Office of Accountability and Whistleblower Protection (OAWP): As  required by the Department of Veterans Affairs Accountability and  Whistleblower Protection Act of 2017, OAWP will take on the  responsibility of, among other things, receiving whistle-blower  complaints. Employee Misconduct and Disciplinary- Action Data Are Hampered by Completeness and Data-Reliability Issues VA Collects Misconduct and Disciplinary-Action Data Using Fragmented Systems

As a federal agency, VA is required to report department-wide information  on certain disciplinary personnel actions to the Office of Personnel  Management (OPM). On the  basis of our review, the 12 information systems are not currently able to  communicate, or interoperate, with one another to provide a complete  picture of misconduct and disciplinary actions across VA.
Table 2 provides an overview of VA’s six information systems and  associated data files that collect partial misconduct and disciplinary-action  data that could potentially be shared with other systems. According to OHRM officials, VA’s information system for recording  adverse disciplinary actions—the Personnel and Accounting Integrated  Data (PAID) system—was not designed to track all misconduct cases. However, PAID does not  track comprehensive information on instances of misconduct such as the  offense, or the date of occurrence, and it does not include instances of  other types of disciplinary actions, such as admonishments or reprimands  that would not affect leave or salary, or result in a Standard Form 50. Our review of a generalizable sample of 544 misconduct case files (from  a universe of 23,622 files) associated with disciplinary actions that affect  pay from October 2009 through May 2015 revealed that VA officials did  not consistently adhere to VA’s policy for retaining files containing  evidence of misconduct. Our review found that  permanent-employee disciplinary files did not adhere to basic principles  outlined in VA Handbook 5021 and lacked evidence to demonstrate that  employees were adequately informed regarding their rights during the  adjudication procedure. In addition, our review of the 23 cases found instances in  which VA facility and program offices did not include sufficient  documentation for their findings, or provide a timely response to the OIG. Case examples of allegations reviewed, and subsequently closed, by the  VA OIG based on its evaluation of evidence provided by facility and  program offices in response to allegations of misconduct can be found in  appendix V.
As shown in table 12, VA facilities’ or program offices’ response letters,  which were sent to the OIG, included a point of contact for further  questions in 15 of the 21 OIG case referrals involving senior officials,  including the individual’s name and a means of contact (phone or e-mail). OAR Data Indicate That Senior Officials Involved in Substantiated Cases of Misconduct May Not Always Be Held Accountable

Our review of VA’s information systems that track misconduct involving  senior officials department-wide indicates that they may not always be  held accountable for misconduct. VA Has Procedures for Investigating Whistle-Blower Allegations of Misconduct, but Investigations Can Lead to Potential Conflicts of Interest

VA has procedures in place to ensure that allegations of misconduct are  investigated, but these procedures allow VA program offices or facilities  where a whistle-blower has reported misconduct to conduct the  investigation. Alternatively, an OIG official stated if allegations of misconduct  are received by the OIG, the OIG has the option of investigating the  allegation or exercising a “right of first refusal” whereby it refers  allegations of misconduct to VA facilities or program offices where the  allegation originated to complete an independent review and provide a  response to the OIG. Consequently, the OIG was unable to produce the investigative  documentation for these 82 disclosures. VA Data and Whistle- Blower Testimony Indicate That Retaliation May Be Occurring

		Individuals Who Reported Wrongdoing Are More Likely to Receive Disciplinary Action and Leave the Agency Than Their Peers

Our analysis of VA data shows that individuals who filed a disclosure of  misconduct with the OSC received disciplinary action, and left the  agency, at a higher rate than the peer average for the rest of VA. We  identified 135 disclosure cases that were received by the OSC between  calendar years 2010 and 2014 and were alleging misconduct. Our interviews with six VA whistle-blowers who claim to have been  retaliated against provided anecdotal evidence that retaliation may be  occurring. Whistle-blowers we spoke to alleged that managers in their  chain of command took a number of actions that were not traceable to  retaliate against the whistle-blowers after they reported misconduct. In addition, VA does not have oversight measures to ensure that all  allegations of misconduct referred by the OIG to facility and program  offices are investigated by an entity outside the control of the facility or  program office involved in the misconduct. Such guidance  should include direction and procedures on addressing blank data fields,  lack of personnel identifiers, and standardization among fields, and on  accessibility. (Recommendation 2)
The Secretary of Veterans Affairs should direct the Office of Human  Resource Management (OHRM) to routinely assess the extent to which  misconduct-related files and documents are retained consistently with  VA’s applicable documentation requirements. (Recommendation 6)
The Secretary of Veterans Affairs should direct the Office of  Accountability and Whistleblower Protection (OAWP) to review responses  submitted by facility or program offices to ensure evidence produced in  senior-official case referrals demonstrates that the six elements required  in VA Directive 0701 have been addressed. (Recommendation  11)
The Secretary of Veterans Affairs should develop oversight measures to  ensure all investigations referred to facility and program offices are  consistent with policy and reviewed by an official independent of and at  least one level above the individual involved in the allegation. Regarding our recommendations to the  Inspector General, the OIG concurred with one recommendation and  partially concurred with the other. Regarding VA’s comments, in its response to our first recommendation  that the Secretary develop and implement guidance to collect complete  and reliable misconduct and associated disciplinary-action data  department-wide, VA concurred and outlined steps it plans to take to  address our recommendations. On our second recommendation, that the Secretary direct applicable  facility and program offices to adhere to VA’s policies regarding  employee-misconduct adjudication documentation, VA concurred. VA also concurred with our third recommendation, that the Secretary  direct the Office of Human Resource Management (OHRM) to routinely  assess the extent to which misconduct-related files and documents are  retained. Given  VA’s comments, we have revised our draft recommendation to have the  Secretary of Veterans Affairs direct OAWP to issue written guidance on  how OAWP will verify that appropriate disciplinary action has been  implemented for all substantiated misconduct by senior officials. Appendix I: Objectives, Scope, and Methodology

Our objectives were to determine the extent to which the Department of  Veterans Affairs (VA) (1) collects reliable information associated with  employee misconduct and disciplinary actions that is accessible and  could be used to analyze misconduct department-wide; (2) retains  documentation that demonstrates VA adheres to its policies when  adjudicating cases of employee misconduct; (3) ensures allegations of  misconduct involving senior officials are reviewed in accordance with VA  investigative standards, and these officials are held accountable; (4) has  procedures to investigate whistle-blower allegations of misconduct; and  the extent to which (5) data and whistle-blower testimony indicate  whether retaliation for disclosing misconduct occurs at VA.
For the first objective, we obtained VA employee misconduct data from 12  information systems operated by various VA components covering  October 2009 through July 2017, where available. The lack of information did not allow for analysis of the types of  actions taken for each case.
Why GAO Did This Study

VA provides services and benefits to veterans through hospitals and other facilities nationwide. Misconduct by VA employees can have serious consequences for some veterans, including poor quality of care. GAO was asked to review employee misconduct across VA. This report reviews the extent to which VA (1) collects reliable information associated with employee misconduct and disciplinary actions, (2) adheres to documentation-retention procedures when adjudicating cases of employee misconduct, (3) ensures allegations of misconduct involving senior officials are reviewed according to VA investigative standards and these officials are held accountable, and (4) has procedures to investigate whistle-blower allegations of misconduct; and the extent to which (5) data and whistle-blower testimony indicate whether retaliation for disclosing misconduct occurs at VA.
GAO analyzed 12 information systems across VA to assess the reliability of misconduct data, examined a stratified random sample of 544 misconduct cases from 2009 through 2015, analyzed data and reviewed cases pertaining to senior officials involved in misconduct, reviewed procedures pertaining to whistle-blower investigations, and examined a nongeneralizable sample of whistle-blower disclosures from 2010 to 2014.

What GAO Found

The Department of Veterans Affairs (VA) collects data related to employee misconduct and disciplinary actions, but fragmentation and data-reliability issues impede department-wide analysis of those data. VA maintains six information systems that include partial data related to employee misconduct. For example, VA's Personnel and Accounting Integrated Data system collects information on disciplinary actions that affect employee leave and pay, but the system does not collect information on other types of disciplinary actions. The system also does not collect information such as the offense or date of occurrence. GAO also identified six other information systems that various VA administrations and program offices use to collect specific information regarding their respective employees' misconduct and disciplinary actions. GAO's analysis of all 12 information systems found data-reliability issues—such as missing data, lack of identifiers, and lack of standardization among fields. Without collecting reliable misconduct and disciplinary action data on all cases department-wide, VA's reporting and decision making on misconduct are impaired.
VA inconsistently adhered to its guidance for documentation retention when adjudicating misconduct allegations, based on GAO's review of a generalizable sample of 544 out of 23,622 misconduct case files associated with employee disciplinary actions affecting employee pay. GAO estimates that VA would not be able to account for approximately 1,800 case files. Further, GAO estimates that approximately 3,600 of the files did not contain required documentation that employees were adequately informed of their rights during adjudication procedures—such as their entitlement to be represented by an attorney. The absence of files and associated documentation suggests that individuals may not have always received fair and reasonable due process as allegations of misconduct were adjudicated. Nevertheless, VA's Office of Human Resource Management does not regularly assess the extent to which files and documentation are retained consistently with applicable requirements.
VA did not consistently ensure that allegations of misconduct involving senior officials were reviewed according to investigative standards and these officials were held accountable. For example, based on a review of 23 cases of alleged misconduct by senior officials that the VA Office of Inspector General (OIG) referred to VA facility and program offices for additional investigation, GAO found VA frequently did not include sufficient documentation for its findings, or provide a timely response to the OIG. In addition, VA was unable to produce any documentation used to close 2 cases. Further, OIG policy does not require the OIG to verify the completeness of investigations, which would help ensure that facility and program offices had met the requirements for investigating allegations of misconduct. Regarding senior officials, VA did not always take necessary measures to ensure they were held accountable for substantiated misconduct. As the figure below shows, GAO found that the disciplinary action proposed was not taken for 5 of 17 senior officials with substantiated misconduct.
As a result of June 2017 legislation, a new office within VA—the Office of Accountability and Whistleblower Protection—will be responsible for receiving and investigating allegations of misconduct involving senior officials.
VA has procedures for investigating whistle-blower complaints, but the procedures allow the program office or facility where a whistle-blower has reported misconduct to conduct the investigation. According to the OIG, it has the option of investigating allegations of misconduct, or exercising a “right of first refusal” whereby it refers allegations of misconduct to the VA facility or program office where the allegation originated. VA does not have oversight measures to ensure that all referred allegations of misconduct are investigated by an entity outside the control of the facility or program office involved in the misconduct, to ensure independence. As a result, GAO found instances where managers investigated themselves for misconduct, presenting a conflict of interest.
Data and whistle-blower testimony indicate that retaliation may have occurred at VA. As the table below shows, individuals who filed a disclosure of misconduct with the Office of Special Counsel (OSC) received disciplinary action at a much higher rate than the peer average for the rest of VA in fiscal years 2010–2014.
Additionally, GAO's interviews with six VA whistle-blowers who claim to have been retaliated against provided anecdotal evidence that retaliation may be occurring. These whistle-blowers alleged that managers in their chain of command took several untraceable actions to retaliate against the whistle-blowers, such as being denied access to computer equipment necessary to complete assignments.

What GAO Recommends

GAO makes numerous recommendations to VA to help enhance its ability to address misconduct issues (several of the recommendations are detailed on the following page).
GAO recommends, among other things, that the Secretary of Veterans Affairs
develop and implement guidance to collect complete and reliable misconduct and disciplinary-action data department-wide; such guidance should include direction and procedures on addressing blank fields, lack of personnel identifiers, and standardization among fields;
direct applicable facility and program offices to adhere to VA's policies regarding misconduct adjudication documentation;
direct the Office of Human Resource Management to routinely assess the extent to which misconduct-related files and documents are retained consistently with applicable requirements;
direct the Office of Accountability and Whistleblower Protection (OAWP) to review responses submitted by facility or program offices to ensure evidence produced in senior-official case referrals demonstrates that the required elements have been addressed;
direct OAWP to issue written guidance on how OAWP will verify whether appropriate disciplinary action has been implemented; and
develop procedures to ensure (1) whistle-blower investigations are reviewed by an official independent of and at least one level above the individual involved in the allegation, and (2) VA employees who report wrongdoing are treated fairly and protected against retaliation.
GAO also recommends, among other things, that the VA OIG
revise its policy and require verification of evidence produced in senior-official case referrals.
VA concurred with nine recommendations and partially concurred with five. In response, GAO modified three of the recommendations. The VA OIG concurred with one recommendation and partially concurred with the other. GAO continues to believe that both are warranted.