VA ADMINISTRATIVE 

INVESTIGATIONS

Improvements Needed 

in Collecting and 

Sharing Information

Report to Congressional Requesters

April 2012

GAO-12-483

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-12-483, a report to 

congressional requesters

April 2012

VA ADMINISTRATIVE INVESTIGATIONS

Improvements Needed in Collecting and Sharing 

Information

Why GAO Did This Study

VA may use an AIB to determine the 

facts surrounding alleged employee 

misconduct or potential systemic 

deficiencies related to VA policies or 

procedures. AIBs do not determine 

corrective actions, such as individual 

disciplinary actions or procedural 

changes, but AIB investigation results, 

including evidence, may be used to 

inform such actions, making it critical 

for AIBs to be convened and 

conducted appropriately.

You expressed interest in the number 

of AIB investigations and their results. 

In this report, GAO examines (1) the 

process VA uses to convene and 

conduct AIB investigations, (2) the 

extent to which VA collects data on AIB 

investigations, and (3) how VA has 

used the results of its AIB 

investigations. GAO focused on AIB 

investigations conducted within VHA; 

reviewed VA documents, including 

policies and procedures, and VHA data 

on AIBs conducted during fiscal years 

2009 through 2011; and interviewed 

VA officials from headquarters and four 

medical centers. To ensure data 

reliability, GAO reviewed VHA’s 

methods to collect AIB data.

What GAO Recommends

GAO recommends that VA establish 

processes to (1) collect and analyze 

aggregate data from AIB investigations 

conducted within VHA, and (2) share 

information about improvements that 

are implemented in response to the 

results of AIB investigations. VA 

concurred with these 

recommendations.

What GAO Found

The Department of Veterans Affairs (VA) has departmentwide policy and 

procedures for convening and conducting administrative investigation boards 

(AIB). The department’s procedures contain requirements for convening and 

conducting AIB investigations, but according to VA officials, they also provide the 

flexibility to tailor an investigation to effectively meet diverse informational needs. 

For example, the VA official convening an AIB investigation is required to select 

AIB members who are impartial and objective, but has flexibility to vary the 

number of members appointed to each AIB based on the matter being 

investigated. VA is currently updating its AIB policy and procedures, but officials 

said the department plans to maintain flexibility in its AIB process. 

VA does not collect and analyze aggregate data on AIB investigations, including 

data on the number of AIB investigations conducted, the types of matters 

investigated, and whether the matters were substantiated, or on any systemic 

deficiencies identified by AIBs. Having aggregate data could provide VA with 

valuable information to systematically gauge the extent to which matters 

investigated by AIBs may be occurring throughout VA’s Veterans Health 

Administration (VHA) and to take corrective action, if needed, to reduce the 

likelihood of future occurrences. Without such data, VA is unable to adequately 

assess the causes or factors that may contribute to deficiencies occurring within 

its medical centers and health care networks. Information on AIB investigations is

maintained by different offices across VA. For example, each medical center or 

network maintains information on each AIB investigation that it conducts. In 

response to GAO’s request for AIB data, VHA administered a web-based survey 

that collected data from all its medical centers and networks on AIB 

investigations they reported conducting during fiscal years 2009 through 2011. 

Survey data showed that medical centers and networks conducted more than 

1,100 investigations during this time period, and the types of matters investigated 

included allegations of inappropriate employee behavior involving patients and 

other employees; individual employee wrongdoing, such as theft and fraud; and 

systemic deficiencies. VHA officials told us that although it administered the webbased survey, the department has no plans to collect and analyze aggregate 

data on AIB investigations conducted within VHA. 

VA has used the results of AIB investigations to inform corrective actions, but 

does not share information about improvements made that could have broader 

applicability. Specifically, VA has used the results of AIB investigations to inform 

systemic changes at the medical centers and networks where AIB investigations 

have been conducted. For example, VA has developed new policies and 

procedures for improving patient and employee safety and developed new 

training programs to expand employees’ knowledge of VA policies and 

procedures. However, VA does not share information about these improvements 

that may have relevance for other areas within VHA. Such information could be 

used to improve not only the quality of patient care provided, but also the 

efficiency of VHA’s overall operations. For example, one medical center included 

in GAO’s review implemented a tracking system to ensure surgical instruments 

are delivered promptly to the operating room and a checklist to ensure the 

availability of needed equipment prior to starting surgery.

View GAO-12-483. For more information, 

contact Debra A. Draper at (202) 512-7114 or 

draperd@gao.gov.
Page i GAO-12-483 VA Administrative Investigation Boards

Letter 1 

VA Has Departmentwide Policy for Convening and Conducting AIB 

Investigations 5

VA Does Not Collect and Analyze Aggregate Data on AIB 

Investigations or the Deficiencies They Identify 11

VA Has Used the Results of AIB Investigations to Inform Corrective 

Actions, but Does Not Share Information about Improvements 

More Broadly 13

Conclusions 18

Recommendations for Executive Action 19

Agency Comments and Our Evaluation 19

Appendix I Characteristics of Selected Federal Agencies’ Administrative 

Investigation Processes 21

Appendix II Comments from the Department of Veterans Affairs 23

Appendix III GAO Contact and Staff Acknowledgments 32

Tables

Table 1: Number of Administrative Investigation Boards Conducted 

in VHA during Fiscal Years 2009 through 2011 12

Table 2: Types of Matters Investigated by Administrative 

Investigation Boards at Four Selected VA Medical Centers 

during Fiscal Years 2009 through 2011 13

Table 3: Number of Employee Corrective Actions That Were 

Informed by Administrative Investigation Boards 

Conducted at Four Selected VA Medical Centers during 

Fiscal Years 2009 through 2011 16

Figure

Figure 1: VA’s Administrative Investigation Process 6

Contents
Page ii GAO-12-483 VA Administrative Investigation Boards

Abbreviations

AIB administrative investigation board

GS General Schedule

VA Department of Veterans Affairs

VHA Veterans Health Administration

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Page 1 GAO-12-483 VA Administrative Investigation Boards

United States Government Accountability Office

Washington, DC 20548

April 30, 2012

The Honorable Richard Burr

Ranking Member

Committee on Veterans’ Affairs

United States Senate

The Honorable Brad Miller

House of Representatives

The Department of Veterans Affairs (VA) operates one of the largest 

health care delivery systems in the nation. In fiscal year 2011, VA 

provided health care services to about 6.2 million veterans through its 

Veterans Health Administration (VHA), which consists of 153 medical 

centers across 21 health care networks.1

For matters of alleged employee misconduct or potential systemic 

deficiencies related to VA policies or procedures, VA may use an 

administrative investigation board (AIB) as a tool to collect evidence and 

determine the facts surrounding the matter being investigated. These 

investigations may focus on alleged individual employee misconduct by 

any VA staff member, regardless of level. AIB investigations may be 

convened throughout VA, including its medical centers, networks, and 

headquarters.

In fiscal year 2011, VHA 

employed about 255,000 staff members at various levels including 

managers, clinicians, and administrative staff.

AIB investigations are important tools, as their results (evidence, findings, 

conclusions, and recommendations) may be used to inform corrective 

actions, whether individual disciplinary actions for employee misconduct, 

or broader policy or procedural changes in cases of identified systemic 

deficiencies.2

 

1

Each network, which VA refers to as a Veterans Integrated Service Network, is 

responsible for management and oversight of its medical centers, which typically include 

one or more hospitals as well as other types of health care facilities, such as outpatient 

clinics and nursing homes.

Apart from AIB investigations, VA uses other tools to 

identify potential areas for improvement. For example, related to issues of 

2

Although results from AIB investigations may be used by VA officials to inform corrective 

actions, AIBs are not involved in determining or implementing any corrective actions. 

 
Page 2 GAO-12-483 VA Administrative Investigation Boards

patient safety, VA uses root cause analysis—a methodology for 

identifying the basic or contributing factors that underlie variations in the 

performance of systems and processes. However, AIB investigations 

serve a unique management role. Unlike information collected from these 

other tools, evidence collected by an AIB investigation may be used by 

management to inform employee disciplinary action.3

You expressed interest in VA’s AIB investigations, including the number 

of investigations and their results. In this report, we focused on AIB 

investigations conducted in VHA, and examined: (1) the process VA uses 

to convene and conduct AIB investigations, (2) the extent to which VA 

collects data on AIB investigations, and (3) how VA has used the results 

of its AIB investigations.

Because of the 

potential implications for VA staff and systems, it is critical for AIBs to be 

convened and conducted appropriately. AIB investigations that do not 

adequately address critical issues, or that reach findings, conclusions, or 

recommendations not supported by the evidence, are an ineffective use 

of resources and may also adversely affect VA’s operations and systems, 

including the quality of care provided in its medical centers; the morale of 

its employees; and its public image.

To determine the process VA uses to convene and conduct AIB 

investigations, we reviewed VA documentation, including VA’s policy and 

procedures for AIB investigations.4

 

3

The information generated from root cause analysis and other tools is confidential and 

protected from disclosure within and outside of VA. See 38 U.S.C. § 5705; 38 C.F.R. 

§§ 17.500-17.511.

We also reviewed documentation and 

interviewed officials from three other federal agencies to gain an 

understanding of their administrations investigation processes, and how 

they compare to VA’s process. Specifically, we selected the Federal 

Bureau of Prisons and the U.S. Navy Bureau of Medicine and Surgery 

because, like VA, these agencies provide health care services. We also 

selected the U.S. Coast Guard because VA officials told us that VA’s AIB 

process was modeled after the Coast Guard’s administrative investigation 

process. We interviewed officials from each of these federal agencies 

who were knowledgeable about their respective agency’s administrative 

4

VA Directive 0700, Administrative Investigations (Mar. 25, 2002) and VA Handbook 0700, 

Administrative Investigations (July 31, 2002) contain VA’s policy and procedures, 

respectively, for AIB investigations.
Page 3 GAO-12-483 VA Administrative Investigation Boards

investigation process. We did not evaluate these three federal agencies’ 

processes for convening and conducting administrative investigations.

To determine the extent to which VA collects data on AIB investigations, 

and how VA has used the results of its AIB investigations, we interviewed 

VA officials about the type of data the department collects and maintains 

on these investigations. Although AIB investigations may be conducted 

throughout VA, we focused our review only on AIB investigations that 

were conducted within VHA. Additionally, we focused on AIB 

investigations conducted during fiscal years 2009 through 2011. In 

response to our request for AIB data, VHA administered a web-based 

survey that collected data from all its medical centers and networks on 

AIB investigations they reported conducting during fiscal years 2009 

through 2011. We reviewed and analyzed the survey data on the number 

of AIB investigations. VA officials told us that data resulting from the 

survey included AIB investigations involving staff at the General Schedule 

(GS) -15 level and below,5 but did not include AIB investigations involving 

senior leadership or matters related to research misconduct within VA 

medical centers or networks or within VHA headquarters.6 Thus, for AIB 

investigations involving senior leadership and matters of research 

misconduct conducted during fiscal years 2009 through 2011, we 

collected and analyzed AIB data maintained by VHA’s Office of Workforce 

Management and Consulting and Office of Research Oversight, 

respectively. We spoke with knowledgeable VHA officials about the data, 

including the methodology used to conduct the web-based survey, and 

their efforts to ensure the reliability of the data. Based on these 

discussions, and our review of related documentation we determined the 

data to be sufficiently reliable for our purposes. We did not evaluate the 

appropriateness of the number of AIB investigations conducted. 

Additionally, we reviewed VA-wide policy and procedures for taking 

disciplinary actions,7

 

5

VA officials told us the data also included staff who are not paid under the GS system, 

such as physicians, dentists, and registered nurses. Throughout this report, we use the 

term “GS-15 level and below” to include these staff.

and specific VA policy and procedures for taking 

6

VA defines senior leadership to include members of the senior executive service; 

associate and assistant directors, chiefs of staff, and nurse executives at its medical 

centers; heads of other VA offices such as networks; GS-15 or equivalent positions in 

VHA headquarters; and all other positions centralized to the Secretary. 

7

VA Directive 5021 and VA Handbook 5021, Employee/Management Relations (Apr. 15, 

2002).
Page 4 GAO-12-483 VA Administrative Investigation Boards

corrective actions against staff involved in research misconduct.8 We also 

reviewed VA’s processes related to AIB investigations, in light of federal 

internal control standards, as documented in GAO’s Standards for 

Internal Control in the Federal Government.

9

For all three objectives, we interviewed officials from VA’s Office of 

Inspector General, Office of General Counsel, and Office of Human 

Resources Management, as well as officials from VHA’s Office of the 

Principal Deputy Under Secretary for Health; Office of the Assistant 

Deputy Under Secretary for Health for Quality, Safety, and Value, 

including its National Center for Patient Safety; Office of Workforce 

Management and Consulting; Office of Research Oversight; and Office of 

the Medical Inspector. These interviews aided our understanding of VA’s 

AIB process, as well as its root cause analysis and peer review 

processes,10 and how VA officials have used the results of these tools to 

inform corrective actions. We also interviewed officials from four medical 

centers—VA Boston Healthcare System, Canandaigua (N.Y.) VA Medical 

Center, Miami VA Healthcare System, and VA Pittsburgh Healthcare 

System. These medical centers varied in terms of complexity,11 size,12

 

8

VHA Directive 1058, Office of Research Oversight (Feb. 9, 2009) and VHA Handbook 

1058.2, Research Misconduct (May 4, 2005).

and the number of AIB investigations conducted during fiscal years 2009 

through 2011. For each medical center, we interviewed human resources 

staff; the medical center director, who also served as the convening 

authority for the AIB investigations we reviewed during this time period; 

and staff who had served as AIB chairs, to obtain information about their 

experiences with the investigations. We also obtained and reviewed 

investigation reports and related documents to identify the types of 

matters investigated by AIBs and the corrective actions that were 

9

GAO, Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1

(Washington, D.C.: November 1999).

10Peer review is an organized process carried out by an individual health care 

professional or committee of professionals to evaluate and make recommendations to 

improve the performance of other professionals.

11We used VA’s assessment of complexity for fiscal year 2008, which the department 

determined using multiple variables, including patient volume, types of clinical programs 

offered, and number of education and research programs.

12Size refers to the number of patients served by the medical center in fiscal year 2010. 
Page 5 GAO-12-483 VA Administrative Investigation Boards

informed by AIB investigations conducted during fiscal years 2009 

through 2011 from the four medical centers included in our review.

We conducted this performance audit from July 2011 to April 2012 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.

VA has departmentwide policy and procedures for convening and 

conducting AIB investigations.13

Officials within VA’s Office of General Counsel—the office responsible for 

the contents of VA’s AIB policy and procedures—are currently reviewing 

and updating the AIB policy and procedures as required every 5 years by 

VA.

According to VA Handbook 0700, the 

department’s procedures are intended “to promote effectiveness and 

uniformity in the conduct and reporting of AIB investigations,” among 

other things. The procedures outlined in the handbook are mandatory, 

except where otherwise indicated. According to VA officials, the policy 

and procedures achieve their intended purpose, while also providing VA 

convening authorities—medical center directors, or any authorities senior 

to them within networks or headquarters—sufficient flexibility and 

discretion to tailor an investigation to effectively meet diverse 

informational needs. For example, convening authorities are required to 

select AIB members who are impartial and objective, but they have 

flexibility to vary the number of members appointed to each AIB based on 

the matter being investigated.

14

 

13VA medical centers also may have local policies to guide the AIB process at their 

respective medical centers. Two of the four medical centers included in our review had 

such local policies. Our review of these policies found that they did not include additional 

procedures for convening and conducting AIB investigations, but rather identified local 

resources, such as medical center officials responsible for coordinating training for AIB 

members and implementing corrective actions.

Although revisions to its AIB policy and procedures were not 

finalized by the time we issued this report, officials within VA’s Office of 

14VA Directive 6330, Directives Management (Feb. 26, 2009).

VA Has 

Departmentwide 

Policy for Convening 

and Conducting AIB 

Investigations 
Page 6 GAO-12-483 VA Administrative Investigation Boards

General Counsel said the department plans to maintain flexibility in its 

AIB process.

VA’s AIB process begins with a convening authority determining the need 

for an AIB investigation. Once convened, the AIB collects evidence, which 

may include witness testimony, and documents its results in an 

investigation report. (See fig. 1 for an overview of VA’s process for 

convening and conducting AIB investigations.)

Figure 1: VA’s Administrative Investigation Process
Page 7 GAO-12-483 VA Administrative Investigation Boards

Convening an AIB investigation involves determining its need, scope, and 

board composition. VA Handbook 0700 states that a convening authority 

may determine whether an AIB investigation is needed based on several 

factors, including the results of a preliminary investigation, any other 

ongoing investigation, or the type of matter being investigated.15 A 

preliminary investigation is an informal process whereby readily available 

information is collected, for instance by obtaining witness statements. 

According to one convening authority, an AIB investigation would likely be 

convened after a preliminary investigation if, for example, conflicting 

witness accounts were provided during this initial investigation. A 

convening authority may also determine that another ongoing review into 

the matter, such as root cause analysis or peer review, meets VA’s needs 

without convening an AIB.16 Moreover, AIBs are not to investigate matters 

that may be criminal in nature without the convening authority first 

coordinating with federal and state law enforcement authorities, including 

VA’s Office of Inspector General.17

A convening authority also determines the scope of the investigation and 

composition of the AIB. An investigation’s scope—the matter to be 

investigated—may be focused on a specific incident involving alleged 

employee misconduct or a broader systemic matter. For example, among 

 

15According to VA Handbook 0700, the decision to convene an AIB investigation should 

not be made by an official whose actions (or failure to act) may be a subject of the 

investigation, or who appears to have a personal stake or bias in the matter to be 

investigated.

16In some cases, even when a root cause analysis or peer review is being conducted, an 

AIB investigation may still be warranted. For example, an AIB may review a matter 

involving a medical procedure performed by a provider who may not have had the 

appropriate credentials or privileges. A root cause analysis also may be conducted on the 

same matter to review the medical center’s processes for credentialing and privileging 

providers. Furthermore, an AIB may be convened, in addition to a root cause analysis or 

peer review, if evidence is needed to support potential employee disciplinary action, 

because the results of these reviews may not be used to inform such actions. According to 

VA, root cause analysis and peer review are generally not conducted concurrently with 

AIB investigations. If VA determines the need for an AIB investigation, because for 

example, there may have been an intentional act that led to an adverse event, any related 

root cause analysis or peer review is suspended or terminated. Additionally, information 

obtained from a root cause analysis or peer review is confidential and may not be used by 

an AIB. These reviews generate confidential records protected from disclosure within and 

outside of VA. See 38 U.S.C. § 5705; 38 C.F.R. §§ 17.500-17.511.

17VA management officials are required to report suspected criminal activity to the 

appropriate VA police or investigatory division, and are also required to report suspected 

felonies immediately to VA’s Office of Inspector General. 38 C.F.R. §§ 1.203,1.204.
Page 8 GAO-12-483 VA Administrative Investigation Boards

the investigation reports we reviewed, one AIB investigated alleged 

physical and verbal abuse of a patient by a VA nursing assistant (an 

employee misconduct matter), while another investigated the facts and 

circumstances surrounding the death of a patient, including whether 

changes to policies and procedures were effectively communicated to 

staff and monitored (a systemic policy matter). In determining the 

composition of the AIB—the number and qualifications of members to be 

appointed—VA Handbook 0700 states that AIBs generally should be 

comprised of one to three members, and the members are to be selected 

primarily based on their expertise and investigative capability, as well as 

their objectivity and impartiality. Convening authorities we interviewed—

medical center directors—said they typically appoint three members to 

ensure that AIBs include a subject matter expert and at least one member 

with investigative experience or training. Moreover, three of these 

convening authorities have appointed AIB members from outside their 

medical center when necessary to ensure the board’s impartiality.

Finally, if the convening authority determines that an AIB is needed, it 

documents the AIB’s scope and member composition in a charge letter, 

which officially authorizes the AIB investigation. During the course of the 

investigation, the convening authority may amend the charge letter, to 

change the scope of the investigation or composition of the AIB, among 

other things. For example, a convening authority included in our review 

initially charged an AIB to investigate an incident involving sexual 

harassment, but later expanded the investigation’s scope to also include 

an incident involving reprisal against the individual who reported the 

harassment. According to one convening authority, it may be more cost 

effective to expand the scope of an investigation to address additional 

matters than to convene a second AIB. The charge letter also 

communicates any waivers to VA’s procedural requirements for the AIB 

investigation. According to VA Handbook 0700, a convening authority 

may waive any of the requirements established by the handbook on a 

case-by-case basis, if, for example, requiring compliance with such 

requirements would not be cost effective.

The charge letter also may authorize the AIB to provide recommendations 

for corrective actions. According to VA Handbook 0700, an AIB only may 

provide recommendations if authorized to do so by the convening 

authority. However, an AIB is prohibited from recommending a specific 

level or type of corrective action, such as termination or suspension, and 
Page 9 GAO-12-483 VA Administrative Investigation Boards

instead may only recommend “appropriate disciplinary action.”18

After the investigation is convened, the AIB collects and analyzes 

evidence, such as witness testimony and documentation, related to the 

matter under investigation. An AIB may obtain witness testimony from VA 

employees, who are obligated to cooperate with the investigation,

Moreover, although an AIB may provide recommendations, convening 

authorities are not required to implement them. Three of the four 

convening authorities we interviewed have authorized AIBs to provide 

recommendations, while one convening authority said that he generally 

has not because AIB members are not privy to all information pertaining 

to an employee who is the subject of the investigation, such as the 

individual’s employment history.

19 as 

well as non-VA employees—including patients—who generally are not 

obligated to cooperate with the investigation. According to VA Handbook 

0700, testimony may be obtained under oath and transcribed by tape 

recording, court reporter, or both.20 Additionally, the AIB may obtain all 

available documents, records, and other information that are material to 

the scope of the investigation, including VA policies, employee personnel 

records, and e-mail correspondence.21 The AIB analyzes the collected 

evidence and develops the findings and conclusions of the investigation, 

including whether any matter investigated was substantiated.22

The AIB documents results—evidence, findings, conclusions, and any 

recommendations—in an investigation report that is forwarded to the 

 

18For AIB investigations related to research misconduct, AIBs are required to recommend 

corrective actions when the investigation finds that research misconduct has occurred.

19See 38 C.F.R § 0.735-12.

20Preliminary investigations, root cause analysis, and peer review do not obtain witness 

testimony under oath. 

21Some information relevant to an investigation, such as patient medical records, may not 

be available to the AIB, or may be subject to specific restrictions on disclosure or use. 

22According to VA Handbook 0700, AIB conclusions, such as whether a matter is 

substantiated, must be “based on at least a preponderance of the evidence.”
Page 10 GAO-12-483 VA Administrative Investigation Boards

convening authority.23 The convening authority reviews the report to verify 

that the AIB sufficiently investigated the matter in accordance with the 

charge letter and VA’s AIB policy.24

Similar to VA, three other federal agencies that we reviewed with 

administrative investigation processes—Federal Bureau of Prisons, U.S. 

Navy Bureau of Medicine and Surgery, and U.S. Coast Guard—have 

policies and procedures in place to guide their administrative 

investigations. Further, the results of these agencies’ administrative 

investigations may be used to inform individual or systemic corrective 

actions. However, the extent to which the administrative investigations 

are expected to provide recommendations for such corrective actions 

varies by agency. (See app. I for characteristics of VA’s and these three 

other federal agencies’ administrative investigation processes.)

The convening authority may ask the 

AIB to further investigate the matter, clarify the information in the 

investigation report, or both. VA considers an AIB investigation to be 

complete once the convening authority certifies the investigation report.

 

23VA Handbook 0700 states that each AIB member is to sign the investigation report, 

which confirms that each finding, conclusion, and recommendation (if included) is agreed 

upon by a majority of the members. AIB members who disagree with any of the findings, 

conclusions, and recommendations should attach a separate opinion identifying the area 

of disagreement.

24A convening authority also may document any waiver to the requirements of VA’s AIB 

policy and procedures in the certification of the investigation report if this has not already 

been included in the charge letter.
Page 11 GAO-12-483 VA Administrative Investigation Boards

VA does not collect and analyze aggregate data on AIB investigations, 

including data on the number of AIB investigations conducted, the types 

of matters investigated, and whether the matters were substantiated, or 

on any systemic deficiencies identified by AIBs. Without these data, VA is 

unable to adequately assess the causes or factors that may contribute to 

deficiencies occurring within all of its medical centers and networks.25

In contrast, through VA’s Patient Safety Program,26

Information on AIB investigations is maintained by different offices across 

VA. For example, each medical center or network maintains the 

investigation report for each AIB investigation that it conducts related to 

VHA staff at the GS-15 level and below. In the absence of having 

aggregate data on AIB investigations, VHA administered a web-based 

survey to medical centers and networks, in response to our request for 

AIB data. These survey data on AIB investigations involving staff at the 

GS-15 level and below, in conjunction with VA data on AIB investigations 

involving senior leadership, showed that VHA conducted 1,143 AIB 

investigations during fiscal years 2009 through 2011.

VA collects and 

analyzes aggregate data on patient safety matters. When an adverse 

event involving patient safety occurs at a medical center, information 

about the event is entered into a tracking system that allows VA to 

electronically monitor patient safety information throughout its health care 

system. Additionally, some of these events are assessed through root 

cause analysis to determine the underlying causes of the adverse event 

and to develop and implement corrective action plans to reduce the 

likelihood of recurrence at the medical center, as well as the potential 

occurrence at other medical centers.

27

 

25According to federal internal control standards, relevant, reliable, and timely information 

is needed throughout an agency to achieve its objectives and to control its operations. 

See GAO, Standards for Internal Control in the Federal Government, 

(See table 1.) 

GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999).

26VA’s Patient Safety Program is designed to identify and fix system flaws that could harm 

patients.

27These investigations do not include matters involving allegations of research 

misconduct. Data on AIB investigations involving these types of matters are maintained 

separately by VHA’s Office of Research Oversight, which reported that medical centers 

conducted a total of eight investigations involving allegations of research misconduct 

during fiscal years 2009 through 2011. According to VHA officials, this office does not 

maintain data on the level of staff involved in these investigations.

VA Does Not Collect 

and Analyze 

Aggregate Data on 

AIB Investigations or 

the Deficiencies They 

Identify
Page 12 GAO-12-483 VA Administrative Investigation Boards

Most of these investigations involved staff at the GS-15 level and below. 

VHA officials told us that although it administered the web-based survey 

in response to our request for data, the department has no plans to 

collect and analyze aggregate data on AIB investigations conducted 

within VHA.

Table 1: Number of Administrative Investigation Boards Conducted in VHA during 

Fiscal Years 2009 through 2011

VA staff level

Number of investigations 

conducted by VHA 

headquarters

Number of investigations 

conducted by medical 

centers and networks Total

GS-15 and belowa 1 1,113 1,114

Senior leadershipb 6 23 29

Total 7 1,136 1,143

Source: GAO analysis of VA data.

Note: The data do not include administrative investigations involving allegations of research 

misconduct because VHA’s Office of Research Oversight does not collect information on the level of 

staff involved in these investigations. VHA’s Office of Research Oversight reported that medical 

centers conducted a total of eight investigations involving allegations of research misconduct during 

fiscal years 2009 through 2011.

a

VA officials told us the data also included staff who are not paid under the GS system, such as 

physicians, dentists, and registered nurses. Additionally, these data do not include investigations 

involving GS-15 staff in VHA headquarters, and any investigations involving this level of staff would 

be included within data for senior leadership.

b

VA defines senior leadership to include members of the senior executive service; associate and 

assistant directors, chiefs of staff, and nurse executives at its medical centers; heads of other VA 

offices such as networks; GS-15 or equivalent positions in VHA headquarters; and all other positions 

centralized to the Secretary.

According to the VHA survey data, the types of matters investigated by 

AIBs during fiscal years 2009 through 2011 included inappropriate 

employee behavior involving patients and other employees; individual 

employee wrongdoing, such as theft and fraud; and systemic 

deficiencies.28

 

28VHA’s survey data did not include examples of the types of systemic deficiencies 

investigated by AIBs. 

Our analysis of AIB investigation reports from the four 

medical centers in our review showed that allegations of inappropriate 

employee behavior involving patients and other employees were the most 

common types of matters investigated by AIBs during fiscal years 2009 

through 2011. (See table 2 for more information on the types of matters 
Page 13 GAO-12-483 VA Administrative Investigation Boards

investigated by AIBs at the four VA medical centers included in our review 

during fiscal years 2009 through 2011.)

Table 2: Types of Matters Investigated by Administrative Investigation Boards at Four Selected VA Medical Centers during 

Fiscal Years 2009 through 2011

Types of matters investigated Description Number

Inappropriate employee behavior 

involving patients

Sexual abuse, physical abuse, verbal abuse, unspecified patient abuse, patient 

death, patient safety, sexual harassment, or other matters such as employees 

accepting gifts from patients. 

24

Inappropriate employee behavior 

involving other employees

Supervisory misconduct or sexual harassment. 13

Unclear VA policies or procedures, or 

violations of policies or procedures

Systemic deficiencies involving unclear policies or procedures that may have 

resulted in an injury to an employee or patient; as well as employees’ lack of 

adherence to VA policies and procedures. 

12

Individual employee wrongdoing Theft or fraud by an employee. 7 

Other Matters that do not fit in any other category, such as missing medical equipment. 11

Total 67

Source: GAO analysis of VA documents.

Notes: During fiscal years 2009 through 2011, the four VA medical centers included in our review 

conducted a total of 49 administrative investigations. The total number of matters investigated is more 

than the total number of investigations conducted during this time period because some boards 

investigated more than one type of matter.

The data do not include administrative investigations involving matters of alleged research 

misconduct. VHA’s Office of Research Oversight reported that two of the eight administrative 

investigations involving allegations of research misconduct occurred at a medical center included in 

our review.

VA has used the results of AIB investigations to inform corrective actions 

taken at individual medical centers and networks to address both 

individual employee misconduct and system deficiencies. However, the 

department does not share information about improvements made in 

response to AIB investigations conducted at certain medical centers and 

networks that could have broader applicability.

VA Has Used the 

Results of AIB 

Investigations to 

Inform Corrective 

Actions, but Does Not 

Share Information 

about Improvements 

More Broadly
Page 14 GAO-12-483 VA Administrative Investigation Boards

To address matters of employee misconduct, VA has used the results of

AIB investigations—evidence, findings, conclusions, and 

recommendations—along with other factors to inform corrective actions 

taken against individual employees.29 These corrective actions range 

from disciplinary actions, such as termination or demotion, to 

nondisciplinary actions, such as counseling, reassignment, or training to 

expand an employee’s knowledge about VA policies and procedures or 

clinical standards, according to information provided by VA officials we 

interviewed.30

A medical center director or appropriate higher level official may use 

results from the investigation to help determine whether any corrective 

actions are warranted, and if so, the type and severity of each action. 

Other VA staff, such as human resources and general counsel staff, may 

also provide guidance to management in determining appropriate 

corrective actions. Specifically, in determining the type and severity of 

corrective actions to be taken, VA officials review the results of the AIB 

investigations, along with other factors related to the alleged misconduct 

being investigated, including the nature and seriousness of the offense, 

whether the conduct was intentional or inadvertent, and the type of 

penalty used for similar matters. VA officials also consider other 

information regarding an employee’s history and conduct, including 

violations of VA policies. For example, medical center officials told us that 

an employee’s history of time and attendance violations may be used in 

addition to the misconduct investigated by the AIB to inform disciplinary 

action against an employee.

Although AIBs may make recommendations for corrective 

actions, they are not involved in determining actual corrective actions 

taken against an individual.

VA does not collect and analyze aggregate information on the specific 

employee corrective actions that were informed by AIB investigations. 

Instead, this information is maintained by different offices throughout VA, 

 

29For the subset of corrective actions that are disciplinary, according to VA’s Office of 

General Counsel, VA may use the evidence obtained through an AIB, but may not use the 

findings, conclusions, or recommendations as support for, or to defend appeals of, 

disciplinary actions. For all other corrective actions, VA may use all the results (evidence, 

findings, conclusions, and recommendations) obtained through an AIB.

30The corrective action categories are based on our analysis of information provided by 

VA officials, including VA Directive 5021, VA Handbook 5021, and information VHA 

collected through its web-based survey.

VA Has Used the Results of 

AIB Investigations to 

Inform Corrective Actions 

against Individual 

Employees
Page 15 GAO-12-483 VA Administrative Investigation Boards

including human resources offices at VA medical centers.31 Information 

provided by VA officials from the medical centers included in our review 

showed that the results of the 49 AIB investigations conducted during 

fiscal years 2009 through 2011 have been used, along with other 

information, to inform 67 employee corrective actions.32 (See table 3.) 

Suspension and training were among the most common corrective 

actions that were informed by AIB investigations taken at these medical 

centers.

 

31Although information on disciplinary corrective actions taken regarding matters of 

research misconduct is maintained by the medical center where the employee is located, 

information on nondisciplinary actions taken on these matters is maintained at VHA’s 

Office of Research Oversight. For the eight research misconduct investigations conducted 

during fiscal years 2009 through 2011, VA officials reported that no corrective actions 

were taken for three of these investigations. For two investigations, the employees 

involved in the alleged misconduct resigned, and for three investigations, several 

corrective actions were taken, including an employee 30-day suspension, retraction of 

research articles, a 3-year prohibition against conducting research, and periodic and 

routine evaluations of the collection and reporting of research data for certain studies.

32VA’s information did not include the total number of VHA staff who had action taken 

against them, but rather the number of corrective actions taken. Individuals could have 

had more than one corrective action taken against them and a single AIB investigation 

could have informed corrective actions against multiple individuals. 
Page 16 GAO-12-483 VA Administrative Investigation Boards

Table 3: Number of Employee Corrective Actions That Were Informed by Administrative Investigation Boards Conducted at 

Four Selected VA Medical Centers during Fiscal Years 2009 through 2011

Corrective action Description Total

Disciplinary action

Termination Involuntary separation of an employee from VA employment. 5 

Suspension Involuntary placement of an employee, for disciplinary reasons, in a non-duty, non-pay status for a 

period of time.

13

Demotion Involuntary reduction in grade, reduction in basic pay based on conduct or performance. 2 

Reprimand Official letter of censure to an employee for major acts of misconduct or deficiency in competence. 

This letter usually remains in the employee’s personnel folder for 3 years.

0 

Admonishment Official letter of censure to an employee for minor acts of misconduct or deficiency in competence. 

This letter usually remains in the employee’s personnel folder for 2 years. 

1 

Nondisciplinary action

Counseling Verbal or written information intended to address an employee’s conduct or performance. 4 

Reassignment An involuntary change in assignment to a different position, location, or both. 10

Training Training to expand an employee’s knowledge of current or new policies and procedures or clinical 

standards.

21

Other Actions that do not fit in the corrective actions listed above or that were not specified. 11

Total 67

Source: GAO analysis of VA documents.

Notes: The corrective action categories are based on our analysis of information provided by VA 

officials, including VA Directive 5021, VA Handbook 5021, and information VHA collected through its 

web-based survey. These corrective actions do not result directly from administrative investigation 

boards (AIB), but rather the results of AIB investigations, along with other information available to VA 

officials, are used to inform the type of corrective action taken. For the subset of corrective actions 

that are disciplinary, according to VA’s Office of General Counsel, VA may use the evidence obtained 

through an AIB, but may not use the findings, conclusions, or recommendations as support for, or to 

defend appeals of, disciplinary actions. For all other corrective actions, VA may use all the results 

obtained through an AIB.

VA’s information did not include the total number of VHA staff who had action taken against them, but 

rather the number of corrective actions taken. Individuals could have had more than one corrective 

action taken against them and a single AIB investigation could have informed corrective actions 

against multiple individuals.

According to VA officials, no employee corrective actions were taken for the two research misconduct 

investigations conducted by a medical center included in our review as the alleged research 

misconduct matters in these investigations were not substantiated.
Page 17 GAO-12-483 VA Administrative Investigation Boards

In addition to informing employee corrective actions, VA has used the 

results of AIB investigations to inform corrective actions related to 

systemic changes at medical centers and networks where AIB 

investigations have been conducted.33

However, VA does not share information about systemic changes that are 

made in response to the results of AIB investigations that may have 

relevance for other areas within VHA.

Specifically, VA has developed 

new policies and procedures for improving patient and employee safety, 

developed new training programs to ensure employees’ knowledge of VA 

policies and procedures, and implemented new or increased oversight of 

medical processes. For example, one medical center in our review used 

an AIB’s findings of missing surgical instruments to support 

implementation of a tracking system to ensure the necessary surgical 

instruments are delivered promptly to the operating room and the 

development and implementation of a checklist to ensure the availability 

of needed equipment prior to starting surgery. This medical center also 

developed new procedures and annual training for clinical staff on the use 

of E-oxygen tanks—large aluminum cylinders that store compressed 

oxygen for medical use—in response to an AIB’s findings that certain 

medical center staff did not know how to provide oxygen to a patient.

34

In contrast, as part of VA’s overall efforts to report and address significant 

matters that affect its operations, VA tracks and shares information from 

root cause analyses it has performed. For example, information gathered 

from root cause analyses has been used by VA’s Patient Safety Program 

to disseminate notices—alerts and advisories—to medical centers when 

actual or potential threats to the health and safety of patients have been 

Although two of the four medical 

center directors we interviewed told us they occasionally have shared 

information about changes made in response to AIB investigations they 

convened with other medical centers within their networks or with VA 

headquarters, this sharing has not routinely or systematically been done.

 

33VA may take employee corrective actions, as well as corrective actions related to 

identified systemic deficiencies in response to results from the same AIB investigation.

34According to federal internal control standards, information sharing between 

organizational components is an essential part of ensuring an effective and efficient use of 

resources. See GAO, Standards for Internal Control in the Federal Government, 

GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999).

VA Has Used Results of 

AIB Investigations to 

Inform Systemic Changes 

at Individual Medical 

Centers and Networks, but 

Does Not Share 

Information More Broadly
Page 18 GAO-12-483 VA Administrative Investigation Boards

identified.35 These notices contain information about the patient safety 

matter, including actions taken, and any new procedures required. For 

example, in fiscal year 2011, following a root cause analysis, VA issued 

an alert regarding the safety of patients in mental health units who were 

using devices such as walkers to obstruct entry to their rooms. As part of 

this alert, VA directed its medical centers to take certain actions to ensure 

the safety of patients admitted to their mental health units. According to 

VA officials, VA’s alerts and advisories are designed to focus attention on 

specific high-risk situations, such as medical equipment that may 

unintentionally harm patients or an unanticipated malfunction of a key 

piece of clinical software. For situations that are not considered high risk, 

VA’s Patient Safety Program uses other information-sharing processes, 

including presentations, conference calls, or publications, to disseminate 

information about lessons learned. However, VHA officials told us that the 

department does not have similar processes for sharing information 

learned from AIB investigations. VHA officials said they rely on medical 

center and network leadership to identify and share such information.

AIBs are an important investigation tool for VA that can lead to 

operational improvements, including improved quality of care provided to 

veterans. However, VA neither collects nor analyzes aggregate data on 

AIB investigations nor does it routinely share information about systemic 

deficiencies identified or corrective actions taken to improve VHA 

operations and services. During fiscal years 2009 through 2011, VHA 

conducted more than 1,100 AIB investigations, yet the lack of such 

information from AIB investigations may result in missed opportunities for 

VA to gauge the extent to which deficiencies occur throughout its medical 

centers and networks to prevent escalation of problems, and to take 

timely corrective action, when needed. Such missed opportunities come 

with a cost when information from these investigations is not used to 

improve the quality and efficiency of VHA operations, including the

delivery of care to veterans.

 

35Alerts disseminate urgent notices that require specific, mandatory, and timely action. 

Advisories are issued when a potential threat due to equipment design, procedural issues, 

or training has been identified. These advisories provide general recommendations for 

medical center directors, who must either implement these recommendations or 

implement procedures that provide equivalent or a higher level of safety than the 

recommendations provided in the advisory notices.

Conclusions 
Page 19 GAO-12-483 VA Administrative Investigation Boards

To systematically gauge the extent to which deficiencies identified by 

individual AIBs may be occurring throughout VHA; and to maximize 

opportunities for sharing information across VHA to improve its overall 

operations, we recommend that the Secretary of Veterans Affairs direct 

the Under Secretary for Health to take the following two actions for AIB 

investigations conducted within VHA:

• establish a process to collect and analyze aggregate data from AIB 

investigations, including the number of investigations conducted, the 

types of matters investigated, whether the matters were substantiated, 

and systemic deficiencies identified; and

• establish a process for sharing information about systemic changes, 

including policies and procedures implemented in response to the 

results of AIB investigations, which may have broader applicability 

throughout VHA.

We provided a draft of this report to VA for comment. In its response, 

which is reprinted in appendix II, VA concurred with our 

recommendations. In its comments, VA identified several activities that 

VHA uses to identify, address, and share information about systemic 

issues in facilities and VHA program offices—including root cause 

analysis and peer review, which we discuss in our report. VA stated that it 

is within the context of these existing activities, which address quality and 

safety issues, that it would explore any new processes for collecting and 

analyzing aggregate data from AIB investigations. We believe that it is 

important for VA to establish such processes, even if they are processes 

within existing activities, to systematically gauge the extent to which 

deficiencies identified by individual AIBs may be occurring throughout 

VHA and to maximize opportunities for sharing information across VHA to 

improve its overall operations.

Additionally, VA stated that its comments focus only on implications and 

issues involving VHA, rather than VA, and suggested a revision to our 

recommendations to reflect this. As stated in the scope and methodology 

of this report, we focused on AIB investigations conducted in VHA, and 

thus our recommendations were only focused on these investigations. We 

revised the wording of our recommendation to clarify that we were 

focusing only on AIB investigations conducted within VHA. (VA also 

provided technical comments, which we have incorporated as 

appropriate.)

Recommendations for 

Executive Action

Agency Comments 

and Our Evaluation
Page 20 GAO-12-483 VA Administrative Investigation Boards

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 a copy of this report to the 

appropriate congressional committees and the Secretary of Veterans 

Affairs. The report also will be available at no charge on GAO’s 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 III.

Debra A. Draper

Director, Health Care
Appendix I: Characteristics of Selected Federal 

Agencies’ Administrative Investigation 

Processes

Page 21 GAO-12-483 VA Administrative Investigation Boards

Characteristic of 

administrative 

investigation 

processes

Department of Veterans 

Affairs 

Federal Bureau of 

Prisons

U.S. Navy Bureau of 

Medicine and Surgery U.S. Coast Guard

Requirement for 

conducting administrative 

investigations

Administrative 

investigations are to be 

conducted in accordance 

with departmentwide 

policy and procedures, 

which allow flexibility to 

tailor an investigation to 

meet diverse 

informational needs.

Administrative 

investigations must be 

conducted in accordance 

with agencywide policy.

Administrative 

investigations must be 

conducted in accordance 

with Navy-wide policy.

Administrative 

investigations must be 

conducted in accordance 

with agencywide policy.

Process for convening 

administrative 

investigations

A convening authority—

medical center directors 

or any authority senior to 

them within networks or 

headquarters—

determines the need and 

scope of the investigation 

based on several factors 

that may include the 

results of a preliminary 

investigation. 

Matters are sorted into 

three categories based 

on their severity and 

potential consequences. 

Officials use these 

categories to determine 

whether an administrative 

investigation will be 

convened by the local 

institution or by another 

office in the agency or 

Department of Justice, 

such as the Office of the 

Inspector General. 

A convening authority—

usually a commanding 

officer—initiates a 

preliminary investigation 

into an incident. Based in 

part on the findings of 

the preliminary 

investigation, and in 

consultation with a Navy 

legal advisor, the 

convening authority may 

authorize an 

administrative 

investigation and if so, 

determines the scope of 

the investigation. 

A convening authority—

usually a senior officer—

generally determines the 

need and scope of 

administrative 

investigations. For 

certain matters, such as 

fires or ship collisions, 

administrative 

investigations are 

required. 

Process for selecting 

individuals to conduct 

administrative 

investigations

The convening authority 

selects individuals 

primarily based on their 

expertise and 

investigative capability, 

as well as their objectivity 

and impartiality. 

Generally, between one 

and three individuals 

should be selected to 

conduct the investigation.

Typically one individual 

designated from the 

institution’s Special 

Investigator Supervisor 

Office—which primarily 

investigates crimes and 

corruption related to 

inmates and staff—

conducts administrative 

investigations. 

The convening authority 

selects one or more 

best-qualified individuals 

to conduct an 

administrative 

investigation based on 

age, education, training, 

experience, length of 

service, and 

temperament. 

The convening authority 

selects the appropriate 

investigating officer. 

Typically, one junior 

officer conducts the 

investigation, but more 

officers may be 

appointed for complex 

incidents. 

Appendix I: Characteristics of Selected 

Federal Agencies’ Administrative 

Investigation Processes
Appendix I: Characteristics of Selected Federal 

Agencies’ Administrative Investigation 

Processes

Page 22 GAO-12-483 VA Administrative Investigation Boards

Characteristic of 

administrative 

investigation 

processes

Department of Veterans 

Affairs 

Federal Bureau of 

Prisons

U.S. Navy Bureau of 

Medicine and Surgery U.S. Coast Guard

Process for documenting 

results from 

administrative 

investigations

Investigation results are 

documented in an 

investigation report that 

includes the evidence, 

findings, conclusions, 

and any 

recommendations. The 

convening authority 

reviews the investigation 

report and certifies the 

investigation as 

complete. 

Investigation results are 

documented in an 

investigation report that 

includes findings and 

conclusions. The Bureau 

of Prison’s Office of 

Internal Affairs reviews 

the investigation report 

and closes the 

administrative 

investigation.

Investigation results are 

documented in an 

investigation report that 

includes findings of fact, 

opinions, conclusions, 

and any 

recommendations. The 

convening authority 

reviews and certifies the 

investigation report.

Investigation results are 

documented in an 

investigation report that 

includes findings, 

opinions, and 

recommendations. The 

convening authority 

reviews the investigation 

report. Any officer senior 

to the convening 

authority may also 

review the investigation 

report. 

Expectation for 

administrative 

investigations reports to 

include 

recommendations

Administrative 

investigation reports may 

provide 

recommendations for 

corrective action if 

authorized to do so by 

the convening authority.

Administrative 

investigation reports do 

not provide 

recommendations for 

disciplinary action, but 

may provide 

recommendations for 

other corrective actions, 

such as employee 

training. 

Administrative 

investigation reports may 

provide 

recommendations for 

corrective action only 

when requested to do so 

by the convening 

authority.

Administrative 

investigation reports are 

expected to provide 

recommendations for 

corrective action.

Source: GAO analysis of administrative investigation policies and procedures, and interviews with officials from the Department of 

Veterans Affairs, Federal Bureau of Prisons, U.S. Navy Bureau of Medicine and Surgery, and U.S. Coast Guard.
Appendix II: Comments from the Department 

of Veterans Affairs

Page 23 GAO-12-483 VA Administrative Investigation Boards

Appendix II: Comments from the Department 

of Veterans Affairs
Appendix II: Comments from the Department 

of Veterans Affairs

Page 24 GAO-12-483 VA Administrative Investigation Boards
Appendix II: Comments from the Department 

of Veterans Affairs

Page 25 GAO-12-483 VA Administrative Investigation Boards
Appendix II: Comments from the Department 

of Veterans Affairs

Page 26 GAO-12-483 VA Administrative Investigation Boards
Appendix II: Comments from the Department 

of Veterans Affairs

Page 27 GAO-12-483 VA Administrative Investigation Boards
Appendix II: Comments from the Department 

of Veterans Affairs

Page 28 GAO-12-483 VA Administrative Investigation Boards
Appendix II: Comments from the Department 

of Veterans Affairs

Page 29 GAO-12-483 VA Administrative Investigation Boards
Appendix II: Comments from the Department 

of Veterans Affairs

Page 30 GAO-12-483 VA Administrative Investigation Boards
Appendix II: Comments from the Department 

of Veterans Affairs

Page 31 GAO-12-483 VA Administrative Investigation Boards
Appendix III: GAO Contact and Staff 

Acknowledgments

Page 32 GAO-12-483 VA Administrative Investigation Boards

Debra A. Draper, (202) 512-7114 or draperd@gao.gov

In addition to the contact named above, Janina Austin, Assistant Director; 

Jennie F. Apter; Julianne Flowers; Lisa Motley; Carmen Rivera-Lowitt; 

C. Jenna Sondhelm; and Brienne Tierney made key contributions to this 

report.

Appendix III: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments 

(290927)
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