oversight

VA Administrative Investigations: Improvements Needed in Collecting and Sharing Information

Published by the Government Accountability Office on 2012-04-30.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

             United States Government Accountability Office

GAO          Report to Congressional Requesters




April 2012
             VA ADMINISTRATIVE
             INVESTIGATIONS
             Improvements Needed
             in Collecting and
             Sharing Information




GAO-12-483
                                               April 2012

                                               VA ADMINISTRATIVE INVESTIGATIONS
                                               Improvements Needed in Collecting and Sharing
                                               Information
Highlights of GAO-12-483, a report to
congressional requesters




Why GAO Did This Study                         What GAO Found
VA may use an AIB to determine the             The Department of Veterans Affairs (VA) has departmentwide policy and
facts surrounding alleged employee             procedures for convening and conducting administrative investigation boards
misconduct or potential systemic               (AIB). The department’s procedures contain requirements for convening and
deficiencies related to VA policies or         conducting AIB investigations, but according to VA officials, they also provide the
procedures. AIBs do not determine              flexibility to tailor an investigation to effectively meet diverse informational needs.
corrective actions, such as individual         For example, the VA official convening an AIB investigation is required to select
disciplinary actions or procedural             AIB members who are impartial and objective, but has flexibility to vary the
changes, but AIB investigation results,        number of members appointed to each AIB based on the matter being
including evidence, may be used to
                                               investigated. VA is currently updating its AIB policy and procedures, but officials
inform such actions, making it critical
                                               said the department plans to maintain flexibility in its AIB process.
for AIBs to be convened and
conducted appropriately.                       VA does not collect and analyze aggregate data on AIB investigations, including
You expressed interest in the number           data on the number of AIB investigations conducted, the types of matters
of AIB investigations and their results.       investigated, and whether the matters were substantiated, or on any systemic
In this report, GAO examines (1) the           deficiencies identified by AIBs. Having aggregate data could provide VA with
process VA uses to convene and                 valuable information to systematically gauge the extent to which matters
conduct AIB investigations, (2) the            investigated by AIBs may be occurring throughout VA’s Veterans Health
extent to which VA collects data on AIB        Administration (VHA) and to take corrective action, if needed, to reduce the
investigations, and (3) how VA has             likelihood of future occurrences. Without such data, VA is unable to adequately
used the results of its AIB                    assess the causes or factors that may contribute to deficiencies occurring within
investigations. GAO focused on AIB             its medical centers and health care networks. Information on AIB investigations is
investigations conducted within VHA;           maintained by different offices across VA. For example, each medical center or
reviewed VA documents, including               network maintains information on each AIB investigation that it conducts. In
policies and procedures, and VHA data          response to GAO’s request for AIB data, VHA administered a web-based survey
on AIBs conducted during fiscal years          that collected data from all its medical centers and networks on AIB
2009 through 2011; and interviewed             investigations they reported conducting during fiscal years 2009 through 2011.
VA officials from headquarters and four        Survey data showed that medical centers and networks conducted more than
medical centers. To ensure data                1,100 investigations during this time period, and the types of matters investigated
reliability, GAO reviewed VHA’s
                                               included allegations of inappropriate employee behavior involving patients and
methods to collect AIB data.
                                               other employees; individual employee wrongdoing, such as theft and fraud; and
What GAO Recommends                            systemic deficiencies. VHA officials told us that although it administered the web-
                                               based survey, the department has no plans to collect and analyze aggregate
GAO recommends that VA establish               data on AIB investigations conducted within VHA.
processes to (1) collect and analyze
aggregate data from AIB investigations         VA has used the results of AIB investigations to inform corrective actions, but
conducted within VHA, and (2) share            does not share information about improvements made that could have broader
information about improvements that            applicability. Specifically, VA has used the results of AIB investigations to inform
are implemented in response to the             systemic changes at the medical centers and networks where AIB investigations
results of AIB investigations. VA              have been conducted. For example, VA has developed new policies and
concurred with these                           procedures for improving patient and employee safety and developed new
recommendations.                               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
View GAO-12-483. For more information,
contact Debra A. Draper at (202) 512-7114 or   are delivered promptly to the operating room and a checklist to ensure the
draperd@gao.gov.                               availability of needed equipment prior to starting surgery.

                                                                                         United States Government Accountability Office
Contents


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




               Page i                           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 ii                                 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 In fiscal year 2011, VHA
                                   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. 2 Apart from AIB investigations, VA uses other tools to
                                   identify potential areas for improvement. For example, related to issues of


                                   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.
                                   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 1                                  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 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
procedures for AIB investigations. 4 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



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.
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 2                                  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 and specific VA policy and procedures for taking


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.
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 3                                  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
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




8
 VHA Directive 1058, Office of Research Oversight (Feb. 9, 2009) and VHA Handbook
1058.2, Research Misconduct (May 4, 2005).
9
 GAO, Standards for Internal Control in the Federal Government, GAO/AIMD-00-21.3.1
(Washington, D.C.: November 1999).
10
  Peer 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.
11
  We 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.
12
    Size refers to the number of patients served by the medical center in fiscal year 2010.




Page 4                                    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
VA Has                 conducting AIB investigations. 13 According to VA Handbook 0700, the
Departmentwide         department’s procedures are intended “to promote effectiveness and
Policy for Convening   uniformity in the conduct and reporting of AIB investigations,” among
                       other things. The procedures outlined in the handbook are mandatory,
and Conducting AIB     except where otherwise indicated. According to VA officials, the policy
Investigations         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.

                       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. 14 Although revisions to its AIB policy and procedures were not
                       finalized by the time we issued this report, officials within VA’s Office of



                       13
                         VA 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.
                       14
                         VA Directive 6330, Directives Management (Feb. 26, 2009).




                       Page 5                                   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 6                              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


15
  According 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.
16
  In 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.
17
  VA 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 7                                  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 8                            GAO-12-483 VA Administrative Investigation Boards
instead may only recommend “appropriate disciplinary action.” 18
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, 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




18
  For AIB investigations related to research misconduct, AIBs are required to recommend
corrective actions when the investigation finds that research misconduct has occurred.
19
 See 38 C.F.R § 0.735-12.
20
  Preliminary investigations, root cause analysis, and peer review do not obtain witness
testimony under oath.
21
  Some 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.
22
  According 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 9                                  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 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.

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.)




23
  VA 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.
24
  A 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 10                                   GAO-12-483 VA Administrative Investigation Boards
                        VA does not collect and analyze aggregate data on AIB investigations,
VA Does Not Collect     including data on the number of AIB investigations conducted, the types
and Analyze             of matters investigated, and whether the matters were substantiated, or
                        on any systemic deficiencies identified by AIBs. Without these data, VA is
Aggregate Data on       unable to adequately assess the causes or factors that may contribute to
AIB Investigations or   deficiencies occurring within all of its medical centers and networks. 25
the Deficiencies They   In contrast, through VA’s Patient Safety Program, 26 VA collects and
Identify                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. 27 (See table 1.)



                        25
                          According 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,
                        GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999).
                        26
                          VA’s Patient Safety Program is designed to identify and fix system flaws that could harm
                        patients.
                        27
                          These 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.




                        Page 11                                  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

                              Number of investigations      Number of investigations
                                   conducted by VHA           conducted by medical
    VA staff level                       headquarters         centers and networks               Total
                         a
    GS-15 and below                                   1                             1,113       1,114
                          b
    Senior leadership                                 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 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




28
  VHA’s survey data did not include examples of the types of systemic deficiencies
investigated by AIBs.




Page 12                                       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         Sexual abuse, physical abuse, verbal abuse, unspecified patient abuse, patient                        24
involving patients                      death, patient safety, sexual harassment, or other matters such as employees
                                        accepting gifts from patients.
Inappropriate employee behavior         Supervisory misconduct or sexual harassment.                                                          13
involving other employees
Unclear VA policies or procedures, or   Systemic deficiencies involving unclear policies or procedures that may have                          12
violations of policies or procedures    resulted in an injury to an employee or patient; as well as employees’ lack of
                                        adherence to VA policies and procedures.
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
VA Has Used the                            taken at individual medical centers and networks to address both
Results of AIB                             individual employee misconduct and system deficiencies. However, the
                                           department does not share information about improvements made in
Investigations to                          response to AIB investigations conducted at certain medical centers and
Inform Corrective                          networks that could have broader applicability.
Actions, but Does Not
Share Information
about Improvements
More Broadly




                                           Page 13                                      GAO-12-483 VA Administrative Investigation Boards
VA Has Used the Results of   To address matters of employee misconduct, VA has used the results of
AIB Investigations to        AIB investigations—evidence, findings, conclusions, and
Inform Corrective Actions    recommendations—along with other factors to inform corrective actions
                             taken against individual employees. 29 These corrective actions range
against Individual
                             from disciplinary actions, such as termination or demotion, to
Employees                    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 Although AIBs may make recommendations for corrective
                             actions, they are not involved in determining actual corrective actions
                             taken against an individual.

                             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,



                             29
                                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 (evidence,
                             findings, conclusions, and recommendations) obtained through an AIB.
                             30
                               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.




                             Page 14                                  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.




31
  Although 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.
32
  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.




Page 15                                 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                    13
                         period of time.
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.                      0
                         This letter usually remains in the employee’s personnel folder for 3 years.
Admonishment             Official letter of censure to an employee for minor acts of misconduct or deficiency in competence.                      1
                         This letter usually remains in the employee’s personnel folder for 2 years.
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                       21
                         standards.
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 16                                       GAO-12-483 VA Administrative Investigation Boards
VA Has Used Results of      In addition to informing employee corrective actions, VA has used the
AIB Investigations to       results of AIB investigations to inform corrective actions related to
Inform Systemic Changes     systemic changes at medical centers and networks where AIB
                            investigations have been conducted. 33 Specifically, VA has developed
at Individual Medical
                            new policies and procedures for improving patient and employee safety,
Centers and Networks, but   developed new training programs to ensure employees’ knowledge of VA
Does Not Share              policies and procedures, and implemented new or increased oversight of
Information More Broadly    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.

                            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. 34 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.

                            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




                            33
                              VA may take employee corrective actions, as well as corrective actions related to
                            identified systemic deficiencies in response to results from the same AIB investigation.
                            34
                              According 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).




                            Page 17                                 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
Conclusions   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.




              35
                Alerts 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.




              Page 18                                GAO-12-483 VA Administrative Investigation Boards
                      To systematically gauge the extent to which deficiencies identified by
Recommendations for   individual AIBs may be occurring throughout VHA; and to maximize
Executive Action      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,
Agency Comments       which is reprinted in appendix II, VA concurred with our
and Our Evaluation    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.)




                      Page 19                           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




Page 20                          GAO-12-483 VA Administrative Investigation Boards
Appendix I: Characteristics of Selected
                                             Appendix I: Characteristics of Selected Federal
                                             Agencies’ Administrative Investigation
                                             Processes


Federal Agencies’ Administrative
Investigation Processes

Characteristic of
administrative
investigation              Department of Veterans Federal Bureau of                   U.S. Navy Bureau of
processes                  Affairs                Prisons                             Medicine and Surgery         U.S. Coast Guard
Requirement for           Administrative                  Administrative              Administrative               Administrative
conducting administrative investigations are to be        investigations must be      investigations must be       investigations must be
investigations            conducted in accordance         conducted in accordance     conducted in accordance      conducted in accordance
                          with departmentwide             with agencywide policy.     with Navy-wide policy.       with agencywide policy.
                          policy and procedures,
                          which allow flexibility to
                          tailor an investigation to
                          meet diverse
                          informational needs.
Process for convening      A convening authority—         Matters are sorted into     A convening authority—       A convening authority—
administrative             medical center directors       three categories based      usually a commanding         usually a senior officer—
investigations             or any authority senior to     on their severity and       officer—initiates a          generally determines the
                           them within networks or        potential consequences.     preliminary investigation    need and scope of
                           headquarters—                  Officials use these         into an incident. Based in   administrative
                           determines the need and        categories to determine     part on the findings of      investigations. For
                           scope of the investigation     whether an administrative   the preliminary              certain matters, such as
                           based on several factors       investigation will be       investigation, and in        fires or ship collisions,
                           that may include the           convened by the local       consultation with a Navy     administrative
                           results of a preliminary       institution or by another   legal advisor, the           investigations are
                           investigation.                 office in the agency or     convening authority may      required.
                                                          Department of Justice,      authorize an
                                                          such as the Office of the   administrative
                                                          Inspector General.          investigation and if so,
                                                                                      determines the scope of
                                                                                      the investigation.
Process for selecting      The convening authority        Typically one individual    The convening authority      The convening authority
individuals to conduct     selects individuals            designated from the         selects one or more          selects the appropriate
administrative             primarily based on their       institution’s Special       best-qualified individuals   investigating officer.
investigations             expertise and                  Investigator Supervisor     to conduct an                Typically, one junior
                           investigative capability,      Office—which primarily      administrative               officer conducts the
                           as well as their objectivity   investigates crimes and     investigation based on       investigation, but more
                           and impartiality.              corruption related to       age, education, training,    officers may be
                           Generally, between one         inmates and staff—          experience, length of        appointed for complex
                           and three individuals          conducts administrative     service, and                 incidents.
                           should be selected to          investigations.             temperament.
                           conduct the investigation.




                                             Page 21                                    GAO-12-483 VA Administrative Investigation Boards
                                             Appendix I: Characteristics of Selected Federal
                                             Agencies’ Administrative Investigation
                                             Processes




Characteristic of
administrative
investigation               Department of Veterans Federal Bureau of                                 U.S. Navy Bureau of
processes                   Affairs                Prisons                                           Medicine and Surgery                    U.S. Coast Guard
Process for documenting     Investigation results are       Investigation results are                Investigation results are               Investigation results are
results from                documented in an                documented in an                         documented in an                        documented in an
administrative              investigation report that       investigation report that                investigation report that               investigation report that
investigations              includes the evidence,          includes findings and                    includes findings of fact,              includes findings,
                            findings, conclusions,          conclusions. The Bureau                  opinions, conclusions,                  opinions, and
                            and any                         of Prison’s Office of                    and any                                 recommendations. The
                            recommendations. The            Internal Affairs reviews                 recommendations. The                    convening authority
                            convening authority             the investigation report                 convening authority                     reviews the investigation
                            reviews the investigation       and closes the                           reviews and certifies the               report. Any officer senior
                            report and certifies the        administrative                           investigation report.                   to the convening
                            investigation as                investigation.                                                                   authority may also
                            complete.                                                                                                        review the investigation
                                                                                                                                             report.
Expectation for             Administrative                  Administrative                           Administrative                          Administrative
administrative              investigation reports may       investigation reports do                 investigation reports may               investigation reports are
investigations reports to   provide                         not provide                              provide                                 expected to provide
include                     recommendations for             recommendations for                      recommendations for                     recommendations for
recommendations             corrective action if            disciplinary action, but                 corrective action only                  corrective action.
                            authorized to do so by          may provide                              when requested to do so
                            the convening authority.        recommendations for                      by the convening
                                                            other corrective actions,                authority.
                                                            such as employee
                                                            training.
                                             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.




                                             Page 22                                                     GAO-12-483 VA Administrative Investigation Boards
Appendix II: Comments from the Department
             Appendix II: Comments from the Department
             of Veterans Affairs



of Veterans Affairs




             Page 23                               GAO-12-483 VA Administrative Investigation Boards
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
                  Appendix III: GAO Contact and Staff
                  Acknowledgments



Acknowledgments

                  Debra A. Draper, (202) 512-7114 or draperd@gao.gov
GAO Contact
                  In addition to the contact named above, Janina Austin, Assistant Director;
Staff             Jennie F. Apter; Julianne Flowers; Lisa Motley; Carmen Rivera-Lowitt;
Acknowledgments   C. Jenna Sondhelm; and Brienne Tierney made key contributions to this
                  report.




(290927)
                  Page 32                               GAO-12-483 VA Administrative Investigation Boards
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