We recommend that the AOC develop a system of accountability that regularly assesses agency performance and that provides clarity in roles, as well as expected outcomes, to include: a) That the HCMD implement a case management system to ensure regular assessment and reporting of agency performance and trends with easily retrievable data; b) Improved training practices for the HCMD ELRB and AOC management staff; c) Updated guidance documents that clarify roles as well as expected outcomes; and d) Development of a knowledge management plan for all personnel involved in disciplinary process.