Charge; Haley Dunn; Angelina Torres; Taylor Matheson; Anne Akin; Paul  Hobart; Jamarla Edwards; Claire Peachey; Eric Hauswirth; Heidi Neilson;  Amanda Miller; and Elizabeth Dretsch. Key contributors to the previous  work on which this testimony is based are listed in our September 2018  report.

This is a work of the U.S. government and is not subject to copyright protection in the  United States. The published product may be reproduced and distributed in its entirety  without further permission from GAO. However, because this work may contain  copyrighted images or other material, permission from the copyright holder may be  necessary if you wish to reproduce this material separately.

Federal reports on Native American youth found challenges—such as poverty and exposure to violence—that can make them susceptible to being arrested, charged, or sentenced in the justice system.

This testimony includes a discussion of our findings:

Overall Native American juvenile delinquency rates declined 2010-2016.

While most Native American youth in the system were at the state or local level, their share of the population in the federal system was higher than their share of the nationwide youth population—likely due to federal jurisdiction on tribal lands.

We also found 122 federal grant programs to address underlying challenges.


VA Medical Centers: VA Should Establish Goals and Measures to Enable Improved Oversight of Facilities' Conditions

VHA oversees one of the largest health care systems, serving approximately 9-million veterans at numerous health care facilities, including 170 medical centers. To ensure a safe environment for veterans and employees, VHA must keep its facilities clean and well maintained.

GAO was asked to examine (1) how VHA medical centers identify maintenance and repair needs and challenges they face in addressing those needs, and (2) to what extent VHA provides oversight to ensure medical centers are providing a safe, clean, and functional environment.

GAO reviewed VHA's procedures and standards related to facility operations and maintenance functions at medical centers and interviewed VHA's administrative office officials regarding oversight of these functions. GAO also interviewed VHA officials from three regional offices and six medical centers selected based on factors such as geographic location and veteran population served, and conducted site visits at four of these medical centers.

Veterans Health Administration's (VHA) medical centers conduct regular inspections of the settings in which patients receive health care services, called the “environment of care”, to identify maintenance and repair needs. These inspections also help ensure compliance with accreditation standards requiring, among other things, that utility systems operate properly and that areas are clean and in good repair. The main three steps in the process associated with these inspections are shown below. In addition to the environment of care inspections, VHA conducts other periodic assessments of facilities' major systems, such as plumbing and air conditioning.

VHA inspections routinely identify deficiencies reflective of an aging infrastructure—VHA's buildings are on average 55 years old. This situation in turn is leading to workload and staffing challenges in addressing maintenance and repair needs. For example, according to VHA's 2017 data, medical centers reported conducting approximately 11,000 total inspections for the year that resulted in about 128,000 identified deficiencies. Most of these deficiencies were closed within 14 business days, as required by VHA. However, nearly 30,000 of them were not closed or had been addressed through a plan for future work. Medical center officials added that correcting deficiencies may only be a temporary solution for issues related to aging structures that need extensive repairs and renovations. In addition, VA headquarters and field officials said that staff vacancies are common and can affect the efficiency and speed of maintenance and repairs.

VHA provides guidance and selected oversight to ensure medical centers implement the process for environment of care inspections. However, VHA lacks performance goals, objectives, and measures that would enable it to provide effective oversight, address challenges, and assess how well it is achieving a clean, safe, and functional environment. As part of ensuring compliance with the inspection process, VHA measures whether medical centers meet certain requirements, such as having appropriate staff present for inspections. VHA does not, however, have measures that enable it to assess how well medical centers are achieving desired outcomes. Although it has stated its intent to develop such measures, VHA has not yet committed to a time frame for doing so.

GAO recommends that VHA set a timeline for defining goals, objectives, and outcome-oriented performance measures that can address challenges and help achieve a clean and safe care environment. VA concurred with the recommendation and provided general and technical comments, which GAO incorporated as appropriate.

The U.S. Department of Veterans Affairs (VA) administers one of the  largest health care systems, serving approximately 9 million enrolled  veterans annually at health care facilities across the country, including  170 VA medical centers, through the Veterans Health Administration  (VHA). To ensure a safe environment for veterans and employees, VHA  is responsible for keeping these facilities safe, clean, and well maintained.

VHA obligated more than $6.5 billion for the operations and maintenance  of its medical facilities for fiscal year 2018. This amount pays for day-to- day functions, such as operating heating and cooling systems, laundering  textiles, maintaining hospital grounds, and making needed repairs. Efforts  related to maintaining the “environment of care”—the setting in which  patients receive health care services—are also a part of day-to-day  operation and maintenance activities. Repairs can range from small,  recurring maintenance projects such as repainting walls and repairing  water leaks in pipes and roofs to larger non-recurring projects such as  upgrading water treatment plants and modernizing boiler systems.

You asked us to review issues related to VHA medical centers’ facility  operations and maintenance functions. In this report, we examine: (1)  how VHA medical centers identify maintenance and repair needs and  challenges the centers face in addressing those needs, and (2) to what  extent VHA provides oversight to ensure medical centers are providing a  safe, clean, and functional environment.

To determine how VHA identifies maintenance and repair needs at  medical centers and challenges they face in addressing those needs, we  reviewed VHA procedures, policies, and standards related to operations  and maintenance functions at medical centers and published reports from  VA, GAO, and relevant stakeholder groups. We also reviewed VHA’s  environment of care inspections data for fiscal years 2016–2017 as  reported by medical centers related to their compliance with facility  maintenance standards. We focused this review on environment of care  inspections because these inspections are identified in VHA guidance as  critical to all aspects of patient care in a medical facility. As such,  environment of care standards are important considerations for VHA’s  engineering staff when planning and executing maintenance and  operations functions. We assessed the reliability of environment of care  inspections data by reviewing documentation and interviewing  knowledgeable agency officials to identify steps VA takes to ensure the  quality and accuracy of the data, such as training inspectors on entering  inspections data. Through these steps, we determined that the data were  sufficiently reliable for the purposes of this reporting objective.

Further, we selected three Veterans Integrated Service Networks (VISN)  and six medical centers—two medical centers within each VISN—for  review and site visits.  We chose the three VISNs to include a range in  terms of geographic location and veteran demographics and ones with  higher numbers of identified deficiencies and percentages of deficiencies  not addressed within 14 days in fiscal year 2017. We chose the six  medical centers based on these factors as well as on their proximity to  the selected VISN’s location, and to include both urban and rural centers.  We conducted in-person site visits at four of the six selected medical  centers and interviewed officials responsible for overseeing, planning,  and budgeting for facility maintenance and operations. We observed the  environment of care inspections process at two of the medical centers  during our site visits. The results of the information obtained at VISNs and  medical centers are not generalizable to the entire population of VISNs  and medical centers. Table 1 shows the VISNs and medical centers  selected for our review.

To determine how VHA provides oversight to ensure medical centers are  providing a safe, clean, and functional environment, we reviewed VHA  policy and guidance on the environment of care inspections process. We  interviewed officials from the VHA administrative office that oversees  compliance in the environment of care at medical centers and the  selected VISNs and medical centers about:  challenges that may affect VHA’s ability to maintain or operate  medical centers;

VHA oversight; and  the implementation of environment of care policies.

We compared the information from these documents and interviews to  best practices for results-oriented management as identified in previous  GAO work.

We conducted this performance audit from June 2017 to November 2018  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.

VHA policy requires that all medical facilities provide a safe, clean,  functional environment for patients, visitors, and employees. The Joint  Commission,  an organization that accredits medical centers and other  hospitals throughout the country, has developed standards that require  medical centers to undertake several actions that relate to engineering,  environmental management, and safety including: maintaining the patient environment by ensuring that a suitable  temperature is maintained, that areas are clean and appropriately  lighted, and furnishings and equipment are in good repair; managing utility systems to ensure operational reliability; and minimizing fire hazards and providing a safety system in case of fire.

To help ensure medical centers maintain these standards, VHA requires  medical centers to conduct regular environment of care inspections of the  facility. According to VHA officials, because of the large size of many  medical centers, most conduct environment of care inspections in a  different part of their facility every week throughout the year. In 2016, a  VHA directive formally established VHA’s Comprehensive Environment of  Care Program (Environment of Care Program) and outlined management  and oversight responsibilities for the program. Environment of care  inspections are a main component of the program.

In addition to the environment of care inspections, VHA uses other  inspections to help execute and oversee facility operations and  maintenance functions. For example, every 3 years, VA contracts for  Facility Condition Assessments, where contractors evaluate all buildings  and major systems at a medical facility (e.g., structural, mechanical, plumbing, and others) and identifies needed repairs and replacements.  This inspection gives a graded score from A to F for VHA facilities, with  “C minus” as the average facility score received for overall infrastructure  conditions at VHA facilities as of 2015. This inspection focuses on major  systems, while environment of care inspections focus on day-to-day  facility conditions, including that of patient-care areas. Furthermore,  preventative maintenance inspections are usually conducted on systems,  such as boilers or heating, ventilation, and air-conditioning (HVAC)  systems, and would vary in frequency based on the manufacturer  requirements. Medical center staff also noted that facility operations and  maintenance issues may be identified by staff in the course of their day- to-day duties and reported to engineering for repair.

VHA medical centers employ staff trained in plumbing, carpentry, grounds  maintenance, and other trades needed to maintain facilities, as well as  housekeeping staff. These employees are responsible for carrying out the  work necessary to ensure medical centers comply with safety standards,  and VHA policies and inspection requirements.

The majority of funding for medical centers, including funding for  operations and maintenance, is determined on the basis of past years’  allocations, veteran populations served, and the types of services  provided. The budget for VA medical facilities has increased by  approximately 30 percent over the last 5 fiscal years.

Medical Centers Rely on Environment of Care Inspections to Identify Deficiencies but May Encounter Challenges in Completing Needed Repairs

The medical center director or a designee, such as the medical center’s  Environment of Care Coordinator, has the overall responsibility for  managing and leading weekly environment of care inspections at a  medical center. Each medical center should have an environment of care  committee, and the medical center director or a designee should facilitate  committee meetings to discuss the environment of care processes,  findings, trends, and any other related issues. Inspections are conducted  by an environment of care inspection team, which is made up of  representatives from various facility departments, including, among  others:

Environmental Management Service—which is responsible for  ensuring a state of physical and biological cleanliness, including  proper handling of waste materials—and

Engineering Service, which is responsible for utilities that allow the  physical plant to function, including basic systems such as heating  and electrical, among others.

According to VHA guidance, the team is to conduct its inspections using a  VHA checklist as a guide to determine if there are any deficiencies. For  example, the checklist includes questions such as:

Are ceiling tiles stained or other signs of leaks?

Are there any electrical hazards present?

Team members record information on deficiencies that they identify into  an Environment of Care inspections database, which is used to document  and track the status of deficiencies.

During interviews with medical center staff at all six of the medical centers  included in our review, officials told us they follow the environment of care  inspections process that VHA guidance outlines. At two of the medical  centers we visited, we accompanied inspections team on environment of  care inspections and observed staff following this process. The inspection  teams walked through the areas designated for inspection, for example  examining conditions of floors, ceilings and fire safety systems. Also, as  we discuss later in the report, VHA officials also monitor aspects of the  inspections process, such as who attends the inspection. VHA officials  told us they also collect data on performance measures related to  utilization of the environment of care checklists and environment of care  inspections process but no longer track these measures because medical  centers achieved 100 percent utilization of these measures in 2015.  Figure 1 below details the process used to identify and address  deficiencies, as outlined in VHA guidance.

As previously mentioned, VHA guidance considers these inspections to  be critical to all aspects of patient care in a medical facility, and officials at  all six medical centers confirmed that they rely on these inspections to  identify needed repairs. For example, officials in one medical center noted  that the frequency and thoroughness of these inspections has helped  them determine day-to-day wear and tear issues and informed their  planning processes. Medical center staff noted that condition deficiencies  identified through this process are often minor but are nonetheless  important to maintenance of a clean and safe patient environment. For  example, a damaged or stained ceiling tile identified during an inspection  could be a potential safety hazard to patients or indicate an issue with  leaking pipes. The replacement of the tile itself is a minor repair, but that  repair could be an indication of an important maintenance issue at the  medical center. As table 2 below shows, the deficiencies commonly  identified through the inspections process include items that need to be  cleaned or dusted or walls that need minor repairs.

Medical center staff we interviewed said, in general, the most common  environment of care deficiencies can be addressed by medical center  staff, but medical centers told us they sometimes use contractors if  warranted. In most cases, a deficiency can be addressed with simple  repairs such as patching and repainting walls, replacing stained and  damaged tiles, or by cleaning. On our site visits, we saw examples of the  types of issues that medical center staff address during environment of  care inspections. In one case, we were shown a recurring deficiency at  the medical center caused by moving hospital beds. Moving beds in and  out of rooms was damaging the plaster corners of a wall near the door.  We were also shown the solution, which was a metal corner guard the  medical center had installed in some rooms, and the center was working  to install corner guards in other locations as funds became available.  Figure 2 below shows examples of deficiencies we observed during  environment of care inspections at medical centers.

Other types of condition deficiencies that are not directly in the  environment of care, such as a broken boiler, typically would not be  identified during environment of care inspections, but rather medical  center staff said they are identified during scheduled preventive  maintenance activities, or during other facility inspections. Regardless of  how they are identified, more serious repairs often require a different  funding and approval process than day-to-day maintenance. For  example, if significant damage occurred to a medical center’s roof and the  cost of repairs is greater than $25,000, it would most likely be deemed a  non-recurring maintenance project and would require approval from either  the VISN or VA’s central office.

Challenges in Addressing Identified Deficiencies

The buildings that VHA manages are, on average, 55 years old, and  many have substantial capital repair and improvement needs. A VA- commissioned report noted that there were significant barriers that facility  management staff faced in maintaining facilities to a high quality.  According to the report, while some of these barriers involved immediate  resource constraints such as budgets for staffing and conducting  maintenance and janitorial tasks, the root cause of many of these issues  is the general age and underlying condition of VHA facilities.

Engineering officials at medical centers told us that the amount of work  associated with conducting weekly inspections and addressing  environment of care deficiencies is substantial. For example, according to  VHA’s data for fiscal year 2017, medical centers reported conducting  about 11,000 weekly inspections, during which more than 128,000  deficiencies were identified. Most deficiencies were closed within 14  business days, as required by VHA policy, but nearly 30,000 deficiencies  across all medical centers had not been addressed within 14 days or had  been addressed through a plan for future work.

One significant factor contributing to the number of deficiencies and the  associated workload is the advanced age of many medical centers. A  VHA commissioned study found that the general age and underlying  condition of medical centers, including VHA buildings’ being older than 50  years on average and lack of capital investment to address infrastructure  concerns, are the root causes of many barriers that facility management  staff faced in achieving their objectives of maintaining high quality  facilities, and exacerbate the workload issues at these medical centers.  This observation was echoed by medical center officials in our review. For  example at one medical center officials told us that in some cases,  correcting deficiencies found on an environment of care inspection is a  temporary solution for issues related to aging structures that need  extensive repairs and renovations. For example, a roof that needs to be  repaired due to leaks and other structural issues may result in an  increase in the number of interior ceiling tiles with water stains.  Maintenance staff must then continue to identify and replace stained  ceiling tiles, until the root cause, which is subject to a different funding  and approval process, is addressed.

Also, medical center staff we interviewed said the administrative  requirements associated with the environment of care program  contributed to workload challenges. Medical center staff are responsible  for entering deficiency data into the Environment of Care inspections  database, which is used to document and track results from the  environment of care inspections. The same staff can also be responsible  for reconciling the environment of care inspections database with other  systems, like the medical center’s work order system and other  inspections databases. Medical center staff said that each deficiency  can result in as many as four or more separate data entry actions in the  Environment of Care inspections database and in a separate system  used to track work orders. As an example of the administrative workload  related to the inspection process, the Long Beach medical center in California, whose main building was built in 1967, reported the most  deficiencies in its VISN. According to VHA data, this medical center  reported more than 3,500 environment of care deficiencies related to  facility condition in fiscal year 2017, and medical center officials said this  resulted in as many as 12,000 or more separate data-entry actions.

Additionally, VHA’s aging information technology systems exacerbate the  administrative workload. VA medical center officials told us that VHA’s  work order system lacks interoperability with the Environment of Care  inspections database, resulting in the need to manually record information  on deficiencies in both systems. Officials we spoke with at VA medical  centers told us that this process can substantially add to post-inspection  workload and to the administrative burden associated with tracking and  closing out deficiencies. Medical center staff also noted that it can often  be the same staff member performing environment of care inspections,  conducting the work to correct deficiencies, and performing administrative  tasks.

Limitations in VA’s information technology systems, among other things,  led GAO to designate VA health care as a high-risk area. Information  technology limitations we previously identified at VA include the outdated,  inefficient nature of certain systems and a lack of system  interoperability.

Staffing shortages have also been recognized by VA’s Central Office staff  as an issue that needs to be addressed across VA facilities. For example,  officials said that in addition to the engineering staff’s shortages  discussed below, there is also a known shortage at many medical centers  of qualified cleaning and janitorial staff, a shortage that can affect the  ability for medical centers to quickly address some of the environment of  care deficiencies. Additionally, we have previously reported that VA is  collaborating with the Office of Personnel Management to address  challenges with recruiting and retaining engineering positions.

Officials at medical centers included in our review discussed the difficulty  of recruiting and retaining employees to perform maintenance work, such  as painters, electricians, and other relevant maintenance trades. All six of  the medical centers reported vacancies during the last year in  engineering department positions that are needed to complete  maintenance and repairs, such as electricians and painters. The extent to  which these medical centers experienced vacancies, however, varied  widely. The lowest number of reported vacancies by a medical center was  two and the highest number of reported vacancies was 49. Factors cited  by medical center officials on why they had difficulty hiring and retaining  staff encompassed a range of issues, including loss of long-time staff due  to retirement, and a lack of qualified applicants for vacant positions. For  example, medical centers located in and around Los Angeles, California,  reported that their location—in a high cost of living area with a competitive  private-sector jobs market—affected their ability to recruit and retain  these employees. Conversely, medical centers located farther from urban  areas reported difficulty finding and retaining staff due to their relatively  rural locations and smaller overall population.

Officials from all six medical centers said that while they endeavor to  address all environment of care deficiencies in accordance with the  inspection requirements, these vacancies affected their ability to perform  maintenance and repair functions. For example, officials from one  medical center reported that four out of seven electrician positions at their  medical center were vacant. The officials said in addition to their rural  location, their need for engineering staff knowledgeable in a range of  electrical systems made recruitment difficult. Their facility has buildings  that are over 50 years old, as well as newer buildings, with significantly  different electrical systems. The officials noted that while all electrical  work was eventually completed, the lack of staff slowed or deferred  repairs, or required contract labor. Another medical center noted that a  shortage of relevant engineering staff meant that work orders and  preventative maintenance functions were backlogged and that they had to  utilize overtime to accomplish required functions. When faced with  changing workload demands and staffing shortages, medical centers can,  and do, utilize contractors.

VHA Takes Steps to Help Medical Centers Comply with Inspection Requirements but Does Not Have Goals or Measures to Determine Program Effectiveness

While VHA provides guidance and oversight to ensure medical centers  implement the environment of care inspection process, it lacks  performance goals, objectives, and measures that would enable it to  assess how well it is achieving its policy of a clean, safe, and functional  environment. We have previously found that results-oriented  organizations set performance goals to define desired program outcomes  and develop performance measures that are clearly linked to these  performance goals and outcomes. Program goals communicate what  results the agency seeks, and performance measures show the progress  the agency is making toward achieving program goals. Performance  measurement also gives managers crucial information to identify gaps in  program performance and plan any needed improvements. Without such  goals and measures in place, VHA is limited in its ability to effectively  manage the Environment of Care Program, including making effective  use of program data and addressing obstacles to improving program  performance.

VHA’s Oversight of the Environment of Care Program Focuses on Compliance with Inspections Requirements

VHA’s oversight of the Environment of Care Program focuses on ensuring  that medical centers are conducting the inspections according to VHA  requirements. To help medical centers achieve compliance with the  inspection requirements, VHA does the following: develops guidance for medical center and VISN staff on their roles  and responsibilities in conducting inspections and compliance  monitoring, and on how to use the Environment of Care inspections  database software; oversees the deployment and maintenance of the Environment of  Care inspections database software, which medical centers use to  track deficiencies and staff attendance at inspections, among other  things; and provides summary reports from inspections data on deficiencies,  closure status, and staff attendance rate at inspections to officials at  the medical center and VISN-level for program management purposes  To monitor a medical center’s compliance with environment of care  requirements, VHA tracks three measures, which, according to VHA  officials, were established to ensure that medical centers were meeting  requirements related to the inspections process, such as having relevant  staff present for the inspections. Table 3 below shows the three measures  VHA currently uses along with the related performance targets.

We have previously reported that performance measures should focus on  outcomes to help agencies manage programs to achieve desired  results. VHA’s current measures do not indicate whether desired  outcomes are being achieved or how effective inspections are but rather  whether staff are following policies related to inspections. As a result,  these measures provide program managers with little information on the  actual quality of the environment of care, such as the level of cleanliness  and safety provided. For example:

One performance measure is based on the requirement that medical  centers address deficiencies within 14 days, either by fixing the  problem or by preparing an action plan describing how the problem  will be fixed. However, because this requirement can be met with an  action plan, it is not a useful measure for understanding the  deficiencies that have not yet been remediated.

Similarly, the two performance measures on staff attendance at  inspections do not directly relate to the condition of the facility but  reflect the level of compliance with inspection requirements. We  spoke with officials at one medical center who said vacancies within  their information security office prevented them from meeting the  inspection team attendance measure. However, officials said the staff  absence did not affect the inspection team’s ability to perform an  inspection and determine facility deficiencies, given that relevant  engineering staff was present.

Furthermore, we have previously reported that VHA needs to strengthen  aspects of the environment of care inspection process to ensure more  complete and accurate data on medical center compliance with  environment of care standards, and provide better oversight of the  system.

VHA Has Not Established Outcome-Oriented Performance Goals, Objectives, and Related Measures

VHA has not defined program goals and objectives and related  performance measures, and is therefore limited in its ability to determine  how well program activities, including the environment of care inspection  process, are supporting the agency’s broader policy of providing a clean,  safe, and functional environment. VHA’s current performance measures  are not tied to specific performance goals for the Environment of Care  Program, as such goals have not yet been created. Nor do these  performance measures provide useful information on the actual condition  of facilities or desired outcomes. As a result, these metrics provide VHA  with limited information on how to better manage the program to ensure  clean, safe, and functional medical facilities that, at a minimum, meet the  Joint Commission standards. Without clearly defined and outcome- oriented goals, it will be challenging for VHA to determine what type of  evaluative information it will need to monitor the progress of the  Environment of Care Program, identify how system-wide challenges such  as staffing shortages are affecting outcomes, and improve medical center  conditions.

VHA has stated it intends to create goals and objectives for the  Environment of Care Program, along with performance measures to  assess whether the goals and objectives are being achieved, but it has  not yet done so. The VHA directive from 2016 that created the  Environment of Care Program directed program officials to establish a  steering committee, whose responsibilities would include, among other  things, developing goals, objectives, and related performance measures  for the program. According to a VHA official, VHA formed this committee  in January 2018, following delays caused by leadership vacancies and  competing demands within the agency. In June 2018, the committee  finalized its charter, which states that the scope of the committee’s  activities is to include defining goals, objectives, performance metrics,  and targets for the Environment of Care Program. VHA officials do not  have a timeline in place for when they expect to complete the steps they  defined in the charter.

To provide quality care for the nation’s veterans, medical centers must be  clean, safe, and functional. This standard can be a challenge given the  substantial capital repair and improvement needs in many of these  facilities. The Environment of Care Program is an important part of VHA’s  efforts to ensure medical centers are maintained in accordance with  accreditation requirements. However, absent clear goals, objectives, and  performance measures, and a timeline for developing them, VHA will  continue to be limited in its ability to assess how effective the program is  at ensuring a safe, clean, and functional environment. Setting outcome- oriented program goals and objectives provides structure to then  reevaluate existing performance measures or set new ones, all of which  would improve oversight, help VHA determine the effectiveness of the  program, and target areas in need of improvement.

We are making the following recommendation to VHA:  The Undersecretary for Health should set a timeline for defining goals,  objectives, and outcome-oriented performance measures for the  Environment of Care Program. (Recommendation 1)

We provided a draft of this product to VA for comment. In its written  comments, reproduced in appendix I, VA stated it concurred with our  recommendation. VA also provided technical comments, which we  incorporated as appropriate.

Additionally, VA provided general comments on our report. In those  general comments, VA questioned how we characterized the  Environment of Care Program in the context of Facility Condition  Assessments, the age of its buildings, and software interoperability, and  stated that responsibility for a successful Environment of Care Program  lies at the medical center. We agree it is important to have a strong  Environment of Care Program that is facilitated by leadership at the  medical center and VISN-levels. However, even with strong leadership  and a robust Environment of Care Program, underlying facility condition  issues—impacted by the age of the facility—can affect the kind of  deficiencies found during inspections. These challenges impacted  elements of the Environment of Care Program at all of the medical  centers in our review.

VA also stated that the report did not adequately reflect the significance of  the environment of care committees at each medical center, and that  performance measures at the national level are measures of compliance,  not a measure of success. We have made relevant revisions in the report  to reflect the role these committees play as a part of the inspections  process. We also agree with VA that the metrics established nationally  are not a measure of success for the various medical centers’  Environment of Care Programs. While the primary responsibility for the  Environment of Care Program and its inspections is at the medical center  and VISN-level, it is still important for VA to have national level  performance measures. Without them, gauging national level  performance and analyzing trends across medical centers is difficult. In  concurring with our recommendation, VA has positioned itself to create  and implement measures to support medical centers and the  Environment of Care Program.

VA also made comments related to the non-recurring maintenance  approval and funding process, and highlighted a pilot to test a tool to  replace its current facility condition assessment. We have made revisions  to footnotes and relevant report sections as appropriate to address the  changes noted by VA to the non-recurring maintenance approval and  funding process, and added a footnote acknowledging the pilot.

We are sending copies of this report to the appropriate congressional  committees, the Secretary of Veterans Affairs, the Undersecretary of  Veterans Affairs for Health, and other interested parties. In addition, the  report is available at no charge on the GAO website at  http://www.gao.gov.

If you or your staff members have any questions regarding this report,  please contact Andrew Von Ah at (202) 512-2834 or vonaha@gao.gov.  Contact points for our Offices of Congressional Relations and Public  Affairs may be found on the last page of this report. Key contributors to  this report are listed in appendix III.

Appendix I: Comments from the Department of Veterans Affairs

Appendix II: Inspections Related to the Condition of Veterans Health Administration’s (VHA) Facilities

Appendix II: Inspections Related to the  Condition of Veterans Health Administration’s  (VHA) Facilities Purpose  The Facility Condition Assessment   evaluates all buildings and major   systems at a medical facility and   identifies needed repairs and   replacements. This inspection   gives a graded score from A to F   for VHA facilities.

Frequency  Facility Condition Assessments are   done on a rotating basis, with each  Veterans Integrated Service Network  (VISN) being evaluated every 3 years.  The information gathered during each  Facility Condition Assessment is put   into a Facility Condition Assessment  database for each facility identified by  building, system, and condition. Each  system has an associated cost for  identified repairs and replacements.  These data allow for planning and  expenditure of resources within the  VISNs. This information enables the  VISN to plan, manage, and direct   capital resources against identified   needs in a consistently managed  approach across the VA system.

Green Environmental Management System  ensures VHA compliance with relevant  federal, state and local environmental   statutes and regulations; increases the  efficiency of energy, water and other   resource usage; helps reduce regulated   air emissions; utilizes pollution prevention  principles; incorporates environmentally  preferable practices for the design,  construction and operation of buildings;   and ensures that VHA facilities are good  neighbors in the local communities.

Green Environmental Management  System inspections are done   annually.

The primary purpose and intent of the   Annual Workplace Evaluation is to ensure  occupational safety and health evaluations   of all worksites are completed and comply   with Occupational Safety and Health  Administration and agency requirements.   The objective is to evaluate Occupational  Safety and Health Administration   compliance, current building conditions,   work practices, and Occupational Safety   and Health Administration program  implementation throughout the facility and   at offsite campuses such as rented office  buildings, clinics, labs, etc.

Annual Workplace Evaluations are  required to be performed at least   once every fiscal year. The Annual  Workplace Evaluation must be   scheduled at least once during a 12- month period +/- 3 months from the   start date of the previous Annual  Workplace Evaluation.

Appendix III: GAO Contacts and Staff Acknowledgements

In addition to the contact named above, Heather J. Halliwell (Assistant  Director), Betsey Ward-Jenks (Analyst-in-Charge), Dwayne Curry, and  Colleen A. Taylor made key contributions to this report. Also contributing  were Kelly Rubin, Michelle Weathers, and Crystal Wesco.

The Veterans Health Administration oversees one of the nation's largest healthcare systems, serving about 9 million veterans at numerous facilities, including 170 medical centers.

To ensure a safe environment for veterans and employees, VHA must keep its facilities clean and well maintained. This can be a challenge given their substantial capital repair and improvement needs.

VHA's Environment of Care Program is an important part of its efforts to ensure its facilities are regularly inspected and meet standards. We recommended VHA develop ways to better measure the program's effectiveness and target areas in need of improvement.