	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 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. General Counsel said the department plans to maintain flexibility in its  AIB process. 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 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. 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. 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. 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. 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. 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. Administrative  investigation reports do  not provide  recommendations for  disciplinary action, but  may provide  recommendations for  other corrective actions,  such as employee  training.
Why GAO Did This Study

VA may use an AIB to determine the facts surrounding alleged employee misconduct or potential systemic deficiencies related to VA policies or procedures. AIBs do not determine corrective actions, such as individual disciplinary actions or procedural changes, but AIB investigation results, including evidence, may be used to inform such actions, making it critical for AIBs to be convened and conducted appropriately.
You expressed interest in the number of AIB investigations and their results. In this report, GAO examines (1) the process VA uses to convene and conduct AIB investigations, (2) the extent to which VA collects data on AIB investigations, and (3) how VA has used the results of its AIB investigations. GAO focused on AIB investigations conducted within VHA; reviewed VA documents, including policies and procedures, and VHA data on AIBs conducted during fiscal years 2009 through 2011; and interviewed VA officials from headquarters and four medical centers. To ensure data reliability, GAO reviewed VHAs methods to collect AIB data.

What GAO Found

The Department of Veterans Affairs (VA) has departmentwide policy and procedures for convening and conducting administrative investigation boards (AIB). The departments procedures contain requirements for convening and conducting AIB investigations, but according to VA officials, they also provide the flexibility to tailor an investigation to effectively meet diverse informational needs. For example, the VA official convening an AIB investigation is required to select AIB members who are impartial and objective, but has flexibility to vary the number of members appointed to each AIB based on the matter being investigated. VA is currently updating its AIB policy and procedures, but officials said the department plans to maintain flexibility in its AIB process.
VA does not collect and analyze aggregate data on AIB investigations, including data on the number of AIB investigations conducted, the types of matters investigated, and whether the matters were substantiated, or on any systemic deficiencies identified by AIBs. Having aggregate data could provide VA with valuable information to systematically gauge the extent to which matters investigated by AIBs may be occurring throughout VAs Veterans Health Administration (VHA) and to take corrective action, if needed, to reduce the likelihood of future occurrences. Without such data, VA is unable to adequately assess the causes or factors that may contribute to deficiencies occurring within its medical centers and health care networks. Information on AIB investigations is maintained by different offices across VA. For example, each medical center or network maintains information on each AIB investigation that it conducts. In response to GAOs request for AIB data, VHA administered a web-based survey that collected data from all its medical centers and networks on AIB investigations they reported conducting during fiscal years 2009 through 2011. Survey data showed that medical centers and networks conducted more than 1,100 investigations during this time period, and the types of matters investigated included allegations of inappropriate employee behavior involving patients and other employees; individual employee wrongdoing, such as theft and fraud; and systemic deficiencies. VHA officials told us that although it administered the web-based survey, the department has no plans to collect and analyze aggregate data on AIB investigations conducted within VHA.
VA has used the results of AIB investigations to inform corrective actions, but does not share information about improvements made that could have broader applicability. Specifically, VA has used the results of AIB investigations to inform systemic changes at the medical centers and networks where AIB investigations have been conducted. For example, VA has developed new policies and procedures for improving patient and employee safety and developed new training programs to expand employees knowledge of VA policies and procedures. However, VA does not share information about these improvements that may have relevance for other areas within VHA. Such information could be used to improve not only the quality of patient care provided, but also the efficiency of VHAs overall operations. For example, one medical center included in GAOs review implemented a tracking system to ensure surgical instruments are delivered promptly to the operating room and a checklist to ensure the availability of needed equipment prior to starting surgery.

What GAO Recommends

GAO recommends that VA establish processes to (1) collect and analyze aggregate data from AIB investigations conducted within VHA, and (2) share information about improvements that are implemented in response to the results of AIB investigations. VA concurred with these recommendations.