Input:
	Overview

In March 2015, Saudi Arabia established a coalition of nations (hereinafter referred to as the Saudi-led coalition or the coalition) to engage in military operations in Yemen against the Ansar Allah/Houthi movement and loyalists of the previous president of Yemen, the late Ali Abdullah Saleh. During 2014, the United States joined Saudi Arabia in demanding that Houthi forces reverse their campaign to occupy the Yemeni capital of Sanaa, but the rapid onset of hostilities in March 2015 forced the Obama Administration to react quickly. At the start of the Saudi-led intervention on March 25, 2015, the Administration announced that the United States would provide "logistical and intelligence support" to the coalition's operations without taking "direct military action in Yemen in support of this effort." Soon thereafter, a joint U.S.-Saudi planning cell was established to coordinate military and intelligence support for the campaign. At the United Nations Security Council, the United States supported the passage of Resolution 2216 (April 2015), which, among other things, required member states to impose an arms embargo against the Houthi-Saleh forces and demanded that the Houthis withdraw from all areas seized during the current conflict.
Since the March 2015 Saudi-led coalition intervention in Yemen, Congress has taken an active role in debating and overseeing U.S. policy in the Arabian Peninsula. Members have considered legislative proposals seeking to reduce Yemeni civilian casualties resulting from the coalition's operations; improve deteriorating humanitarian conditions; end restrictions on the flow of goods and humanitarian aid; combat Iranian support for the Houthis; preserve maritime security in the Bab al Mandab Strait; and/or support continued Saudi-led coalition and U.S. efforts to counter Al Qaeda and Islamic State forces in Yemen.
Beyond Yemen, many Members have appeared to view the conflict through the prism of a broader regional rivalry between Saudi Arabia and Iran, and the U.S. effort to limit Iran's malign regional influence. Others lawmakers have viewed the Yemen conflict as indicative of what they perceive as problems in the U.S.-Saudi relationship, a concern that deepened after the killing of Saudi journalist Jamal Khashoggi by Saudi government personnel in October 2018. Congress has considered but has not enacted proposals to curtail or condition U.S. defense sales to Saudi Arabia.
Responding to the Saudi-led intervention in Yemen also appears to be reinvigorating some Members' interest in strengthening the role of Congress in foreign policy vis-à-vis the executive branch. Debate in Congress over Yemen has featured bipartisan statements of interest in asserting the prerogatives of the legislative branch to limit executive branch power, specifically using war powers legislation and the appropriations and authorization processes to curb U.S. military involvement in support of coalition operations. Congressional scrutiny of U.S. policy in Yemen also has led to legislative changes to global authorities, such as the Department of Defense's authority to enter into and use acquisition and cross servicing agreements with partner militaries.

	Congress, the Obama Administration, and Yemen (2015-2016)

		2015

Congressional interest in the Yemen conflict has evolved and grown gradually and was not widespread at the outset of the coalition's March 2015 intervention in Yemen. In early to mid-2015, congressional interest in U.S. foreign policy in the Middle East centered on the Iran nuclear deal and Operation Inherent Resolve against the Islamic State in Iraq and Syria.
Several months after the March 2015 intervention, the Saudi-led coalition had not achieved a conclusive victory and what modest gains had been made on the ground were offset by mounting international criticism of growing civilian casualties from coalition air strikes. In Congress, several lawmakers began to express concern about the deteriorating humanitarian situation in Yemen.
In late September 2015, Representative Ted W. Lieu wrote a letter to the Joint Chiefs of Staff advocating for a halt to U.S. support for the Saudi-led coalition until it instituted safeguards to prevent civilian casualties. In October 2015, 10 Members of Congress wrote a letter to President Obama urging him to "work with our Saudi partners to limit civilian casualties to the fullest extent possible." In October 2015, Senator Markey stated that "I fear that our failure to strongly advocate diplomacy in Yemen over the past two years, coupled with our failure to urge restraint in the face of the crisis last spring, may put the viability of this critical [U.S.-Saudi] partnership at risk."
By the fall of 2015, as the Obama Administration tried to balance its concern for adhering to the laws of armed conflict with its support for Gulf partners, lawmakers began to express their concern over U.S. involvement in the coalition's intervention by scrutinizing U.S. arms sales to Saudi Arabia. When the Administration informally notified Congress of a proposed sale of precision guided munitions (PGMs) to Saudi Arabia, some Senators sought to delay its formal notification. After the formal notification in November 2015, Senate Foreign Relations Committee (SFRC) leaders jointly requested that the Administration notify Congress 30 days prior to associated shipments, marking the first use of this prior notification request authority. At that time, no related joint resolutions of disapproval on proposed sales of PGMs to the kingdom were introduced, but the delay and additional notification request demonstrated congressional concern.

		2016

By the one-year anniversary of the Saudi-led intervention in Yemen, a more defined opposition to U.S. support for the coalition had begun to coalesce amid repeated international documentation of human rights abuses and errant coalition airstrikes. In April 2016, legislation was introduced that sought to place conditions on future proposed sale notifications, previously approved sales, or transfers of PGMs to Saudi Arabia. Proposed amendments to FY2017 defense legislation would have added some similar conditions on the use of funds to implement sales of PGMs or prohibited the transfer of cluster munitions to Saudi Arabia. The PGM amendment was not considered, but the cluster munitions amendment was narrowly defeated in a June 2016 House floor vote.
In the spring and summer of 2016, the United Nations held multiple rounds of peace talks in Kuwait aimed at brokering an end to the conflict. From April 2016 to August 2016, the Saudi-led coalition had largely spared Yemen's capital Sanaa from aerial strikes as part of its commitment to the cessation of hostilities. When U.N.-mediated peace talks collapsed in August 2016, the Saudi-led coalition resumed bombing and the war intensified.
During the summer of 2016, the Obama Administration reduced some U.S. support for Saudi Arabia's air campaign in Yemen by withdrawing U.S. personnel assigned to a joint U.S.-Saudi planning cell. Nevertheless, overall U.S.-Saudi cooperation continued and, in August 2016, the Obama Administration notified Congress of a proposed sale of M1A2S tanks to Saudi Arabia. In response, some lawmakers wrote to request that President Obama withdraw the proposal, citing concerns about Yemen. In September 2016, joint resolutions of disapproval of the proposed tank sale were introduced in the Senate ( S.J.Res. 39 ) and House ( H.J.Res. 98 ). On September 21, 2016, the Senate voted to table a motion to discharge the SFRC from further consideration of S.J.Res. 39 (71-27, Record Vote 145). During debate over the motion, many Senators argued in favor of continued U.S. support for Saudi Arabia, with Senator Lindsey Graham remarking "To those who want to vote today to suspend this aid to Saudi Arabia, people in Iran will cheer you on."
In the wake of an October 2016 Saudi airstrike on a funeral hall in Sanaa that killed 140 people, the Obama Administration initiated a review of U.S. security assistance to Saudi Arabia. Based on that review, it put a hold on a planned sale of precision guided munitions (PGMs) to Saudi Arabia and limited intelligence sharing, but maintained counterterrorism cooperation and refueling for coalition aircraft.
In the final months of the Obama Administration, U.S. Armed Forces briefly exchanged fire with forces party to the conflict. In October 2016, Houthi-Saleh forces launched anti-ship missiles at U.S. Navy vessels on patrol off the coast of Yemen. The attacks against the U.S. ships marked the first time U.S. Armed Forces had come under direct fire in the war. The Obama Administration responded to the attacks against U.S. naval vessels by directing the Armed Forces to fire cruise missiles against Houthi-Saleh radar installations. The Obama Administration described the U.S. strikes as self-defense and indicated that it did not want to deepen its direct involvement in the conflict. In August and November 2016, then-Secretary of State John Kerry made several attempts to broker a peace initiative in Oman, but his efforts were rejected by the parties themselves.

		Analysis

By the end of 114 th Congress, the war in Yemen was becoming a more significant foreign policy issue for lawmakers. While a growing number of Members were becoming critical of the U.S. role in supporting the Saudi-led coalition amid a deteriorating humanitarian situation in Yemen, more lawmakers still viewed the conflict through a regional lens rather than as a localized affair. Amid significant congressional opposition to the 2015 nuclear agreement with Iran (Joint Comprehensive Plan of Action or JCPOA), some Members viewed Iran's support for the Houthi movement and the broader conflict in Yemen as an example of Iran's malign regional activities not directly addressed by the JCPOA. As the Houthis targeted Gulf state infrastructure on land and vessels at sea, their behavior was touted as evidence of Iran's growing capabilities to threaten U.S. and Gulf security.
Just as some Members considered the Yemen conflict primarily a proxy war between the Iran-backed Houthis and the Saudi-led coalition, others viewed it as a test of long-standing U.S. commitments to supporting Saudi Arabian security. Supporters of the relationship, while acknowledging that Saudi Arabia's conduct of the war was at times problematic, argued that to curtail U.S. arms sales or other defense support to the kingdom would weaken a vital partner that was under threat from a hostile nonstate actor on its southern border.
Others lawmakers charged that continued U.S. support for the coalition was not improving coalition behavior but damaging the U.S. reputation for upholding commitments to international law and human rights. Legislation seeking to limit U.S. arms sales to Saudi Arabia was not enacted in the 114 th Congress, but marked the beginning of the broader congressional debate that has continued.
As the Trump Administration prepared to assume office, human rights organizations and aid groups were pressing Congress to become more attuned to the growing humanitarian crisis in Yemen. Though the Obama Administration had taken some steps, particularly in late 2016, to limit U.S.-coalition cooperation and restrict deliveries of PGMs to Saudi Arabia, nongovernmental groups deemed such action as insufficient. According to Human Rights Watch, "Whatever conditionality the Obama administration thought it had created—in holding up the transfer of precision munitions near the tail end of Obama's term and suspending cluster munition transfers earlier—ultimately did not have meaningful impact in reining in the continued Saudi-led coalition attacks on civilians."

	Congress, the Trump Administration, and Yemen (2017-2018)

		2017

From the beginning of his Administration, President Donald Trump has signaled strong support for the Saudi-led coalition's operations in Yemen as a bulwark against Iranian regional interference. He initiated a review of U.S. policy toward Yemen, including President Obama's October 2016 restrictions on U.S. arms sales and intelligence sharing to the coalition. On March 19, 2017, just prior to his visit to Saudi Arabia, President Trump notified Congress that he was proceeding with three proposed direct commercial sales of precision guided munitions technology deferred by the Obama Administration, subject to congressional review.
In May 2017, the Administration officially notified Congress of its intention to proceed with proposed sales of precision guided munitions technologies that the Obama Administration had deferred, while announcing plans to increase training for Saudi Arabia's air force on both targeting and the Law of Armed Conflict. Congress debated another resolution of disapproval ( S.J.Res. 42 ) of these proposed PGM sales in June 2017 (see below). After completing the policy review in July 2017, President Trump directed his Administration "to focus on ending the war and avoiding a regional conflict, mitigating the humanitarian crisis, and defending Saudi Arabia's territorial integrity and commerce in the Red Sea."
As President Trump entered office, the dynamics of the conflict in Yemen were changing, and the coalition launched a new offensive along Yemen's 280-mile western coastal plain ultimately aimed at taking the strategic Houthi-held port city of Hudaydah. In early 2017, the coalition's gradual advance toward Hudaydah, coupled with an ongoing deterioration in humanitarian conditions, sparked some Members of Congress to implore the Administration to improve aid access and negotiate a cease-fire. In March 2017, several House Members wrote a letter to then-Secretary of State Rex Tillerson urging him to "use all U.S. diplomatic tools to help open the Yemeni port of Hodeida [Hudaydah] to international humanitarian aid organizations." A month later, another group of House Members wrote to President Trump stating that Congress should approve any new U.S. support to the coalition amid its offensive against Hudaydah.
On June 13, 2017, the Senate debated another resolution ( S.J.Res. 42 ) to disapprove of three direct commercial sales of PGMs to Saudi Arabia. During Senate floor consideration over the motion to discharge the Senate Foreign Relations Committee from further consideration of S.J.Res. 42 , Members once again weighed various issues, such as the U.S.-Saudi bilateral relationship, countering Iran, and limiting U.S. involvement in the war in Yemen. Some lawmakers suggested that U.S. arms sales and military support to the coalition had enabled alleged violations of international humanitarian law, while others argued that U.S. support to the coalition improved its effectiveness and helps minimize civilian casualties.
For example, during floor debate, Senator Graham argued that "If we are worried about collateral damage in Yemen, I understand the concern. Precision weapons would help that cause, not hurt it." Senator Murphy retorted, saying "What we are asking for is to hold off on selling these precision-guided munitions until we get some clear promise—some clear assurance—from the Saudis that they are going to use these munitions only for military purposes and that they are going to start taking steps—real steps, tangible steps—to address the humanitarian crisis." On June 13, 2017, the Senate voted to reject the motion to discharge the Senate Foreign Relations Committee from further consideration (47-53, Record Vote 143), and a companion resolution was not taken up in the House ( H.J.Res. 102 ).
Representative Ro Khanna introduced a concurrent resolution ( H.Con.Res. 81 ) pursuant to the War Powers Resolution ( P.L. 93-148 ) in a bid to end U.S. support for the coalition's military intervention. After consultation between House leaders and supporters of the resolution on a compromise approach, the House agreed to delay expedited consideration of the resolution until after the November 2016 election and then adopted a nonbinding alternative ( H.Res. 599 , 366-30, 1 Present, Roll no. 623).
In his first year in office, while President Trump sought to improve relations with Saudi Arabia, counter Iran, and increase U.S. counterterrorism activity in Yemen, his Administration also at times took strong positions on the need for members of the coalition to improve humanitarian access, pursue a settlement to the conflict, and take measures to prevent civilian casualties.
After a Houthi-fired missile with alleged Iranian origins landed deep inside Saudi Arabia in November 2017, the coalition instituted a full blockade of all of Yemen's ports, including the main port of Hudaydah, exacerbating the country's humanitarian crisis. The White House issued four press statements on the conflict between November 8 and December 8, including a statement on December 6 in which President Trump called on Saudi Arabia to "completely allow food, fuel, water, and medicine to reach the Yemeni people who desperately need it. This must be done for humanitarian reasons immediately."
On December 20, 2017, the Saudi-led coalition announced that it would end its blockade of Hudaydah port for a 30-day period and permit the delivery of four U.S.-funded cranes to Yemen to increase the port's capability to off-load commercial and humanitarian goods. The next day, the White House issued a statement welcoming "Saudi Arabia's announcement of these humanitarian actions in the face of this major conflict."

		2018

As the Saudi-led coalition intervention entered its fourth year, some in the Senate also proposed use of the War Powers Resolution as a tool for ending U.S. support for the coalition's military intervention. On February 28, 2018, Senator Bernie Sanders introduced S.J.Res. 54 , a joint resolution to "direct the removal of United States Armed Forces from hostilities in the Republic of Yemen that have not been authorized by Congress (except for those U.S. forces engaged in counterterrorism operations directed at al Qaeda or associated forces)." Efforts in the Senate followed a late 2017 attempt in the House (see Table 1 below), in which a concurrent resolution directing the President to remove U.S. forces from Yemen was tabled in favor of a House-passed nonbinding resolution.
Throughout 2018, between Congress and the Trump Administration and within Congress itself, there was disagreement as to whether U.S. forces assisting the Saudi-led coalition have been introduced into active or imminent hostilities for purposes of the War Powers Resolution. Some Members claimed that by providing support to the Saudi-led coalition, U.S. forces have been introduced into a "situation where imminent involvement in hostilities is clearly indicated" based on the criteria of the War Powers Resolution. The Trump Administration disagreed. In February 2018, the Acting Department of Defense General Counsel wrote to Senate leaders describing the extent of current U.S. support , and reported that "the United States provides the KSA-led coalition defense articles and services, including air-to-air refueling; certain intelligence support; and military advice, including advice regarding compliance with the law of armed conflict and best practices for reducing the risk of civilian casualties."
On March 20, 2018, the Senate considered S.J.Res. 54 on the floor. During debate, arguments centered on a number of issues, ranging from concern over exacerbating Yemen's humanitarian crisis to reasserting the role of Congress in authorizing the use of armed force abroad. After then-Foreign Relations Committee Chairman Senator Bob Corker promised to propose new legislation and hold hearings scrutinizing U.S. policy in Yemen, a majority of Senators voted to table a motion to discharge the Foreign Relations committee from further consideration of S.J.Res. 54 . Senator Robert Menendez made remarks expressing conditional support for Senator Corker's approach, a view shared by some other Senators who voted to table the motion.
The Foreign Relations Committee held a hearing on Yemen a month later. In parallel testimony before Congress, U.S. defense officials stated that while the United States refueled Saudi aircraft and provided advice on targeting techniques, CENTCOM did not track coalition aircraft after they were refueled and did not provide advice on specific targets. Then-Assistant Secretary of Defense for International Security Affairs Robert S. Karem testified that "It's correct that we do not monitor and track all of the Saudi aircraft aloft over Yemen." During the same hearing, U.S. officials acknowledged that pressure from Congress has altered how the Administration deals with the coalition over the Yemen conflict. Acting Assistant Secretary of State for Near Eastern Affairs David Satterfield told Senator Todd Young and the SFRC the following:
Senator, your efforts, the efforts of your colleagues in this body and on this Committee have been exceedingly helpful in allowing the Administration to send a message from whole of government regarding the very specific concerns we have over any limitations, restrictions, constraints on the ability of both humanitarian and commercial goods specifically to include fuel to have unrestricted and expeditious entry into Yemen. And that messaging which comes from us, the Executive Branch, also comes from this body is extremely important.
After the promised hearing, the Senate Foreign Relations Committee also proposed new legislation to place conditions on U.S. assistance to the coalition. In May, the committee reported S.J.Res. 58 to the Senate; it would have prohibited the obligation or expenditure of U.S. funds for in-flight refueling operations of Saudi and Saudi-led coalition aircraft that were not conducting select types of operations if certain certifications cannot be made and maintained.
The Senate Armed Services Committee incorporated the provisions of the SFRC-reported text of S.J.Res. 58 as Section 1266 of the version of the FY2019 National Defense Authorization Act (NDAA) that it reported to the Senate on June 5, 2018 ( S. 2987 ). The provision was modified further and passed by both the House and Senate as Section 1290 of the conference version of the FY2019 NDAA ( H.R. 5515 ). It was signed into law as P.L. 115-232 in mid-August, giving the Administration until mid-September 2018 to make certain certifications. In a statement accompanying the President's signing of P.L. 115-232 into law, President Trump objected to provisions such as Section 1290, stating the Administration's view that such provisions "encompass only actions for which such advance certification or notification is feasible and consistent" with "[his] exclusive constitutional authorities as Commander in Chief and as the sole representative of the Nation in foreign affairs."
As Congress continued to question the role of the United States in supporting coalition operations in Yemen, the pace and scale of fighting on the ground increased dramatically by the summer of 2018. On June 12, 2018, the Saudi-led coalition launched "Operation Golden Victory," aimed at retaking the Red Sea port city of Hudaydah. As coalition forces engaged Houthi militants in and around Hudaydah, humanitarian organizations warned that if port operation ceased, famine could become widespread throughout northern Yemen. On June 12, nine Senators wrote a letter to Secretary of State Pompeo and then-Secretary of Defense Mattis saying, "We are concerned that pending military operations by the UAE and its Yemeni partners will exacerbate the humanitarian crisis by interrupting delivery of humanitarian aid and damaging critical infrastructure. We are also deeply concerned that these operations jeopardize prospects for a near-term political resolution to the conflict."
Several weeks later, Senator Robert Menendez, the ranking member on the Senate Foreign Relations Committee, placed a hold on a potential U.S. sale of precision guided munitions to Saudi Arabia and the United Arab Emirates. In a June 28 letter to Secretary of State Pompeo and Secretary of Defense Mattis, Senator Menendez said,
I am not confident that these weapons sales will be utilized strategically as effective leverage to push back on Iran's actions in Yemen, assist our partners in their own self-defense, or drive the parties toward a political settlement that saves lives and mitigates humanitarian suffering…. Even worse, I am concerned that our policies are enabling perpetuation of a conflict that has resulted in the world's worst humanitarian crisis.
On August 9, the coalition conducted an airstrike that hit a bus in a market near Dahyan, Yemen, in the northern Sa'ada governorate adjacent to the Saudi border. The strike reportedly killed 51 people, 40 of whom were children. The coalition claims that its airstrike was a "legitimate military operation" and conducted in response to a Houthi missile attack on the Saudi city of Jizan a day earlier that killed a Yemeni national in the kingdom. The U.S. State Department called on the Saudi-led coalition to conduct a "thorough and transparent investigation into the incident."
Several Members of Congress wrote to the Administration seeking additional information regarding U.S. operations in the wake of the August 2018 coalition strike at Dahyan. Several Senators also submitted an amendment to the FY2019 Defense Department appropriations act ( H.R. 6157 ) that would have prohibited the use of funds made available by the act to support the Saudi-led coalition operations in Yemen until the Secretary of Defense certifies in writing to Congress that the coalition air campaign "does not violate the principles of distinction and proportionality within the rules for the protection of civilians." The provision did not apply to support for ongoing counterterrorism operations against Al Qaeda and the Islamic State in Yemen.
On September 12, Secretary of State Mike Pompeo issued a certification that would allow the use of FY2019 defense funds to support in-flight refueling of coalition aircraft to continue, per the terms of Section 1290 (see discussion above) of the FY2019 National Defense Authorization Act (NDAA, P.L. 115-232 ). Some Members of Congress criticized the Administration's actions, asserting that the coalition has not met the act's specified benchmarks for avoiding civilian casualties in Yemen.
On September 26, several House Members introduced H.Con.Res. 138 , which sought to direct the President to remove U.S. Armed Forces from hostilities in Yemen, except for Armed Forces engaged in operations authorized under the 2001 Authorization for Use of Military Force, within 30 days unless and until a declaration of war or specific authorization for such use has been enacted into law. In response to a similar initiative in the Senate, the Administration submitted a detailed argument expressing its view that U.S. forces supporting Saudi-led coalition operations are not engaged in hostilities in Yemen.
By late 2018, the prospect of widespread famine in Yemen coupled with international reprobation over the killing of Jamal Khashoggi pressured the Administration and the coalition to accelerate moves toward peace talks. On October 30, then-Secretary of Defense James Mattis and Secretary of State Mike Pompeo called for all parties to reach a cease-fire and resume negotiations. On November 9, Secretary Mattis further announced that effective immediately, the coalition would use its own military capabilities—rather than U.S. capabilities—to conduct in-flight refueling in support of its operations in Yemen.
Though fighting continued along several fronts, on December 13, 2018, Special Envoy of the United Nations Secretary-General for Yemen Martin Griffiths brokered a cease-fire centered on the besieged Red Sea port city of Hudaydah (Yemen's largest port). As part of the U.N.-brokered deal (known as the Stockholm Agreement), the coalition and the Houthis agreed to redeploy their forces outside Hudaydah city and port. The United Nations agreed to chair a Redeployment Coordination Committee (RCC) to monitor the cease-fire and redeployment. The international community praised the Stockholm Agreement as a first step toward broader de-escalation and a possible road map to a comprehensive peace settlement.
Also on December 13, 2018, the Senate amended and passed S.J.Res. 54 (56-41), which, among other things, directed the President to remove U.S. forces from hostilities in Yemen, except U.S. forces engaged in operations directed at Al Qaeda or associated forces. In the House, lawmakers twice narrowly approved rules resolutions containing provisions that made similar resolutions directing the President to remove U.S. forces from hostilities in Yemen ineligible for expedited consideration ( H.Res. 1142 and H.Res. 1176 ). On December 13, the Senate also passed S.J.Res. 69 , which, among other things, expresses the sense of the Senate that Saudi Crown Prince Mohammed bin Salman is responsible for the murder of the journalist Jamal Khashoggi and that there is no statutory authorization for United States involvement in hostilities in the Yemen civil war.

		Analysis

The 115th Congress frequently debated the extent and terms of the United States' involvement in the ongoing conflict in Yemen. Lawmakers questioned the extent to which successive Administrations have adhered to existing law related to providing security assistance, including sales or transfers of defense goods and defense services, while upholding international human rights standards (e.g., 22 U.S.C. §2754 or 22 U.S.C. §2304). They also enacted new legislation that would condition or prohibit the use of U.S. funds for some activities related to Yemen and extend legislative oversight over the executive branch's policy toward the war in Yemen.
While the House and its Rules Committee voted to make resolutions with respect to war powers and Yemen ineligible for expedited consideration, the Senate passage of S.J.Res. 54 at the conclusion of the 115 th Congress demonstrated growth in congressional opposition to U.S. involvement in the Saudi-led coalition intervention in Yemen relative to previous years. Over time, the balance of votes shifted in favor of measures that could be described as critical or restrictive of U.S. support for Saudi-led coalition operations with regard to arms sales, oversight measures, and war powers measures.
Nevertheless, after nearly four years of conflict, it remains difficult to identify the locus of congressional consensus about Yemen. Many in the House and Senate state that they seek to preserve cooperative U.S.-Saudi relations in broad terms and express concern about Iranian activities in Yemen, while also expressing support for expanded humanitarian access and efforts to bring the conflict to a close. Some lawmakers express opposition to the intervention and U.S. involvement on moral grounds, citing errant coalition airstrikes and the prospect of a looming famine. Others argue the conflict's continuation creates opportunities for Iran and Sunni Islamist extremist groups to expand their influence and operations in Yemen. Still others may have come to oppose continued U.S. support for the intervention based on factors not directly related to Yemen itself, including the opaque mechanisms used by the executive branch to support the coalition and/or anger with the Saudi government over the killing of Jamal Khashoggi.
It remains to be seen whether recent congressional consideration of Yemen legislation is a harbinger of broader efforts by Members of Congress to reassert congressional prerogatives toward U.S. foreign policy writ large. Measures to enhance oversight over U.S. support to the Saudi-led coalition and U.S. strategy toward Yemen have received broad bipartisan support, while proponents of other recently considered arms sales and war powers measures have used mechanisms to ensure privileged consideration of their proposals.
The 116 th Congress may continue to debate U.S. support for the Saudi-led coalition and Saudi Arabia's conduct of the war in Yemen. It is uncertain whether lawmakers may also broaden the scope of their oversight activities beyond the current conflict to more fully address the root causes of Yemen's chronic instability. Even if the United States is no longer an active supporter of coalition military efforts, Yemen itself has been devastated by years of war and remains the world's worst humanitarian crisis. Experts expect Yemen to require sustained international attention and financial assistance in order to help local actors reach and sustain a political settlement. This suggests that Congress may grapple with questions about the conduct of U.S. diplomacy, the provision of U.S. security support, and the investment of U.S. assistance and defense funds for years to come.

Output:
This product provides an overview of the role Congress has played in shaping U.S. policy toward the conflict in Yemen. Summary tables provide information on legislative proposals considered in the 115th and 116th Congresses. Various legislative proposals have reflected a range of congressional perspectives and priorities, including with regard to
the authorization of the activities of the U.S. Armed Forces related to the conflict; the extent of U.S. logistical, material, advisory, and intelligence support for the coalition led by Saudi Arabia; the approval, disapproval, or conditioning of U.S. arms sales to Saudi Arabia; the appropriation of funds for U.S. operations in support of the Saudi-led coalition; the conduct of the Saudi-led coalition's air campaign and its adherence to international humanitarian law and the laws of armed conflict; the demand for greater humanitarian access to Yemen; the call for a wider government assessment of U.S. policy toward Yemen and U.S. support to parties to the conflict; the nature and extent of U.S.-Saudi counterterrorism and border security cooperation; and the role of Iran in supplying missile technology and other weapons to the forces of the Houthi movement.
The 116th Congress may continue to debate U.S. support for the Saudi-led coalition and Saudi Arabia's conduct of the war in Yemen, where fighting has continued since March 2015. The war has exacerbated a humanitarian crisis in Yemen that began in 2011; presently, the World Food Program reports that 20 million Yemenis face hunger in the absence of sustained food assistance. The difficulty of accessing certain areas of Yemen has made it hard for governments and aid agencies to count the war's casualties. Data collected by the U.S. and European-funded Armed Conflict Location & Event Data Project (ACLED) suggest that 60,000 Yemenis have been killed since January 2016.
The Trump Administration has opposed various congressional proposals, including initiatives to reject or condition proposed U.S. arms sales or to require an end to U.S. military support to Saudi-led coalition operations in Yemen. Many in Congress have condemned the October 2018 murder of Saudi journalist Jamal Khashoggi by Saudi government personnel, and in general, the incident appears to have exacerbated existing congressional concerns about Saudi leaders and the pace, scope, and direction of change in the kingdom's policies.
This product includes legislative proposals considered during the 115th and 116th Congresses. It does not include references to Yemen in Iran sanctions legislation, which are covered in CRS Report RS20871, Iran Sanctions. For additional information on the war in Yemen and Saudi Arabia, please see the following CRS products.
CRS Report R43960, Yemen: Civil War and Regional Intervention.
CRS Report RL33533, Saudi Arabia: Background and U.S. Relations.
CRS Insight IN10729, Yemen: Cholera Outbreak.


Input:
	Background

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

		Environment of Care Inspections

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 there loose floor tiles/carpet?
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.

			Workload

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

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.

	Conclusions

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.

	Recommendation for Agency Action

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)

	Agency Comments and Our Evaluation

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

	GAO Contact

	Staff Acknowledgments

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.

Output:
Why GAO Did This Study

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.

What GAO Found

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.

What GAO Recommends

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.