Recommendation: The Under Secretary for Health should, in collaboration with relevant VBA and NCA officials, improve its process to accurately identify all on-campus veteran deaths by suicide by ensuring that it uses updated information and corroborates information with VA facility officials. (Recommendation 1)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should expand the policy requirement for a root cause analysis to include all cases of on-campus veteran death by suicide, regardless of whether the veterans involved were enrolled in VHA health care services at the time of their death. (Recommendation 2)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Under Secretary for Health should direct the Office of Mental Health and Suicide Prevention to expand its analyses of on-campus veteran deaths by suicide to include all relevant information VA collects for these incidents, such as data from root causes analyses and information collected through the Behavioral Health Autopsy Program. (Recommendation 3)

Agency: Department of Veterans Affairs
Status: Open

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

Recommendation: The Assistant Secretary of DOE's Office of Environmental Management should direct RL to conduct a root cause analysis to identify any programmatic causes that may have led to the collapse of PUREX Tunnel 1. (Recommendation 1)

Agency: Department of Energy: Office of the Assistant Secretary for Environmental Management: Environmental Management Consolidated Business Center
Status: Open

Comments: DOE concurs with this recommendations and has agreed to conduct a root cause analysis examining the programmatic cause leading to the Hanford PUREX tunnel collapse. In DOE's October 2020 Audit Report regarding the implementation of recommendations in our report, DOE states that the Office of Environmental Management is taking action to implement this recommendation, but that action is still insufficient to satisfy the recommendation.

Recommendation: The Secretary of Energy should ensure DOE headquarters offices responsible for the oversight of EM sites' field offices conduct an assessment of RL's management and oversight of the Hanford Site contractor's surveillance and maintenance activity for contaminated excess facilities. Based on the results of this assessment, DOE headquarters offices should consider whether such assessments should be conducted on a periodic basis. (Recommendation 3)

Agency: Department of Energy: Office of the Secretary
Status: Open

Comments: DOE concurs with this recommendation and the Office of Environmental Management agreed to conduct an assessment, in coordination with headquarters oversight offices, of the Richland Operations Office's management and oversight of the Hanford Site contractor's surveillance and maintenance activities for contaminated excess facilities. In DOE's October 2020 Audit Report regarding the implementation of recommendations in our report, DOE states that the Office of Environmental Management is taking action to implement this recommendation, but that action is still insufficient to satisfy the recommendation.

Recommendation: 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, the Secretary of Veterans Affairs should direct the Under Secretary for Health to 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.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation and noted that it would explore any new processes for collecting and analyzing aggregate data from AIB investigations. In September 2015, VA reported that VHA had established a workgroup to review this recommendation and also had created a database to collect and analyze aggregate data from AIB investigations into senior executive service (SES) employees. Based on the results of an informal survey as well as its analysis of AIB data for SES employees, VA stated that central office oversight of the AIB process is not needed and that several systems already in place capture data on system-wide risks (e.g., sexual assault reporting, Issue Briefs, and National Center for Patient Safety Patient Safety Information System Program). In December 2016, VA reported that it convened another workgroup in September 2016 to re-examine this recommendation. That workgroup ultimately determined that oversight of AIBs at the national level continues to not be warranted. In April 2018, VA reported that it does not intend to take any further action in response to this recommendation, and it reaffirmed this position in March 2020.

Recommendation: 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, the Secretary of Veterans Affairs should direct the Under Secretary for Health to 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.

Agency: Department of Veterans Affairs
Status: Open

Comments: VA concurred with this recommendation and noted that it would explore any new processes for collecting and analyzing aggregate data from AIB investigations. In September 2015, VA reported that it had established a working group to review this recommendation. In addition, VA also had created a database to collect and analyze aggregate data from AIB investigations into senior executive service (SES) employees to identify trends and address deficiencies. Based on an informal survey of its working group and its analysis of AIB data for SES employees, VA stated that VISNs currently provide adequate oversight of the AIB process and notify VA central office when appropriate and that a comprehensive review of its AIB data for SES employees identified no system-wide issues. Ultimately, VA stated that it could not justify the resources needed to implement this recommendation. In April 2018, VA reported that it does not intend to take any further action in response to this recommendation, and it reaffirmed this position in March 2020.