VA Police:

Actions Needed to Improve Data Completeness and Accuracy on Use of Force Incidents at Medical Centers

GAO-20-599: Published: Sep 8, 2020. Publicly Released: Sep 8, 2020.

Multimedia:

  • PODCAST: VA Police Use of Force at Medical Centers

    The Veterans Health Administration manages medical centers that provide millions of veterans with necessary care like mental health services, critical care, and physical therapy. VA police are staffed to these facilities, and are responsible for protecting patients, staff, visitors, and property. However, there have been complaints about the VA police’s use of force. We talk to Gretta Goodwin—an expert in law enforcement and a director in our Homeland Security and Justice team—about her recent report on VA police and use of force incidents at medical centers.

    View the transcript

Additional Materials:

Contact:

Gretta L. Goodwin
(202) 512-8777
goodwing@gao.gov

 

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

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

The 5 categories of force from least force to lethal force are: officer presence, verbal direction, empty hand control, intermediate weapon, and deadly force

Multimedia:

  • PODCAST: VA Police Use of Force at Medical Centers

    The Veterans Health Administration manages medical centers that provide millions of veterans with necessary care like mental health services, critical care, and physical therapy. VA police are staffed to these facilities, and are responsible for protecting patients, staff, visitors, and property. However, there have been complaints about the VA police’s use of force. We talk to Gretta Goodwin—an expert in law enforcement and a director in our Homeland Security and Justice team—about her recent report on VA police and use of force incidents at medical centers.

    View the transcript

Additional Materials:

Contact:

Gretta L. Goodwin
(202) 512-8777
goodwing@gao.gov

 

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

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.

What GAO Recommends

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.

For more information, contact Gretta L. Goodwin at (202) 512-8777 or goodwing@gao.gov.

Recommendations for Executive Action

  1. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: 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)

    Agency Affected: Department of Veterans Affairs

  2. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: 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)

    Agency Affected: Department of Veterans Affairs

  3. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: 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)

    Agency Affected: Department of Veterans Affairs

  4. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: 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)

    Agency Affected: Department of Veterans Affairs

  5. Status: Open

    Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

    Recommendation: 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)

    Agency Affected: Department of Veterans Affairs

 

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