Please be advised that this administrative investigation guidebook is intended only as a training tool and guide. It is sincerely hoped that its contents will serve to facilitate the three (3) stages of the investigative process: Planning and preparation, fact gathering, and analysis and report writing. It should not be viewed as a formal policy nor should it be interpreted as such. Further, its contents do not necessarily apply to investigations conducted by the Office of Inspector General.
In investigation is a methodical process whereby the true facts about a situation or event are ascertained. An individual assigned to act as a member on a board of investigation normally has minimal investigative experience. This training handbook is intended to act as a guide to the investigative process. It will familiarize the board member with the components of the process and educate the board member in the skills necessary to achieve the board’s goals.
The Guidebook was originally developed and prepared by:
4. Preparing the Report of Investigation 42
1. ADMINISTRATIVE INVESTIGATIONS
Definition: An administrative investigation is an impartial inquiry, authorized by a facility director or higher level manager, to be conducted at any time deemed necessary, to determine facts and collect evidence in connection with a matter in which the VA is or may be a part in interest.
Authority: The Secretary of Veterans Affairs is responsible for assuring compliance with the laws governing veterans benefits. To assure that the intent of these laws is fulfilled, alleged irregularities in the administration of these laws, and violations of regulations and policies of the department, must be investigated. Though investigations may be ordered in any branch of the VA, provisions of the Department of Veterans Affairs Directive and Handbook 0700 (dated March 25, 2002) addresses when and in what circumstances formal boards of investigation may be required. A facility Director may also authorize an administrative investigation in cases other than those incidents stipulated by agency policy and guidelines.
Purpose of the Investigation: The purpose of an investigation is to compile factual information upon which to base conclusions, recommendations, actions, or decisions, where no action is supported. Investigations also identify areas for improvement and/or identify system problems, and can preserve and record recollections for future use. Administrative investigations are not appropriate forums for pursuing allegations of criminal conduct, which must be referred to the proper authority in accordance with VA Manual MP-1, Part I, Chapter 16.
Mandatory Investigations: Certain incidents require mandatory investigations in the VHA, and may prompt investigation in other branches of the VA. Where there are indications of criminal activity, the incidents should be referred to criminal investigators, before a decision is made to initiate an administrative investigation. Mandatory investigations include:
Alleged patient abuse: Acts against patients that involved physical, psychological, sexual, or verbal abuse. VA directives state that the "intent" of an employee to abuse is not a determinant as to whether an incident meets the categorization requirements for patient abuse. However, to sustain charges through arbitration or Merit Systems Protection Board (MSPB) hearings, intent often becomes an essential element. The patient's perception of how he was treated is an essential component of this determination; the fact that a given patient has limited or no cognitive ability does not exclude the possibility that abuse occurred.
Deaths: Deaths related to procedure, equipment malfunctions, or failure to diagnose;
Falls: Resulting in patient death;
Homicide: The death of a patient or staff member intentionally caused by a patient, or the death of a patient intentionally caused by another individual;
Medication errors: resulting in serious injury or death;
Missing Patients: found seriously injured or dead;
Patient or staff assaults: resulting in serious injury or death;
Patient injury (including medical device-related injury): resulting in serious injury or death;
Transfusion errors: Blood administered to the wrong patient; administered when not ordered; etc. that results in serious injury or death;
Sentinel errors: A sentinel event is an adverse event that results in the loss of life or limb or permanent loss of function. Examples of sentinel events: death resulting from medication error, an assault, or suicides by patients who received services from the medical facility within the prior 30 days;
Unplanned clinical occurrences: Unplanned clinical occurrences are occurrences that result in hospitalization or increased hospital stay for more than observation (including, but not limited to, injuries resulting from assaults against patients or staff, sexual assaults, suicide attempts, patient abuse, fires, falls, and medication errors); identified error that could have, but by chance did not, result in a sentinel event or an adverse event involving hospitalization or increased hospital stay for more than observation; unplanned clinical occurrences which may result from either acts of commission or omission, e.g., administration of the wrong medication or failure to make a timely diagnosis of cancer;
Potentially compensable events: Such as determined by the Chief of Staff.
Allegation or complaint regarding an organization having involvement with the VA;
Loss, theft, or destruction of government or personal property or funds, once declined for criminal investigation;
Incident or circumstance, that effects or impact upon the efficiency, reputation, or image of the Department, which the Director believes should be investigated.
Focused Reviews: The VHA Patient Safety Improvement Handbook (PSI) lists adverse events, which must be reported to the Veterans Integrated Service Network (VISN). A focused review will be conducted for each event. Adverse events are untoward incidents, therapeutic misadventures, iatrogenic injuries or unexpected occurrences that have negative consequences. Sentinel events and unplanned clinical occurrences are the major categories of adverse events. A sentinel event is an adverse event that results in the loss of life or limb or permanent loss of function. Examples of sentinel events: death resulting from medication error, an assault, or suicides by patients who received services from the medical facility within the prior 30 days, and adverse events deemed likely to trigger substantial negative publicity.
Peer Reviews: Peer reviews provide a practitioner with a timely opinion of a peer concerning:
The quality and appropriateness of medical care provided a patient when a medical center fails to meet pre-established quality assurance criteria, as the result of an unexpectedly adverse patient outcome; or
The Filing of an action in a court of competent jurisdiction against the Department of Veterans Affairs and/or a medical center as the result of an incidence of alleged medical malpractice (tort claim), or
As requested by competent authority.
Supervisory Fact Finding: Supervisory fact finding is used for initial gathering of facts associated with a particular incident, usually by collecting individual signed statements. These statements are not sworn. This process may indicate an administrative investigation may become necessary to resolve conflicting statements that will be relied on by the department for further action.
Potential Applications of an Administrative Investigation Work Product:
Administrative Tort Claims: Investigations that look into individual events may be used in investigations of tort claims filed against the agency.
Equal Employment Opportunity (EEO): May be used as evidence in litigation against the agency.
Disciplinary Boards: Administrative investigations may serve as evidence in support of major adverse actions taken against employees.
Merit Systems Protection Board (MSPB): May serve as evidence in support of adverse actions taken against employees
Workers Compensation: May be used as evidence for or against a lost time injury claim against the agency.
Disciplinary Actions: May serve as evidence in support of admonishments, reprimands, suspensions, or discharges.
State Licensing Boards: May serve as basis for reporting substandard patient care to an individuals licensing board.
Clinical Privileges: May serve as the basis for reduction or revocation of clinical privileges.
Criminal Proceedings Reduction and/or Revocation of Privileges