VA Administrative Investigations: Improvements Needed in Collecting and Sharing Information
Released: 2012-05-30T00:00:00

Letter

VA Has Departmentwide Policy for Convening and Conducting AIB Investigations

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.)

VA Does Not Collect and Analyze Aggregate Data on AIB Investigations or the Deficiencies They Identify

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.)

VA Has Used the Results of AIB Investigations to Inform Corrective Actions, but Does Not Share Information about Improvements More Broadly

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 against Individual Employees

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.)

Conclusions

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.

Recommendations for Executive Action

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.

Agency Comments and Our Evaluation

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.)

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Appendix I: Characteristics of Selected Federal Agencies’ Administrative Investigation Processes

Characteristic of administrative investigation processes Requirement for conducting administrative investigations

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.

Appendix II: Comments from the Department of Veterans Affairs

Appendix III: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

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.