VA Administrative Investigations: Improvements Needed in Collecting and Sharing Information
Published: 2012-04-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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 web-based 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.
section_title: What GAO Recommends
paragraphs: 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.

section_title: Letter
paragraphs: 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   In fiscal year 2011, VHA  centers across 21 health care networks.employed about 255,000 staff members at various levels including  managers, clinicians, and administrative staff.
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.
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.identify potential areas for improvement. For example, related to issues of   Apart from AIB investigations, VA uses other tools to  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. 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.
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.
To determine the process VA uses to convene and conduct AIB  investigations, we reviewed VA documentation, including VA’s policy and   We also reviewed documentation and  procedures for AIB investigations.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  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, 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. 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, and specific VA policy and procedures for taking  corrective actions against staff involved in research misconduct. 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.
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   and how VA officials have used the results of these tools to  processes, 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, size,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  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.
subsections: section_title: VA Has Departmentwide Policy for Convening and Conducting AIB Investigations
paragraphs: VA has departmentwide policy and procedures for convening and  conducting AIB investigations. 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.
VA Directive 6330, Directives Management (Feb. 26, 2009).
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.)
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. 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. 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.
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  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  instead may only recommend “appropriate disciplinary action.”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.
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,  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. 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. The AIB analyzes the collected  evidence and develops the findings and conclusions of the investigation,  including whether any matter investigated was substantiated.
The AIB documents results—evidence, findings, conclusions, and any  recommendations—in an investigation report that is forwarded to the  convening authority. 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.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.
The convening authority may ask the  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.)
section_title: VA Does Not Collect and Analyze Aggregate Data on AIB Investigations or the Deficiencies They Identify
paragraphs: 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.
In contrast, through VA’s Patient Safety Program, 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.
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. (See table 1.)
VA’s Patient Safety Program is designed to identify and fix system flaws that could harm  patients.
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.
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. 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  investigated by AIBs at the four VA medical centers included in our review  during fiscal years 2009 through 2011.)
section_title: VA Has Used the Results of AIB Investigations to Inform Corrective Actions, but Does Not Share Information about Improvements More Broadly
paragraphs: 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.
subsections: section_title: VA Has Used the Results of AIB Investigations to Inform Corrective Actions against Individual Employees
paragraphs: 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. 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.actions, they are not involved in determining actual corrective actions  taken against an individual.
Although AIBs may make recommendations for corrective  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.
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,  including human resources offices at VA medical centers. 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.Suspension and training were among the most common corrective  actions that were informed by AIB investigations taken at these medical  centers.   (See table 3.)
section_title: Conclusions
paragraphs: 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.
section_title: Recommendations for Executive Action
paragraphs: 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.
section_title: Agency Comments and Our Evaluation
paragraphs: 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.)
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.
section_title: Appendix I: Characteristics of Selected Federal Agencies’ Administrative Investigation Processes
subsections: section_title: Characteristic of administrative investigation processes Requirement for conducting administrative investigations
paragraphs: Department of Veterans  Affairs  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.
Federal Bureau of  Prisons  Administrative  investigations must be  conducted in accordance  with agencywide policy.
U.S. Navy Bureau of  Medicine and Surgery  U.S. Coast Guard  Administrative  investigations must be  conducted in accordance  with Navy-wide policy.
Administrative  investigations must be  conducted in accordance  with agencywide policy.
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.
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.
Department of Veterans  Affairs  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.
Federal Bureau of  Prisons  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.
U.S. Navy Bureau of  Medicine and Surgery  U.S. Coast Guard  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.
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.
section_title: Appendix II: Comments from the Department of Veterans Affairs
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: 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.