Inter-American Organizations: U.S. Agencies Support Oversight Mechanisms but Could Enhance Their Monitoring of U.S. Assistance Agreements

The United States is a member of the OAS, PAHO, IICA, and PAIGH, which promote democracy, health care, agricultural development, and scientific exchange.

GAO was asked to review U.S. assistance to these four organizations. In this report, GAO (1) assesses the extent to which the organizations' strategic goals align with those of U.S. agencies; (2) examines how the organizations oversee the use of their funds and the extent to which U.S. agencies have supported those efforts; (3) assesses the extent to which U.S. agencies included key monitoring provisions as part of assistance agreements; and (4) assesses the extent to which U.S. agencies had documentation of monitoring activities, including those called for by these provisions. GAO analyzed documents and interviewed officials from State, USAID, HHS, USDA, and the organizations. GAO also analyzed a nongeneralizable sample of 12 of the 60 assistance agreements that were awarded by State, USAID, HHS, and USDA to OAS, PAHO, and IICA and were active during calendar years 2014 through 2016. For each agency, GAO selected three agreements with the lowest, median, and highest dollar value.

GAO found that strategic goals of the Organization of American States (OAS), the Pan American Health Organization (PAHO), the Inter-American Institute for Cooperation on Agriculture (IICA), and the Pan-American Institute of Geography and History (PAIGH) are predominantly aligned with the strategic goals of the Department of State (State), the U.S. Agency for International Development (USAID), the Department of Health and Human Services (HHS), and the U.S. Department of Agriculture (USDA). For example, IICA's strategic goals of a productive agricultural sector, enhancing agricultural development, and food security are aligned with USDA's foreign assistance goals. State, USAID, HHS, and USDA fund activities in the form of assistance agreements (e.g., grants and cooperative agreements) with OAS, PAHO, and IICA, which in 2016 totaled $32 million. According to agency officials, the agencies employ mechanisms to ensure that these agreements align with U.S. strategic goals.

OAS, PAHO, IICA, and PAIGH have established mechanisms for overseeing their use of funds, such as external auditors, internal audit boards, and anti-fraud and ethics policies. State and USDA have directly supported these mechanisms. For example, State engaged in the selection process for OAS's Inspector General.

GAO's review of 12 selected assistance agreements found that USDA included no financial or performance monitoring provisions in one of its agreements and that State did not include two key monitoring provisions in one of its agreements, called for by applicable guidance. GAO found that the remaining 10 agreements it reviewed contained all key monitoring provisions and that State has since taken corrective action.

GAO found that U.S. agencies did not have full documentation of 18 of the 42 monitoring activities required by the 12 assistance agreements GAO reviewed (see table). For example, USDA did not have full documentation, such as for financial reports, of any of its 10 required monitoring activities and USDA officials did not explain their lack of documentation. USAID officials explained that their lack of full documentation was due, in part, to grant officers not always following their document management policies. State and HHS have since taken corrective action. If an agency does not have full documentation of monitoring activities, it may lack information needed to make appropriate budgetary and programmatic decisions.

GAO recommends that (1) USDA ensure inclusion of all monitoring provisions as part of agreements and (2) USAID and USDA ensure full documentation of monitoring activities. USDA and USAID concurred with GAO's recommendations.

The United States is a member of the Organization of American States  (OAS), the Pan American Health Organization (PAHO), the Inter- American Institute for Cooperation on Agriculture (IICA), and the Pan- American Institute of Geography and History (PAIGH). OAS, PAHO, IICA,  and PAIGH work to, among other things, promote democracy, security,  health care, agricultural development, and scientific exchange. The  United States engages with other countries in the region through its  membership in these inter-American organizations to promote U.S.  interests in the Western Hemisphere.

The Department of State (State) provides the United States’ assessed  contributions to these four organizations’ regular budgets. State, the U.S.  Agency for International Development (USAID), the Department of Health  and Human Services (HHS), and the U.S. Department of Agriculture  (USDA) also provide project-specific voluntary contributions to the OAS,  PAHO, and IICA through grants and cooperative agreements (referred to  hereafter as assistance agreements or simply agreements). For calendar  year 2016, the United States’ assessed contributions to these four  organizations totaled over $130 million, and voluntary contributions to the  OAS, PAHO, and IICA totaled $32 million. Together, the four  organizations oversaw over $358 million in total member-state  contributions for calendar year 2016.

We were requested to review several issues related to U.S. support for  these four inter-American organizations. In this report, we (1) assess the  extent to which the organizations’ strategic goals align with those of U.S.  agencies; (2) examine how the organizations oversee the use of their  funds and the extent to which U.S. agencies have supported those  efforts; (3) assess the extent to which U.S. agencies included key  monitoring provisions as part of their assistance agreements; and (4)  assess the extent to which U.S. agencies had documentation of  monitoring activities, including those called for by these provisions.

To address our first objective, we compared the strategic goals articulated  by the four organizations against the U.S. strategic goals for foreign  assistance in the region. We also reviewed relevant U.S. agency  documentation of efforts to ensure goal alignment. To address our  second objective, we reviewed the organizations’ internal control  documentation and interviewed officials from State, USAID, HHS, and  USDA and from the four organizations. To address the third and fourth  objectives, we identified 60 active assistance agreements that these  agencies awarded to OAS, PAHO, and IICA during calendar years 2014  through 2016 and selected a nongeneralizable sample of 12 agreements,  three each from HHS, State, USAID, and USDA. We selected the three  agreements from each agency based on the lowest, median, and highest  dollar value. For the third objective, we then assessed whether the  agencies’ agreements included key monitoring provisions implementing  applicable agency guidance. We identified key monitoring provisions for  agencies to include as part of their agreements as provisions which  ensure oversight over the use of funds, such as financial and progress  reports. For the fourth objective, we assessed the extent to which the  agencies had documentation of required monitoring activities. We  examined documentation of activities called for by assistance  agreements. We also interviewed officials from the four U.S. agencies.  See appendix I for details on our scope and methodology.

We conducted this performance audit from July 2016 to December 2017  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.

The U.S. government engages with the governments of other countries in  the Western Hemisphere through various inter-American organizations  including the OAS, PAHO, IICA, and PAIGH. According to State, the OAS  is the primary inter-American political forum through which the United  States engages with other countries in the Western Hemisphere to  promote democracy, human rights, security, and development. PAHO  serves as the Regional Office for the Americas of the World Health  Organization, the United Nations agency on health. IICA supports  agricultural development and rural well-being through technical  cooperation and the execution of agricultural projects throughout the  hemisphere. PAIGH specializes in regional cartography, geography,  history, and geophysics and has facilitated the settlement of regional  border disputes. According to U.S. agency officials, the organizations’  regional knowledge and technical expertise make them effective  implementing partners for projects serving U.S. national interests and  priorities throughout the hemisphere.

U.S. Contributions to Inter- American Organizations

Member states collectively finance these organizations by providing  assessed and voluntary contributions (see table 1).

For each organization, its member states’ assessed contributions are  intended to finance the organization’s regular budgets, which generally  cover the organization’s day-to-day operating expenses, such as facilities  and salaries. Member states also finance certain OAS, PAHO, and IICA  activities and projects through voluntary contributions. According to U.S.  officials, the United States provides voluntary contributions to the OAS,  PAHO, and IICA primarily through assistance agreements for specific  projects from State, USAID, HHS, and USDA.

The Institute of Internal Auditors (IIA) provides the framework for  international organizations to oversee funds such as the assessed  contributions provided by member states to OAS, PAHO, IICA, and  PAIGH. The institute’s authoritative guidance, International Standards for  the Professional Practice of Internal Auditing, includes mandatory  performance standards that describe the nature of internal audit activities  and provide criteria for evaluating these activities. Organizations are  required to subscribe to these IIA standards, according to PAIGH officials  and OAS, PAHO, and IICA documents.

U.S. Agencies Oversee the Execution of Their Assistance Agreements

Assistance agreements are a critical tool the U.S. government uses to  achieve important national objectives. As we have previously reported,  effective oversight and internal control are important to provide  reasonable assurance to federal managers and taxpayers that assistance  agreements are awarded properly, recipients are eligible, and federal  funds are used as intended and in accordance with applicable laws and  regulations. State, USAID, HHS, and USDA oversee funds provided to  OAS, PAHO, and IICA through assistance agreements using monitoring  activities such as financial and performance reports. Within each of these  agencies, various bureaus and offices are responsible for awarding and  managing assistance agreements to these inter-American organizations,  including State’s Office of Weapons Removal and Abatement in the  Bureau of Political-Military Affairs, USAID’s Office of U.S. Foreign  Disaster Assistance, HHS’s Centers for Disease Control and Prevention  and its Food and Drug Administration, and USDA’s Animal and Plant  Health Inspection Service. The documentation of these monitoring  activities as called for by federal standards for internal control enables the  agencies to determine the effectiveness of the agreement activity.

The Strategic Goals of the Four Inter- American Organizations Are Predominantly Aligned with U.S. Agencies’ Strategic Goals

We found that the strategic goals of the four inter-American organizations  are predominantly aligned with the high-level strategic goals for the  Western Hemisphere documented by State, USAID, HHS, and USDA.  According to officials, the agencies all consider U.S. strategic goals when  deciding which projects to fund at OAS, PAHO, and IICA. State, USAID,  HHS, and USDA have goals for foreign assistance to the Western  Hemisphere, as shown in table 2. For example, four of the five goals in  State and USAID’s Joint Strategy correspond with goals at the OAS, IICA,  and PAIGH. U.S. agencies, on an ongoing basis, evaluate each inter- American organization to ensure U.S. and organization goals are aligned.

Officials from all four agencies provided examples of how they help to  ensure alignment of U.S. strategic goals when funding projects at OAS,  PAHO, and IICA.

State: According to State officials, State created an Annual Performance and Budget Review process in 2014 specifically to review entities, such as the OAS, that receive voluntary contributions funded through the International Organization and Programs account.  This process examines performance of State-funded activities relative  to those activities from the previous year and the extent to which the  activities advance U.S. priorities and objectives. State officials further  noted that the Annual Performance and Budget Review helps inform  State’s decision-making on what to include in the following year’s  budget request. For example, during the 2016 review for the OAS  Development Assistance Program, State reported the program’s  significant activities, funds expended, and achievements such as  training government officials on successful small business policies in  the United States.

USAID: According to USAID officials, USAID’s project design and  approval policies and procedures ensure that all USAID-funded  activities are linked to applicable U.S. and USAID strategies. USAID’s  agency guidance requires, at a minimum, that each project or activity  must be formally approved in writing by the relevant Mission Director  or Principal Officer for a given program. Officials stated that this  approval memo and supporting documentation address a number of  planning considerations, including how the proposed activity aligns  with broader strategies. Furthermore, officials stated that USAID’s  lawyers review project approval documentation prior to final approval  and verify that the activity complies with all applicable statutes,  regulations, and policies.

HHS: According to HHS officials, HHS engages with PAHO on its  Biennial Work Plans, which are operational planning instruments that  PAHO uses to identify activities that it can implement within each of its  member states. HHS officials noted that they use PAHO’s Biennial  Work Plan to strengthen U.S. approaches on issues of common  concern and to advance U.S. priorities within the region. According to  HHS officials, proposals for technical cooperation projects are  required to correspond to one of the technical priorities in PAHO’s  strategic plan for 2014–2019 and to be aligned with the HHS global  strategy and U.S. priorities.

USDA: USDA officials said that they compare the U.S. strategic goals  with IICA’s goals and objectives when they formulate project  proposals with IICA to ensure that the projects are aligned with U.S.  priorities for the region. Additionally, USDA officials told us that USDA  helped shape and influence IICA’s recent 10-year strategic plan,  ensuring that IICA’s strategic objectives were closely aligned with U.S.  strategic goals.

OAS, PAHO, IICA, and PAIGH Have Established Oversight Mechanisms

OAS, PAHO, IICA, and PAIGH have established mechanisms for  overseeing their use of assessed and voluntary contributions, such as  external auditors and internal audit boards as required by IIA standards.  State and USDA have directly supported these oversight mechanisms.

The Four Organizations Have Oversight Mechanisms as Required by the IIA

OAS, PAHO, IICA, and PAIGH have oversight mechanisms, as shown in  table 3. The four organizations follow the internal control standards of the  IIA, codified in the International Standards for the Professional Practice of  Internal Auditing, according to PAIGH officials and OAS, PAHO, and IICA  documents. All four organizations have internal and external auditors, as  required by these standards. Furthermore, OAS, PAHO, and IICA have  additional oversight mechanisms, such as anti-fraud policies and program  evaluation processes. The officials we interviewed from State, USAID,  HHS, and USDA expressed confidence in the four organizations’  management of their assessed and voluntary contributions.

All four organizations document the status of their financial and internal  control activities in audit reports posted on their public websites. For  example, the OAS Office of the Inspector General’s April 2017 Annual  Report included an update on its five ongoing audits and investigations.  The report also outlined progress made against prior recommendations.

U.S. Agencies Support Oversight Mechanisms at OAS, PAHO, and IICA

U.S. agency officials support budget and administrative subcommittees in  three of the four organizations and promote the participation of U.S.  experts on independent audit committees, as shown in table 4. For  example, according to officials, State plays a significant role in promoting  policies on oversight and accountability at the four organizations through  formal engagement in deliberations and decision-making of each  organization’s governing body and through informal engagement with  other member states and the secretariat by recommending best practices  in governance, management, and oversight. State and USDA are also  directly involved in implementing some of the additional oversight  mechanisms at the organizations. For example, a USDA official serves as  a member of IICA’s Audit Review Committee. Additionally, an IICA official  told us the United States was involved in defining IICA’s Convention and  Rules of Procedure for its governing bodies, which established the  requirement for internal and external auditing.

According to State officials, the United States led efforts to strengthen  oversight at several of the organizations under review in recent years,  such as advocating for the creation of an ethics officer position at PAHO,  proposing language to strengthen the authority and independence of the  OAS’s Office of the Inspector General, and encouraging the creation of  audit committees at both organizations. In addition, State has played a  lead role in supporting the ongoing reform of the OAS administration,  which includes improved oversight and accountability, according to  officials from the OAS and the U.S. Mission to the OAS.

Two of Four U.S. Agencies Did Not Include All Key Monitoring Provisions in the Agreements We Reviewed

We reviewed 12 selected assistance agreements that the four U.S.  agencies awarded to OAS, PAHO, and IICA that were active during  calendar years 2014 through 2016, and found that two agencies did not  consistently include all key monitoring provisions in their agreements.  While HHS and USAID implemented applicable guidance by including all  key monitoring provisions in their agreements, USDA and State did not  do so. USDA and State agency officials did not explain why USDA and  State did not include these monitoring provisions in their agreements.  However, State has since taken corrective action to ensure that they are  included in future agreements, according to State officials.

Agency Guidance Calls for Agencies to Conduct Monitoring Activities; Internal Control Standards State That Agencies Should Document These Requirements with Provisions in the Agreements

Applicable agency guidance calls for agencies to conduct monitoring  activities as part of their oversight of their agreements. Each of the four  agencies has established agency-specific guidance that outlines the  monitoring activities for assistance agreements. In some cases, the  agency-specific guidance may mandate additional monitoring activities  beyond those called for in applicable federal regulations, such as risk  assessments. For example, State’s guidance calls for the creation of a  monitoring plan. Federal standards for internal control require that  agencies include in agreements all key provisions delineating the parties’  responsibilities. For the 12 agreements we reviewed, the number of total  key monitoring provisions per agreement varied—including within one  agency—depending on when the agency issued and updated its  guidance relative to when the agreements were approved.

Federal standards for internal control call for agencies to document  internal controls, transactions, and significant events. Specifically,  internal control standards state that agency management should include  internal control activities (e.g., monitoring activities) in policies or  directives for transactions such as assistance agreements.

HHS and USAID Included All Key Monitoring Provisions in Their Assistance Agreements, but USDA and State Did Not

For the 12 assistance agreements we reviewed, USDA and State did not  include provisions implementing 6 of the 55 total (11 percent) applicable  monitoring activities required by applicable guidance to carry out required  monitoring activities (see table 5). State took corrective action in 2015 by  issuing a standard operating procedure.

USDA: USDA did not include 4 of the 13 key monitoring provisions  implementing the applicable guidance for the three USDA agreements  we reviewed (see table 6). Two of the agreements and supporting  documentation each included all four key applicable monitoring  provisions. However, Agreement 2 in the table did not include 4 of the  5 monitoring provisions in the agreement or work plan, which  documents the monitoring provisions. The agreement partially  included performance goals, because it included objectives for the  agreement’s activities, but did not include time frames to complete all  of the activities. The USDA grant official did not explain why the work  plan did not adhere to applicable federal regulations when it was  drafted and approved.

State: State did not include 2 of the 21 key monitoring provisions  implementing the applicable guidance for the three State agreements  we reviewed (see table 7). Two of the agreements and supporting  documentation we reviewed included the 7 monitoring provisions  implementing the requirements in the applicable agency guidance.  However, one agreement awarded in 2012 did not include 2 of the  provisions: a risk assessment and a monitoring plan. That office that  awarded this agreement took corrective action in 2015 by issuing a  standard operating procedure requiring that risk assessments and  monitoring plans accompany its grants and cooperative agreements.

USAID: USAID included both key monitoring provisions implementing  the applicable guidance for the three USAID agreements we reviewed  (see table 8). USAID’s Automated Directives System 308, Standard  Provisions for Cost-Type Awards to Public International Organizations  contains two key monitoring provisions for agreements. USAID  incorporated the monitoring provisions nearly verbatim into the  agreements we reviewed, using templates from this guidance for  required terms and conditions.

HHS: HHS included the 15 monitoring provisions implementing the  applicable guidance for the three HHS agreements we reviewed (see  table 9).

None of the U.S. Agencies Had Full Documentation of Monitoring Activities Called for by All of Their Assistance Agreements That We Reviewed

None of the agencies provided us with full documentation to demonstrate  their adherence to the required monitoring activities called for in all of  their agreements that we reviewed, including the previously mentioned  key monitoring provisions that we reviewed. State and HHS have taken  corrective actions to address the gaps we found in documentation for the  agreements we reviewed. Agency officials told us that they use these  monitoring documents, such as financial and progress reports, to inform  future budgetary and programmatic decisions. Therefore, they may lack  information needed to make such decisions if they do not have access to  complete monitoring documentation.

Assistance Agreements Include Requirements for Monitoring Activities; Internal Control Standards Say Agencies Should Document These Activities

According to federal standards for internal control, each agency is to  include key monitoring provisions as part of its agreements. In the  individual assistance agreements, the agencies specify the requirements  to fulfill these activities, such as requiring financial reports on a quarterly  basis or including specific information in performance reports. Grants  officers at times, if they deem it necessary or appropriate, include  additional monitoring provisions requiring activities beyond those required  by the applicable guidance, such as site visits.

Federal standards for internal control call for agency management to  design monitoring activities, such as financial and performance reporting,  so that all transactions are completely and accurately recorded.

Recording these activities maintains their relevance and value to  management in controlling operations and making decisions. Without  access to complete monitoring documentation, the agencies risk  weakening the effectiveness of these controls.

U.S. Agencies Did Not Have Full Documentation of Monitoring Activities for Most of the Agreements We Reviewed

None of the four U.S. agencies had full documentation of all of the  monitoring activities required by their agreements we reviewed (see table  10). The agencies did not have full documentation of monitoring activities  for 9 of the 12 agreements we reviewed. For the 42 monitoring activities  identified across all of the individual agreements, the four agencies did  not have full documentation of 18 of the activities (43 percent). However,  State took corrective action in May 2017 to address its gaps in  documentation, and according to HHS officials, the Food and Drug  Administration addressed its gap in documentation by implementing its  agreement monitoring program in fiscal year 2018.

USDA did not have full documentation of any of the 10 monitoring  activities we identified (see table 11). USDA demonstrated that it had  partially documented 2 of the 10 monitoring activities (20 percent) by  providing us with some, but not all, quarterly performance reports. For  one of the agreements, USDA had no documentation of the monitoring  activities for that agreement. For its other two agreements, USDA did not  have full documentation of the required monitoring activities. USDA  officials did not explain why they did not have full documentation. Without  full documentation of the required monitoring activities, USDA may not  have the information it needs to make appropriate budgetary and  programmatic decisions.

USAID did not have full documentation of 2 of the 11 total monitoring  activities (18 percent) we identified across the three agreements we  reviewed (see table 12). USAID had partial documentation of those 2  monitoring activities. For example, USAID provided us with some, but not  all, records such as financial reports required by the terms of the  monitoring activities in the agreements.

According to USAID officials, the agencies’ lack of complete monitoring  documentation was in part due to agency officials not following some of  their agency’s requirements for managing agreement documents, such as  placing all documents in a shared document management system. For  example, for one of the agreements we reviewed, USAID officials stated  that they stored some agreement documentation electronically—such as  modifications, correspondence with the agreement recipient, and  quarterly financial reports—but primarily maintained paper files.

USAID officials told us they use the monitoring documents of these  agreements, such as financial and progress reports, to inform future  budgetary and programmatic decisions. For example, according to USAID  officials, USAID uses monitoring documents to identify and address  potential project delays or other “red flags.” For one of the agreements we  reviewed, USAID officials stated these monitoring reports also assist  them in determining whether to award additional funds and establish new  indicators in subsequent agreements. Without full documentation of the  required monitoring activities, USAID may not have the information it  needs to make appropriate budgetary and programmatic decisions.

State did not have full documentation for 5 of the 16 monitoring activities  (31 percent) we identified across the three agreements we reviewed (see  table 13). However, State had partial documentation of 4 of those 5  monitoring activities. For example, State had some, but not all, records  such as standard reporting metrics, required by the terms of the  monitoring activities in one of the agreements. State did not have  documentation of one of the monitoring activities (site visits).

According to State officials, the agency’s lack of complete monitoring  documentation was in part due to agency officials not following some of  the agency’s requirements for managing agreement documents, such as  placing all documents in a shared document management system. For  example, according to State officials, for one of the agreements we  reviewed, the grants officer mistakenly had saved site visit reports and  similar documents to personal folders because the officer did not know  how to use State’s grant document storage system. As a result, neither  the current grants officer nor other State officials could retrieve these  documents.

In May 2017, after awarding the agreements we reviewed, State took  corrective action by issuing the Federal Assistance Directive to establish  internal guidance, policies, and procedures for all domestic and overseas  grant-making bureaus, offices, and posts within the department when  administering federal financial assistance. The directive notes that State  implemented a grant management system for domestic and overseas  grants to resolve its “significant deficiency in the management of Federal  financial assistance.” In addition, the directive indicates that officials from  State’s Bureau of Administration, Office of the Procurement Executive,  Federal Assistance Division will evaluate compliance with risk  assessment requirements and review documentation for selected  agreements each fiscal year. One of the stated purposes of these reviews  is to mitigate risk by strengthening management and oversight of awards,  including grants. According to a State Office of Inspector General report,  State should complete the full deployment of this system for overseas  grants in fiscal year 2019.

HHS did not have full documentation of 1 of the 5 applicable monitoring  activities (20 percent) we identified across the three agreements we  reviewed (see table 14). HHS had partial documentation of the  semiannual progress report activity for one of its agreements, required by  the terms of its agreement. HHS officials did not explain why they did not  have full documentation for this monitoring activity. HHS had full  documentation of all applicable monitoring activities for the other two  agreements we reviewed.

According to agency officials, the Food and Drug Administration, which  administered one of the HHS agreements we reviewed, has taken  corrective action to evaluate its agreement documentation and address  deficiencies. According to HHS officials, the Food and Drug  Administration developed a pilot program intended to provide an  additional layer of oversight to ensure adherence to the terms of each  agreement. Under the pilot, officials said, a grant monitoring specialist  reviews the agreement documentation and monitoring reports to identify  agreements that need additional assistance. According to HHS officials,  the Food and Drug Administration implemented this program in fiscal year  2018 and will eventually include all Food and Drug Administration  agreements.

U.S. assistance agreements for projects with inter-American  organizations further U.S. strategic goals in the Western Hemisphere, but  State, HHS, USAID, and USDA did not consistently include all key  monitoring provisions as part of their assistance agreements or  demonstrate that they had full documentation of monitoring activities for  the agreements we reviewed. Of these four agencies, USAID and USDA  have not taken corrective actions. Monitoring the implementation of U.S.  assistance agreements and fully documenting the results of such  monitoring are key management controls to help ensure that U.S.  agreement recipients use federal funds appropriately and effectively. The  agencies risk weakening the effectiveness of these controls by not  including all key monitoring provisions called for by applicable agency  guidance. Further, if the agencies do not have full documentation of the  agreements’ required monitoring activities, they may not be able to  effectively manage federally funded projects that support U.S. strategic  goals. In addition, agencies may not have all the information they need to  make budgetary and programmatic decisions.

We are making a total of three recommendations: one to USAID and two  to USDA.

The USAID Administrator should ensure that USAID officials have full  documentation of required monitoring activities in agreements with inter- American organizations. (Recommendation 1)

The Secretary of Agriculture should ensure that USDA includes all key  monitoring provisions specified by applicable guidance as part of  agreements with inter-American organizations. (Recommendation 2)

The Secretary of Agriculture should ensure that USDA officials have full  documentation of required monitoring activities in agreements with inter- American organizations. (Recommendation 3)

We provided a draft of this report for comment to State, USAID, HHS, and  USDA. USDA concurred with our recommendations in an e-mail. In its  written comments, reproduced in appendix IV, USAID stated that it has  policies, procedures, and training in place for the officials who manage  these agreements. In response to our recommendations, USAID stated  that it will issue an agency notice to remind all such officials of these  responsibilities, including the requirement to maintain complete files for  each agreement.

State and HHS did not provide formal comments. They did provide  technical comments, which we incorporated as appropriate.

As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies of this report to the  appropriate congressional committees, the Secretary of State, the  Administrator of the U.S. Agency for International Development, the  Secretary of Health and Human Services, and the Secretary of  Agriculture. 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) 512-9601, or melitot@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 V.

Appendix I: Objectives, Scope, and Methodology

Congressional requesters asked us to review several issues related to the  Organization of American States (OAS), the Pan American Health  Organization (PAHO), the Inter-American Institute for Cooperation on  Agriculture (IICA), and the Pan-American Institute of Geography and  History (PAIGH). In this report, we (1) assess the extent to which the  organizations’ strategic goals align with those of U.S. agencies; (2)  examine how the organizations oversee the use of their funds and the  extent to which U.S. agencies have supported those efforts; (3) assess  the extent to which U.S. agencies included key monitoring provisions as  part of their assistance agreements; and (4) assess the extent to which  U.S. agencies had documentation of monitoring activities, including those  called for by these provisions.

To address the first objective, we gathered documentation and  interviewed officials from the four U.S. agencies and the four  organizations to determine the U.S. strategic goals for foreign assistance  to the Western Hemisphere and the goals of the four organizations.  According to Department of State (State) and U.S. Agency for  International Development (USAID) officials, the strategic document that  underpins their foreign assistance priorities for the region is The  Department of State’s Bureau of Western Hemisphere Affairs’ and  USAID’s Bureau for Latin American and Caribbean Affairs’ Joint Regional  Strategy. Department of Health and Human Services (HHS) officials said  that HHS’s relevant strategic document is The Global Strategy of the U.S.  Department of Health and Human Services. U.S. Department of  Agriculture’s (USDA) strategic goals for foreign assistance, according to  officials, are outlined in the United States Department of Agriculture  Strategic Plan FY2015–2018. The OAS outlined its strategic goals in the  Comprehensive Strategic Plan of the Organization, adopted on October  31, 2016. PAHO’s goals are laid out in Strategic Plan of the Pan  American Health Organization 2014–2019. IICA’s strategic document is  the IICA 2010–2020 Strategic Plan, which took effect in October 2010.  PAIGH’s strategic document is the Declaration and Guide for the Pan  American Agenda 2010-2020. We compared the strategic goals  articulated by the four organizations against U.S. strategic goals to  assess the extent to which the organizations’ goals contribute to U.S.  interests in the region. We then interviewed officials from the four  agencies and reviewed relevant documentation on efforts they undertake  to ensure that U.S.-funded activities align with U.S. strategic goals.

To address the second objective, we reviewed documentation of the  organizations’ internal control mechanisms and confirmed our findings  with the organizations. We identified mechanisms to include policies,  directives, rules, practices, and organizational structures that can have an  oversight role in the use of the organizations’ funds. We also interviewed  officials from State, USAID, HHS, and USDA to discuss their support of  these mechanisms.

To address the third objective, we identified 60 active assistance  agreements that these agencies oversaw with OAS, PAHO, and IICA  during calendar years 2014 through 2016 and selected a  nongeneralizable sample of 12 agreements, three each from State,  USAID, HHS, and USDA. To determine which agreements we would  review for each agency, we selected the three agreements with the  lowest, median, and highest dollar value. If any of an agency’s  agreements supported the same country or activity or were for one-time  projects such as seminars, we selected the next appropriate agreement  based on dollar value.

For these selected agreements, we then identified the applicable agency  guidance for monitoring activities in the agreements, which we define as  all documents related to each agreement provided to us by the agencies,  such as monitoring reports. The number of key monitoring provisions  varied—even within each agency—depending on when agency guidance  was issued and updated relative to when the agreements were approved.  USDA did not have applicable internal agency-specific guidance for  monitoring of assistance agreements at the time it awarded the  agreements we reviewed; thus, with USDA’s input, we used the  applicable sections of the Code of Federal Regulations, which together  have five key monitoring provisions for agreements. However, USDA  approved two of the agreements in 2012 and the third agreement in 2016,  and this third agreement was subject to an amended version of the Code  of Federal Regulations, which added an additional provision for  performance goals. State’s four applicable grants policy directives have seven key monitoring provisions for agreements that were applicable at  the time the agreements we reviewed were approved. USAID’s Standard  Provisions for Cost-Type Awards to Public International Organizations  (PIOs): A Mandatory Reference to ADS Chapter 308 has two key  monitoring provisions for agreements: audits and records, and the  organization’s adherence to their rules. HHS’s grants policy has five key  monitoring provisions for grant documentation.

We identified key monitoring provisions for agencies to include as part of  agreements to ensure oversight of the use of funds, such as financial and  progress reports. For the 12 agreements in our sample, we analyzed the  assistance agreements from the four agencies, and then determined the  extent to which the agencies’ agreements included key monitoring  provisions implementing monitoring activities called for by applicable  agency guidance. We did not include subsequent amendments to these  12 agreements in our review of key monitoring provisions. We interviewed  officials from State, USAID, HHS, and USDA (1) to confirm we were  applying the appropriate federal or agency guidance and (2) to discuss  instances in which the agreements did not include key monitoring  provisions.

To address the fourth objective, we reviewed the 12 selected assistance  agreements and guidance to identify specific required monitoring  activities, such as financial and program reports, site visits, and other  forms of oversight. The agreements specify the requirements for these  activities such as requiring financial reports on a quarterly basis. For  these 12 agreements, we reviewed all the documentation provided to us  by the agencies, then determined the extent to which the agencies had  full documentation of key monitoring activities as specified in the  assistance agreements, including those called for by key monitoring  provisions, as well as those called for by guidance when the monitoring  provisions were absent. We did not include subsequent amendments to  these 12 agreements in our review of monitoring activities. We  interviewed officials from State, USAID, HHS, and USDA to discuss  instances in which the agency did not have full documentation of key  monitoring activities. We also discussed how State, USAID, and HHS  agency officials manage their agreement documentation and use the  information in the agreements’ required monitoring documentation.

Appendix II: Financial Oversight Mechanisms of Four Inter-American Organizations

The Organization of American States (OAS), Pan American Health  Organization (PAHO), the Inter-American Institute for Cooperation on  Agriculture (IICA), and the Pan-American Institute on Geography and  History (PAIGH) have established mechanisms for overseeing their use of  funds. Tables 15–18 show the mechanisms (oversight policies and  oversight committees and organizations) for each of these inter-American  organizations, as confirmed by the organizations’ officials.

Appendix III: Key Monitoring Provisions Implementing Federal Regulations or Agency Guidance

To oversee the execution of their agreements, the Department of State  (State), the U.S. Agency for International Development (USAID), the  Department of Health and Human Services (HHS), and U.S. Department  of Agriculture (USDA) are to conduct monitoring activities called for by  applicable federal regulations or agency guidance and document these  provisions in assistance agreements as called for by federal standards for  internal control. We identified key monitoring provisions implementing the  applicable agency guidance for State, USAID, HHS, and the applicable  regulations for USDA, as shown in table 19. For both the agency  guidance and the federal regulations, those listed are the ones that were  in effect when the agreements in our sample were approved. Some of the  agency guidance and regulations have since been amended or  superseded.

Appendix IV: Comments from the U.S. Agency for International Development

Appendix V: GAO Contact and Staff Acknowledgments

In addition to the contact named above, Pierre Toureille (Assistant  Director), Julia Jebo Grant (Analyst-in-Charge), Leslie Stubbs, and Paul  Sturm, Alana Miller, and Shirley Min made key contributions to this report.  In addition, David Dayton, Martin de Alteriis, Neil Doherty, Jeff Isaacs,  and Alex Welsh provided technical assistance.

The United States belongs to several organizations that promote health care, democracy, and other causes in the Americas. For example, the Organization of American States is investigating actions of the Venezuelan government against its citizens, and the Pan American Health Organization is fighting malaria in Haiti and elsewhere. U.S. assessed and voluntary contributions to four of these organizations totaled over $160 million in 2016.

We found that agencies' agreements with the organizations further U.S. strategic goals. However, we made recommendations for agencies to improve their oversight of financial and performance monitoring.


New Trauma Care System: DOD Should Fully Incorporate Leading Practices into Its Planning for Effective Implementation

Traumatic injury is a major cause of death and disability in the military, but improved trauma care has the potential to improve these outcomes. DOD has worked to improve trauma care over time, such as by establishing a Joint Trauma System Defense Center of Excellence to examine trauma care and share best practices.

To improve trauma care across DOD, the NDAA for Fiscal Year 2017 directed DOD to establish a new JTS within DOD's Defense Health Agency. The NDAA requires that the new JTS include four specified elements, and also required DOD to submit to Congress an implementation plan that included the four elements. The NDAA also included a provision for GAO to review DOD's planning for the new JTS.

GAO assessed whether the implementation plan includes the four required elements and the extent to which DOD's planning efforts to date reflect leading practices from prior GAO work, such as identifying goals and strategies to achieve those goals. To conduct its work, GAO assessed DOD's implementation plan and other supplemental planning documents identified by DOD, and interviewed DOD officials.

The Joint Trauma System (JTS) implementation plan submitted to Congress by the Department of Defense (DOD) in August 2017 includes a description of the four elements required by the National Defense Authorization Act (NDAA) and an overview of implementation activities. For example, it indicates how the Army's current JTS Defense Center of Excellence will become part of DOD's new JTS.

However, the plan and other supplemental planning documents prepared to date do not fully incorporate leading practices for planning as identified by prior GAO work. GAO has previously found that implementation plans incorporating these leading practices—goals, strategies to achieve goals, risks that can affect goals, and plans to assess progress toward goals—help ensure organizations achieve their objectives. For each of the four required elements, GAO found that these leading practices either were partially incorporated or had not been incorporated:

Element 1—Serve as the reference body for all trauma care provided across the military health system. DOD documents include specific goals, such as consolidating data from multiple trauma registries. They also include some strategies to achieve the goals, such as identifying lead offices and time frames to complete specific actions. However, the documents provide limited details on actions DOD plans to take, and do not indicate how DOD plans to address risks or assess its progress.

Element 2—Establish standards of care for trauma care services. DOD documents include a goal to develop, publish, and assess clinical practice guidelines that serve as standards of trauma care. These documents also describe how the new JTS will continue to produce, update, and monitor adherence to the guidelines. However, they do not fully indicate plans to address risks, such as ensuring effective dissemination.

Element 3—Coordinate the translation of research from DOD centers of excellence into standards of clinical trauma care. DOD planning documents do not incorporate any leading practices for this element. DOD officials told GAO that clinical standards incorporate relevant research and that officials responsible for trauma care standards routinely interact with officials responsible for research. Officials expect this practice to continue under the new JTS.

Element 4—Coordinate the incorporation of lessons learned from trauma education and training partnerships into clinical practice. DOD planning documents do not incorporate any leading practices for this element. According to officials, DOD must first establish a separate directorate responsible for partnerships with civilian trauma centers before determining how to incorporate lessons from partnerships into the new JTS.

According to DOD, the JTS implementation plan is a general overview of implementation activities, and planning efforts are ongoing. By not fully incorporating leading practices in its planning documents, DOD may be missing opportunities to ensure that the JTS is effectively implemented, to provide more effective trauma care across the military, and to help reduce trauma-related deaths and disabilities.

GAO recommends that DOD incorporate leading practices in its planning to guide implementation efforts. DOD agreed with the recommendation.

Traumatic injury is a major cause of death and disability within the  military, but more effective trauma care has the potential to increase  survivability and reduce disabilities after injuries. For example,  Department of Defense (DOD) researchers found that approximately 24  percent of all servicemembers who died in combat from 2001-2011 could  have survived if improved and more timely medical care were made  available. Over the last two decades, DOD has worked to improve the  care it provides to servicemembers and others, with a goal of reducing  deaths and disabilities caused by trauma. Previous efforts included the  establishment of a Joint Trauma System, a Defense Center of Excellence  (JTS DCOE) within the U.S. Army, which has been responsible for  providing organized and coordinated capability for injury prevention, care,  and rehabilitation support of DOD trauma initiatives across the Military  Health System. A 2016 report by the National Academies of Sciences,  Engineering, and Medicine noted widespread improvements over time in  both military and civilian trauma care, but also acknowledged  inconsistencies in care that continue to result in preventable injuries and  deaths.

To improve trauma-related care across DOD, the National Defense  Authorization Act (NDAA) directed DOD to set up a new joint trauma  system (JTS) within its Defense Health Agency (DHA) that includes  required elements such as serving as a reference body for trauma care  provided across the military health system, and establishing standards of  trauma care at military medical treatment facilities. The NDAA also  required DOD to submit an implementation plan for this effort and  included a provision for us to review this plan. In this report, we examine  the extent to which DOD’s planning efforts include the required elements  and incorporate leading practices for implementation planning identified in  our prior work.

To do our work we reviewed DOD’s August 2017 implementation plan  and interviewed DOD officials about the existing JTS DCOE and the  plans and status of implementing each of the required elements.  Additionally, we reviewed and assessed the implementation plan and  supplemental planning documents identified by DOD against leading  practices for planning identified in our prior work. Specifically, we  identified four leading practices that agencies may include when planning  for program implementation: (1) goals for the program, (2) strategies to  achieve goals, (3) risks that can affect goals, and (4) plans to assess  progress toward goals. We also used Standards for Internal Control in the  Federal Government to assess DOD’s efforts. (See table 1 for more detail on these leading practices.) We then determined whether DOD’s  planning documents for each of the four elements required by the NDAA  fully incorporated, partially incorporated, or did not incorporate the leading  practices for planning.

We conducted this performance audit from June 2017 to March 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.

U.S. Army’s Joint Trauma System Defense Center of Excellence

Since the mid-2000s, DOD and the military health system have worked to  decrease trauma-related morbidity and mortality by improving trauma  care in DOD’s military treatment facilities and by conducting research on  providing trauma care. As part of these efforts, the Army established the  JTS DCOE, which serves to provide advice on trauma care across the  military.

The JTS DCOE performs several functions to improve trauma care,  including overseeing the DOD Trauma Registry (DODTR)—a database that  captures trauma data from the time servicemembers are injured on  the battlefield to when they are treated by providers in the United  States. The JTS DCOE uses DODTR data to conduct performance  improvement activities and to identify gaps in medical capabilities to  direct ongoing and future combat casualty care research, trauma skills  training, and combat casualty care. The JTS DCOE also provides  data from the registry to collaborating military and civilian personnel  conducting medical research. managing the development, monitoring, and review of Clinical  Practice Guidelines (CPGs). These guidelines, developed by subject  matter experts using data from DOD’s trauma registry, are created to  inform medical professionals of best practices based on medical  evidence, with a goal of minimizing inappropriate variation in medical  practice and improving care for trauma injuries, specifically when  military servicemembers are deployed. The development of CPGs is  an ongoing process that takes place during times of war and peace,  according to DOD officials. developing and providing training curriculum for first responders to  trauma-related injuries. The JTS DCOE seeks to identify lessons  learned from trauma care that can be used as part of this training, to  help improve the medical readiness of trauma care providers.

NDAA Requirement for a New DOD Joint Trauma System

To create a formalized, consistent trauma system across DOD, the NDAA  required that a new JTS be operated under the direction of DHA. DHA  officials expect to begin initial operation of the new JTS in July 2018.  Additionally, DOD plans to realign the existing JTS DCOE and its current  functions under DHA. Section 707 (a)(2) of the NDAA required DOD to  submit an implementation plan to Congress for the new JTS in June  2017, 180 days after the NDAA was enacted. The NDAA also includes a  provision for us to review DOD’s plan within 180 days after DOD  submitted it to Congress, and for DOD to implement the new JTS 90 days  after we submit our review. The NDAA required that the new JTS and  DOD’s implementation plan include the following four elements:  1.  serve as the reference body for all trauma care provided across the  2.  establish standards of care for trauma services provided at military  3.  coordinate the translation of research from DOD’s centers of  excellence into standards of clinical trauma care, and  4.  coordinate the incorporation of lessons learned from trauma education  and training partnerships pursuant to section 708 of the NDAA into  clinical practice.

DOD’s Joint Trauma System Implementation Plan Includes the Four Elements Required by the NDAA, but Does Not Yet Fully Incorporate Leading Practices for Planning

The implementation plan submitted by DOD to Congress on August 7,  2017 includes a description of the four elements required by the NDAA. It  also provides an overview of the implementation activities, including  realigning the U.S. Army’s current Joint Trauma System Defense Center  of Excellence to become part of the new system within DHA.

Although the implementation plan includes the four required elements,  neither it nor DOD’s supplemental planning documents prepared to date  fully incorporate leading practices, which we have previously identified.  These leading practices, such as the establishment of goals and the  identification of strategies to achieve those goals, play an important role  in enabling an organization to achieve its objectives. We found that  DOD’s planning documents, prepared to date, incorporate only some of  the leading practices. (See table 2).

DOD officials acknowledged that the agency’s plans are presently  incomplete because this process is ongoing. They stated that DOD is  continuing to plan for implementing all four elements of the JTS— including efforts to incorporate leading practices. DOD’s planning  documents that have been prepared to date and our assessment of each  of the four elements are described below.

Element One—Serve as a Reference Body for Trauma Care

DOD’s planning documents incorporate goals associated with this  element, but only include partial information about the strategies,  associated risks, and plans to assess progress. Without including more  complete information about plans to serve as a reference body for trauma  care, it is unclear how well prepared DOD is to implement this element.

Goals: According to a planning document, DOD has two goals for  JTS to serve as a reference body:  1) consolidating disparate trauma registries into the  DODTR. According to DOD officials, there are currently  about 70 disparate registries, some of which collect  trauma-related information for various entities across DOD.  2) developing a common trauma lexicon—a dictionary of  common trauma care terminology to assist in the  assessment of trauma-related injury data.

Strategies: In addition to defining goals, the documents also  include some strategies to achieve those goals, such as specific  actions that DOD plans to take and target dates for accomplishing  these actions. For example, the documents outline plans to take  action to define key terms such as “preventable death,” “non- survivable injury,” “potentially survivable injury,” and others by a  target date of July 2018. The documents also identify DHA as the  lead office within DOD that is responsible for executing and  achieving this action.

The planning documents do not yet fully reflect the strategies  needed to accomplish these goals. For example, although the  documents discuss actions and milestones associated with goals  for this element, they do not yet provide complete information on  the resources and costs needed for implementation. The  documents state that DHA will conduct an organizational analysis  to determine what organizational structure, staffing needs, and  other resources are needed for implementation at a later date.  They also state that funding levels for DHA’s operation of the  DODTR will be based on the existing JTS DCOE funding levels.  However, another planning document indicates that the  infrastructure for the DODTR’s existing host network—operated by  the United States Army Institute of Surgical Research—would be  insufficient to support the planned JTS and DODTR expansion,  and that integrating even a single additional registry or component  of a registry into the DODTR would require an adjustment to the  funding for the system. Given that the planned activities for the  new JTS would require an expansion beyond the scope of the  current JTS DCOE responsibilities and activities, additional  planning for equipment and network support costs may be  necessary to ensure that the new JTS has sufficient resources to  meet its goals.

Risks: The planning documents identify risks that could affect the  JTS’s ability to serve as a trauma reference body, but the  documents do not yet specify how DOD plans to assess or  respond to these risks. For example, although one of the planning  documents identifies potential shortfalls in the DODTR host  network’s ability to support an increased number of users—which  are expected as the various disparate registries are  consolidated—none of the documents yet address the estimated  impact of this risk on DOD’s goals or how it plans to respond to  the risk. Not planning for assessing and responding to risks could  increase the likelihood that they become problematic, and  negatively affect DOD’s goal for the JTS.

Plans to Assess Progress: The planning documents do not yet  fully indicate how DOD plans to assess progress made towards  the goals for consolidating registries or developing a lexicon of  common trauma terms, as would be consistent with leading  practices. The documents include a description of a baseline for  performance related to DOD’s goal to develop a lexicon of  common trauma terms, but they do not yet include plans to  monitor the progress made towards this goal or to assess the  results of monitoring. Additionally, the documents do not yet  establish a performance baseline, a system to monitor progress,  or a plan to assess the results of monitoring for DOD’s other goal  for this element—to consolidate registries into the DODTR.  Without a fully-developed system for assessing the  implementation’s progress—practices which are consistent with  federal internal control standards for risk assessment—DOD may  be unable to determine progress toward the goals it has identified  for this element.

Element Two—Establish Standards of Trauma Care for Military Services

DOD’s planning documents incorporate goals and plans to assess  progress, but do not yet fully incorporate leading practices related to  strategies and risks.

Goals: According to the documents, DOD’s goal for this element  is twofold:  1) to develop, publish, and assess standards of care in  DOD’s CPGs.  2) to determine if the CPG development process can be  improved. DOD publishes CPGs to provide trauma care  providers with recommended practices for the provision of  care, based on available evidence. According to DOD  documents, the CPGs minimize variations from evidence- based best practices, which help to save lives.

Strategies: DOD’s planning documents describe how the new  JTS will continue to produce, update, and monitor adherence to  CPGs and designates JTS as the office that is primarily  responsible for leading these efforts. Although DOD’s planning  documents include information needed for the JTS to establish  standards of care through CPGs, they do not yet fully reflect the  strategies necessary to achieve DOD’s goal. DOD officials  indicated that the new JTS will develop, publish, and assess  CPGs using the same process used by the existing JTS DCOE.  DOD officials told us that CPGs are currently reviewed on an  annual basis and updated once every two years, on average.  According to DOD officials, this frequency exceeds standards  established by leading civilian organizations. Once updated,  officials disseminate CPGs by posting them on a website, sharing  them with DOD officials responsible for training trauma care  providers, and discussing them at weekly conference calls on  combat casualty care. Officials also told us that the existing JTS  lacks authority to require that trauma care providers adhere to  recommendations made in CPGs. In addition, DOD’s planning  documents acknowledge that the existing process lacks sufficient  mechanisms to ensure timely updates and effective dissemination,  but do not yet indicate what plans are needed to make  improvements in these areas. Without additional planning to  improve mechanisms for CPG development and dissemination,  DOD faces uncertainty regarding the new JTS’s ability to ensure  that the CPGs it produces are up to date and effectively  disseminated to military trauma care providers, which may  ultimately impact the trauma care that it provides.

Risks: The planning documents identify risks associated with the  development and dissemination of trauma care CPGs, such as an  inconsistent process for dissemination. However, they do not yet  include information on determining the potential effects of these  risks, nor do they include how DOD expects to respond, which are  both leading practices for risk assessment and are consistent with  federal internal control standards. Without additional planning,  DOD may not be fully prepared to address risks related to  updating and disseminating CPGs.

Plans to Assess Progress: The planning documents include  detailed information about how DOD uses performance measures  for each CPG to assess progress in provider adherence to trauma  care standards. The documents also establish a baseline for  provider performance, a system for ongoing performance  monitoring, and a process for evaluating the results of  monitoring—performance measurement activities that can help  the department track progress towards the goal it has established  for this element.

Element Three— Coordinate the Translation of Research into Trauma Care Standards

One of the planning documents provides a general overview of how DOD  plans to coordinate the translation of research from its centers of  excellence—including the JTS DCOE and other trauma care centers of  excellence—into trauma care standards, but the planning documents  have yet to incorporate any of the four leading practices, including goals,  strategies, risks, or plans to assess progress. According to DOD officials,  the current JTS DCOE routinely translates research into trauma care  standards by creating and updating these standards to incorporate the  findings and results of relevant research. DOD officials also told us the  current JTS DCOE routinely interacts with the various DOD organizations  responsible for trauma-related research, such as by holding weekly  discussions on trauma care issues. Officials stated that they do not  expect these interactions to change as the JTS DCOE transitions to the  new JTS. However, the planning documents do not yet provide any detail  about how these interactions will inform clinical standards. Without  including detailed information in the planning documents on how DOD  expects to coordinate the translation of research into trauma care  standards, it is unclear whether the JTS will be fully prepared to ensure  that clinical standards are up-to-date and based on the most relevant  evidence from research. This is critical to ensuring the effectiveness of  the trauma care provided.

Element Four— Incorporate Lessons Learned from Trauma Education and Training Partnerships

The planning documents for this element do not yet incorporate any of the  four leading practices, including goals, strategies to achieve goals, risks,  or plans to assess progress. Officials indicated that planning for the  implementation of this element will be incomplete until DOD establishes  the new Joint Trauma Education and Training Directorate responsible for  establishing these partnerships. Section 708 of the NDAA states that  DOD may enter into partnerships with civilian trauma centers to provide  trauma care providers with maximum and continuous exposure to a high  volume of critically injured patients. According to DOD officials, planning  for incorporating lessons learned will begin after the directorate reaches  initial operating capacity, which they anticipate in 2018. DOD officials also  told us that the JTS will collaborate with the directorate for trauma  education and training partnerships, once it is established, to plan the  translation of relevant lessons learned into clinical practice. Because  planning for this element is still incomplete, it is unclear whether DOD will  be prepared to use information from these clinical partnerships to improve  the effectiveness of the trauma care it provides to injured service  members.

In an effort to reduce preventable deaths and disabilities due to trauma,  and as required by the NDAA, DOD is planning for the implementation of  its new JTS. Specifically, the department has submitted its  implementation plan to Congress as required and has developed other  supplemental planning documents that describe how it plans to address  the four required elements of the new system. Incorporating these  elements is a critical step for DOD as it works to improve trauma care  consistently across the military health system. Although the NDAA  requires that DOD begin implementation in 2018, DOD’s planning is  ongoing, and its planning documents do not fully incorporate leading  practices that can help ensure the success of its efforts. As it moves  forward, DOD has the opportunity to update its efforts and planning  documents to fully incorporate these leading practices. By not doing so,  DOD may be missing an opportunity to ensure that its efforts to  implement a new JTS are effective and to help reduce trauma-related  deaths and injuries across the military.

To fully implement the four required elements of the new Joint Trauma  System, the Director of the Defense Health Agency should fully  incorporate leading practices—including establishing goals, planning  strategies to achieve goals, identifying and addressing risks, and  assessing progress—in its planning to guide implementation efforts.  (Recommendation 1)

We provided a draft of this report to DOD for comment. DOD provided  written comments, which are reprinted in appendix I, and technical  comments, which we incorporated as appropriate. In its written  comments, DOD concurred with our recommendation to fully incorporate  leading practices in its planning to guide JTS implementation efforts.  DOD’s written comments also referred to technical concerns regarding  the timeliness of its updates to clinical practice guidelines. Specifically,  the comments indicate that DOD updates these guidelines more  frequently than standards established by leading civilian organizations.  Our report includes a description of DOD’s processes for developing and  updating these guidelines, including the frequency of the updates, and we  added a statement regarding DOD officials’ comparison of this frequency  to civilian standards.

We are sending copies of this report to the appropriate congressional  committees, the Secretary of Defense, 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 have any questions about this report, please contact  me at (202) 512-7114 or 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 Defense

Appendix II: GAO Contact and Staff Acknowledgments

In addition to the contact above, Will Simerl (Assistant Director), Carolyn  Garvey (Analyst-in-Charge), Sarah Sheehan, Jennie Apter, and  Jacquelyn Hamilton made key contributions to this report.

DOD researchers found that about 24% of military servicemembers who died in combat from 2001-2011 could have survived if better and more timely trauma care had been available.

To help reduce preventable deaths and disabilities, DOD is planning for a new trauma care system. However, we found that DOD's planning documents do not fully incorporate certain practices, like clear goals and strategies, that could help the department more effectively implement its new system.

We recommended that DOD fully incorporate leading practices into its ongoing planning to help ensure the success of its efforts to improve trauma care.