GAO: VA Disability Benefits: Board of Veterans’ Appeals Should Address Gaps in Its Quality Assurance Process

Why GAO Did This Study

Each year, the Board adjudicates thousands of cases in which a veteran was dissatisfied with the Department of Veterans Affairs’ (VA) initial decision on their claim for benefits. However, researchers and Congress have raised questions about how the Board ensures the quality of its adjudications.

GAO was asked to review the Board’s QA process. This testimony examines (1) how the Board assures and measures the quality of its adjudicative decisions, and (2) the extent to which the Board builds and uses evidence to assess its QA process.

GAO reviewed relevant federal laws and Board documents. GAO analyzed QA data provided by the Board for fiscal years 2019 through 2022 and assessed its reliability. GAO also reviewed relevant quality assurance literature and interviewed VA officials, attorneys, VLJs, and subject matter experts, including researchers and veterans service organizations. GAO also conducted group discussions with randomly selected Board decision-writing attorneys and VLJs.

What GAO Found

The Board of Veterans’ Appeals (Board) has a quality assurance (QA) process and a related accuracy measure for its decisions. Specifically, its QA process involves: 1) checking a random sample of draft decisions for certain types of Board-defined errors each month through its case review process; and 2) monitoring outcomes of Board decisions that were further appealed to the U.S. Court of Appeals for Veterans Claims (CAVC). The Board uses results from these activities to provide various interventions, such as individual feedback to veteran law judges (VLJs) or training. The Board also calculates and publishes an accuracy rate that represents error-free adjudications. However, GAO found shortfalls in the Board’s process for calculating this measure. Contrary to federal internal control standards, GAO found that the Board did not have:

1. written policies or procedures for calculating its accuracy rate or managing case review error data, or
2. checks on its accuracy rate calculation.

As a result, the Board lost data and GAO could not verify accuracy rates provided by the Board in 2 of 4 fiscal years. Until the Board develops written policies and procedures, the Board will likely continue to have difficulty supporting the accuracy of its publicly reported measure.

GAO found gaps in the Board’s efforts to build and use evidence—such as a lack of data and analysis—to assess its QA process and related activities. GAO analyses of CAVC and Board data show that over the past 3 fiscal years, CAVC remanded (sent back) about 80 percent of appealed Board decisions, often because CAVC found the Board’s explanation of its findings to be inadequate. However, GAO found that the Board lacked evidence to better understand and address these and other issues and set priorities to help improve its QA process. Specifically:

• Board officials told GAO it has no comprehensive, written plan outlining how it will accomplish the mission and goals of its QA process.
• Board officials told GAO they had not fully analyzed trends or underlying causes of the most common Board-identified errors or CAVC remands.
• The Board has not systematically or comprehensively built or used evidence to better understand and improve its interventions, such as collecting feedback about training.
• The Board does not assess VLJ decisions for consistency, such as whether common misunderstandings of policy or law exist in decisions.

GAO’s prior work has identified key practices for evidence-based decision-making. These practices involve building and assessing evidence and using it to foster a culture of continuous improvement. Absent such a process and a plan to guide it, the Board is not positioned to fully understand and address underlying causes of the most common errors and remands or understand consistency—evidence which is needed to target and implement effective interventions and foster continuous improvement of its QA efforts.

Recommendations

GAO is making four recommendations, including that the Board develop policies for calculating its accuracy rate; develop and implement an evidence-based decision-making process for its QA efforts; and study decision-making consistency. The Board generally agreed with three recommendations and disagreed with the fourth about consistency. GAO continues to believe that the recommendation is valid as discussed in the report.

Details here.

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