VA Police: Actions Needed to Improve Data Completeness and Accuracy on Use of Force Incidents at Medical Centers
Fast Facts
About 5,000 police officers at the Department of Veterans Affairs are responsible for securing and protecting 138 VA medical centers nationwide. We examined VA policies and data on the use of force.
VA police officers record incidents in a central database, but we found this data is not complete or accurate enough to determine trends in use of force at these centers. For example, 176 of 1,214 records we reviewed did not include the specific categories of force used. Also, investigations at the local level of possible misuse of force were not always tracked by VA headquarters.
We made 5 recommendations to address these and other issues.
The Five Categories of Force on VA's Use of Force Continuum
Highlights
What GAO Found
The Department of Veterans Affairs' (VA) policy on use of force states that police officers must use the minimal level of force that is reasonably necessary to gain control of a situation and should only utilize physical control methods on an individual when the force is justified by the individual's actions. To guide officers, VA developed a Use of Force Continuum Scale to define and clarify the categories of force that can be used.
Categories of Force on the VA’s Use of Force Continuum Scale
According to VA policy, all police officers must receive training on the VA's use of force policy when hired and biannually thereafter. Officers are trained—through classroom lectures and scenarios that emphasize effective communication techniques—to use the minimal level of force to deescalate a situation.
Officers record use of force incidents electronically and the chief of police decides which, if any, use of force incidents need to be investigated in accordance with VA guidance. Chiefs of Police at the six facilities GAO visited conducted investigations in a similar manner, by reviewing evidence and comparing an officer's action with the VA's use of force policy to determine whether actions were justified. While most investigations are conducted at the local level, VA headquarters may also run investigations for certain incidents, such as when it receives a complaint against an officer.
VA police officers record incidents in a database, Report Executive, but GAO's analysis indicates that VA data on use of force incidents are not sufficiently complete and accurate for reporting numbers or trends at medical centers nationwide. For example, GAO found that 176 out of 1,214 use of force incident reports did not include the specific type of force used. Further, Report Executive does not track incidents by individual medical centers. By addressing these limitations, VA can more effectively monitor use of force trends by type of force or medical facility, among other variables, to understand the VA's use of force incidents nationwide. GAO also found that VA does not systematically collect or analyze use of force investigation findings from local medical centers, limiting its ability to provide effective oversight. Specifically, there is no policy requiring Chiefs of Police to submit all investigations on use of force to VA headquarters, and VA does not have a database designed to collect and analyze data on use of force investigations. Collecting and analyzing such data nationwide would allow VA to better assess the impact of its deescalation policies and improve the agency's oversight efforts.
Why GAO Did This Study
About 5,000 VA police officers are responsible for securing and protecting 138 VA medical centers across the country. These officers are authorized to investigate crimes, make arrests, and carry firearms.
The Dr. Chris Kirkpatrick Whistleblower Protection Act of 2017 included a provision that GAO assess aspects of the VA police services. This report addresses (1) what the VA's policies are on the use of force by police officers at medical centers, and what training officers receive on the use of force; (2) how VA records and investigates use of force incidents at medical centers; and (3) the extent to which VA sufficiently collects and analyzes use of force data at medical centers.
To address these objectives, GAO reviewed VA policies, procedures, and training materials on the use of force and interviewed VA officials at headquarters and six local medical centers, selected to represent varying size and locations. GAO reviewed VA data on use of force incidents recorded from May 10, 2019, through May 10, 2020—the most recent full year data were available.
Recommendations
GAO is making five recommendations, including that VA improve the completeness and accuracy of its use of force data; implement a tool to analyze use of force incidents at medical centers nationwide; ensure that medical centers submit all use of force investigations to VA headquarters; and analyze the use of force investigation data. The VA concurred with each of GAO's recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Veterans Affairs | The Secretary of VA should improve the completeness and accuracy of use of force data in Report Executive by addressing (1) incomplete categorization of the type of force used, (2) inaccurate data on the highest level of force used, and (3) the potential for duplicate data entries. (Recommendation 1) |
The VA agreed with the recommendation and stated it would take steps to modify the Report Executive database--the VA Police's Record Management System that stores use of force data--to ensure use of force information was recorded completely and accurately. In March 2021, the VA stated that the Report Executive system was updated to include a mandatory field for officers to enter the type of force used in an incident before allowing the officer to continue with the incident report. In addition, the VA stated that, based on GAO feedback, the Report Executive system was modified to include a clearer and more accurate set of options for officers to select the type of force used in an incident. Finally, the VA stated that facility-level police leadership would place more emphasis on training officer on how to fill out use of force incident reports, and would utilize the incident report review and approval process to ensure there were no duplicate reports logged in the system. In July 2021, the VA provided documentation of the changes made to the Report Executive system, including revising and streamlining the categories officers use to report use of force incidents and to identify the highest level of force used. As a result, this recommendation is closed as implemented.
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| Department of Veterans Affairs | The Secretary of VA should implement plans to include analytical features in Report Executive that will position the agency to analyze use of force data at VA medical centers nationwide, including by officer; type of force used; and facility, among other variables. (Recommendation 2) |
The VA agreed with the recommendation and stated the agency would work with the Report Executive vendor to add further analytical capabilities to the system. In March 2021, the VA stated they had added the capability to sort use of force data by the 18 geographic regions called the Veterans Integrated Service Network. In July 2021, the VA provided documentation of the updated Report Executive system to demonstrate the database allows for analysis of use of force incidents by officer, type of force used, and facility, among other variables. As a result, this recommendation is closed as implemented.
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| Department of Veterans Affairs | The Secretary of VA should ensure that medical centers submit records of all locally initiated use of force investigations and any resulting disciplinary action to VA headquarters office(s) with responsibility for police oversight. (Recommendation 3) |
The VA agreed with the recommendation and stated the agency would take steps to ensure the results of disciplinary actions taken against officers for use of force related incidents would be forwarded to the VA headquarters office with oversight responsibility over VA police. In March 2021, the VA stated that the Veterans Health Administration (VHA) has created an electronic database within the Office of the VHA Senior Security Officer to store police misconduct investigations, and that these investigations are shared between VHA and the Office of Security and Law Enforcement as they occur. In July 2021, the VA provided documentation of its revised Standard Operating Procedures requiring VA police units to submit all reportable use of force incidents to the VA Office of Security and Law Enforcement within 24 hours. Reportable incidents include those involving a weapon, using hard empty-hand control techniques, or resulting in an injury or an individual requesting medical attention. The use of force notification is entered into an electronic database and sent to the Office of Security and Law Enforcement and the Office of the VHA Senior Security Officer. As a result, this recommendation is closed as implemented.
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| Department of Veterans Affairs | The Secretary of VA should implement plans for obtaining a quality database to collect all locally initiated use of force investigations at medical centers. (Recommendation 4) |
The VA agreed with the recommendation and stated the agency would work to identify and procure a database capable of tracking and monitoring use of force investigations. In March 2021, the VA completed market research to identify 3 suitable database solutions capable of tracking and analyzing VA police use of force incidents. In July 2021, the VA conducted pilots on two systems being tested by officials responsible for overseeing VA police, and that the Office of Security and Law Enforcement and the Veterans Health Administration were developing timeframes for procuring a fully functional, standalone Internal Affairs system to track and monitor police use of force across the VA. In September 2022, the VA awarded a contract to procure an Internal Affairs database capable of storing information on use of force incidents. In February 2023, the VA told us it planned to start using the system once they trained officers on how to use the database, and once the contractor makes database modifications to meet VA Police requirements. On October 1, 2023, VA implemented the new records management system that enables reporting and tracking of use of force incidents for VA Police. VA Police Standard Operating Procedures require officers to enter all use of force incidents into the records management system. As a result, this recommendation is closed as implemented.
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| Department of Veterans Affairs | Once positioned to do so, the Secretary of VA should analyze all use of force investigations and any resulting disciplinary action by facility; officer; and outcome, among other variables. (Recommendation 5) |
The VA agreed with the recommendation and stated the agency would take steps to analyze use of force data once a suitable database solution was obtained. In March 2021, the VA stated it had plans to analyze data on officers' use of force. In the short term, VA stated it would develop a dashboard to track and monitor prosecution dispositions and police administrative personnel matters. The dashboard was anticipated to be implemented in March 2021. Further, the VA stated the agency planned to acquire an Internal Affairs system to track and monitor police use of force across the VA (referenced in our update on recommendation 4). In July 2021, the VA provided documentation of its dashboard (called Law Enforcement Oversight Tracking) and a sample analysis of use of force incidents by officer, facility, and any resulting disciplinary action, as applicable, among other variables. As such, the agency is well-positioned to analyze use of force investigations and any resulting disciplinary actions once it obtains a fully functional, standalone Internal Affairs system. In February 2023, VA told us that in September 2022 the department awarded a contract to procure an Internal Affairs database capable of storing information on use of force incidents. As of October 1, 2023, VA is using the records stored in its records management system to analyze all use of force incidents, investigations and any resulting disciplinary action by facility, officer, and outcome, among other variables. As a result, this recommendation is closed as implemented.
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