[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]




        ADDRESSING CONTINUED WHISTLEBLOWER RETALIATION WITHIN VA

=======================================================================

                                HEARING

                               before the

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATION

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                               __________

                         MONDAY, APRIL 13, 2015

                               __________

                           Serial No. 114-13

                               __________

       Printed for the use of the Committee on Veterans' Affairs



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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               CORRINE BROWN, Florida, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         MARK TAKANO, California
DAVID P. ROE, Tennessee              JULIA BROWNLEY, California
DAN BENISHEK, Michigan               DINA TITUS, Nevada
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana             KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana             TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York                 JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American 
    Samoa
MIKE BOST, Illinois
                       Jon Towers, Staff Director
                Don Phillips, Democratic Staff Director

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATION

                    MIKE COFFMAN, Colorado, Chairman

DOUG LAMBORN, Colorado               ANN M. KUSTER, New Hampshire, 
DAVID P. ROE, Tennessee                  Ranking Member
DAN BENISHEK, Michigan               BETO O'ROURKE, Texas
TIM HUELSKAMP, Kansas                KATHLEEN RICE, New York
JACKIE WALORSKI, Indiana             TIMOTHY J. WALZ, Minnesota

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hearing records of the Committee on Veterans' Affairs are also 
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                            C O N T E N T S

                              ----------                              

                         Monday, April 13, 2015

                                                                   Page

Addressing Continued Whistleblower Retaliation Within VA.........     1

                           OPENING STATEMENTS

Mike Coffman, Chairman...........................................     1
    Prepared Statement...........................................    38
Ann Kuster, Ranking Member.......................................     2
    Prepared Statement...........................................    39

                               WITNESSES

Ms. Meghan Flanz, Director, Office of Accountability Review, 
  Department of Veterans Affairs.................................     4
    Prepared Statement...........................................    40
Hon. Carolyn Lerner, Special Counsel, Office of Special Counsel..     6
    Prepared Statement...........................................    42
Dr. Christian Head, Associate Director-Chief of Staff--Legal and 
  Quality Assurance, Greater Los Angeles VA Healthcare System....     7
    Prepared Statement...........................................    46
Dr. Maryann Hooker, Neurologist, Wilmington VA Medical Center, 
  President, Local 342, American Federation of Government 
  Employees......................................................     9
    Prepared Statement...........................................    51
Mr. Richard Tremaine, MBA, Associate Director, VA Central Alabama 
  Healthcare System..............................................    10
    Prepared Statement...........................................    53

                             FOR THE RECORD

Project on Government Oversight..................................    54
Kimberly Hughes Statement........................................    57

                        QUESTIONS FOR THE RECORD

Questions, From: Chairman Mike Coffman...........................    60
Questions, From: Chairman Mike Coffman and Responses: From: VA...    61

 
        ADDRESSING CONTINUED WHISTLEBLOWER RETALIATION WITHIN VA

                              ----------                              


                         Monday, April 13, 2015

                  House of Representatives,
                    Committee on Veterans' Affairs,
              Subcommittee on Oversight and Investigations,
                                                   Washington, D.C.
    The subcommittee met, pursuant to notice, at 4:00 p.m., in 
Room 334, Cannon House Office Building, Hon. Mike Coffman 
[chairman of the subcommittee] presiding.
    Present:  Representatives Coffman, Roe, Benishek, 
Huelskamp, Walorski, Kuster, Rice, and Walz.
    Also Present: Representative Roby.

           OPENING STATEMENT OF CHAIRMAN MIKE COFFMAN

    Mr. Coffman. Good afternoon. This hearing will come to 
order. I want to welcome everyone to today's hearing, titled 
Addressing Continued Whistleblower Retaliation Within VA.
    I would like to ask unanimous consent that Hon. Martha Roby 
from the State of Alabama be allowed to join us at the dais as 
she has been very active in this case--in the case of one of 
our witnesses here today. Seeing no objection.
    Additionally, I would like to ask unanimous consent that 
three statements be entered into the hearing record, two from 
whistleblowers and one from the Project on Government 
Oversight. Hearing no objection, so ordered.
    Mr. Coffman. The hearing will focus on the treatment of 
whistleblowers within the Department of Defense--I'm sorry--
within the Department of Veterans Affairs, particularly the 
types and levels of retaliation they experience when reporting 
problems. This will serve as a follow-up to the hearing 
conducted by the committee on July--in July 2014, where we will 
address what progress the Department has made since then to 
correct its retaliatory culture and where VA has failed to 
protect conscientious employees who seek to improve services 
for our Nation's veterans.
    The three whistleblowers we will hear from today come from 
VA facilities across the country. The hostility they received 
for their conscientious behavior shows that the retaliatory 
culture, where whistleblowers are castigated for bringing 
problems to light, is still very alive and well in the 
Department of Veterans Affairs.
    The truth of the matter is that Congress needs 
whistleblowers within Federal agencies to help identify 
problems on the ground in order to remain properly informed for 
the development of effective legislation. For example, the 
national wait time scandal that this committee revealed at a 
hearing just over a year ago, which resulted in the Secretary 
of the Department resigning, simply would not have occurred 
without responsible VA employees stepping forward to fix 
problems. In the years since that scandal originally came to 
light, a new Secretary has come to the Department and he has 
stated that one of his primary missions is to end whistleblower 
retaliation within VA.
    The Congress also passed legislation that makes it easier 
for the Secretary to fire poor performing and bad acting senior 
executive service employees. And who, in some cases, perpetuate 
and encourage retaliatory behavior.
    Despite these efforts, retaliation is still a popular means 
used by certain unethical VA employees to prevent positive 
change and maintain the status quo within the Department. In 
January, full committee Chairman Jeff Miller introduced 
legislation, which I cosponsored, that would improve 
protections provided to whistleblowers within VA. It will also 
discourage supervisors and other managerial employees from 
attempting to retaliate against whistleblowers by imposing more 
strenuous penalties for engaging in retaliation, including 
suspension, termination, and loss of bonuses.
    It is very simple. If you retaliate against or stifle 
employees who are trying to improve VA, for our Nation's 
veterans, you should not be working for VA and you certainly 
should not receive a bonus for your despicable actions. To that 
end, I encourage Members to join with numerous VSOs and 
whistleblower protection groups in support of H.R. 571, the 
Veterans Affairs Retaliation Prevention Act.
    Along with the whistleblowers here today, we will hear from 
the Office of Special Counsel regarding the efforts VA has made 
since our last hearing to improve its treatment of 
whistleblowers and where improvements remain absent and needed.
    I was very pleased to learn that the Office of Special 
Counsel recently took action on behalf of a whistleblower in 
the VA from the Eastern Colorado healthcare System. This 
employee was removed from her nursing duties and assigned to a 
windowless basement after reporting the misconduct of a 
coworker. Thanks to the efforts of OSC, this whistleblower has 
returned to her nursing duties at another clinic while her 
reprisal claims are being investigated.
    Representatives of VA will also be here to address why 
whistleblowers continue to have their livelihoods jeopardized 
for attempting to make VA a better service provider for our 
Nation's veterans. I look forward to the discussion we will 
have here today on this important issue.
    With that, I now yield to Ranking Member Kuster for any 
opening remarks she may have.

    [The prepared statement of Chairman Mike Coffman appears in 
the Appendix]

         OPENING STATEMENT OF RANKING MEMBER ANN KUSTER

    Ms. Kuster. Thank you, Mr. Chairman. And thank you to our 
witnesses for being with us today.
    This afternoon, the Subcommittee on Oversight and 
Investigation is holding a follow-up hearing to the hearing 
that our full committee held last July. I believe that some of 
the most effective hearings this subcommittee holds are follow-
up hearings. They enable us to examine progress that has been 
made and current problems that still exist at the VA. That is 
the core of our work here, to identify problems and work 
together to fix them and ensure the highest quality of care is 
being delivered to every veteran.
    Today's hearing will focus on VA's treatment of 
whistleblowers who play a crucial role in ensuring the VA is 
held accountable for providing quality care for our Nation's 
veterans. Whistleblowers were instrumental in helping this 
committee uncover the wrongdoing in Phoenix, Arizona, which 
helped inform our drafting of the Veterans Access Choice 
Accountability Act of 2014. We must ensure that no one is 
afraid to come forward to report instances of mismanagement or 
wrongdoing that hinders our veterans' ability to receive care.
    In terms of the Department of Veterans Affairs and its 
treatment of whistleblowers, a great deal of progress has been 
made. VA has established the Office of Accountability Review 
and has reorganized the Office of the Medical Inspector. The VA 
is also the first Cabinet-level agency to satisfy the 
requirements for the Office of Special Counsel's Whistleblowers 
Certification Program. In addition, the VA and the OSC have 
implemented an expedited review process for whistleblower 
retaliation claims. I am pleased to hear that the VA has taken 
these steps moving forward. However, there are still too many 
problems that exist regarding how the VA treats and handles 
whistleblowers.
    OSC is responsible for whistleblower complaints from all 
across the Federal Government, yet it estimates that 40 
percent--40 percent, close to half of its incoming cases in 
2015, will be filed by VA employees. OSC reports that the 
number of new whistleblower cases that VA employees remains 
``overwhelming'', and that its monthly intake of new VA 
whistleblower cases remains high, at a rate of nearly 150 
percent above historic levels. According to OSC, these alarming 
cases include disclosures of ``waste, fraud, abuse and threats 
to the health and safety of our veterans.''
    The large number of complaints received from VA employees 
is, to some extent, a reflection of the size of the VA, but it 
also raises serious red flags as to the continuing problems 
that are systemic throughout the VA and its treatment of VA 
employees.
    The OSC testimony highlights some troubling concerns that 
the VA sometimes investigates the whistleblowers themselves 
rather than investigating allegations raised by those 
whistleblowers. The OSC also references several cases where the 
medical records of whistleblowers were improperly and 
unlawfully accessed in what seems to be attempts to discredit 
some whistleblowers. As a New York Times article last year 
outlined, there is a ``culture of silence and intimidation and 
a history of retaliation at the VA.''
    According to the whistleblowers testifying before us this 
afternoon, this is still the case today. They will testify 
about this environment of intimidation and retaliation and the 
use of sham peer reviews and investigations in order to silence 
whistleblowers.
    As I stated before, I believe that the VA has made some 
progress in this area, but clearly more remains to be done. 
VA's culture of retaliation and intimidation did not happen 
overnight, but it is the culmination of decades of problems 
that are deeply ingrained in the VA system. We must also not 
forget that the vast majority of VA employees are involved in 
healthcare, an industry that also is seen by many to be 
intolerant of whistleblowers. This culture of intimidation and 
fear for VA employees cannot be changed overnight. But for the 
sake of our veterans and the sake of ensuring that the VA is 
providing the highest quality of care, this culture must be 
changed.
    Many of the VA's problems that we will discuss today 
highlight the VA's lack of accountability and the absence of 
collaborative spirit between VA leadership and VA employees in 
order to seriously address whistleblower complaints. This 
afternoon, let us begin the process of identifying what steps 
the VA needs to take going forward as the VA works toward the 
Secretary's goal of ``sustainable accountability.''
    I am hopeful that this subcommittee can continue to work in 
a bipartisan fashion to find ways to assist the VA in its 
monumental task of changing this longstanding culture and 
reform the manner in which whistleblowers are treated, by 
improving the process whereby all VA employees are working 
toward the common goal of helping and serving our veterans.
    Mr. Chairman, again I thank you for holding this follow-up 
hearing. And before I yield back, I want to take a moment and 
thank our whistleblowers for appearing before us today. It 
takes real courage to put your careers at risk for coming 
forward and calling attention to these problems and concerns. 
It is my hope that we move forward creating a culture at the VA 
that welcomes whistleblowers and acknowledges your importance 
in better serving our veterans. I hope that, in the months and 
years ahead, the VA will be known as an organization that 
welcomes and encourages all employees to work together to solve 
problems.
    And I yield back.

    [The prepared statement of Ms. Ann Kuster appears in the 
Appendix]

    Mr. Coffman. Thank you, Ranking Member Kuster.
    Mr. Coffman. I ask all members waive their opening remarks 
as per this committee's custom.
    With that, I invite the first and only panel to the witness 
table, that is seated at the witness table. On the panel, we 
will hear from Ms. Meghan Flanz, Director of the VA's Office of 
Accountability Review; the Hon. Carolyn Lerner, Special 
Counsel; Dr. Christian Head, M.D., Associate Director, Chief of 
Staff, Legal and Quality Assurance for the Greater Los Angeles 
VA healthcare System; Dr. Maryann Hooker, M.D., Neurologist and 
President of AFGE Local 342 at the Wilmington VA Medical 
Center; and Mr. Richard Tremaine, Associate Director of the VA 
Central Alabama Healthcare System. All of your complete written 
statements will be made part of the hearing record.
    Ms. Flanz, you are now recognized for 5 minutes.

                   STATEMENT OF MEGHAN FLANZ

    Ms. Flanz. Thank you, Chairman Coffman, Ranking Member 
Kuster, and members of the committee. I appreciate the 
invitation today to present an update on the Department's 
activities related to whistleblower protection. VA exists to 
serve veterans. That service takes place through interactions 
between veterans and frontline VA employees: Doctors and 
nurses, claims processors, cemetery workers, and countless 
others upon whom VA depends to serve veterans with the dignity, 
compassion, and dedication they deserve.
    We depend on those same employees to have the moral courage 
to help us serve veterans and taxpayers better by helping to 
make our processes and policies better, safer, more effective, 
and more efficient. The Department's responsibility to protect 
whistleblowers is an integral part of our obligation to provide 
safe, high quality healthcare and other benefits to veterans in 
legally compliant and fiscally responsible ways.
    It is important to keep in mind that the underlying purpose 
of the whistleblower protection rules is to encourage candid 
disclosure of information, so problems can be quickly 
identified and corrected. VA is fully committed to correcting 
problems in VA programs and to ensuring fair treatment for 
employees who bring problems to light.
    Secretary MacDonald talks frequently about his vision of 
sustainable accountability, which he describes as a workplace 
culture in which VA leaders provide the guidance and resources 
employees need to successfully serve veterans. And employees 
freely and safely inform leaders when challenges hinder their 
ability to succeed. We need a work environment in which all 
participants, from frontline staff and first-line supervisors 
to top VA officials, freely share what they know, whether good 
news or bad, for the benefit of veterans and as good stewards 
of the taxpayers money.
    To reach these goals, the Department has taken several 
important steps. Last summer, the Secretary reorganized and 
assigned new leadership to the VA office of the medical 
inspector, which investigates disclosures related to patient 
care. He also established my office, the Office of 
Accountability Review or OAR, to ensure leader accountability 
for serious misconduct, including whistleblower retaliation.
    In addition to its ongoing work investigating leader 
misconduct, OAR is also working to improve the Department's 
ability to track whistleblower disclosures and actions taken in 
response to those disclosures across the entire VA system.
    VA has also improved its collaboration with the Office of 
Special Counsel. Last summer, VA requested and received 
certification under OSC's 2302(c) Certification Program. That 
certification reflects the Department's commitment to educating 
employees and supervisors about the whistleblower protection 
rules. VA has also negotiated with OSC an expedited process to 
speed corrective action for employees who are experiencing 
retaliation.
    More recently, we have asked OSC to help us expand that 
collaborative process to facilitate more efficient 
accountability actions against supervisors who engage in 
retaliation. We are also working with OSC to create a robust 
new face-to-face training program to ensure all VA supervisors 
fully understand their roles and responsibilities under the 
whistleblower protection rules.
    Since Secretary McDonald was confirmed last July, he and 
other VA leaders have made it their practice to meet with 
whistleblowers as they travel across the VA system and to 
engage with those who have raised their hands and their voices 
to identify problems and propose solutions. They do that both 
to acknowledge the critical role whistleblowers play in 
improving VA programs and to model to supervisors throughout VA 
the engaged, open, and accepting behavior they expect them to 
exhibit when subordinates step forward to express concerns.
    The Department deeply appreciates the assistance of this 
committee and other congressional offices in supporting 
whistleblowers and identifying problems VA needs to address. 
Last month, I had the opportunity to appear before this 
subcommittee to provide the Department's views on several 
pending bills, including two related to whistleblowers. At that 
time, I acknowledged--and I reiterate today--that the 
Department still has work to do to ensure that all 
whistleblower disclosures received prompt and effective 
attention and that all whistleblowers are protected from 
retaliation.
    I acknowledged then, and I reiterate today, that 
notwithstanding significant efforts on our part, VA is still 
working toward the full culture change we must achieve to 
ensure all employees feel safe disclosing problems and that any 
supervisor who retaliates is held accountable.
    On behalf of the Department, I am committed to continue to 
work with OSC and with this committee to get things right. I am 
honored that Secretary McDonald and Deputy Secretary Gibson 
have asked me to assist them in this critical effort. This 
concludes my testimony. I look forward to answering any 
questions you may have.

    [The prepared statement of Ms. Meghan Flanz appears in the 
Appendix]

    Mr. Coffman. Ms. Lerner, you are now recognized for 5 
minutes.

              STATEMENT OF THE HON. CAROLYN LERNER

    Ms. Lerner. Thank you. Chairman Coffman, Ranking Member 
Kuster, and members of the subcommittee, thank you for the 
opportunity to testify today about the U.S. Office of Special 
Counsel and our ongoing work with whistleblowers from the 
Department of Veterans Affairs.
    Last July, I spoke to this committee about OSC's early 
efforts to respond to the unprecedented increase in 
whistleblower cases from the VA. Since then, there has been 
substantial progress. For example, the OSC and the VA started 
an expedited review process for retaliation claims, as has been 
noted. This process has resulted in relief for many VA 
whistleblowers, including landmark settlements on behalf of 
Phoenix VA employees.
    In total, OSC has secured relief for over 45 VA 
whistleblowers. These settlements are putting courageous public 
servants back on the job and serving veterans. These 
settlements are also sending a message to other VA employees 
that if they come forward and report problems, they will be 
protected from retaliation.
    In my earlier testimony, I also addressed several serious 
problems with investigations by the VA's Office of Medical 
Inspector or OMI. In response to my concerns and this 
committee's concerns, the VA directed a comprehensive review of 
all aspects of OMI's operations, and this review has led to 
positive change.
    A recent whistleblower case is demonstrative. The case 
concerns a whistleblower disclosure from an employee at 
Beckley, West Virginia. In response to OSC's referral, the 
medical inspector determined that the Beckley facility was 
trying to save money by substituting medications with older, 
cheaper drugs. The substitutions were made over the objections 
of mental health providers, and the decision was driven solely 
by cost concerns without any legitimate medical basis. This was 
a clear violation of VA policies.
    OMI's investigation found the substituted medications 
created medical risks to veterans. In a call for review of all 
patients who were impacted to determine if there was any harm 
caused as a result of the drug substitution, OMI also 
recommended that discipline be considered for Beckley 
leadership and others who are responsible.
    While the facts of this case are very troubling, the OMI 
response is a sign of progress from where we were just 9 months 
ago. In an organization the size of the VA, problems are bound 
to occur. Therefore, it is critical that when whistleblowers 
identify problems, they are addressed swiftly and responsibly. 
A properly functioning OMI is key to doing so.
    Finally, since last year, the VA became the first Cabinet-
level Department to complete OSC's whistleblower certification 
program. In addition to fulfilling the basic certification 
requirements, the VA is working with OSC to conduct additional 
trainings for managers, supervisors, and lawyers at the 
regional level.
    The commitment we are seeing from VA leadership to correct 
and eliminate retaliation has not consistently filtered down to 
the regional facilities, so additional training for regional 
employees may help address this issue.
    I want to close by flagging one additional and ongoing area 
of concern. Often where a whistleblower comes forward with an 
issue of real importance, the VA's investigation focuses on the 
whistleblower instead of their disclosure. There are too many 
problems with this approach. First, by focusing on the 
whistleblower, the health and safety issue that was raised may 
not receive the attention that it deserves.
    Second, instead of creating a welcoming environment, it 
could chill future whistleblowing if employees believe that by 
reporting problems their own actions will come under intense 
scrutiny.
    The VA's focus should be on solving its systemic problems 
and holding accountable those who are responsible, not on going 
after whistleblowers. We look forward to working with the VA 
and the committee to further address this important issue.
    In conclusion, we very much appreciate the committee's 
ongoing attention to the issues we have raised. I thank you for 
the opportunity to testify today, and I look forward to taking 
your questions.
    Mr. Coffman. Thank you, Ms. Lerner.

    [The prepared statement of Ms. Carolyn Lerner appears in 
the Appendix]

    Mr. Coffman. Dr. Head, you are now recognized for 5 
minutes.

               STATEMENT OF CHRISTIAN HEAD, M.D.

    Dr. Head. Thank you, Mr. Coffman, Ms. Kuster, and all other 
members for inviting me again to, I think, a very important 
meeting.
    Since my last testimony in July of 2014, when I returned 
back to West LA VA Hospital, in my position as associate 
director, my leadership, my direct leader was--essentially 
reassigned--I basically was assigned to a chief of staff 
outside of West Los Angeles, to Long Beach Hospital, who I have 
never met and still have never met.
    I started to notice that my patients were being reassigned 
mid-therapy to other surgeons. When I questioned this, senior 
leadership at my hospital, essentially the chief of staff said, 
``If you don't like it, you are a whistleblower, take it to 
Congress. There is nothing they can do to me.'' I reported this 
statement to Congress and also to the Office of Special 
Counsel.
    Following that, I was prevented to go into the operating 
room when I had a patient under anesthesia. I was told my 
credentials to go in the operating room had been revoked. When 
I questioned that, an hour later, they were told, ``Oops. We 
made a mistake. It is okay, Dr. Head.'' Unfortunately, veterans 
and other hospital officials overheard that conversation.
    I have essentially been removed from my office in the chief 
of staff suite, transferred to the fourth floor. The cleaning 
crew told me they believe it used to be a nursing storage unit. 
There is a hole in the floor. The computer monitor was cracked, 
nonfunctional, along with some of the other equipment in the 
room. A group of the janitors got together and said, ``This is 
a shame. Let's get together and clean up this room for Dr. 
Head.'' When this was reported to chief of staff, a piece of 
plastic was placed over the hole in the floor. The janitorial 
service said it was a trip hazard and that I shouldn't go to 
that office. So effectively I have been functioning without a 
real office since I have testified to Congress.
    There have been investigators who came out to the hospital, 
but other employees have reported that it seemed to be more of 
an investigation into me than my actual complaints. When Donna 
Beiter was questioned about this, it turns out that VA 
submitted court records saying the reason why I was removed 
from the chain of command was because I testified in Congress. 
There is a sworn affidavit submitted by Donna Beiter that said 
I questioned her authority and that is why I was transferred 
out of the chief of staff offices. Because I questioned her 
authority in Congress. I don't remember actually mentioning 
Donna Beiter's name personally during my original testimony.
    Through all of this, I have always placed veterans ahead of 
me, essentially. And today I think we should focus on the 
veterans. I will--because of the way I was brought up, I will 
always take a stand for--this population is extremely 
vulnerable at this time.
    You remember I made reference to an email in November of 
2012 that is part of the packet I have submitted where I 
questioned the irregularities of the consults. I also noticed 
that there were a number of patients, after review of the 
number of colon cancers, that were entering the system but 
later appearing with advanced cancer. I did this as a team 
player, asking for a briefing to all of the chief of staff. I 
was rebuffed.
    I want to go on the record to be more specific. One, I 
witnessed the systematic deletion of 179 consults. Two, that 
the systemic deletion of these consult reviews, most of them 
were done by nonmedical staff. Three, I witnessed the direct 
batch deletion, the order given by my immediate supervisor, of 
40,000 consults. The number of deletions is three to four times 
what happened in Phoenix.
    The other thing I want to go on record--and I realize this 
will probably result in me losing my job, but I think the 
veterans deserve better--$25,000 was given to our VA. Where is 
it? It was reported as being given for informatics.
    I'm sorry, I have run out of time.
    Mr. Coffman. Could you review that number with us again?
    Dr. Head. I'm sorry. $25 million was appropriated over a 2-
year period to our hospital to improve access for veterans. 
Thank you.
    Mr. Coffman. Thank you.

    [The prepared statement of Dr. Christian Head appears in 
the Appendix]

    Mr. Coffman. Dr. Hooker--I'm sorry.

               STATEMENT OF MARYANN HOOKER, M.D.

    Dr. Hooker. Mr. Chairman and members of the committee, 
thank you for the opportunity to speak on continued 
whistleblower retaliation within VA. My written statement 
outlines the types and extent of reprisal against Federal 
employees that continues unabated. Retaliation against 
whistleblowers is destructive and costly to our Nation in so 
many ways and too convenient a weapon to be used without any 
fear of its consequences. When whistleblowers sound an alarm, 
it is for the safety and well-being of the veterans we serve. 
Veterans and whistleblowers are inextricably linked. Harm to 
one is harm to the other.
    My written statement speaks of VA as a house divided, with 
power and resources for the VA itself gained at the expense of 
care provision to the veterans we serve. For example, I had the 
honor of meeting an 88-year-old World War II veteran several 
weeks ago. He arrived in an electric wheelchair as he was 
unable to walk due to injuries many years prior that were not 
related to military service. Same for the loss of use of his 
left arm and hand, as well as the loss of use of his right 
shoulder. He was unable to see out of his right eye due to 
glaucoma causing near blindness.
    He related that he was living in a room at the YMCA in 
downtown Wilmington, Delaware, that being all he could afford 
on $500 a month Social Security and $500 a month nonservice-
connected pension. He was sent to the Y after a stay at our 
medical facility as an answer to homelessness.
    Years ago, he could have called our facility's extended 
care section his home. But due to yearly mandates progressively 
reducing the percentage of beds in the facility's community 
living center earmarked for extended care in favor of more 
rapid turnover and hence more billables and collections, this 
88-year-old World War II veteran was sent to live at the YMCA. 
Because he is not service-connected, VA feels no obligation to 
provide long-term care to him.
    Whose community is the community living center and what 
type of living is being provided? True to this 88-year old 
World War II veteran's generation, he believed that a bed in 
our community living center must be needed for someone in worse 
shape than he. This from a man with no effective use of his 
legs, no effective use of his arms, and almost no sight.
    What do we look at when we evaluate success? Are efficiency 
and expediency the only measures of a productive day? What is 
the most important thing?
    There is a spirit that enters the body at birth and a 
spirit that leaves the body at death. Our Nation was founded on 
spirit, the spirit of liberty and justice for all. Our veterans 
defend our Nation with their body, their mind, and their 
spirit. When they come to the VA for care of their body and 
mind, must they have their spirit crushed? And when healthcare 
providers advocate for veterans needs, must they suffer abuse?
    Whistleblowers are passionate people who care about 
veterans and the true mission of VA. VA for Veterans, not VA 
for itself. Thank you for the honor of representing them.
    Mr. Coffman. Thank you, Dr. Hooker.

    [The prepared statement of Maryann Hooker, M.D. appears in 
the Appendix]

    Mr. Coffman. Mr. Tremaine, you have now 5 minutes.

                 STATEMENT OF RICHARD TREMAINE

    Mr. Tremaine. Thank you, Chairman Coffman, committee 
members and our Representative Roby. I am here with you today 
to testify about the unacceptable vicious and ongoing 
retaliation against Dr. Sheila Meuse and myself for our 
whistleblower activity at Central Alabama's healthcare system 
where the director, James Talton, became the first senior 
executive servicemember in history fired for neglect of duty. 
The chief of staff, also under investigation, was on paid leave 
for 6 months and quietly retired in December of 2014.
    With disingenuous claims of improvement, there remains an 
atmosphere of exclusion and retaliation against those who did 
not support Talton or subsequently the dangerously 
inexperienced leadership and ineffectual management of Mr. 
Robin Jackson, the deputy network director over Talton during 
his tenure and who was immediately supplanted as interim 
director by Charles Sepich, division director.
    Dr. Meuse and I were two seasoned and experienced yet 
idealistic newcomers to the leadership team of CAVHCS in March 
of 2014. Although we both identified scheduling manipulations, 
illegal hiring practices, continued use of paper wait lists, 
severely delayed consults, critical levels of understaffing, 
fraud, and a complete breakdown of human resources and the 
business office directly to Talton, we quickly concluded he 
would not support our efforts to hold staff accountable.
    In June of 2014, we were forwarded an email sent to Talton 
in April of 2013 alerting him to critical scheduling 
manipulations from a staff position. Since Talton was 
publically claiming no prior knowledge of any scheduling 
manipulations, we became seriously concerned about his 
integrity and, on June 11, raised those concerns directly to 
Robin Jackson and Charles Sepich. We also informed them that we 
had been contacted by Representative Martha Roby on June 10, 
regarding her face-to-face meeting with Talton.
    Immediately after our June 11, confidential disclosures to 
Sepich and Jackson, the severe retaliations from Talton 
escalated exponentially. We later learned it was because Sepich 
and Jackson had communicated every word of our confidential 
conversation about Talton directly to Talton that very same 
day.
    On June 24, I sent an emergent email plea to Sepich 
informing him of continued violent outbursts and management--
excuse me, mismanagement by Talton. The very next morning, I 
was forced off the Montgomery VA campus by order of Robin 
Jackson. I was devastated to realize that I had been betrayed.
    I was constructively removed from my leadership 
responsibilities and prevented in acting in any leadership 
capacity by Talton and subsequently by Jackson in humiliating 
all-employee emails.
    Although Sepich had promised me that he would immediately 
begin a fact-finding to help us, in fact, 4 days earlier he had 
already chartered a fact-finding to investigate fabricated 
allegations by Talton and Jackson against us. That fact finding 
was chaired by a subordinate of Sepich. As a result, Sepich and 
Jackson requested an AIB from VACO on us without any specific 
charges. The AIB was conducted by OAR the week of October 27, 
with the results due on January 19, 2015. Instead the AIB 
requested additional on-sight testimony, citing a new 
allegation put forward by a union president who was not 
selected for a promotion, thus extending the investigation and 
its scope. One of the AIB members, a sitting director, was also 
a former subordinate and friend of Charles Sepich.
    Incredulously, during my first year at CAVHCS, I had been 
under the weight of investigations for 305 out of 365 days 
without a single charge and beginning within my first 45 days 
of work. It is difficult to describe the level of disrespect, 
harassment, and retaliation we endured from Talton, Sepich, and 
Jackson as he removed hospital services from my authority, 
initiated major reorganizations and realignments adversely 
impacting my position and without my input. My direct reports 
bypassed me, reporting directly to him at his request. I was 
excluded from key informational resources, blocked from 
critical administrative reports on major program assessments 
and important site reviews. In fact, when I asked for the 
complete administrative assessment done by Jackson himself a 
month before I arrived, he told me, ``If you want to see it, 
request it through a Freedom of Information Act.''
    In an amazing failure of leadership, Sepich and Jackson 
actually detailed Dr. Meuse out of the State for 90 days in the 
middle of this crisis.
    I speak with you today with a heavy heart disgusted by the 
continued coverups and a discrediting campaign through open-
ended investigation and the attempted destruction of my career 
by the VA that I have always loved serving and being a part of.
    So many VA employees are closely monitoring this issue and 
hoping VA leadership at all levels will demonstrate a 
commitment to true excellence and transparency by creating an 
environment free from whistleblower reprisal and retaliation.
    If the retaliatory actions from CAVHCS and VISN 7 against a 
dedicated veteran executive and a brilliant career woman 
executive, both who have committed their lives to serving our 
veterans is tolerated in the least, it will most certainly have 
a chilling effect on any others considering stepping forward to 
protect the organization we all love serving veterans through.
    I have feared the loss of my job and career, and we both 
fear a further loss of our personal and professional 
reputations. But Dr. Meuse and I sat in disbelief a year ago 
and agreed, at that moment in time, that we didn't have a 
choice because it was more important to protect our veterans 
than protecting either one of our own careers.
    We respectfully request that you immediately address the 
overt whistleblower retaliation that has become rampant in our 
VA. Again, thank you for your commitment to our veterans, and I 
am available to answer any questions.

    [The prepared statement of Richard Tremaine appears in the 
Appendix]

    Mr. Coffman. Well, thank the panel so much for your 
testimony today and particularly to the whistleblowers.
    You know, as a combat veteran, my heart is out to you. I 
think you are fighting for our Nation's veterans today who have 
made tremendous sacrifices in defense of this country.
    And I would like to ask the whistleblowers a question 
first, all three of you, and that is: To your knowledge, has 
there been any disciplinary action taken, to those that have, 
you know, intentionally created the kind of hostile workplace 
that you have testified today, in terms of retaliation against 
you?
    Start, Mr. Tremaine.
    Mr. Tremaine. Chairman, there has been none.
    Mr. Coffman. Dr. Hooker.
    Dr. Hooker. None.
    Mr. Coffman. Dr. Head.
    Dr. Head. None.
    Mr. Coffman. Okay.
    Question now. Ms. Lerner, if you look at the number of 
cases from the VA that have gone before the USC, compared to 
other agencies of the Federal Government, it seems 
substantially higher. I think a simple comparison would be to 
the Department of Defense. I believe that has double the number 
of Federal civil service employees and yet there are more cases 
last year, I think, that came forward from the Department of 
Veterans Affairs than the Department of Defense. Can you 
explain the--just the nature of the volume of cases coming from 
the VA?
    Ms. Lerner. We have a Map Quest in the back first.
    We do get more retaliation cases and disclosures from the 
VA than any other Federal agency, any other department in the 
government, and the numbers are increasing. Just for 
comparison, as you have said, the complaints that we get from 
the VA are higher than the DoD, which has double the number of 
employees.
    So, you know, we know that people come forward when they, 
you know, feel that they, you know, have to, to protect the 
life of a veteran or the health and safety, and so the fact 
that people are coming forward is a very positive sign. While 
the numbers are bad and they are increasing and that has to 
stop, I personally am encouraged that more people are coming 
forward because, A, we need to know where the problems exist. 
We can't fix them until we do. And so I am encouraged that 
people feel confident that they will get some relief when they 
come to our agency and that they will get some results.
    We know--the number one reason whistleblowers come forward 
is because they feel an obligation. The number one reason they 
don't come forward is because they feel that they are not going 
to get any results. Nothing will happen if they come forward. 
So, you know, it is a double-edged sword. On the one hand, we 
are not happy that the numbers are increasing and our staff is 
completely overwhelmed by the work. On the other hand, we are 
glad that they feel comfortable and confident coming to us and 
so that is a positive thing.
    Mr. Coffman. Okay. Ms. Flanz.
    Ms. Flanz. I would certainly echo what Ms. Lerner has said. 
We are encouraged to know that people do feel comfortable 
raising disclosures whether it is to members of this committee, 
members of Congress----
    Mr. Coffman. I don't--Ms. Flanz, I don't know if they feel 
comfortable. I think they are willing to take a risk.
    Ms. Flanz. And I would agree with that. I also really want 
to thank the whistleblowers who have come forward today to 
provide their stories. It is an act of courage and it is 
something that we in the Department need to learn to celebrate, 
because disclosures about problems give us an opportunity to 
fix those problems. If we don't know about them, don't learn 
about them, then, we are not able to improve service.
    To Ms. Lerner's point, we do need to understand what it is 
that is driving these numbers, continuing to drive these 
numbers and to be careful not to assume either bad or good 
things about the numbers. The fact that people are coming 
forward with their concerns is an indicator that we continue to 
have some issues that require attention. But again, the fact 
that they are bringing them forward means we have the 
opportunity to identify those problems and move forward with 
solutions.
    Mr. Coffman. Ms. Flanz, can you comment to me about--can 
you give me some idea--so we just had testimony from the 
witnesses here, that are whistleblowers, that no disciplinary 
action has been taken against those who have retaliated against 
them.
    Can you give me any data in terms of actions that the VA 
has taken in terms of disciplining those who have retaliated 
against our whistleblowers?
    Ms. Flanz. Absolutely. I cannot speak to the cases of the 
individuals at the table here. As I understand it from my 
colleagues at the Office of Special Counsel, their issues 
remain pending, so I am not going to speak to the particulars--
--
    Mr. Coffman. How many pending cases can you refer to?
    Ms. Flanz. We currently have, in my office, 80 ongoing 
investigations of which 15 involve, among other things, 
whistleblower retaliation. We also--we keep a database of 
employee disciplinary actions taken across the Department. 
Until the late summer of last year, we did not have any 
particular database that showed discipline across the VA. We 
have begun to collect that data. Among the things that go into 
that database are general descriptions of the charges that are 
used to support the discipline. One of the charges is, 
something having to do with prohibited personnel practice. That 
is a generic term that includes whistleblower retaliation, 
among other things. Another type of charge is retaliation.
    The information that I have is that, in the approximately 
one year we have been collecting information, we have 22 
actions in our database that include charges related to 
prohibited personnel practices or retaliation. It is not a 
large enough number. I will say that right now. We have more 
work to do to ensure that the individuals who have retaliated 
against whistleblowers. As Ms. Lerner and her staff bring cases 
to us to provide corrective remedies to the employees who have 
been subjected to retaliation, we need to be able to move 
expeditiously----
    Mr. Coffman. Okay. I am sorry. I am running over my time--I 
am running over my time.
    I just want to say that this seems like such a typical 
hearing when you are giving us a lot of great news. We have 
three individuals here who have testified, not just--who have 
testified before, that no disciplinary action is taken against 
those who have retaliated against them and that situation 
remains unchanged.
    Ranking Member Kuster.
    Ms. Kuster. Thank you, Mr. Chairman.
    I want to address my remarks to Ms. Flanz and Ms. Lerner, 
but I do want to thank the whistleblowers for bringing your 
individual cases and encourage you to work with our good 
colleagues. I know Representative Roby is on the case for you, 
Mr. Tremaine--and encourage you to work with the Office of 
Special Counsel as well to make sure that you get the 
protection that you deserve and we don't have any other 
tragedies.
    Mr. Tremaine. Yes, ma'am. May I just say that, absolutely, 
the Office of Special Counsel has been a lifeline. Working with 
Paige Kennedy and Nadia Pluta throughout this ordeal for the 
last year made a huge difference. I don't think there is any 
question they are totally understaffed, but the opportunities I 
had to speak with them made a huge difference in my ordeal.
    Ms. Kuster. Good. I hope your situation will get resolved. 
It sounds like we have got 45 settlements of VA whistleblower 
cases which hopefully did bring some relief. I know there have 
been reinstatements with back pay and such, and it is important 
to send that signal to others.
    One of the issues that I wanted to get at is this issue of 
VA culture and--because it seems to me that the idea that it 
has gone to the OSC is sort of a recognition that this issue 
has blown up to a place where it wasn't resolved at a lower 
level. And I want to make sure that we have a collaborative 
workplace throughout the agency.
    I did note, of the chart that we received, of the top 
agencies providing case work, it is true that the VA is higher 
than the DoD. What is interesting for me--and I don't know if 
they can get this on the camera--but that the VA and the DoD 
are right at the top, and then it dropped dramatically down for 
every other agency in the Cabinet. I am curious about sort of 
the hierarchal nature and structure of VA and DoD and whether 
it is a greater challenge to change the environment.
    But I am also curious--and this is to Ms. Flanz--what steps 
are being taken to foster a more collaborative workplace? And 
in the interest of time, I will just combine this with my 
follow-up question. We hear about steps that are taken here in 
DC for improvement. But how are these--what are the specific 
steps that are being taken to improve VA culture and ensure 
accountability on the frontline at the VISNs step by step with 
the people that can protect the lives of these whistleblowers 
and protect the quality of service to all veterans?
    Ms. Flanz. I want to speak to both of those questions. I 
think I heard two of them.
    Ms. Kuster. Okay.
    Ms. Flanz. One with respect to improving the culture at the 
frontline across the VA system. The Veterans Health 
Administration has an office call the National Center For 
Organization Development, and that office is looking at an 
issue of psychological safety and how psychological safety can 
be improved in VA workplaces. Psychological safety is a larger 
term of which I think protecting whistleblowers is very 
definitely a component.
    The head of that National Center For Organization 
Development speaks in terms of four cornerstones of the just 
culture that is required to ensure that patient care is 
provided in an environment in which people feel safe and the 
workplace is as we want it to be. Those four cornerstones are 
transparency, accountability, psychological safety, and risk-
taking and innovation. Those four things need to be in balance. 
To the extent that transparency perhaps is stressed above all 
other things, you may get people feeling less safe and/or less 
willing to engage in risk taking and innovation. Similarly, if 
accountability is overly stressed, you may sacrifice some of 
the other issues. So the experts are focusing on tools for 
employees and supervisors across the VA system, to improve 
psychological safety within the framework of those four 
cornerstones.
    With respect to accountability for whistleblower 
retaliation, we are working on a number of things. First, we 
need to capture the attention and understanding of medical 
center directors, regional office directors, and regional 
counsel, right there at the facility level. Ms. Lerner's staff, 
they are coming to give a training program to our regional 
counsels who are coming to town later this month. We will 
address them, and then we will begin with some training, new 
training that we are going to roll out to supervisors, training 
first regional counsel attorneys and H.R. professionals from 
the facility level and then having them serve as the trainers.
    So we really need to get at two things. We need to make 
sure that the environment in the workplace is appropriately 
safe, and we also need to improve understanding on the part of 
supervisors and attorneys as to what the ramifications are for 
retaliation.
    Ms. Kuster. Thank you very much.
    Mr. Coffman. Ms. Flanz, just a quick question. On April 9, 
2014, the story emerged about the wait time scandal in the 
Phoenix VA. How many--since that time, how many disciplinary 
actions have been taken against those who have retaliated 
against whistleblowers? Not pending cases, but how many cases 
have been finalized?
    Ms. Flanz. I apologize. The numbers that I brought I didn't 
breakdown by month or year. So----
    Mr. Coffman. How many cases have--you talked only about 
pending cases. How many cases have been finalized where those 
who have retaliated against whistleblowers have been 
disciplined?
    Ms. Flanz. I am aware, through my office, of three. But as 
I said, the numbers from the facility level are kept in our 
database, and I could--I would love to provide you specifics, 
which I just don't have at my fingertips.
    Mr. Coffman. You are here to testify before the Congress on 
this issue and you don't have specifics?
    Ms. Flanz. I have the specifics that I have which----
    Mr. Coffman. That is--how convenient. I will ask you for 
those on record, for you to submit those to this committee.
    Mr. Coffman. Dr. Benishek.
    Dr. Benishek. Thank you, Mr. Chairman.
    Frankly, I am--I kind of agree with the chairman. I am a 
little bit frustrated by this, because these--Dr. Head, I think 
you testified earlier that you are not familiar with his case.
    Ms. Flanz. I am actually quite familiar with it, but given 
some ongoing litigation, I am not free to speak to the 
specifics of it here.
    Dr. Benishek. Are you familiar with all the cases?
    Ms. Flanz. I am.
    Dr. Benishek. Are you familiar with all the cases that are 
in your department?
    Ms. Flanz. Those that involve senior leaders in terms of 
culpability, yes.
    Dr. Benishek. Are there 80 active cases? Is that--is that 
the number?
    Ms. Flanz. We have 80 active investigations of which 
approximately 15 involve some element of an allegation of 
whistleblower retaliation.
    Dr. Benishek. Well, how many cases have you closed in the 
last year?
    Ms. Flanz. My office has been operating since July of 2014. 
We have closed dozens. I could get you that number.
    Dr. Benishek. In only three cases of those dozens have 
there been disciplinary action in, is that what you are saying?
    Ms. Flanz. Each of our cases results either in a specific 
finding that the alleged misconduct couldn't be substantiated 
or it results in a recommendation around discipline, yes.
    Dr. Benishek. Let me ask a question about--concerning Ms. 
Lerner's written testimony. There is all kinds of cases here 
she has documented, you know, specific cases.
    Are the people involved--Ms. Lerner, you don't get involved 
in the discipline of the person who did the--who retaliated 
against the whistleblower. You are primarily concerned that the 
whistleblower is restored; is that correct?
    Ms. Lerner. Generally our attention is on relief for the 
whistleblower.
    Dr. Benishek. Do you then report these issues to Ms. 
Flanz's----
    Ms. Lerner. Yes.
    Mr. Benishek [continuing]. Department, then, so that she 
can act on those?
    Ms. Lerner. Sure. Yes. We are working with Ms. Flanz and 
the Office of Accountability Review to expedite their 
identification of cases where disciplinary action is 
appropriate.
    I also just want to mention that we know of at least 40 
disciplinary actions against employees who were complicit in 
the wrongdoing identified by whistleblowers. So, on the 
disclosure side where people come to us and make a disclosure 
of health and safety problems or the wrongdoing, as part of our 
review of the agency's investigation, we look to see whether 
they have taken disciplinary action. And on that side of the 
equation, we know of at least 40 since--about 2 years ago.
    Dr. Benishek. All right.
    Ms. Lerner. So that is a little bit encouraging.
    Dr. Benishek. I am just disappointed that, Ms. Franz, you 
are only aware of three cases in all these--three cases of 
disciplinary action being taken amongst all the cases in the 
last year. It seems surprising to me. Especially in view of the 
fact, like Dr. Head here, was here last summer and, you know, 
is still under investigation. Mr. Tremaine, it seems like he is 
under quite a bit of distress here.
    Let me ask Dr. Head. Dr. Head, what have you been doing in 
the last--you know, since your last, well, your last testimony 
here? What actions have you taken because it seems like you are 
still having trouble?
    Dr. Head. Well, I continue to report each and every 
retaliatory event. You know----
    Dr. Benishek. Has anybody come to you like from Ms. Flanz's 
department to ask you questions about what has been going on?
    Dr. Head. From the Office of Special Counsel, they have 
communicated with us, more recently the investigative unit.
    Dr. Benishek. Does the Office of Accountability Review talk 
to you?
    Dr. Head. They have, but I--it has been disappointing.
    Dr. Benishek. Okay. Mr. Tremaine, I heard you testify 
earlier that you have been in contact with Ms. Lerner's 
department. Is there anybody else you have been talking to?
    Mr. Tremaine. No, sir. Other than the--other than the AIB 
after about six--I want to say 12, 13 hours of grilling over 2 
days, over--I'm sorry--over 3 days.
    Dr. Benishek. They were talking to you?
    Mr. Tremaine. They were talk--they weren't talking. They 
were grilling.
    Dr. Benishek. Well, what do you mean grilling? What were 
they doing?
    Mr. Tremaine. Well, they were investigating. You know, they 
were--I thought--and I told them, I clearly thought it was a 
sham and I expressed that to them on multiple occasions during 
the investigation.
    I mean, one of the--one of the most interesting questions, 
the question they wanted asked or answered the most, dealt with 
the fact that I had identified a vehicle that was driving--a 
government vehicle on a Friday night at 8:30 in the evening, 
after I left the office at 8:30, it didn't have any taillights 
on it at all. So I stopped that vehicle and notified the driver 
there weren't any taillights on before the driver got on a 
darkened highway. And then the next Monday, I inquired about 
what the vehicle was doing out at 8:30 because, you know, we 
had had vehicles destroyed by staff and we had had vehicles 
used to take staff to crack houses. And I had a concern about 
why that vehicle was out.
    The OAR AIB investigation was more concerned--excuse me--
was more concerned why I stopped the vehicle. And when I 
expressed that--you know, I was born in Ohio and I suspect 
that, maybe as just a good Samaritan, all three of the AIB 
members advised me that they would never have done anything 
like that. And I thought that was incredulous. And then they 
questioned me why I questioned the employee on Monday without a 
union representative. And I told them, well, you know, I am 
still number two in the organization at the time and I felt I 
had a responsibility to ask what the vehicle was doing out 
there at 8:30 at night. That is my----
    Dr. Head. I also----
    Dr. Benishek. I am out of time here, I guess, Mr. Chairman. 
Thank you.
    Dr. Head. I just wanted to say one thing. I also felt that 
a lot of times these investigations were more about us, but not 
necessarily about the facts of what we have complained about. 
And my experience is very similar to that.
    Mr. Tremaine. Yes.
    Mr. Coffman. Miss Rice, you are now recognized for 5 
minutes.
    Ms Rice. I am going to try and organize this. I am at a 
loss for words.
    First of all, I don't understand your attitude, Ms. Flanz, 
with all due respect to you. The fact that you can sit there 
and come here with literally no information and you can't 
answer a question with any specificity is very, very 
disturbing.
    I don't understand how the two of you, Ms. Flanz and Ms. 
Lerner, can say that there has been progress, when we have Ms. 
Lerner saying that she attributes the increase in complaints 
from people at the VA to the fact that people are feeling more 
comfortable coming forward at the same time that Ms. Flanz is 
admitting that there has been literally no accountability on 
the part of the people retaliating against whistleblowers.
    Can either one of you explain that conundrum to me?
    Ms. Flanz. I would like very much to try.
    Ms Rice. Great.
    Ms. Flanz. We are committed to ensuring that supervisors 
who retaliate against whistleblowers are held accountable.
    Ms Rice. Let me stop right here. I just have to interrupt 
you.
    It seems to me that--and maybe this is my prosecutorial 
background--if you want to send a message that people, 
wrongdoers are going to be held accountable, you actually have 
to hold at least one accountable. And if you look at the 
numbers of complaints, they far outweigh any level of 
accountability.
    So please explain that.
    Ms. Flanz. Again, I would like to, very much.
    We have ongoing investigations right now that will provide 
us with the evidence necessary to hold employees, supervisors 
accountable. Until very recently, we have not had the 
collaboration with OSC that we have now that allows us to use 
the evidence that they have pulled together to give us a jump 
start so we don't have to start fresh with our investigations.
    We will, whenever the evidence shows that retaliation has 
been engaged in----
    Ms Rice. Okay.
    Ms. Flanz [continuing]. We will hold people accountable.
    Ms Rice. So let me ask you this. Why is it that a 
determination that a whistleblower was not giving accurate 
information a much easier determination to make than 
retaliation against a whistleblower?
    You answer that question for me. Because what I am hearing 
from the three whistleblowers here is you guys have no problem 
saying this whistleblower was wrong but you have no ability to 
hold a wrongdoer accountable. Explain that.
    Ms. Flanz. With all due respect, that is not really how the 
process works. We are----
    Ms Rice. No, no, no, no, no. I have to stop you, because I 
have very limited time.
    This is a very simple question. Why is it that you are able 
to come to the conclusion that whistleblowers have made 
allegations that were not based in fact, and you can do that 
pretty expeditiously, seems to me, and you can't do as 
expeditious an investigation when it comes to holding a 
retaliator against a whistleblower accountable?
    Because guess what? The numbers support what I am saying. 
You can give whatever explanation you want, but I am telling 
you right now, the level of disrespect that you are showing to 
the veterans--who, by the way, if--and we know allegations are 
true, in terms of the treatment, mistreatment of patients, the 
lists--all the laundry list of stuff that we know is going on. 
Okay? Everyone knows that it is there.
    You are telling me that you are spending all this time to 
try to hold someone accountable. Let's forget about what is 
happening about actually fixing the problem, where veterans are 
not getting the services that they need. That is another 
disturbing thing to me. That is almost an afterthought to you.
    So I can't hear an explanation that includes some kind of, 
well, you know--and, believe me, I am a lawyer, so I get the 
whole, ``There is an ongoing investigation, so I can't 
answer.'' It is a very convenient way of getting out of 
answering a question that you don't want to answer. So I know 
that. And I apologize. My blood is boiling, and this is a 
disgrace.
    So please give me a succinct answer, and then I will end, 
on why it is that it is easier for you to come to the 
determination that whistleblowers are wrong before you can come 
to the--in a faster way than you can say that these retaliators 
are wrong.
    Because the number-one way we know we are going to stop 
this is just hold one retaliator accountable. And I don't mean 
docking their pay. I mean firing them.
    Go ahead.
    Ms. Flanz. I understand. It has to do with the burden of 
proof. When we do fire an employee, we are required to show 
that the preponderance of the evidence supports the action. It 
really is----
    Ms Rice. Okay. I get the whole ``burden'' thing. Then that 
is why you should have more people working on that to do it 
even faster. Because this system is not going to get fixed--and 
you can talk about, oh, we changed the culture, here we did 
this, we set up that, oh, it is all so much better--if 
retaliators aren't being held accountable. That is the bottom 
line. And I don't see that.
    Thank you very much, Mr. Chairman.
    Mr. Coffman. Thank you, Miss Rice.
    Dr. Roe, you are recognized for 5 minutes.
    Dr. Roe. Thank you, Mr. Chairman.
    I guess the direction I want to go is with Dr. Head and Mr. 
Tremaine and Dr. Hooker too.
    When you make an allegation, obviously, you are not a team 
player right then. So what is it to lead me to believe that you 
are just not an incompetent employee, you know, you are a 
troublemaker, you don't want to work with the team? We have all 
been on the team before.
    And when you are looking, what is to make me--because I 
have seen this happen before, where you--how do I know Dr. Head 
is really a very good doctor? You just might not be very good, 
so we just move you out of the clinic and put you in a closet 
or somewhere and essentially move you out of clinical care just 
to get you out of the way.
    And it is very hard to protect your reputation if you have 
two or three or four senior people ahead of you who are making 
those allegations. So how do you protect yourself from that, to 
follow up on Miss Rice's statements? How do you do that?
    Dr. Head. It is a----
    Dr. Roe. How do I know you are not, sitting here?
    Dr. Head. Well, my reputation speaks for itself. And my 
education and clinical expertise and track record speaks for 
itself. A lawsuit has never been filed against me. I have never 
had what is called a level 3 complaint filed against me until 
after I testified in Congress.
    Dr. Roe. I am being facetious, Doctor.
    Dr. Head. I understand. I understand, but I think the whole 
world needs to understand this.
    I am a team player because I have followed the chain of 
command. Every complaint I have made, every allegation of 
malfeasance, the problems with the wait times, the deletion of 
consults, suggesting perhaps medical staff should review the 
consults or deletions rather than non-medical expertise, rather 
than students, should be do the deletions.
    It is common, though, to--as I said before, what is the 
first thing they do? They take the whistleblower, they isolate 
them. Second, they defame them. Third, they push them out.
    Once they have them isolated and defamed--and then they try 
to go back and rewrite history, suggesting, perhaps, it is 
something that they have done to cause the action against them. 
And they send out their surrogates, usually trained 
professionals without the institution, to suggest that perhaps 
that person is a bad person, not a good doctor.
    But you know something? My strength comes from my patients, 
actually. And I often tell them, I get much more out of seeing 
you than I give you. And I do my best every day of the week to 
make sure that I give them the best care possible. The mistake 
I made initially during this process was to allow them to push 
me out of care. But I am stronger now only because I have 
insisted and I fight to see as many veterans as possible.
    Dr. Roe. I think the problem is when you stick your head 
up.
    Dr. Head. Yes.
    Dr. Roe. It is easier to keep your head down. You don't get 
arrows if you do that.
    Dr. Head. Yes.
    Dr. Roe. If you stick your head up and speak out, you get a 
lot of arrows. And the point is the people shooting the arrows 
don't seem to have any going back their way.
    And, Mr. Tremaine, here you come into a new shop, you know, 
you are working in there, you see some issues, you point them 
out, and what happens is you, then, become the problem.
    Mr. Tremaine. Yes, sir. And with 24 1/2 years of VA 
experience at eight different facilities and never anything 
less than an outstanding rating and nothing, including a letter 
of counseling, in those 24 years.
    After arriving in central Alabama, really quickly we 
discovered and I discovered and then, simultaneously, Dr. 
Meuse, as the assistant director, we started kind of comparing 
notes a little bit, and we both realized we were team players. 
And we would have done anything on the team that was going to 
fix things. But I promise you, we are never going to be on the 
wrong team. We are not going to be on the team that disrespects 
or harms veterans.
    I mean, I am a veteran myself, an Air Force--who comes from 
a family of veterans. I have my son here, who will most likely 
be an Air Force veteran. I would rather he go back to 
University of Colorado in Boulder, my alma mater, but if he 
wants to go serve, I will support him 100 percent.
    But when he gets out, you know, I want to make sure he 
walks into a VA--any VA across this Nation, the minute he 
crosses that threshold, he should be treated with respect and 
dignity, period, bottom line. It shouldn't be a matter of, 
well, which team are you going to be on? There is only team, 
and that is the right team.
    And when we got down to CAVHCS, both Dr. Meuse and I 
realized the wrong team was in place. And we tried our best to 
help that team, to reenergize that team, but, as it turned out, 
that team didn't want to be helped. That team wanted to protect 
themselves and attack us. But neither Dr. Meuse or I would give 
up that fight and give up on our veterans.
    Dr. Roe. Well, I thank the three of you for being here and 
speaking out.
    I think it will help other people, Mr. Chairman, around the 
country to have the courage to stick their head up instead of 
keeping their head down and letting things go by that 
shouldn't, that potentially could harm veterans.
    I yield back.
    Mr. Coffman. Thank you, Dr. Roe.
    Mr. Walz, you are now recognized for 5 minutes.
    Mr. Walz. Thank you, Chairman.
    And thank you all for being here.
    The VA can't achieve its mission of providing the highest 
quality care to our veterans if we have a culture of fear or a 
culture where the practitioners aren't able to do what they 
need to do.
    And it feels like, since I have been here--and I know I am 
somewhat biased, as a cultural studies teacher. This issue of 
culture is never far from us, and we have talked about it. It 
is difficult.
    We were out in Tomah, a week ago or so, on a field hearing 
on this very issue of overprescription of opioids. And a 
whistleblower, if you will, Christopher Kirkpatrick, was one of 
those people who brought that to people's attention. He was 
backed up on that by the IG's report. And Christopher is now 
dead.
    We have another whistleblower out there whose medical 
record, a veteran, was looked into with the very clear example 
of trying to find a mental health issue to try and discredit 
them, which is so despicable on so many levels, because the 
very stigmas we are trying to overcome amongst mental health 
and mental parity is being used against the people who are 
talking about it.
    So this is a cancer. And I know the attempt to try--and I 
am grateful that we start to bring it to light. But in so many 
of these cases, the difficulties to overcome--and I think Miss 
Rice was hitting on this, this whole preponderance of the 
evidence. And we understand that you have to make a case and 
you can't just accuse people and there is workplace safety and 
you have collective bargaining agreements and things that make 
sense. They are there to protect, which I will come back to. 
Thank goodness for Dr. Hooker and the Local 342 for providing 
some democracy in the workplace, where management can't just 
run roughshod over employees.
    But with that being said, this issue seems to me--and I 
know this runs deeper than all of you at the table. I just 
looked up in the dictionary, the Webster's dictionary, looked 
up ``whistleblower.'' Do you know what the synonyms are? 
``Betrayer,'' ``fink,'' ``informant,'' ``nark,'' ``rat''; 
related words, ``collaborator.'' That says something about our 
culture that runs deep, and this is hard. That is why what you 
two are doing becomes even more important, to ensure us that 
the integrity is there.
    And I am going to hit on where Dr. Benishek was and I think 
Dr. Roe was getting at. I went through the list--and I am 
grateful that it appears that we are starting to get some 
justice for the whistleblowers. But that is one piece of this. 
The accountability piece you talked about--the thing that 
troubles me most in the nine cases you listed--now, I may be 
wrong, because they are summaries. But it appears that only 
Charles Johnson at the Columbia VA actually led to changes in 
how business was done in a hydration practice that was wrong.
    Am I wrong to assume--because my concern on this is that 
this is threefold: justice for the whistleblower, 
accountability for the perpetrator, and improved quality of 
care to stop that. Because, really, when you adjudicated these 
things, all you gave them back is what they should have had in 
the first place. You don't get a pat on the back for doing the 
right thing. And that is what it appears like we are asking 
for. ``Look at us. We paid them back the money.'' Oh, because 
you fired them incorrectly in the first place.
    So could--I don't know if it is Ms. Flanz or Ms. Lerner, 
and I know maybe we are talking to the wrong people for 
implementation of these changes, but are we seeing true change, 
in your mind, or are we just going through the motions and 
paying people backpay that they should have never been taking 
anyway?
    And, by the way, it is not the VA who settles, it is the 
taxpayer who settles, when they do this wrong, just to be 
clear.
    Ms. Flanz. Absolutely. We are seeing changes, not as 
quickly and not as profoundly as we should. We will get there. 
We are seeing changes.
    The Office of the Medical Inspector, in particular, when 
they go out to investigate a disclosure that comes to us 
through Ms. Lerner's office, if it is a disclosure having to do 
with a problem with patient care, their recommendations 
include, if there is a whistleblower who is named, not just 
protection for that individual, but substantive change around 
whatever the problem is that was disclosed. And the Department 
has an obligation to provide the information about what it is 
going to do and provide updates in terms of progress toward the 
correction of the problem.
    So, absolutely, that is--it is fundamental. That is really 
what the whole process is about.
    Ms. Lerner. Let me just add a couple of things.
    I mean, I think culture change requires many elements. This 
is not a problem that just developed overnight. It has been 
around for a long time. It is not going to get solved 
overnight. But here are things that we see that really make a 
difference in changing a culture.
    Number one, you have to have a message from the top. 
Leadership has to be very strong. Some of the things that we 
have seen Secretary McDonald do, like meeting with 
whistleblowers when he goes to visit facilities, that sends a 
great message. So that----
    Mr. Walz. This troubles me, though, if I could interrupt 
you. Was Secretary Shinseki unethical?
    Ms. Lerner. I am sorry.
    Mr. Walz. Was Secretary Shinseki unethical then? Did you 
ever get an impression that he didn't care about this? Or those 
that came before him in----
    Ms. Lerner. I mean, I think a lot of the problem under 
Secretary Shinseki's term was that the Office of Medical 
Inspector was doing nothing when they found a problem. So when 
there was a disclosure, what the Office of Medical Inspector 
would do is say, yes, in this isolated incident, maybe the 
whistleblower is right, but it is not really a problem, there 
is no harm to patient care----
    Mr. Walz. And that is different now?
    Ms. Lerner. And that is very different now. The Office of 
Medical Inspector is different. After our report almost a year 
ago, the Office of Medical Inspector was changed around. The 
person who was heading it left.
    We are seeing a change, as I mentioned in my testimony, in 
the types of investigations that they are doing, including 
disciplinary action as a----
    Mr. Walz. My time is up, but when we come back around 
again, I would like to have the other three address that. 
Because I think that is fundamental, if this has made a 
significant difference, because that is an important piece.
    I yield back.
    Mr. Coffman. Dr. Huelskamp, you are now recognized for 5 
minutes.
    Dr. Huelskamp. Thank you, Mr. Chairman. I appreciate you 
holding this hearing. I wish it were not necessary. I wish we 
had seen the type of changes--I think we wouldn't be sitting 
here if we were comfortable with what has happened.
    I want to follow up on one thing that was just mentioned, 
and that was, I believe Ms. Lerner mentioned the travel by the 
Secretary and other top VA leaders.
    Have they visited--and this may be a question for Ms. 
Flanz. She makes reference that, visiting with whistleblowers.
    Has the Secretary, current Secretary, visited the L.A. 
facility where Dr. Head works?
    Ms. Flanz. Yes, he has.
    Dr. Huelskamp. And did he meet with Dr. Head at that time?
    Ms. Flanz. I honestly don't know. Dr. Head would know.
    Dr. Huelskamp. Okay.
    Mr. Head.
    Dr. Head. Yes, I was prevented from meeting with the 
Secretary. I was told that my ID badge was--there was a problem 
with my badge. I went to human resources----
    Dr. Huelskamp. Say that again. Something wrong with your 
badge?
    Dr. Head. I was told that you had to have an updated PIV 
card on your badge, that mine had expired, and that I would not 
be allowed to see the Secretary. And so I----
    Dr. Huelskamp. Did that expire when you were before the 
congressional committee, by any chance?
    Dr. Head. There is a possibility it could have expired soon 
after.
    Dr. Huelskamp. And I appreciate that, Doctor. I am going to 
go back to----
    Dr. Head. But I was instructed to get that taken care of. I 
went to human resources. When I was in human resources trying 
to resolve the issue, which was resolved, they had instructed 
me that a block had been placed on my ID and they had a problem 
with the block.
    And I was called, saying, you can meet with the Secretary 
now. Dr. Norman has said that it is not necessary to have an 
updated PIV card. The problem is the Secretary had just 
finished his presentation.
    Dr. Huelskamp. Very troubling.
    Ms. Flanz, any response to that? I mean, you made the claim 
that--I mean, this is a very public whistleblower. Dr. Head has 
put his reputation on the line in, I think, a very courageous 
move, very public. Was he not searched out to sit down and say, 
let's solve this problem?
    Ms. Flanz. I was not consulted. If I had been, I sure would 
have wanted to try to intervene.
    The Secretary does make a point to model the behavior he 
wants to see in all supervisors. I am very sorry that Dr. Head 
wasn't able to meet with him because I know that conversation 
would have been of use to both of them.
    Dr. Huelskamp. Are there any other whistleblowers--I mean, 
you made the statement that he would like to meet with 
whistleblowers. Any others that he skipped that you know of? Or 
how many times has he met with whistleblowers?
    Ms. Flanz. It is my understanding he seeks them out every 
time he goes to a VA facility.
    Dr. Huelskamp. Except for Dr. Head's situation, I guess?
    Ms. Flanz. This is the first that I am hearing that Dr. 
Head was unable to meet with him.
    Dr. Huelskamp. Well, I would appreciate that when you make 
statements for the record--and we have lacked a lot certainty. 
This is a pretty certain statement, that, boy, we are really 
working hard on that.
    So I want to confirm, if I understood correctly earlier, 
that no VA supervisors have been fired for retaliation against 
whistleblowers?
    Ms. Flanz. That is not correct.
    Dr. Huelskamp. So how many have been fired?
    Ms. Flanz. The ones that I know of fall within the 
jurisdiction of my office, which only looks at senior managers, 
so I can't speak to the folks below that level. We have been 
involved in recommending termination for three individuals 
whose charges included whistleblower retaliation.
    Dr. Huelskamp. So they have been terminated?
    Ms. Flanz. Yes.
    Dr. Huelskamp. The second question will follow up on the 
issue of whistleblower medical records--and may we have the 
names of those who were terminated?
    Ms. Flanz. Not in this public forum, but I would be happy 
to provide them.
    Dr. Huelskamp. I will follow up, then, on whistleblower 
medical records.
    Ms. Lerner, you made reference to that later in your 
written testimony, that perhaps supervisors or others have 
accessed illegally medical records of whistleblowers in order 
to discredit them.
    Can you describe that situation? This is just shocking and 
astonishing, that that would actually be occurring in the VA.
    Ms. Lerner. I mean, we have raised some of these concerns 
directly with the VA and with the IG. What we are seeing is a 
pattern of not just accessing medical records but 
investigations opened after someone comes forward for things 
like HIPAA violations or Privacy Act violations, relatively 
minor violations that become the focus of the investigation, 
rather than the underlying disclosure that the whistleblower 
came forward with initially.
    And it is really problematic from, you know, lots of 
perspectives. One of them is that, obviously, the underlying 
disclosure isn't being looked at, but it also has a very 
chilling effect on other whistleblowers. And so we are----
    Dr. Huelskamp. But the HIPAA violation is by the VA 
retaliating against the whistleblowers, as I understand, not 
the whistleblowers----
    Ms. Lerner. Well, it is both--it is all of those things. It 
is----
    Dr. Huelskamp. My question is about medical records of 
whistleblowers being accessed. So that actually has occurred? 
Do you have any idea roughly how many times that has----
    Ms. Lerner. I don't know the number. I can find out for 
you. I know we have cases that involve improper access to the 
whistleblower's medical records. Because, obviously, lot of the 
people who work at the VA get their care from the VA, and so 
their medical records are there, and----
    Dr. Huelskamp. Of course, the VA, as a governmental agency, 
is exempt from HIPAA. Is that correct?
    Ms. Lerner. I don't----
    Dr. Huelskamp. So, Ms. Flanz, you are shaking your head. 
So, then, what is the penalty for inappropriately accessing 
whistleblower medical records?
    Ms. Flanz. There is a range of penalties. And in each case, 
we have to look to see whether, in fact, the individual who 
accessed the record had a business reason to do so.
    I am also deeply troubled by this. We do see it far more 
often than you would expect. I don't know whether that is 
because so many of our employees are veterans who receive their 
care at VA facilities. It is a deeply troubling phenomenon.
    Dr. Huelskamp. Well, I would say my idea for penalty for 
that would be immediate dismissal.
    I yield back, Mr. Chairman.
    Mr. Coffman. Thank you, Dr. Huelskamp.
    Ms. Roby, you are now recognized for 5 minutes.
    Ms. Roby. Well, first, thank you to the chairman for the 
invitation to join you today. Many of you know I don't sit on 
your committee, but I do sit on the Appropriations MILCON-VA 
Subcommittee. And Mr. Tremaine is my constituent.
    And I am very grateful to have you here today.
    Two observations, quickly--and to the ranking member, thank 
you.
    One, two huge understatements: first, to say that these 
people are coming forward shows that there are issues that 
still need some attention; as well as this saying that we hear 
over and over again that you can't change a culture overnight. 
Well, it has been a year, it has been almost a year since Mr. 
Tremaine and I had our first conversation. So we are kind of 
tired of hearing you can't change this culture overnight. It 
hasn't been overnight; it has been a year.
    And so here we are today--and, Mr. Tremaine, I was 
traveling up here today, and I was thinking about us being in 
this room together today and how significant that is. And I 
just want to thank you for being willing to tell me the truth 
when no one else was. For you and Dr. Meuse to step forward to 
reveal the horrible circumstances in Montgomery and Tuskegee 
just says a lot of about who you are.
    And I just want to--I have thanked you many times for this, 
but I am going to take this opportunity today publicly, Mr. 
Chairman and Ranking Member, to thank Mr. Tremaine and the 
other whistleblowers that are here, who I don't know, but I 
appreciate your courage, as well.
    Thanks to Mr. Tremaine, we uncovered layers of scandal at 
the Central Alabama VA, thousands of missing x rays, 
manipulated medical records, as Mr. Tremaine referenced, the VA 
employee who took a recovering veteran to a crackhouse and 
only--it took a year and a half, even though the administration 
knew that this had happened, it took a year and a half for that 
individual to be fired. This is the culture that we are talking 
about.
    And, here, a year later, we have taken a step backwards, 
when an AP article that we saw at the end of last week showed 
that Montgomery and Tuskegee, the two hospitals that Mr. 
Tremaine worked at, were number one and number two for the 
worst in the country. Because there is a new scam now, Mr. 
Chairman and Ranking Member. It is, let's schedule the 
appointment within the timeframe required, but we will cancel 
it 30 minutes before the appointment and reschedule it so that 
on the books, once again, it looks as though the VA is doing 
what they are supposed to do.
    And, by the way, if they come in--I learned this just last 
week, and you probably already know this. But if a mental 
health patient comes in and asks to be seen as a walk-in, they 
only get reimbursed for half their travel expenses than they 
otherwise would have as an appointment-holder--which, by the 
way, was only canceled 30 minutes prior to their arrival.
    This is the kind of stuff that we are hearing directly from 
veterans. And I have to tell you, nothing has improved. We have 
taken steps backwards.
    And so, Mr. Tremaine, thank you for being here.
    But, to that point, I want to ask you--because I have asked 
nicely for a year, and all apologies to those who raised me, 
but I am a little over being nice at this point--how often, Mr. 
Tremaine, in the last 6 months did a professional staff member 
from the Secretary of the VA's office here in Washington sit in 
your regularly scheduled staff meetings at CAVHCS?
    Mr. Tremaine. Zero, as far as I know, Congresswoman.
    Ms. Roby. Zero. Right. Zero.
    So Senator Shelby from Alabama and myself sent a letter, 
when all of this information was revealed, that we wanted 
Washington VA to come down and directly oversee what was 
happening at Central Alabama VA.
    Over the last 6 months, has there been any presence from 
the national VA in Central Alabama, a direct link to the 
Secretary's office here in Washington, to oversee what is 
happening at CAVHCS in the last 6 months?
    Mr. Tremaine. Not to my knowledge, ma'am.
    Ms. Roby. Okay. And so, in your view, has the Secretary and 
other top leadership here in Washington shown a direct, 
sustained interest and investment in correcting the problems at 
CAVHCS?
    Mr. Tremaine. No, ma'am.
    Ms. Roby. So would you say that Washington followed through 
with its promise to directly oversee the overhaul at CAVHCS, or 
was the work staffed out to Mr. Sepich and Mr. Jackson? Who, by 
the way, Mr. Sepich was the VISN 7 director, and Mr. Jackson is 
now the acting director after Mr. Talton was removed.
    Mr. Tremaine. Yes, he was placed there by Mr. Sepich. He 
was the deputy network director. And when Mr. Talton was fired, 
Robin Jackson came in as the director. And, again, I think I 
pointed out that I thought he was woefully----
    Ms. Roby. And I am a visitor here, so I have to be real 
careful not to violate your rules of 5 minutes, but if I can 
just point out one other thing.
    Ms. Flanz was in the room with me and the Deputy Secretary 
when I asked Mr. Sepich to be included in the same 
investigation that Mr. Tremaine and Dr. Meuse were subject to 
intense interrogation. Because Mr. Sepich was the boss of the 
first senior administrator that was fired for mismanagement and 
misconduct under the law that this Congress passed last August. 
Mr. Sepich quietly retired 1 week ago.
    Thank you for letting me be here, Chairman and Ranking 
Member.
    Thank you to Mr. Tremaine and Dr. Head and Dr. Hooker. I 
just can't tell you how much I appreciate your courage and your 
willingness to help us help get this right.
    Mr. Tremaine. Well, thank you, Representative. And I think 
that, you know, your passion speaks for itself.
    And I think when I mentioned about being on the right team, 
I mean, there is no question that, you know, our 
Representative, Martha Roby, has been an advocate for veterans 
that, you know, we haven't seen the likes of.
    So thank you so much for that, ma'am.
    Mr. Coffman. Ms. Kuster.
    Ms. Kuster. Thank you very much.
    Just a brief follow-up along the lines of Representative 
Rice. And I want to ask Ms. Lerner--this is sort of procedural, 
but I think it will get at an important point.
    You talked about the Office of Medical Inspector now doing 
a more proactive or interactive follow-up to the 
recommendations, and you mentioned including disciplinary 
action. And that seems to be what is hanging in the room over 
this hearing, our disappointment that it sounds as though it is 
a more rigorous investigation of the whistleblowers than of 
those that have been standing behind retaliation.
    And, to me--and I think this is what Representative Rice is 
getting at--if you want to actually change the culture, you 
have to change the view, not just it is the first step that we 
will take care of whistleblowers and treat them fairly, but 
that something will actually happen to those employees who 
enter into retaliation.
    I am an attorney, I understand the burden of proof. But can 
you follow up with this role--maybe we don't have the right 
witness here, in terms of the Office of Medical Inspector--what 
types of disciplinary action? And can we ask for any data that 
may be available on the disciplinary action that has actually 
been taken?
    Ms. Lerner. Sure.
    I think there are two different processes here. The Office 
of Medical Inspector investigates once we get a disclosure that 
we refer for investigation. So that process is separate. And 
one of the things that we look at when we decide whether the 
Office of Medical Inspector's investigation report is adequate 
and before we report to the President and to the Congress is, 
have they taken appropriate corrective action? Where they found 
a problem, has someone been disciplined? Has relief been 
provided?
    And that is not--what they do is not really retaliation 
investigations. Where we are seeing the problem with 
retaliatory investigations is with the IG and with the regional 
counsel. The problem really is that, when someone comes forward 
with a disclosure, then an investigation is often opened up 
into their own behavior.
    So, about 80 percent of the time, when people come to us 
with a disclosure, they experience retaliation. We can protect 
them from retaliation if they come forward, but the Office of 
Medical Inspector is really just looking at the underlying 
disclosure.
    Ms. Kuster. So then there is a procedure that is missing. 
Because my colleague Mr. Walz talked about how you need to deal 
with protecting the whistleblower, you need to deal with making 
the long-term changes for the health and well-being of the 
veterans, but I want to get at the crux of the matter.
    Who is investigating the retaliatory action, and what is 
the disciplinary procedure for that person? Do you follow me? 
We are----
    Ms. Lerner. Sure.
    Ms. Kuster. We are going to miss the forest for the trees 
here.
    Ms. Lerner. Yes. When someone makes a disclosure and they 
experience retaliation, they have a number of options. They can 
go to the accountability review. They can go to the IG. They 
can come to OSC. They can come to Congress.
    If they experience retaliation, we can open up an 
investigation, or we can use our expedited review process to 
try and get relief very quickly for them. And we have been able 
to get relief quickly for at least----
    Ms. Kuster. But you are still talking about relief to 
protect them. I want to follow--keep----
    Ms. Lerner. Protect the whistleblower.
    Ms. Kuster [continuing]. Keep going on the track. What is 
the procedure for a disciplinary proceeding to set the example?
    I mean, look, that is half of what the criminal justice 
system is all about, it is part of what an employee justice 
system is about, to set this example. Here, we are modeling the 
behavior of this collaborative approach. Over here, we don't 
want this to happen, sending somebody to an office with a hole 
in the floor, sending somebody else to an office with no 
windows. You know, these are things that are not tolerable, and 
we are going to demonstrate that to all the other employees in 
this VISN by saying, oh, that person was let go, they didn't 
uphold a standard of cooperative, collaborative spirit that we 
hold dear in our workplace.
    Ms. Lerner. Disciplinary action is really key to 
accountability. There is no question about it. In terms of 
changing a culture, you have to hold people accountable. It 
deters future violations, as well.
    Our primary focus is on making the whistleblower whole and 
putting the whistleblower back. You know, we have 130 employees 
for our agency, and we have to prioritize where we put our 
efforts.
    Ms. Kuster. Sure. But----
    Ms. Lerner. But what we do is, where we identify a case 
where we think disciplinary action is appropriate, where 
someone has been retaliated against, we work with the Office of 
Accountability Review, we work with the VA general counsel, and 
we try and get the agency to take disciplinary action. And we 
have several cases in the pipeline right now, in fact, that 
will involve disciplinary action. We are trying to pivot and 
focus more and more on disciplinary action as an agency.
    But our first priority has been getting people back to 
work. When someone has been fired, we want them back to work. 
When someone has been moved to the basement, we want to get 
them back. And we have been very successful, actually, in doing 
that.
    Ms. Kuster. Well, my time is up, but I want to make the 
point that the sooner you can get to the disciplinary action 
for the retaliatory behavior, the shorter the list of cases you 
are going to be piling through for years on end of examples 
such as these. So you need to set an example. But thank you.
    And I apologize for going over.
    Mr. Coffman. Dr. Benishek, you are now recognized for 5 
minutes.
    Dr. Benishek. Dr. Head, you still don't have an office, 
basically, because you were put in this bad office?
    Dr. Head. It is shameful. And it is kind of----
    Dr. Benishek. But is that true? Are you still basically----
    Dr. Head. Well, I have that office that they would like 
to----
    Dr. Benishek. Ms. Flanz, why hasn't he gotten his regular 
office back?
    Ms. Flanz. I don't know, but I will find out.
    Dr. Benishek. I think that is a pretty good question to 
ask, because obviously he is here in good faith, and I would 
like to get an answer to that question.
    Dr. Head, the guy, your supervisor, is that the same 
supervisor you have had all the way along for this whole 
ordeal?
    Dr. Head. No. On paper, it is Dr. Norman Ge. He is the 
chief of staff at Long Beach. But, really, it is Dr. Dean 
Norman who has been responsible for this.
    Dr. Benishek. That is the same person that has been there 
right along?
    Dr. Head. Yes.
    Dr. Benishek. Ms. Flanz, apparently, VA employees often 
confidentially provide patient information necessary to 
substantiate allegations of improper care to this subcommittee. 
This is not a HIPAA violation, so why are employees sometimes 
accused of privacy violations for this activity?
    Ms. Flanz. I think it is a function of confusion on the 
part of supervisors. VA is appropriately very protective of 
protected patient care information, and not all supervisors are 
aware of the right of employees to provide that information to 
this committee and to other oversight bodies.
    Dr. Benishek. Ms. Lerner, what changes have occurred in the 
Office of Special Counsel since the last year's hearing? Is 
there anything that has substantially changed in the office?
    Ms. Lerner. Well, we have had many more cases to 
investigate in the last year. We have been able to do a little 
bit of hiring. We have been able to hire someone to work full-
time on VA cases in the expedited review system and hire 
additional staff to work the cases.
    I mean, our process works. We have been getting relief for 
whistleblowers. We are getting people back to work. We are 
getting them stays of adverse personnel actions. You know, 
people, you know, I think, feel more comfortable and know about 
us, so we are getting more cases.
    Dr. Benishek. All right. Thank you.
    Dr. Hooker, I want to give you a chance to speak for a 
minute, because I don't think you have been heard from enough. 
Tell me what your response is today to the testimony of Ms. 
Flanz and Ms. Lerner.
    Dr. Hooker. Well, I can tell you by illustrating that we 
had a whistleblower who reported an inappropriate practice of 
giving Suboxone medication to help people who have addiction 
problems. And you are really technically not supposed to 
continue giving that medication if someone has an abnormal 
urine drug screen, so repetitive positive urine drug screens 
should be a cause for not giving that medication anymore.
    We had a clinical nurse specialist who reported that 
practice going on, and rather than investigate, they 
investigated that nurse. He has been sitting in a clinical 
clerical position even though he is a clinical nurse 
specialist. He is essentially doing no functions. He is in a 
windowless office, reporting to clerks who need, you know, 
something moved or carried around, when he has a master's 
degree and is going for his Ph.D. And he is on Active Duty, 
just this past weekend, in the Reserves.
    They have now proposed on Friday--he did contact the Office 
of Special Counsel back in August when he was first detailed. 
And they did propose discipline against him this Friday, a 
proposed suspension, on something that occurred in 2013 and a 
couple of other things that they allege occurred in 2014.
    Dr. Benishek. Let me just interrupt you a minute, because I 
have heard of this before from the other members, other 
physicians, saying that they get a peer-reviewed gig against 
you, something that they can put against you without 
referencing the thing that you brought up.
    Dr. Hooker. Right.
    Dr. Benishek. Is that your experience, as well?
    Dr. Hooker. Yes. My personal experience when I have been in 
the limelight for reporting things, I only had one time when I 
was called to a peer-review committee, and I have worked for 
the VA over 26 years.
    And this particular instance, there was no peer in the room 
or on a telephone to be my peer. There was a dietician in the 
room, and there were, you know, a few other, like, you know, 
occupational therapists, in addition to a smattering of 
physicians. But there was no true peer for me to address my 
concern to. That was number one.
    Number two is that the----
    Dr. Benishek. So the peer-review process is flawed at your 
facility, it sounds like.
    Dr. Hooker. Yes, in certain circumstances, very flawed. 
Because people that they want to, you know, in a sense, 
harass--I had another colleague--well, several colleagues, who 
had no true peer in the room when they went before the peer-
review committee.
    Then we have people who are in the inner circle, who are 
the team players, who don't get peer-reviewed for cases that 
should be peer-reviewed and then others who get peer-reviewed 
for cases that really should not be peer-reviewed.
    Dr. Benishek. Thank you, Dr. Hooker.
    Thank you, Mr. Chairman.
    Mr. Coffman. Miss Rice, you are now recognized for 5 
minutes.
    Ms Rice. Thank you, Mr. Chairman.
    Ms. Flanz, I would just like to go back to the conversation 
we were having where you were talking about the burden of proof 
for retaliators.
    What is the burden of proof that you apply when you are 
looking into allegations made by whistleblowers?
    Ms. Flanz. In any case, it depends on the tribunal that 
might hear an action.
    Ms Rice. Say it is you.
    Ms. Flanz. I am not a tribunal.
    Ms Rice. Well, I mean, say it is you making a 
recommendation to a DA's office or--who? The U.S. attorney? Who 
are the possible offices you could make----
    Ms. Flanz. In most cases, employee discipline is going to 
be subject to appeal to the Merit Systems Protection Board. The 
Merit Systems Protection Board in almost all cases applies a 
preponderance-of-the-evidence standard.
    Ms Rice. Is that true for both retaliators and for 
whistleblowers?
    Ms. Flanz. If an action is going to be taken against an 
employee that is subject to appeal, if it is a suspension, a 
demotion, a removal, most actions--now, there are differences 
if we are talking about Title 38 doctors and nurses, who have 
their own disciplinary process.
    But if we are talking about a government employee under 
Title 5, if the allegation is that that person did something 
wrong and should be disciplined and the appeal goes to MSPB, in 
most cases, the preponderance-of-the-evidence standard would 
apply.
    Ms Rice. And in terms of any disciplinary action that is 
meant to be taken against a retaliator or a whistleblower, they 
both have built-in protections in the law, whether it is by 
their union representation or whomever--no? There is none?
    Dr. Hooker. Not for pure Title 38. That is a little glitch 
in the system----
    Ms Rice. Well, that is something----
    Dr. Hooker [continuing]. Pertaining to section 7422 of 
Title 38.
    The Secretary of Veterans Affairs controls our clinical 
practice, our clinical competence. So what the Secretary says 
goes. And that is typically delegated to a chief of staff 
locally, who can be very, very, very retaliatory to physicians 
who do not play according to the party line or who are not team 
players.
    Ms Rice. That is interesting.
    Mr. Chairman, obviously, maybe that is something that we 
should, as a committee, look into trying to fix.
    So, in my prior life as a prosecutor, there was a saying 
that is true not just in the world of criminal justice but, 
unfortunately, I see it here in the world of VA and 
specifically whistleblowers. And that term is, ``Snitches get 
stitches.'' And while Dr. Head, Dr. Hooker, and Mr. Tremaine 
don't have the actual physical stitches, they surely are 
bearing the figurative ones.
    Thank you, Mr. Chairman.
    Mr. Coffman. Thank you, Miss Rice.
    Dr. Huelskamp, you are recognized for 5 minutes.
    Dr. Huelskamp. Thank you, Mr. Chairman.
    I am still trying to figure out parts of the testimony. But 
I am looking at a document from November 2014, ``Rebuilding 
Trust,'' from the VA Secretary.
    At that time, he did note that there were over 100 
investigations currently being undertaken. Do you have a rough 
figure of what those numbers are today?
    Ms. Flanz. I believe he was speaking to the IG's ongoing 
investigations into alleged misuse of scheduling and wait-list 
systems. The IG was, at its most active point, active at 98 
sites. They have completed their work at several of them.
    Let me just make sure I have the right data here.
    They have completed their work at 43 of those sites. They 
have substantiated some scheduling impropriety at 14 of the 43. 
They found no particular impropriety at 29. And their 
investigations are ongoing at the balance.
    Dr. Huelskamp. So that is, of the 100 from November, still 
haven't gotten to the second half of those? Are my numbers 
correct?
    Ms. Flanz. The IG has not yet delivered to the Department 
its report in the others. Yes.
    Dr. Huelskamp. Okay. So 5 months later from this report to 
the public by the Secretary, and half these--I mean, these 
serious investigations have yet to be completed or be started 
or we don't know the status of those?
    Ms. Flanz. You would really have to ask the IG.
    Dr. Huelskamp. Okay. Well, this is coming from the 
Secretary of the VA, and I appreciate you are representing the 
Department.
    Ms. Flanz. Yes.
    Dr. Huelskamp. Can you ask them for me? This is from the 
Secretary. This says, ``working diligently to cooperate with 
investigations by the inspector general, the Justice 
Department, and Office of Special Counsel.'' So this is all 
those together.
    And so, do you know roughly a comparable figure today? More 
or less? But if I understand correctly, though, half of these 
have yet to be completed or even start the investigation.
    Ms. Flanz. I believe the IG has started them all and 
probably even finished quite a few but not yet delivered their 
reports.
    Dr. Huelskamp. Okay. And this would be, presumably, where 3 
individuals have been fired, out of 100 investigations? Is that 
what we are looking at here?
    Ms. Flanz. The question that you posed before about 
individuals, to which I gave you the answer three, had to do 
with whistleblower retaliation. The IG is looking at something 
different, and so that would be a different number.
    Dr. Huelskamp. Okay. What is that number, then?
    Ms. Flanz. I am here today to talk about whistleblower 
retaliation. And I apologize, I don't have the number of 
actions taken as a result of the IG's findings.
    Dr. Huelskamp. Okay.
    Well, one thing I will ask about your testimony--and you 
were before this subcommittee last month. I am just curious, 
when you put together this testimony, who do you visit with 
above you to clear this testimony? I mean, do you visit with 
the Secretary himself and the Deputy Secretary and they clear 
this testimony before the committee?
    Ms. Flanz. There is a process that includes our leadership, 
yes.
    Dr. Huelskamp. And so they approve everything in your 
testimony?
    Ms. Flanz. The front office approves all testimony, yes.
    Dr. Huelskamp. So nobody in the front office knew that Mr. 
Head did not have an opportunity to visit with the Secretary, 
even though, reading this, I would suggest you assumed that 
he--you are suggesting everyone was talked to. So somebody 
looked at this and let you say that a visit might have been 
made? Am I understanding that correctly?
    Ms. Flanz. My testimony is that the Secretary makes a point 
of meeting with whistleblowers as he travels throughout the 
system. My testimony didn't specifically speak to any meeting 
with Dr. Head.
    Dr. Huelskamp. What about the other two individuals 
testifying?
    Dr. Hooker.
    Dr. Hooker. When the Secretary of Veterans Affairs came to 
our facility, he did not meet with any whistleblowers per se.
    We asked for a private meeting with him, because we had 
sent a letter in November about a number of people under 
investigation that we felt were inappropriate, administrative 
investigation boards that appeared to be sham investigation 
boards. He had a strict schedule. We were allowed to go with 
another union for 15 minutes together jointly. I was unable to 
go because I had patient care duties, so my colleagues in the 
union went.
    Dr. Huelskamp. Mr. Tremaine.
    Mr. Tremaine. The Secretary didn't visit our facilities. 
The Deputy Secretary did, but he did not meet with any of us.
    Dr. Huelskamp. Okay.
    I am just about out of time. If I might ask of Ms. Flanz, 
of the 15 corrective actions that were identified from the 
Office of Special Counsel, I would like to know how many of 
those actually had visits with senior VA officials.
    Ms. Flanz. I don't know.
    Dr. Huelskamp. Would you please find out and report to the 
committee?
    Ms. Flanz. Yes, sir.
    Dr. Huelskamp. I yield back, Mr. Chairman.
    Mr. Coffman. Thank you, Dr. Huelskamp.
    Mr. Walz, you are now recognized for 5 minutes.
    Mr. Walz. Thank you, Mr. Chairman.
    Again, and I am going to follow along a little bit, I am 
going to venture out on a limb. I will bet you get a call from 
the Secretary now. Ms. Flanz might back me on that, I would 
bet.
    But it goes to something bigger for me. I would argue and 
go back to this issue with Secretary Shinseki and others, I 
think many times they are let down by those around them. And it 
takes us back to that core issue of delegation of authority. In 
an organization this big, that has to happen. And so I want to 
get to this training, how we are going to change it, how we are 
going to make it better.
    And I want to talk about OSC 2302(c). I would bet everybody 
in this room, at one time or another, has gone through some 
form of professional training, whether it was on a Friday 
afternoon or there was a retreat or something like that. And I 
bet in our professional careers you can count and tell the ones 
that were highly effective and those that were forgettable. 
This is an important issue.
    I am going to go to this. Have any of the three of you, Dr. 
Head, Dr. Hooker, and Mr. Tremaine, have any of you received 
OSC 2302(c) whistleblower certification training?
    Dr. Hooker. No, I have not.
    Mr. Tremaine. I have not.
    Dr. Head. No.
    Mr. Walz. Don't you wish those three would have got it?
    Ms. Lerner. Can I speak to that?
    Mr. Walz. Sure.
    Ms. Lerner. I think what--what the 2302(c) certification 
training is is--it is not a specific training. There are five 
steps that agencies have to take to become certified. And one 
of them is--I mean, a lot of it is a training component, but it 
means putting posters at facilities, providing information to 
new employees about retaliation and their rights, providing 
information to current employees----
    Mr. Walz. Is there confusion on that?
    Ms. Lerner. I am sorry?
    Mr. Walz. Is there confusion on that in the VA, that if 
someone tells you about a practice, isn't it widely known that 
you don't move them from their office without due process or 
anything? And, again, yes, facetiously, but I am fit to be tied 
here.
    Ms. Lerner. I mean, I think the problem----
    Mr. Walz. Do you believe this is going to work?
    Ms. Lerner. You know, I think the problem is that it has to 
filter down to the regions. I think that the message is good 
coming out of headquarters, but the folks who are actually 
implementing it need more training.
    Mr. Walz. Dr. Head, is this going to work?
    Dr. Head. I think the current practices need a big change.
    Mr. Walz. So it is a step in the right direction.
    I would venture to say this. I always think about this as 
training focuses on technique and content, development focuses 
on people. I would argue VA's issue is people, focusing on 
that, in these positions.
    I would argue--and this is what always pains me, is the 
vast majority--and these hearing are very difficult for me, 
because there is a whole bunch of dedicated VA employees out 
there that are giving and sacrificing and doing great service, 
and their morale is hurting when they hear us do this. The 
problem is it tends to be some of those folks in that 
management chain that do that.
    So my question to the three of you is, what would be the 
most effective thing we can do? And I don't want to belittle 
the training part of it. I should go on the record and be clear 
about that. I think you need to know that, and I think it is 
good to do a refresher course on what is appropriate, what is 
legal, what is there, and all that. So I am doing that. I 
just--it seemed to be a central focus of what we are going to 
do to change this.
    I would ask the three of you, what should we be doing more 
of?
    Mr. Tremaine. Well, I think one of the--your definition, 
when you used the Webster's definition of a ``whistleblower,'' 
I think that in itself is really derogatory. You know, I don't 
think that--that in itself just, I think, kills a lot of 
people. When they think whistleblower, they think negativity. I 
think that, again, you have to embrace that. You have to 
embrace the whistleblower and acknowledge that and acknowledge 
that there are problems, and you have to resolve those 
problems.
    And so I think that, you know, again, just that 
acknowledgment and that openness, the transparency, is 
critically important. And we just don't have that. We have the 
retaliation. That seems to be the first step anytime a 
whistleblower comes forward.
    Mr. Walz. Why the fear? Why not wanting to be better? Why 
not wanting to hear that? You can take everything with a grain 
of salt. Like, each one of us in our personal lives, when you 
get positive feedback, especially those you trust, those around 
you and other people. Why that resistance to hearing the truth?
    Mr. Tremaine. You know, I don't know. I think you hit the 
nail on the head when you said there are many VA employees. I 
mean, the majority of the VA employees, you know, 99.9 percent 
of the VA employees----
    Mr. Walz. Yes.
    Mr. Tremaine [continuing]. Are going to work every single 
day and love taking care of veterans and doing the right thing. 
And you just have that small minority that, you know, feel that 
they can utilize taxpayer money to do whatever they want and 
retaliate and call----
    Mr. Walz. Do you think Miss Rice is right, that there just 
needs to be some teeth in this thing, that folks need to know 
it is not going to be tolerated? Is there a patience to this?
    And, again, I don't want to step on anybody's due process 
rights, but you hear the frustration across the spectrum up 
here that nobody is ever held accountable. And it is not a 
juvenile desire to see punishment for the sake of punishment. 
It is about making sure good people are served.
    Dr. Hooker. For professionals, we don't have due process 
rights in the traditional sense. So 7422 prevents us from 
having that due process right.
    In the community, I would be held to the standards of my 
peers. In the VA, the Secretary tells me what I do and how I do 
it. So I can't argue, in a sense, the way I could with 
colleagues. I don't have the collegial oversight. I have 
clerks, in a sense, telling me how to practice medicine.
    And then if I call the Office of Special Counsel and I 
report, because I did----
    Mr. Walz. That is a big problem.
    Dr. Hooker. Well, I did come across evidence that another 
veteran employee reported 2 years before I discovered it 
through a proposed termination of another employee who had 
brought up some issues. So she was put in another windowless 
office in the basement. She had two master's degrees and a 
counseling degree.
    But where I am going with this is that when I reported to 
the IG--I'm sorry, the employees went to the Office of Special 
Counsel, I went to the inspector general. The report basically 
goes back to the VA. And, actually, I did call the OSC on all 
the nine people I currently have sitting home getting paid at 
high professional salary levels for not doing their job, when 
they haven't really--they don't even know why they are home.
    I have an ophthalmologist who is home. She was just removed 
one day, just threatened with--you know, so when we do report 
to those outside agencies, they turn it over to the VA for 
investigation. I am not a farmer, but I would have trouble 
asking the fox how many hens are left in the coop when the 
feathers are sticking out of the fox's mouth.
    Mr. Walz. Well, most of it boggles my mind, but the thing 
that keeps coming back to me is that this is how deep this is. 
What is the deal with this office thing and moving people to 
the basement? And it just boggles my mind. That isn't 
intimidation; that is your definition of violence in the 
workplace, in my opinion.
    Dr. Hooker. It is unacceptable.
    Mr. Walz. Okay.
    I went over my time----
    Dr. Head. One----
    Mr. Walz [continuing]. And I don't know if the chairman 
wants to follow up.
    Dr. Head. One quick final point.
    There has to be accountability. You know, moving me to, you 
know, a storage bin, you know, makes me feel bad. But they are 
trying to send a message not only to me, they are trying to 
send a message to everyone there saying, look at Dr. Head, he 
thinks he is great. He went and testified in front of Congress. 
They said they are going to protect him. But you know 
something? On my VA, no. They listen to me. And Congress can't 
do a thing about it.
    And they are trying to intimidate all the other potential--
I like to label whistleblowers as patriots. We should name them 
in the VA system, these patriots. They are trying to suppress 
their willingness to try to make a better life for these 
veterans, and it is just--it is shameful.
    Mr. Coffman. Thank you, Dr. Head.
    Let me just say also that the retaliation simply isn't 
limited to employees of the VA but also patients of the VA who 
step forward.
    And in Colorado, we had a case last year where a patient 
gave a statement to an investigative reporter, and the reporter 
then called the VA and talked to the public affairs individual 
for that particular VISN. And the public affairs individual 
said, ``Oh, you really don't want to talk to this person. He is 
a patient undergoing psychiatric care.''
    I sent a letter to the Secretary of the Veterans Affairs. I 
have never gotten a response to this date.
    Our thanks to the witnesses. You are now excused.
    Today, we have had a chance to hear about problems that 
exist within the Department of Veterans Affairs with regard to 
whistleblower retaliation. From the testimony provided and 
questions asked today, I am dismayed at the failure of the 
Department to adequately protect conscientious employees who 
seek to improve services provided to our veterans.
    As such, this hearing was necessary to accomplish a number 
of items: to, number one, allow VA to highlight what efforts it 
has made to improve whistleblower protection, practices, and 
processes; two, address where improvements either have not been 
made or where insufficient attempts give way to continued 
retaliation experienced by whistleblowers; and, three, assess 
next steps to be taken both by VA and by this committee to 
ensure that those employees who seek to correct problems within 
the Department are adequately protected.
    I ask unanimous consent that all members have 5 legislative 
days to revise and extend their remarks and include extraneous 
material.
    Without objection, so ordered.
    Mr. Coffman. I would like to once again thank all of our 
witnesses and audience members for joining us at today's 
hearing.
    With that, this hearing is adjourned.
    [Whereupon, at 5:56 p.m., the subcommittee was adjourned.]

                                 

              Prepared Statement of Chairman Mike Coffman

    Good afternoon. This hearing will come to order.
    I want to welcome everyone to today's hearing titled, ``Addressing 
Continued Whistleblower Retaliation Within VA.'' I would like to ask 
unanimous consent that the Hon. Martha Roby from the state of Alabama 
be allowed to join us on the dais, as she has been very active in the 
case of one of our witnesses here today. Additionally, I would like to 
ask unanimous consent that two statements be entered into the hearing 
record: one from a whistleblower and one from the Project on Government 
Oversight. Hearing no objection, so ordered.
    This hearing will focus on the treatment of whistleblowers within 
the Department of Veterans Affairs, particularly the types and levels 
of retaliation they experience when reporting problems. This will serve 
as a follow-up to the hearing conducted by the Committee in July 2014, 
where we will address what progress the department has made since then 
to correct its retaliatory culture and where VA has failed to protect 
conscientious employees who seek to improve services for our nation's 
veterans.
    The three whistleblowers we will hear from today come from VA 
facilities across the country. The hostility they receive for their 
conscientious behavior shows that the retaliatory culture, where 
whistleblowers are castigated for bringing problems to light, is still 
very much alive and well in the Department of Veterans Affairs. The 
truth of the matter is, the Congress needs whistleblowers within 
federal agencies to help identify problems on the ground in order to 
remain properly informed for the development of effective legislation.
    For example, the national wait times scandal that this Committee 
revealed at a hearing just over one year ago, which resulted in the 
Secretary of the department resigning, simply would not have occurred 
without responsible VA employees stepping forward to fix problems. In 
the year since that scandal originally came to light, a new Secretary 
has come to the department, and he has stated that one of his primary 
missions is to end whistleblower retaliation within VA.
    The Congress also passed legislation that makes it easier for the 
Secretary to fire poor performing and bad acting Senior Executive 
Service employees who in some cases perpetrate and encourage 
retaliatory behavior. Despite these efforts, retaliation is still a 
popular means used by certain unethical VA employees to prevent 
positive change and maintain the status quo within the department. In 
January, full committee Chairman Jeff Miller introduced legislation 
that would improve protections provided to whistleblowers within VA.
    It will also discourage supervisors and other managerial employees 
from attempting to retaliate against whistleblowers by imposing more 
strenuous penalties for engaging in retaliation, including suspension, 
termination, and loss of bonuses. It is very simple, if you retaliate 
against or stifle employees who are trying to improve VA for our 
nation's veterans, you should not be working for VA, and you certainly 
should not receive a bonus for your despicable actions.
    To that end, I encourage Members to join with numerous VSOs and 
whistleblower protection groups in support of H.R. 571, the Veterans 
Affairs Retaliation Prevention Act. Along with the whistleblowers here 
today, we will hear from the Office of Special Counsel regarding the 
efforts VA has made since our last hearing to improve its treatment of 
whistleblowers and where improvements remain absent and needed. A 
representative of VA will also be here to address why whistleblowers 
continue to have their livelihoods jeopardized for attempting to make 
VA a better service provider for our nation's veterans. I look forward 
to the discussion we will have here today on this important issue.
    With that, I now yield to Ranking Member Kuster for any opening 
remarks she may have.

                                 

         Prepared Statement of Ranking Member Ann Mclane Kuster

    Thank you Mr. Chairman.
    This afternoon, the Subcommittee on Oversight and Investigations is 
holding a follow-up hearing to a hearing this Committee held last July. 
I believe that some of the most effective hearings this Subcommittee 
holds are follow-up hearings--they enable us to examine progress made 
and current problems that still exist at the VA. That is the core of 
our work here--to identify problems and work together to fix them and 
ensure the highest quality of care is being delivered to our veterans.
    Today's hearing will focus on VA's treatment of whistleblowers, who 
play a crucial role in ensuring the VA is held accountable for 
providing quality care for our nation's veterans. Whistleblowers were 
instrumental in helping this Committee uncover wrongdoing at the 
Phoenix VA, which helped inform our drafting of the Veterans Choice 
Act. We must ensure that no one is afraid to come forward to report 
instances of mismanagement or wrongdoing that hinders our veterans' 
ability to receive care.
    In terms of the Department of Veterans Affairs and its treatment of 
whistleblowers, a great deal of progress has been made. VA has 
established the Office of Accountability Review and has reorganized the 
Office of the Medical Inspector. The VA is also the first cabinet-level 
agency to satisfy the requirements for the Office of Special Counsel's 
whistleblower certification program. In addition, VA and the OSC have 
implemented and expedited the review process for whistleblower 
retaliation claims.
    I am pleased to hear how the VA has taken these steps moving 
forward, however there are still many problems that still exist 
regarding how the VA treats and handles whistleblowers. OSC is 
responsible for whistleblower complaints from across the Federal 
government, yet it estimates that 40 percent, close to half of its 
incoming cases in 2015, will be filed by VA employees. OSC reports that 
the number of new whistleblower cases from VA employees ``remains 
overwhelming'' and that its monthly intake of new VA whistleblower 
cases remains high at a rate of nearly 150 percent over historical 
levels. According to OSC, these alarming cases include disclosures of 
``waste, fraud, abuse, and threats to the health and safety of our 
veterans.''
    The large number of complaints received from VA employees is, to 
some extent, a reflection of the size of the VA, but it also raises 
serious red flags as to the continuing problems that are systemic 
throughout the VA system and the treatment of VA employees.
    The OSC testimony highlights some troubling concerns that the VA 
sometimes investigates the whistleblowers themselves, rather than 
investigating allegations raised by those whistleblowers. The OSC also 
references several cases where the medical records of whistleblowers 
were improperly and unlawfully accessed in what seems to be attempts to 
discredit some whistleblowers.
    As a New York Times article last year outlined, there is a 
``culture of silence and intimidation'' and a history of retaliation at 
the VA. According to the whistleblowers testifying before us this 
afternoon, this is still the case today. They will testify about this 
environment of intimidation and retaliation, and the use of sham peer 
reviews and investigations in order to silence whistleblowers.
    As I stated before, I believe that VA has made some progress in 
this area, but clearly, more remains to be done. VA's culture of 
retaliation and intimidation did not happen overnight, but is a 
culmination of decades of problems that are deeply ingrained into the 
VA system. We must also not forget that the vast majority of VA 
employees are involved in healthcare, an industry that also has been 
seen by many to be intolerant of whistleblowers.
    This culture of intimidation and fear for VA employees cannot be 
changed overnight. But for the sake of our veterans, and for the sake 
that ensuring the VA is providing the highest quality of care, this 
culture MUST be changed. Many of VA's problems that we will discuss 
today highlight VA's lack of accountability and the absence of a 
collaborative spirit between VA leadership and VA employees in order to 
seriously address whistleblowers complaints.
    This afternoon let us begin the process of identifying what steps 
the VA needs to take going forward as the VA works toward the 
Secretary's goal of ``sustainable accountability.''
    I am hopeful that this Subcommittee can continue to work in a 
bipartisan fashion to find ways to assist the VA in its monumental task 
of changing this long-standing culture and reform the manner in which 
whistleblowers are treated, and improve the process where all VA 
employees are working toward the common goal of helping and serving our 
veterans.
    Mr. Chairman, again, I thank you for holding this follow-up 
hearing. Before I yield back I want to take a moment and thank our 
whistleblowers for appearing before us today--it takes real courage to 
put your careers at risk for coming forward and calling attention to 
problems and concerns. It is my hope that as we move forward we can 
create a culture at VA that welcomes whistleblowers and acknowledges 
their importance in better serving our veterans. I hope that in the 
months and years ahead VA will be known as an organization that 
welcomes and encourages all employees to work to solve problems.
    I yield back the balance of my time.

                                 

                   Prepared Statement of Meghan Flanz

    Good afternoon, Chairman Coffman, Ranking Member Kuster, and 
Members of the Committee. Thank you for inviting me here today to 
present an update on the Department's activities related to 
whistleblower protection.
    VA exists to serve Veterans. That service takes place through 
interactions between Veterans and front-line VA employees--physicians, 
nurses, and other clinicians in VA hospitals, claims processing staff 
in regional benefits offices, cemetery workers and countless others--
upon whom VA depends to serve Veterans with the dignity, compassion, 
and dedication they deserve. We depend on those same employees to have 
the moral courage to help us serve Veterans and taxpayers better by 
helping to make our processes and policies better, safer, and more 
effective and efficient. Within this context, the Department's 
responsibility to protect whistleblowers is an integral part of our 
obligation to provide safe, high-quality healthcare, and other benefits 
to Veterans in legally-compliant and fiscally-responsible ways. 
Protecting whistleblowers from retaliation is a key component of 
carrying out VA's core mission in accordance with its institutional 
values (I CARE--integrity, commitment, advocacy, respect, excellence). 
Veterans expect VA leadership to cultivate an environment that empowers 
our employees and demands accountability in service to our Veterans. We 
are making progress, and under Secretary McDonald's leadership, we will 
reach our goal of ensuring that every employee feels safe in raising 
concerns, and is protected from any retaliation when they choose to do 
so.
    It is important to keep in mind that the underlying purpose of the 
whistleblower protection rules is to encourage the candid disclosure of 
information about problems with governmental programs and processes, so 
that deficiencies can be corrected and unsafe or unlawful behavior can 
be quickly corrected. Of necessity, there are teeth built into the law 
in terms of penalties for supervisors who retaliate against 
whistleblowers, but the penalties exist to support the primary focus on 
information flow and quality, safety, or process improvement.
    VA is fully committed to correcting deficiencies in its processes 
and programs, and to ensuring fair treatment for whistleblowers who 
bring those deficiencies to light. Secretary McDonald talks frequently 
about his vision of ``sustainable accountability,'' which he describes 
as a workplace culture in which VA leaders provide the guidance and 
resources employees need to successfully serve Veterans, and employees 
freely and safely inform leaders when challenges hinder their ability 
to succeed. We need a work environment in which all participants--from 
front-line staff through lower-level supervisors to senior managers and 
top VA officials--feel safe sharing what they know, whether good news 
or bad, for the benefit of Veterans and as good stewards of the 
taxpayers' money.
    To reach these goals, the Department has taken several important 
steps to improve the way we address operational deficiencies, and to 
ensure that those who disclose such deficiencies are protected from 
retaliation:

 Reorganization and new leadership in the Office of the Medical 
Inspector (OMI), the component of the Veterans Health Administration 
that reviews whistleblower disclosures related to VA healthcare 
operations;
 Establishment of the Office of Accountability Review (OAR) to 
ensure leadership accountability;
 Completion of all requirements for certification under the 
Office of Special Counsel's (OSC) 2302(c) certification program;
 Improved collaboration with OSC, including negotiating an 
unprecedented expedited process to speed corrective action for 
employees who have been subjected to retaliation;
 Formal VA leadership communication to all employees regarding 
the importance of whistleblower protection, emphasizing that managers 
and supervisors bear a special responsibility for enforcing 
whistleblower protection laws; and
 Required annual training by all senior executives (Course 
title: ``Whistleblower Rights and Protection and Prohibited Personnel 
Practices'').

    Last summer, the Secretary reorganized and assigned new leadership 
to the VA Office of the Medical Inspector (OMI). He also established 
the Office of Accountability Review, or OAR, to ensure leadership 
accountability for whistleblower retaliation and other serious 
misconduct. In addition to its ongoing work investigating allegations 
of retaliation and other misconduct by senior leaders, OAR is also 
working to improve the Department's ability to track whistleblower 
disclosures - and actions taken in response to those disclosures - 
across the entire VA system, whether the disclosure is referred to VA 
by OSC, comes in through the VA Office of Inspector General (OIG) 
Hotline, is brought to the Department's attention by this Committee or 
an individual Member of Congress, or is communicated by a VA employee 
directly to his or her supervisor .
    VA has also improved its collaboration with OSC, especially with 
respect to whistleblower retaliation training and remedies. Last 
summer, VA requested and received certification under OSC's 2302(c) 
certification program. That certification reflects the Department's 
compliance with five requirements related to training employees and 
supervisors about whistleblower protection rules, and providing 
information about whistleblower rights and processes to current 
employees as well as new hires. Last summer, VA also negotiated with 
OSC, an expedited process to speed corrective action for employees who 
have been subjected to retaliation. That process, which is 
unprecedented and unparalleled in Federal government, allows OSC and VA 
to work as partners to protect whistleblowers from retaliation. More 
recently, we have asked OSC to help us expand that collaborative 
process to facilitate more efficient accountability actions for 
supervisors who engage in retaliatory conduct. We are also working with 
OSC's Training and Outreach staff to create a robust new face-to-face 
training program for VA supervisors, to ensure they understand their 
roles and responsibilities with respect to responding to whistleblower 
disclosures, and protecting employees who make those disclosures.
    Since Secretary McDonald was confirmed last July, he and other VA 
leaders have made it their practice to meet with whistleblowers when 
they travel to VA facilities, and to engage with those who have raised 
their hands and their voices to identify problems and propose 
solutions. They do that both to acknowledge the critical role 
whistleblowers play in improving the quality, safety, and effectiveness 
of VA programs, and to model to supervisors throughout VA the engaged, 
open, accepting behavior they expect them to exhibit when subordinates 
step forward to express concerns. Secretary McDonald, Deputy Secretary 
Gibson, and other VA leaders have also initiated countless meetings, 
phone calls, and other communications with Members of this Committee, 
with committee staff, and with other Congressional committees and 
members to talk about particular whistleblowers for whom Members have 
expressed concern. The Department deeply appreciates the assistance of 
this Committee and others in identifying potential retaliation so we 
can stop it, and in ensuring that the problems whistleblowers disclose 
receive prompt, and fulsome attention.
    Last month I had the opportunity to appear before this Subcommittee 
to provide the Department's views on several pending bills, including 
two related to whistleblowers. At that time I acknowledged, and I 
reiterate today, that the Department has had and continues to have 
problems ensuring that whistleblower disclosures receive prompt and 
effective attention, and that whistleblowers themselves are protected 
from retaliation. And I acknowledge today that, notwithstanding 
significant and ongoing efforts on our part, VA is still working toward 
the full culture change we must achieve to ensure all employees feel 
safe disclosing problems, or that all supervisors who engage in 
retaliatory behavior are held promptly and meaningfully accountable. At 
the subcommittee hearing last month, I articulated the Department's 
concerns that the proposed legislative approaches to improving VA's 
responses to whistleblower disclosures might have unintended 
consequences. At the same time, I committed, on behalf of the 
Department, to continue to work with OSC and with this Committee to get 
things right, and I reaffirm that commitment to you today. I am honored 
that Secretary McDonald and Deputy Secretary Gibson have asked me to 
assist them in this critical effort.
    Mr. Chairman, this concludes my testimony. I look forward to 
answering the Committee's questions.

                                 

                  Prepared Statement of Carolyn Lerner

    Chairman Coffman, Ranking Member Kuster, and Members of the 
Subcommittee:
    Thank you for the opportunity to testify today about the U.S. 
Office of Special Counsel (OSC) and our ongoing work with 
whistleblowers at the Department of Veterans Affairs (VA).
    In July of last year, I spoke to this Committee about OSC's early 
efforts to respond to the unprecedented increase in whistleblower cases 
from VA employees. Since that time, and as detailed in the sections 
below, there has been substantial progress. For example, OSC and the VA 
implemented an expedited review process for retaliation claims. This 
process has generated timely and comprehensive relief for many VA 
whistleblowers. In addition, in response to OSC's findings, the VA 
overhauled the Office of Medical Inspector (OMI), and has taken steps 
to better respond to the patient care concerns identified by 
whistleblowers. Finally, in response to the influx of whistleblower 
claims, the VA became the first cabinet-level department to complete 
OSC's ``2302(c)'' whistleblower certification program. The program 
ensures that employees and managers are better informed of their rights 
and responsibilities under the whistleblower law.
    Despite this significant progress, the number of new whistleblower 
cases from VA employees remains overwhelming. These cases include 
disclosures to OSC of waste, fraud, abuse, and threats to the health 
and safety of veterans, and also claims of retaliation for reporting 
such concerns. OSC's monthly intake of VA whistleblower cases remains 
elevated at a rate nearly 150% higher than historical levels. The 
percentage of OSC cases filed by VA employees continues to climb. OSC 
has jurisdiction over the entire federal government, yet in 2015, 
nearly 40% of our incoming cases will be filed by VA employees. This is 
up from 20% of OSC cases in 2009, 2010, and 2011.
    These numbers provide an important overview of the work OSC is 
doing. And, while these numbers point to an ongoing problem, it is 
important to put them in context. The current, elevated number of VA 
whistleblower cases can be viewed as part of the larger effort to 
restore accountability at the VA, and do not necessarily mean there is 
more retaliation than before the scheduling and wait list problems came 
to light, or that there are more threats to patient health and safety. 
Instead, these numbers may indicate greater awareness of whistleblower 
rights and greater employee confidence in the systems designed to 
protect them.
    The current VA leadership has shown a high level of engagement with 
OSC and a genuine commitment to protecting whistleblowers. As many VA 
officials and Members of this Committee have repeatedly stated, culture 
change in an organization the size of the VA is difficult and will take 
time. But, if the current number of whistleblower cases is an 
indication of employees' willingness to speak out, then things are 
moving in the right direction.

I. Whistleblower Retaliation--Collaboration With the VA to Provide 
Expedited Relief to VA Employees

    My July 2014 statement to the Committee summarized a series of 
whistleblower retaliation cases. I noted, ``The severity of these cases 
underscores the need for substantial, sustained cooperation between the 
VA and OSC as we work to protect whistleblowers and encourage others to 
report their concerns.'' I further noted that Acting (now Deputy) 
Secretary Gibson had committed to resolving meritorious whistleblower 
retaliation cases with OSC on an expedited basis.
    Since that time, OSC, working in partnership with the VA's Office 
of General Counsel (OGC), implemented an expedited review process for 
whistleblower retaliation cases. This process has generated significant 
and timely results on behalf of VA employees who were retaliated 
against for speaking out. To date, we have obtained 15 corrective 
actions for VA whistleblowers through this process, including landmark 
settlements on behalf of Phoenix VA Medical Center (VAMC) employees. 
Summaries of the cases in which the employees consented to the release 
of their names are included below:

 Katherine Mitchell, Phoenix VAMC--Dr. Mitchell blew the 
whistle on critical understaffing and inadequate triage training in the 
Phoenix VAMC's emergency room. According to Dr. Mitchell's complaint, 
Phoenix VAMC leadership engaged in a series of targeted retaliatory 
acts that included ending her assignment as ER Director. Dr. Mitchell, 
has 16 years of experience at the Phoenix VAMC, and also testified 
twice before this Committee last year. Among other provisions, Dr. 
Mitchell's settlement included assignment to a new position that allows 
her to oversee the quality of patient care.

 Paula Pedene, Phoenix VAMC--Ms. Pedene was the chief 
spokesperson at the Phoenix VAMC, with over two decades of experience. 
She made numerous disclosures beginning in 2010, including concerns 
about financial mismanagement by former leadership at the medical 
center. Many of the allegations were substantiated by a November 2011 
VA Office of Inspector General review. Subsequently, according to Ms. 
Pedene's reprisal complaint, Phoenix VAMC management improperly 
investigated Pedene on unsubstantiated charges, took away her job 
duties, and moved her office to the basement library. Among other 
provisions, Ms. Pedene's settlement includes assignment to a national 
program specialist position in the Veterans Health Administration, 
Office of Communications.

 Damian Reese, Phoenix VAMC--Mr. Reese is a Phoenix VAMC 
program analyst. He voiced concerns to Phoenix VAMC management about 
the amount of time veterans had to wait for primary-care provider 
appointments and management's efforts to characterize long wait times 
as a ``success'' by manipulating the patient records. After making this 
disclosure, Mr. Reese had his annual performance rating downgraded by a 
senior official with knowledge of his email. Mr. Reese agreed to settle 
his claims with the VA for mutually agreed upon relief.

 Mark Tello, Saginaw VAMC--Mr. Tello was a nursing assistant 
with the VAMC in Saginaw, Michigan. In August 2013, he told his 
supervisor that management was not properly staffing the VAMC and that 
this could result in serious patient care lapses. The VAMC then issued 
a proposed removal, which was later reduced to a five-day suspension 
that Mr. Tello served in January 2014. The VA again proposed his 
removal in June 2014. OSC facilitated a settlement where the VA agreed, 
among other things, to place Mr. Tello in a new position at the VA 
under different management, to rescind his suspension, and to award him 
appropriate back pay.

 Richard Hill, Frederick, MD--Dr. Hill was a primary care 
physician at the Fort Detrick, Community Based Outpatient Clinic (CBOC) 
in Frederick, Maryland, which is part of the Martinsburg, West Virginia 
VAMC. In March 2014, Dr. Hill made disclosures to VA officials, the VA 
Office of Inspector General, and others regarding an improper diversion 
of funds that resulted in harm to patients. Specifically, Dr. Hill 
expressed serious concerns about the lack of clerical staff assigned to 
his primary care unit, which he believes led to significant errors in 
patient care and scheduling problems. In early May 2014, the VA issued 
Dr. Hill a reprimand. Dr. Hill retired in July 2014. As part of the 
settlement agreement between Dr. Hill and the VA, the VA has agreed to, 
among other provisions, expunge Dr. Hill's record of any negative 
personnel actions.

 Rachael Hogan, Syracuse VAMC--Ms. Hogan is a registered nurse 
(RN) with the VAMC in Syracuse, New York. She disclosed to a superior a 
patient's rape accusation against a VA employee and, when the superior 
delayed reporting the accusations to the police, warned the superior 
about the risks of not timely reporting the accusations. Later, she 
complained that a nurse fell asleep twice while assigned to watch a 
suicidal patient and that another superior engaged in sexual 
harassment, and made a number of other allegations regarding the two 
superiors. In spring 2014, the two superiors informed Ms. Hogan that 
they would seek a review board to have her terminated because of her 
``lack of collegiality'' and because she was not a good fit for the 
unit, and gave her an unsatisfactory proficiency report. The VA agreed 
to stay the review board for the duration of OSC's investigation. As 
part of the final settlement, the agency permanently reassigned Ms. 
Hogan to a RN position under a new chain of command, corrected her 
performance evaluation, and agreed to cover the costs for an OSC 
representative to conduct whistleblower protection training at the 
facility.

 Charles Johnson, Columbia VAMC--Mr. Johnson, a technologist in 
the radiology department at the VA Medical Center in Columbia, South 
Carolina, disclosed that a doctor ordered him to hydrate a patient 
using a new, unfamiliar method in February 2014. Due to his concerns 
about the new hydration method, Mr. Johnson consulted with two 
physicians about the method, neither of whom would verify the method's 
safety. Mr. Johnson then contacted his union, which suggested he send 
an email seeking clarification of the method under the VA's ``Stop The 
Line For Patient Safety'' policy. In July 2014, Mr. Johnson was issued 
a proposed five-day suspension by the same doctor whose hydration 
method Mr. Johnson had questioned. In October 2014, at OSC's request, 
the VA agreed to stay Mr. Johnson's suspension. In February 2015, Mr. 
Johnson and the VA settled his case, under which the VA will, among 
other things, rescind the proposed suspension and evaluate the 
hydration method.

 Phillip Brian Turner, San Antonio, TX--Mr. Turner is an 
advanced medical support assistant in a VA Behavioral Health Clinic in 
San Antonio, Texas. In April 2014, Mr. Turner emailed his supervisor 
and others about his concerns that the agency did not follow proper 
scheduling protocols and may have falsified or manipulated patient wait 
times for appointments. The next day, VA management instructed him to 
stop emailing about the VA's scheduling practices. Several weeks later, 
in May 2014, VA management directed Mr. Turner to sign four copies of 
the VA's media policy, which he refused to do. On May 9, 2014, an 
article in the San Antonio Express-News--one of the largest newspapers 
in Texas--quoted a high-level VA official as stating that the agency 
had conducted an investigation into Mr. Turner's allegations and that 
Mr. Turner retracted his comments about the improper scheduling 
practices. Mr. Turner denies making any such retraction. The VA's 
actions in this case raise important concerns due to the potential 
chilling effect on other whistleblowers. The case was settled in 
February 2015 and the VA agreed to several corrective actions.

 Debora Casados, Denver, CO--Ms. Casados is a nurse in the VA 
Eastern Colorado healthcare System. In August 2014, she reported that a 
coworker sexually assaulted two other VA staff members and made 
inappropriate sexual comments to her. Human resources told Ms. Casados 
and the other staff that they were not permitted to discuss the 
allegations and threatened them with disciplinary action if they did 
so. In October, human resources removed Ms. Casados from her nursing 
duties at the clinic and reassigned her to administrative tasks. In 
January 2015, she was moved again, this time to a windowless basement 
office to scan documents. In February, her superior denied Ms. Casados 
leave to care for her terminally ill mother. On April 3, 2015, the VA 
agreed to OSC's request for an informal stay on behalf of Ms. Casados, 
returning her to nursing duties at another clinic while OSC 
investigates her whistleblower reprisal claims to determine if 
additional corrective action and disciplinary action are appropriate.

    Including these cases, in 2014 and 2015 to date, OSC has secured 
either full or partial relief for over 45 VA employees who have filed 
whistleblower retaliation complaints. OSC is on track to help nearly 
twice as many VA employees in 2015 as in 2014. These positive outcomes 
have been generated by the OSC-VA expedited settlement process, OSC's 
normal investigative process, and OSC's Alternative Dispute Resolution 
program. OSC is currently examining about 110 pending claims of 
whistleblower retaliation at the VA involving patient health and 
safety, scheduling, and understaffing issues. These pending claims 
involve VA facilities in 38 states and the District of Columbia. We 
look forward to updating the Committee as these cases proceed.

II. Whistleblower Disclosures and the Office of Medical Inspector

    In my July 2014 testimony, I raised concerns about the VA's 
longstanding failure to use the information provided by whistleblowers 
as an early warning system to correct problems and prevent them from 
recurring. I summarized a series of cases in which the Office of 
Medical Inspector (OMI) identified deficiencies in patient care, such 
as chronic understaffing in primary care units, and the inadequate 
treatment of mental health patients in a community living center. In 
each case, OMI failed to grasp the severity of the problems, attempted 
to minimize concerns, and prevented the VA from taking the steps 
necessary to improve the quality of care for veterans.
    In response to our concerns, the VA directed a comprehensive review 
of all aspects of OMI's operation. Overall, we believe this review has 
resulted in positive change. A recent whistleblower case is 
demonstrative.
    The case concerns a whistleblower disclosure from a VA employee in 
Beckley, West Virginia. In response to OSC's referral, OMI conducted an 
investigation and determined that the Beckley VAMC attempted to meet 
cost savings goals by requiring mental health providers to prescribe 
older, cheaper antipsychotic medications to veterans, to alter the 
current prescriptions for veterans over the objections of their 
providers, with no clinical review or legitimate clinical need for the 
substitutions, in violation of VA policies. The investigation 
additionally found the substituted medications could create medical 
risks and ``may constitute a substantial and specific risk'' to the 
health and safety of impacted veterans. In addition, the OMI 
investigation found that the formal objections of at least one mental 
health provider were not documented in the meeting minutes at which the 
provider raised concerns.
    The OMI investigation called for a clinical care review of the 
condition and medical records of all patients who were impacted, and an 
assessment of whether there were any adverse patient outcomes as a 
result of the changed medications. OMI also recommended that, where 
warranted, discipline be taken against Beckley VAMC leadership and 
those responsible for approving actions that were not consistent with 
VA policy, and which could constitute a substantial and specific danger 
to public health and the safety of veterans.
    While the facts of this case are troubling, the OMI response is 
encouraging. In an organization the size of the VA, problems will 
occur. Therefore, it is critical that when whistleblowers identify 
problems, they are addressed swiftly and responsibly. And OMI is an 
integral component in doing so.
    In recent days, we have received additional information from 
whistleblowers indicating that the OMI recommendations may not have 
been fully implemented by Beckley VAMC management. Accordingly, we will 
follow up with the VA to verify that all OMI recommendations in the 
Beckley investigation, including disciplinary action and necessary 
changes to the prescription protocol, have been taken.

III. Training Initiatives and Areas of Ongoing Concern

    A. OSC's 2302(c) Certification Program

    In my July 2014 statement to the Committee, I referenced the VA's 
commitment to complete OSC's ``2302(c)'' Certification Program. In 
October 2014, the VA became the first cabinet-level department to 
complete OSC's program. The OSC Certification Program allows federal 
agencies to meet their statutory obligation to inform their workforces 
about the rights and remedies available to them under the Whistleblower 
Protection Act, the Whistleblower Protection and Enhancement Act 
(WPEA), and related civil service laws. The program requires agencies 
to complete five steps: (1) Place informational posters at agency 
facilities; (2) Provide information about the whistleblower laws to new 
employees as part of the orientation process; (3) Provide information 
to current employees about the whistleblower laws; (4) Train 
supervisors on their responsibilities under the whistleblower law; and 
(5) Display a link to OSC's website on the agency's website or 
intranet.
    The most important step in this process is the training provided to 
supervisors. Ideally, this training is done in person with OSC staff, 
to provide an opportunity for supervisors to ask questions and engage 
in a candid back and forth session. However, in an organization the 
size of the VA, with tens of thousands of supervisors, in-person 
training is extremely difficult to accomplish. Nevertheless, at the 
VA's initiative, we are working to develop ``train the trainer'' 
sessions, so we can reach as many supervisors as possible in real time. 
We also anticipate presenting information on the whistleblower law at 
an upcoming meeting of VA regional counsel.
    Based on the claims OSC receives, VA regional counsel will benefit 
from additional training on whistleblower retaliation. Such training 
will assist in preventing retaliatory personnel actions from being 
approved by the legal department at local facilities, and will also 
help to facilitate resolutions in OSC matters. The commitment we are 
seeing from VA leadership to correct and eliminate retaliation against 
whistleblowers has not consistently filtered down to regional counsel. 
Supplemental training for regional counsel may go a long way to address 
that issue.

B. Investigation of Whistleblowers

    An additional and ongoing area of concern involves situations in 
which a whistleblower comes forward with an issue of real importance to 
the VA--for example, a cover-up of patient wait-times, sexual assault 
or harassment, or over-prescription of opiates--yet instead of focusing 
on the subject matter of the report, the VA's investigation focuses on 
the whistleblower. The inquiry becomes: Did the whistleblower violate 
any regulations in obtaining the evidence of wrongdoing? Has the 
whistleblower engaged in any other possible wrongdoing that may 
discredit his or her account?
    There are two main problems with this approach. First, by focusing 
on the individual whistleblower, the systemic problem that has been 
raised may not receive the attention that it deserves. And second, 
instead of creating a welcoming environment for whistleblowers to come 
forward, it instills fear in potential whistleblowers that by reporting 
problems, their own actions will come under intense scrutiny.
    The VA's focus--not just at headquarters, but throughout the 
department--should be on solving its systemic problems, and holding 
those responsible for creating them accountable. While there may be 
instances in which an individual whistleblower's methods are 
particularly troublesome and therefore require investigation, such an 
investigation should be the exception and not the rule, and should only 
be undertaken after weighing these competing concerns.

C. Accessing Whistleblowers' Medical Records

    A final, related issue of ongoing concern is the unlawful accessing 
of employee medical records in order to discredit whistleblowers. In 
many instances, VA employees are themselves veterans and receive care 
at VA hospitals. In several cases, the medical records of 
whistleblowers have been accessed and information in those records has 
apparently been used to attempt to discredit the whistleblowers. We 
will aggressively pursue relief for whistleblowers in these and other 
cases where the facts and circumstances support corrective action, and 
we will also work with the VA to incorporate these additional forms of 
retaliation into our collaborative training programs.

IV. Conclusion

    We appreciate this Committee's ongoing attention to the issues we 
have raised. I thank you for the opportunity to testify, and am happy 
to answer your questions.

                   Special Counsel Carolyn N. Lerner

    The Hon. Carolyn N. Lerner heads the United States Office of 
Special Counsel. Her five-year term began in June 2011. Prior to her 
appointment as Special Counsel, Ms. Lerner was a partner in the 
Washington, D.C., civil rights and employment law firm Heller, Huron, 
Chertkof, Lerner, Simon & Salzman, where she represented individuals in 
discrimination and employment matters, as well as non-profit 
organizations on a wide variety of issues. She previously served as the 
federal court appointed monitor of the consent decree in Neal v. DC 
Department of Corrections, a sexual harassment and retaliation class 
action.
    Prior to becoming Special Counsel, Ms. Lerner taught mediation as 
an adjunct professor at George Washington University School of Law, and 
was a mediator for the United States District Court for the District of 
Columbia and the D.C. Office of Human Rights.
    Ms. Lerner earned her undergraduate degree from the University of 
Michigan, where she was selected to be a Truman Scholar, and her law 
degree from New York University (NYU) School of Law, where she was a 
Root-Tilden-Snow public interest scholar. After law school, she served 
two years as a law clerk to the Hon. Julian Abele Cook, Jr., Chief U.S. 
District Court Judge for the Eastern District of Michigan.

                                 

                Prepared Statement of Dr. Christian Head

Introduction

    Chairman, Hon. Mike Coffman
    Ranking Member, Hon. Ann Kuster
    Dr. Christian Head \1\ comes before Congress to testify, not 
motivated by any political agenda, but based purely on a genuine 
interest in seeking solutions to address employee mistreatment, but 
most importantly, to improve the healthcare provided to our Country's 
heroes. Dr. Head submits this testimony in response to Congress's 
request to appear and testify on this issue.
---------------------------------------------------------------------------
    \1\ To avoid confusion, I will refer to myself in the third person 
throughout this testimony.
---------------------------------------------------------------------------
    Dr. Head is uniquely qualified to testify regarding issues within 
the VA system. Dr. Head is a world-renown, board certified Head and 
Neck Surgeon. Between 2002 through 2013, Dr. Head held dual 
appointments at the UCLA David Geffen School of Medicine becoming a 
tenured Associate Professor in Residence of Head and Neck Surgery, as 
well as an attending surgeon at the West Los Angeles Campus of the VA 
Greater Los Angeles Healthcare System (``GLAHS''). In 2007, Dr. Head 
was promoted to Associate Director, Chief of Staff, Legal and Quality 
Assurance within GLAHS.
    Dr. Head's clinical and academic successes over the years have been 
numerous. However, despite Dr. Head's many accomplishments and 
contributions to the medical profession, Dr. Head has endured and 
witnessed, firsthand, illegal and inappropriate discrimination and 
retaliation of physicians, nurses, and staff members within GLAHS. 
Throughout this testimony, Dr. Head will speak on the growing number of 
complaints coming from VA employees, complaints ranging from 
discrimination and retaliation to complaints regarding substandard 
patient care and treatment.

Background

    Dr. Christian Head is a prominent Head and Neck Surgeon who cares 
deeply about the veteran patients under his care. Dr. Head has been 
described as ``one of our finest surgeons in Southern California. . . . 
[Who is] generous with his time and talent, helping Veterans and giving 
back to our community both locally and nationally. . . . [W]ho will 
make a difference in our world with his skills as a surgeon, his 
scientific research and laboratory.'' As his colleague Dr. James 
Andrews has said, Dr. Head ``has tirelessly worked to improve the 
quality assurance of this institution,'' ``his tireless work ethic and 
cheerful attitude is highly admirable,'' ``[h]e should be a role model 
for every physician employed by the VA,'' and ``[t]he VA is very 
fortunate to have Dr. Christina Head as part of their team.'' (See 
Exhibit A.) Unfortunately, Dr. Head has been the victim of outrageous 
racial harassment, discrimination, and retaliation occurring within 
GLAHS.
    Dr. Head obtained his Doctor of Medicine degree from Ohio State 
University, College of Medicine in 1993. Between 1992 and 1993, Dr. 
Head completed an Internship in Surgery at the University of Maryland 
at Baltimore. Between 1994 and 1996, Dr. Head commenced his employment 
with a Fellowship in Neuro-Otology Research at UCLA School of Medicine. 
Between 1996 and 1997, Dr. Head completed a Surgical Internship at UCLA 
School of Medicine. Between 1997 and 2002, Dr. Head worked as a 
Resident in the UCLA School of Medicine Head and Neck Surgery 
Department. In 2002, Dr. Head joined the faculty as a Visiting 
Professor in Head and Neck Surgery at UCLA. In 2002, Dr. Head also 
joined GLAHS. During his time with GLAHS, Dr. Head worked as a Head and 
Neck Surgeon, and in 2007, was promoted to Associate Director, Chief of 
Staff, Legal and Quality Assurance within GLAHA. In August 2003, Dr. 
Head joined the faculty of the UCLA Geffen School of Medicine as a full 
time Head and Neck Surgeon. Dr. Head left UCLA in 2013. Dr. Head has 
been board certified in Head and Neck Surgery since June 2003.
    Over the years, Dr. Head's work has included clinical practice, 
surgery, academia, and research. Dr. Head has received accolades for 
his work, including the National Institute for Health-National Cancer 
Institute Faculty Development Award. In or around 2001 to 2002, Dr. 
Head was nominated for the UCLA Medical Center Physician of the Year 
award. In or around November 2003, Dr. Head launched the UCLA Jonsson 
Cancer Center Tumor Lab, which has been tremendously successful, 
yielding valuable research and benefitting many physicians and patients 
at UCLA and worldwide. In 2003, Dr. Head was one of a few surgeons 
nationwide to receive the Faculty Development Award from the National 
Institute of Health Comprehensive Minority Biomedical Branch, intended 
to increase the number of minority physicians in cancer research at 
major academic institutions.
    Dr. Head's supervisors have included Marilene Wang, M.D. (``Dr. 
Wang''), UCLA/GLAHS Head and Neck Surgeon and Dr. Head's previous 
clinical supervisor at GLAHS; Dean Norman, M.D. (``Dr. Norman''), GLAHS 
Chief of Staff; Matthias Stelzner, M.D. (``Dr. Stelzner''), GLAHS Chief 
of Surgical Services; Donna Beiter, RN, MSN (``Ms. Beiter''), GLAHS 
Director, and Norman Ge, M.D. (``Dr. Ge''). Dr. Head's immediate 
supervisor at UCLA was Gerald Berke, M.D. (``Dr. Berke''), Chairman of 
the UCLA Department of Head and Neck Surgery, who has tremendous power 
and influence at GLAHS.

Retaliation Against Dr. Head Since His July 8, 2014 Testimony Before 
Congress

    On or about July 8, 2014, at the request of Congress, Dr. Head 
testified before the House Committee on Veterans' Affairs regarding 
``VA Whistleblowers: Exposing Inadequate Service Provided to Veterans 
and Ensuring Appropriate Accountability.''2
    During Dr. Head's testimony before Congress, he outlined exactly 
the pattern for retaliation within the VA system: isolate, defame, and 
attack professional competence. As the following facts will show, since 
Dr. Head's testimony before Congress, his supervisors, Director Donna 
Beiter and Chief of Staff Dr. Dean Norman, have done exactly this--they 
immediately attempted to defame his credibility, then they tried to 
revoke his operating room (``OR'') privileges in an attempt to attack 
his professional competence, and then they isolated Dr. Head within the 
workplace.
    Since July 8, 2014, based on information and belief, Director 
Beiter and Dr. Norman are making untrue and disparaging comments to 
other VA staff members about Dr. Head. Dr. Norman has claimed that Dr. 
Head is lying about Dr. Marilene Wang's timecard fraud, despite Dr. 
Wang and Dr. Norman previously testifying under oath that Dr. Wang was 
found to have committed timecard fraud and that the OIG recommended 
that Dr. Wang be terminated from her leadership position.
    In or around late--July 2014, Dr. Head's patients started being 
taken away and reassigned to Dr. Wang. Around this time, Dr. Norman 
also stated to Dr. Head that ``Dr. Wang is not going anywhere,'' and 
``If you don't like it, you're a whistleblower, take it to Congress.''
    On or about August 15, 2014, Dr. Head was prevented from entering 
the main operating room by the OR Nurse Director. The OR Nurse Director 
made a loud statement, ``Dr. Head you have no surgical privileges, you 
cannot enter the operating room.'' Dr. Head asked her to call hospital 
privileging. The OR Nurse Director asked for the ``white book'' and 
next to Dr. Head's name in bold print was, ``NO OR PRIVILEGES'' with 
expiration in 5/2016. This event was witnessed by numerous hospital 
staff, nurses, and surgeons. The OR Nurse Director called hospital 
privileging who confirmed that Dr. Head had full surgical privileges. 
The event was meant to humiliate and retaliate against Dr. Head and to 
further defame his good name and professional reputation. There were 
others on the list in the ``white book'' with expired credentials, but 
no bold print ``NO OR PRIVILEGES'' next to their name. This event could 
have also jeopardized patient care as there was a patient in the 
operating room waiting for surgery.
    In or around Mid-August 2014, Dr. Head was notified that he would 
no longer be reporting to Dr. Norman, but instead to Dr. Norman Ge. Dr. 
Head was troubled by this information considering that Dr. Ge is 
extremely good friends with Dr. Norman, and Dr. Head felt that this 
reassignment would do nothing to decrease the retaliation.
    Further, on or about August 22, 2014, Dr. Head was informed that 
the VA, at the direction of Director Beiter and Dr. Norman, would be 
transferring Dr. Head's office out of the Chief of Staff area, located 
in the nicely furnished/decorated 6th floor, into a tiny, dirty, poorly 
furnished closet-sized office on the 4th floor so that Dr. Head ``could 
be by himself and not have to interact with others.'' The locks on the 
doors and computer passwords were changed so that Dr. Head would no 
longer have access to his office or computer.
    On or about September 5, 2014 and September 24, 2014, Dr. Head 
attended two depositions (interviews under penalty of perjury) 
conducted by federal investigator Clara Trapnell. During one of these 
depositions, Investigator Clara Trapnell informed Dr. Head that the 
reason he was transferred and reassigned a new office, essentially 
demoting Dr. Head, was ``because of his lawsuit.''
    On or about January 20, 2015, the VA filed court documents in which 
they admitted that the reason they retaliated against Dr. Head--by 
removing his Chief of Staff duties and transferring him out of the 
luxurious Chief of Staff suite on the 6th floor into a tiny, dirty, 
poorly furnished closet-sized office on the 4th floor--was ``because of 
[Dr. Head's] statements to Congress.'' (For an excerpt of this 
document, see Exhibit B.)
    On or about March 12, 2015 at approximately 10:00 a.m., Dr. Head 
was contacted by Jessica O'Connell M.D. by phone inquiring why Dr. Head 
was not in clinic at the West Los Angeles VA Hospital. Dr. O'Connell 
was told by Mark Harris--who is supervised by Christine Gonzales 
([email protected]) ( VA cell 310-429-7090)--that Dr. Head 
was not in clinic seeing his patients. However, at that exact moment, 
Dr. Head was in fact seeing his second patient, Heath Johnson. Dr. Head 
immediately reported this incident to Dr. O'Connell and Dr. Stelzner in 
the Department of Surgery. Further, Robert Lopez, Dr. Stelzner's 
administrative assistant, also inquired by phone why Dr. Head was not 
in clinic seeing patients and also stated that Mr. Harris reported Dr. 
Head for not being at his duty station. Dr. Head asked Mr. Lopez to 
come to his clinic to confirm Dr. Head's presence so as not to disrupt 
patient care further. Dr. Head's presence in his clinic was 
subsequently confirmed. Personnel within the VA stated that Mr. Harris 
informed them that he had previously worked with Dr. Head at the 
Sepulveda VA Clinic and alleged that Dr. Head has a long history of 
``not seeing patients and being late,'' defamatorily implying that Dr. 
Head provides poor patient care. Dr. Head's patient, Mr. Johnson, 
described Mr. Harris as rude and disruptive and stated that it appeared 
Mr. Harris was trying to cause problems where none existed. Mr. Johnson 
also overheard the VA scheduler inform Mr. Harris that Dr. Head was in 
the hospital and would be seeing patients momentarily.
    On or about March 19, 2015, Dr. Head was contacted by front desk 
personnel at the West Los Angeles VA Clinic that Dr. Head had a patient 
waiting to be seen at 12:45 p.m. The patient had arrived late and the 
front desk personnel were all out to lunch. Dr. Head was in the clinic 
theater until 12:20 p.m., but had left the VA at approximately 12:45 
p.m. for medical reasons. Dr. Head asked the staff if one of Dr. Head's 
colleagues could see the patient, but the patient decided to 
reschedule. Dr. Head was informed that the patient was not upset.
    On or about March 26, 2015, Dr. Head was told that Mr. Harris asked 
several employees to write points of contact stating that Dr. Head was 
late to clinic on that day. Dr. Head had a full day of clinic and, 
unknown to Mr. Harris, Dr. Head had notified his supervisors, Dr. 
Norman Ge; Dr. Jessica O'Connell, director of Surgery; Ms. Debbie 
Blaisdell, administrative assistant in the Chief of Staff office; and 
the Sepulveda Head and Neck Clinic scheduler that Dr. Head would be out 
on sick leave. Dr. Head received confirmatory emails from those 
individuals.
    Dr. Head has been approached by several VA employees, along with a 
veteran patient who witnessed these events. Mr. Harris's behavior has 
been retaliatory and defamatory, making false statements to employees 
and patients about Dr. Head's professional and clinical competence, 
thereby creating a hostile work environment that is both confusing and 
inhospitable to the clinical care environment and seriously jeopardizes 
patient care, all at a time veterans should be reassured that the 
health professionals are capable of providing them with the best 
medical care.
    On or about April 6, 2015, the VA informed Dr. Head that he had 
formally been demoted from his position as Chief of Staff, further 
compounding the retaliation against Dr. Head for his truthful testimony 
before Congress in July 2014.

Retaliation Against Other Whistleblowers

    Because of Dr. Head's leadership position within GLAHS and his 
willingness to stand up against wrongdoers within the system, Dr. Head 
has become aware of many other VA employees who are enduring their own 
retaliation. The following are just a few select instances of 
retaliation being faced by other VA employees.

Incident 1:

    Dr. Tom Howard is another renowned physician within the Veterans' 
Affairs Greater Los Angeles Healthcare System who has been subjected to 
discrimination, harassment, and retaliation by management. Dr. Howard 
has occupied the position of a Staff Pathologist at GLAHS for 
approximately the last eight years. Dr. Howard has an exemplary record 
with the VA and has even received a Notice of Grant Award from the 
National Heart, Lung and Blood Institute (NHLBI). In addition to being 
a staff pathologist at GLAHS, Dr. Howard is a Principal Investigator 
currently conducting the largest hemophilia study of its kind ever 
funded in the United States as a result of the prestigious NHLBI grant 
he received.
    Beginning in September 2009, Dr. Howard was subjected to an 
extremely hostile work environment created by his clinical service 
chief, Dr. Farhad Moatamed, as a result of the NHLBI grant that he 
received. This hostile work environment led Dr. Howard to develop a 
stress-related illness which required him to take time off to recover. 
Dr. Howard requested advanced sick leave from his second line 
supervisor, Dr. Jessica Wang-Rodriguez. Despite being aware of Dr. 
Howard's disability and the circumstances that caused it, Dr. Wang-
Rodriguez repeatedly denied his advanced sick leave requests, forcing 
him to take leave without pay. Believing that he had been discriminated 
against due to his disability, Dr. Howard contacted an Equal Employment 
Opportunity (EEO) counselor on or about January 9, 2014.
    In or around May 2014, Dr. Howard was forced to return to work, due 
to financial reasons, despite not having fully recovered from his work-
related illness. Upon his return, Dr. Wang-Rodriguez moved him from the 
coagulation lab, which was his specialty, to a new lab supervised by 
Ms. Eva Archuleta, who had participated in harassing him in the past. 
On or about May 23, 2014, Dr. Howard became aware of the mishandling of 
patient specimens when a week's worth of patient samples were lost. He 
made complaints regarding the failure to transport patient samples 
properly by the Transportation Division under the VA Engineering 
Department. Dr. Howard believed that this was a serious problem that 
needed to be addressed immediately, as it was compromising patient care 
and safety.
    On or about June 9, 2014, shortly after Dr. Howard made this 
complaint, he was suspended. However, before he was to serve his 
suspension, Dr. Wang-Rodriguez postponed it until further notice. Then, 
on or about October 10, 2014, Dr. Wang-Rodriguez purposefully held a 
meeting in Dr. Moatamed's former office which Dr. Howard was required 
to attend. This meeting was held in the office where his former 
supervisor subjected him to harassment, such as yelling, screaming, 
threats, and demeaning comments. This exacerbated his ongoing work-
related illness to the point where he needed to seek leave; however, 
Dr. Wang-Rodriguez again denied his requests for advanced sick leave. 
In late November 2014, Dr. Wang-Rodriguez was removed as Dr. Howard's 
supervisor. She is now under investigation due to her actions against 
Dr. Howard and other issues within her department.
    In or around January 2015, Dr. Howard became aware that a large 
number of blood and patient samples that were drawn from veterans over 
the last several years and sent out to Quest Diagnostics for analytical 
testing were not entered into the medical records of the veterans from 
the greater Los Angeles area. As such, the VA's clinical providers who 
were depending on these tests to guide the medical management of the 
veterans were apparently never informed of the results of these tests. 
Dr. Howard performed a preliminary investigation in which he reviewed a 
21-page list comprised of unreported patient laboratory test results 
which showed all of the ``esoteric tests'' (i.e., those tests that cost 
the VA greater than $300.00 per assay performed by the contract 
referral laboratory) which were performed by Quest, but the results of 
which were never reported to the GLA Laboratory Information System, nor 
were the results ever relayed to the veteran patients. From this 
review, it appears that this specific lapse in reporting of lab test 
results has been going on since approximately January 2012, with the 
number of patients potentially affected being as high as 168. After 
making his complaints regarding this serious breakdown of care to 
veteran patients, Dr. Howard experienced retaliation in the form of his 
office being searched and a greater interest and criticism from upper 
management in his day-to-day work activities. Recently, in or around 
April 2015, Dr. Howard was removed from his position as Medical 
Director of the Clinical Laboratories at Sepulveda Ambulatory Care 
Clinic.

Incident 2:

    In another instance, Nafiseh Moghadam, P.A., a nurse practitioner 
within the VA, was discriminated and retaliated against by Dr. Marilene 
Wang, based in part on her national origin and Muslim faith. After 
seeing this employee working with Dr. Head, Dr. Wang also told this 
employee not to work with Dr. Head or provide him any assistance with 
patient care. Because of Dr. Wang's discriminatory animus towards this 
employee, as well as continued retaliation against Dr. Head, Dr. Wang 
had the employee terminated the day before her probationary period 
ended. This illegal behavior by Dr. Wang was supported by Donna Beiter 
and Dr. Dean Norman. (See Exhibit C.)

Incident 3:

    One employee, who has been a surgical technician at West Los 
Angeles VA Medical Center for the last seven years, has experienced 
discrimination based on his national origin (Filipino) in the form of 
derogatory comments and retaliation for making complaints about 
unprofessional behavior and time card fraud. After making complaints, 
the employee has been placed on suspensions for minor infractions for 
which other employees receive no discipline. Additionally, bonuses have 
not been awarded to him when other subpar employees have been awarded 
bonuses.

Incident 4:

    Christy Rodriguez is a medical instrument technician in anesthesia 
at West Los Angeles VA Medical Center for the past ten years. During 
Ms. Rodriguez's employment with the VA, she was subjected to a hostile 
work environment based on her national origin (Hispanic), age, and 
sexual orientation. Ms. Rodriguez has been passed over for promotion 
and has not been afforded opportunities for career development, despite 
repeatedly asking her supervisors. Additionally, Ms. Rodriguez's 
schedule has also been altered, negatively impacting her ability to 
take care of her ailing mother.

Incident 5:

    Muriel Alford was a Case Manager for the Office of Resolution 
Management, Western Operations who has worked for the federal 
government for practically her entire career. During her employment 
with the VA, Ms. Alford was discriminated against due to her race 
(African-American) and sex (female), and has been retaliated against 
for engaging in prior Equal Employment Opportunity (EEO) activity. She 
experienced a constant stream of hostility from her Team Leader and was 
denied appropriate training by her managers as part of a plan to force 
her out, as she was an older African American female who had filed two 
prior EEO complaints. This pressure ultimately forced her to resign 
from federal service after 35 years.

Incident 6:

    Deanna Anderson has been a Supervisory Medical Records 
Administrator Specialist with the Veterans' Affairs Greater Los Angeles 
Healthcare System since May 2006. During Ms. Anderson's employment with 
the VA, she has been subjected to discrimination based on her race 
(African-American) and retaliation for making protected complaints. She 
has been passed over for promotion and pay raises. Additionally, she 
has had to compete for her own position that she has rightfully held 
for many years.

Conclusion

    Dr. Head provides this testimony with the hopes of finding 
solutions to address employee mistreatment and improve the quality of 
healthcare provided to our Country's veterans. As a long-time employee 
within the VA healthcare system, Dr. Head is optimistic that 
appropriate changes can be implemented, and he looks forward to being 
an integral part of that change and the bright future that is ahead.
    By: Christian Head, M.D., April 26, 2016
    For additional information, you may contact Dr. Christian Head 
through his attorneys:
    Lawrance A. Bohm, Esq., Bradley J. Mancuso, Esq., Kelsey K. 
Ciarimboli, Esq.
    Bohm Law Group, 4600 Northgate Blvd., Suite 210, Sacramento, CA 
95834, Phone (916) 927-5574, Fax (916) 927-2046
    To access Dr. Head's previous written testimony to Congress, please 
visit: https://veterans.house.gov/witness-testimony/christian-head-md. 
To access Dr. Head's previous oral testimony to Congress, please visit: 
http://www.c-span.org/video/?320316-1/hearing-whistleblowers-va.

                Prepared Statement of Dr. Maryann Hooker

    Thank you, Mr. Chairman, and Members of the Committee for allowing 
me to address continued whistleblower retaliation within VA. My 
involvement with whistleblower retaliation dates to November, 2011, 
when my colleague, Dr. Michelle Washington, testified before the Senate 
Veterans Affairs Committee on the lack of access to mental health 
treatment. Not only was Dr. Washington retaliated against before and 
after her testimony, but other professional colleagues closely 
associated with her and with our professional union, AFGE Local 342, 
were retaliated against, as well. Methods of retaliation included 
denial of administrative leave, unsatisfactory performance rating, 
exclusion from department communications, removal of professional 
duties, enhanced scrutiny of clinical record charting, investigation by 
the OIG, and being the subject of a formal Administrative Investigation 
Board (AIB).
    Since then, others who have spoken out against management practices 
or managers who have spoken in favor of their subordinates have been 
retaliated against, removed from their regular duties, or have left VA 
under pressure or unwillingly. In September, 2014, AFGE Local 342 
members announced a no-confidence vote over management's sudden 
downgrading of surgical services and further reduction in clinical 
offerings, such as inpatient bed availability. Subsequent retaliation 
against AFGE Local 342 members included non-consideration for internal 
position vacancies, an extraordinary increase in workload, a noticeable 
reduction in workload, inaccurate labor mapping, loss of 
electroencephalography services for Veterans at the facility, and a 
number of staffing adjustments.
    The following professionals remain detailed away from their regular 
duties to date:
    Associate Chief Nurse (almost one year), Nurse Manager (almost one 
year), Registered Nurse (seven months), Nurse Manager (six months), 
Nurse Manager (two months), Radiologist (five months), 
Otorhinolaryngologist (five months), Ophthalmologist (one month), 
Quality Manager (two months), Nurse Executive (six months), and Senior 
Project Engineer (almost three years).
    None were involved in scheduling, though all are involved in access 
to care. Many of the individuals made disclosures to senior management 
and would be considered whistleblowers if the information had been 
reported outside VA. Several AIBs have been convened reportedly 
examining different areas of practice, such as surgery services, 
pathology services, long-term care, inpatient care services, and non-VA 
care services. Two individuals reportedly had no alleged misconduct 
confirmed after investigations were completed, yet the individuals 
remain on detail. Almost all were not told the scope of any 
investigation or any reason for an investigation. None were given any 
forewarning of any concerns regarding their performance.
    The disruptions from these personnel moves continue to have a very 
negative effect on staff. A GAO report on ``VA Administrative 
Investigations'' (GAO-12-483) found it critical for AIBs to be convened 
and conducted appropriately, as well as for information to be shared 
about improvements implemented in response to the results of AIB 
investigations. Compliance appears lacking in the aforementioned 
instances. Since the personnel moves do not appear to have been made to 
correct behavior or to have been made for the efficiency of public 
service, they appear to be a waste of medical talent and a waste of VA 
funding. Plans to realign VA services by addressing or right-sizing 
legacy programs, transitioning from a hospital bed-based system of care 
to an ambulatory/primary care model, and shifting resources from low-
volume programs to other programs already were announced in 2011. There 
should be no underlying fear of discussing and planning for staffing 
adjustments driving these personnel moves. With no overt valid cause 
for their occurrence, constitutional rights appear maligned.
    Psychological safety in a work setting has been defined as the 
extent to which employees feel able to ask questions or bring up team 
issues without being afraid of hurting their reputation, status or 
career. In a psychologically safe environment, employees have a shared 
belief that it is safe to take interpersonal risks, such as asking for 
help, admitting a mistake, questioning a procedure, or pointing out a 
mistake, and view these actions as ``worth the trouble.'' (Adapted from 
Edmondson, A.C. [1999] Psychological safety and learning behavior in 
work teams. Administrative Science Quarterly, 44,350-383)
    Workplace violence as defined by VA is any physical assault, 
threatening behavior, or verbal abuse that occurs while working or on 
duty. Lateral violence includes bullying, scapegoating, smearing 
someone's reputation, refusal to help, exclusionary behavior, 
intimidation, or other incivility. (Veterans Health Administration 
Workforce Succession Strategic Plan 2011) Bullying includes these 
behaviors familiar to VA employees: establishing impossible deadlines 
that will set up the individual to fail, undermining or deliberately 
impeding a person's work, removing areas of responsibilities without 
cause, constantly changing work guidelines, withholding necessary 
information or purposefully giving the wrong information, assigning 
unreasonable duties or workload which are unfavorable to one person, 
under work or creating a feeling of uselessness, unwarranted or 
undeserved punishment, and excluding or isolating someone socially.
    Data from the Stress and Aggression study (VISNs 23 and 11) 
indicate that the predominant trigger of aggressive behavior in staff 
is related to frustrating systems and processes, while the main 
triggers of aggressive behavior in patients are frustrating 
interactions with staff and the ensuing sense of powerlessness. 
Enabling people to relate to one another with confidence and trust, and 
to root out suspicion and mistrust, is a way to strengthen democratic 
spirit and a sense of community. When officials and employees forget 
they are rendering a public service and behave in a manner to suit 
their own convenience rather than that of the public they are supposed 
to serve, a social institution can lose its humanity. (Jaques, Elliott 
[1976] General Theory of Bureaucracy) When money and resources 
available to government are diverted from the benefit of citizens, the 
seeds of conflict are sown.
    Corruption, as defined by the United States Institute of Peace, is 
the abuse of entrusted power for private gain. Corruption creates a 
system whereby money and connection determines who has access to public 
services and who receives favorable treatment. (Governance, Corruption, 
and Conflict) Corruption undermines the trust and shared values that 
make a society work. Howard Wolpe, scholar and former US 
Representative, called corruption a symptom of divided societies, where 
success (or survival) comes at the expense of others. ``To the extent 
that you can begin to alter that paradigm--to generate interdependence, 
and to recognize that collaboration can strengthen one's own self-
interest, you begin to impact the drivers of corruption.''
    The story of VA is a story of two different organizations; there is 
the VA that takes care of Veterans, and there is the VA that takes care 
of itself. If VA is pictured as a diamond, Veterans are at one tip of 
the diamond, while the VA Secretary is at the other tip of the diamond. 
Between the Secretary and the Veteran is what whistleblowers perceive 
to be ever-expanding layers of management consuming the majority of 
funds earmarked for their task, and creating an increasingly 
challenging system denying them success in providing good care.
    Whistleblowers tend to be those closest to Veterans in the diamond 
model. Whistleblowers tend to report on the VA-for-VA system when it 
appears to be operating at the expense of the VA-for-Veterans system. 
Concerns arise with regularity at the start of each fiscal year when 
medical center directors announce a `zero budget increase' for 
operations. A knee-jerk response leads to consolidation of functions 
and hiring freezes. Salary dollars of professional staff typically are 
identified as the largest line item in the budget requiring trimming. 
New strategic goals and increased overhead costs also are givens. Since 
Veterans Equitable Resource Allocation (VERA) is driven by provider 
encounters and reportedly accounts for 75% of medical center budget 
allocations, flat-line budgets typically lead to the cutting of 
clinical personnel that further drop future VERA reimbursement and 
cause more cuts to staffing in the long run.
    Along with ever-escalating demands to meet performance measures, 
unclear role relationships and inadequate channels of authority lead to 
constant personal manipulation at all levels. Licensed professionals 
subject to Sec. 7422 of Title 38 are constrained further by the 
Secretary's control over clinical practice and competence, leading to 
their experiencing additional inequalities and abuses. Reports to OIG, 
OMI, OSC, EEO, or JCAHO more often than not are sent for investigation 
to the very same VA reported for not following its own rules and 
regulations. This is in sharp contrast to The Washington Post report 
earlier this year on an Atlanta jury convicting 11 teachers of 
racketeering and other crimes in a standardized test-cheating scandal 
by teachers and administrators who felt under pressure to meet certain 
score goals at the risk of sanction if they failed. Why is VA not held 
to the same standard of correction?
    Respectfully, Maryann Hooker, MD, President, AFGE Local 342

    ``If men were angels, no government would be necessary. If angels 
were to govern men, neither external nor internal controls on 
government would be necessary. In framing a government which is to be 
administered by men over men, the great difficulty lies in this: you 
must first enable the government to control the governed; and in the 
next place, oblige it to control itself.'' By: James Madison

                 Prepared Statement of Richard Tremaine

    Dear Chairman Coffman
    I am here with you today to testify about the unacceptable, vicious 
and ongoing retaliation against Dr. Sheila Meuse and myself for our 
whistleblower activity at the Central Alabama Veterans Healthcare 
System (CAVHCS), where the Director, James Talton, became the first SES 
(Senior Executive Service) member in history fired for neglect of duty. 
The Chief of Staff, also under investigation, was on paid leave for six 
months, and quietly retired in December 2014.
    With disingenuous claims of improvements, there remains an 
atmosphere of exclusion and retaliation, against those who did not 
support Talton, or subsequently, the dangerously inexperienced 
leadership, and ineffectual management of Robin Jackson, the Deputy 
Network Director over Talton during his tenure, and who was immediately 
planted as interim director by Charles Sepich, the VISN 7 Director.
    Dr. Meuse and I were two seasoned and experienced, yet idealistic 
newcomers to the leadership team of CAVHCS in March 2014. Although we 
both identified scheduling manipulations, illegal hiring practices, 
continued use of paper wait lists, severely delayed consults, critical 
levels of understaffing, fraud, and a complete breakdown of HR (Human 
Resources Management), directly to Talton, we quickly concluded he 
would not support our efforts to hold staff accountable.
    In June 2014 we were forwarded an e-mail message sent to Talton in 
April of 2013, alerting him to critical scheduling manipulations from a 
staff physician. Since Talton was publicly claiming no prior knowledge 
of any scheduling manipulations, we became seriously concerned about 
his integrity, and on June 11, raised those concerns directly to Robin 
Jackson and Charles Sepich. We also informed them that we had been 
contacted by Representative Martha Roby on June 10, regarding her face 
to face meeting with Talton.
    Immediately after our June 11 confidential disclosures to Sepich 
and Jackson, the severe retaliations from Talton escalated 
exponentially. We later learned it was because Sepich and Jackson had 
communicated every word of our confidential conversation about Talton, 
directly to Talton that very same day.
    On June 24 I sent an emergency e-mail plea to Sepich, informing him 
of continued violent outbursts and mismanagement by Talton. The very 
next morning I was forced off the Montgomery VA campus by order of 
Robin Jackson. I was devastated to realize that I had been betrayed.
    I was constructively removed from my leadership responsibilities, 
and prevented from acting in any leadership capacity by Talton and 
subsequently, by Jackson in humiliating all-employee e-mails.
    Although Sepich had promised me that he would immediately begin a 
fact finding to help, in fact, four days earlier he had already 
chartered a fact finding to investigate fabricated allegations by 
Talton and Jackson against us. That FF was chaired by a subordinate of 
Sepich. As a result, Sepich and Jackson requested an AIB 
(Administrative Investigative Board) from VACO on us without any 
specific charges.
    The AIB was conducted by the OAR (VA's Office of Accountability 
Review) the week of October 27, 2014, with results due on January 19, 
2015. Instead, the AIB requested additional, on-site testimony, citing 
a new allegation put forward by a union president who was not selected 
for a promotion, thus extending the investigation, and its scope.
    One of the AIB members, a sitting director, was a former 
subordinate, and friend of Charles Sepich.
    Incredulously, during my first year at CAVHCS, I had been under the 
weight of investigations for 305 out of 365 days without a single 
charge, and beginning within my first 45 work days.
    It is difficult to describe the level of disrespect, harassment, 
and retaliation we endured from Talton, Sepich, and Jackson as he 
removed hospital services from my authority, initiated major 
reorganizations and realignments adversely impacting my position, and 
without my input. My direct reports bypassed me, reporting to him at 
his request. I was excluded from key informational resources, blocked 
from critical administrative reports of major program assessments, and 
important site reviews.
    In fact, when I asked for the complete administrative assessment 
done by Jackson himself, a month before I arrived, he told me, ``If you 
want to see it, request the information under the Freedom of 
Information Act (FOIA).''
    In an amazing failure of leadership, Sepich and Jackson actually 
detailed Dr. Meuse out of the state for 90 days, in the middle of our 
crisis!
    I speak with you today with a heavy heart disgusted by continued 
cover-ups, a discrediting campaign through open-ended investigations, 
and the attempted destruction of my career, by the very VA I have 
always loved being part of.
    So many VA employees are closely monitoring this issue, and hoping 
VA leadership at all levels will demonstrate a commitment to true 
excellence and transparency, by creating an environment free from 
Whistleblower Reprisal and Retaliation.
    If the retaliatory actions from CAVHCS and VISN 7 against a 
dedicated veteran executive and brilliant career woman executive, both 
who have committed their lives to serving our Veterans, is tolerated in 
the least, it will most certainly have a chilling effect on any others 
considering stepping forward to protect the organization we all love 
serving Veterans through.
    I have feared the loss of my job and career, and we both fear a 
further loss of our personal and professional reputations, but Dr. 
Meuse and I sat in disbelief a year ago, and agreed at that moment in 
time, we didn't have a choice, because it was more important to protect 
our Veterans, than protecting either one of our own careers.
    We respectfully request that you immediately address the overt 
whistleblower retaliation that has become rampant in our VA.
    We thank you for your commitment to our Veterans.
    Sincerely,

    Richard J. Tremaine, MBA, Associate Director, CAVHCS
    With Acknowledgement and support, Dr. Sheila Meuse, Assistant 
Director, (retired 3.31.15)

                                 

                        Statement for the Record

                    Project on Government Oversight

    Subcommittee on Oversight and Investigations Hearing on 
``Addressing Continued Whistleblower Retaliation Within VA''
    Fear and Retaliation at the Department of Veterans Affairs
    In the spring of 2014, the Project on Government Oversight (POGO) 
put out the call to whistleblowers within the Department of Veterans 
Affairs (VA) to provide an inside perspective on the issues the 
Department was facing.
    In our 34-year history, POGO has never received as many submissions 
on a single issue. Nearly 800 current and former VA employees and 
veterans from 35 states and the District of Columbia contacted us. POGO 
reviewed each of the submissions, and found that concerns about the VA 
go far beyond long or falsified wait times for medical appointments; 
they extend to the quality of healthcare services veterans receive.
    A recurring and fundamental theme became clear: VA employees across 
the country fear they will face repercussions if they dare to raise a 
dissenting voice.
    POGO wrote a letter to Acting VA Secretary Sloan Gibson in July 
last year, highlighting three specific cases of current or former 
employees who agreed to share details about their personal experiences 
of retaliation.\1\
---------------------------------------------------------------------------
    \1\ Letter from Project on Government Oversight to Sloan D. Gibson, 
then-Acting Secretary of the Department of Veterans Affairs, about Fear 
and Retaliation in the VA, July 21, 2014. http://www.pogo.org/our-work/
letters/2014/pogo-letter-to-va-secretary-about-va-employees-
claims.html.
---------------------------------------------------------------------------
    In California, a VA inpatient pharmacy supervisor was placed on 
administrative leave and ordered not to speak out after protesting 
``inordinate delays'' in delivering medication to patients and 
``refusal to comply with VHA regulations.'' In one case, he said, a 
veteran's epidural drip of pain control medication ran dry, and another 
veteran developed a high fever after he was administered a chemotherapy 
drug after its expiration point.
    In Pennsylvania, a former VA doctor told POGO that he had been 
removed from clinical work and forced to spend his days in an office 
with nothing to do. This action occurred after he complained that, in 
medical emergencies, physicians who were supposed to be on call were 
failing or refusing to report to the hospital. The Office of Special 
Counsel (OSC) shared his concerns, writing ``[w]e have concluded that 
there is a substantial likelihood that the information that you 
provided to OSC discloses a substantial and specific danger to public 
health and safety.'' \2\
---------------------------------------------------------------------------
    \2\ Letter from Karen Gorman, Deputy Chief, Disclosure Unit Office 
of Special Counsel, to Dr. Thomas Tomasco, about Dr. Tomasco's 
allegations, OSC File No. DI-13-0416, March 21, 2013.
---------------------------------------------------------------------------
    In Appalachia, a former VA nurse told POGO she was intimidated by 
management and forced out of her job after she raised concerns that 
patients with serious injuries were being neglected. In one case she 
was reprimanded for referring a patient to the VA's patient advocate 
after weeks of being unable to arrange transportation for a medical 
test to determine if he was in danger of sudden death. ``Such an 
upsetting thing for a nurse just to see this blatant neglect occur 
almost on a daily basis. It was not only overlooked but appeared to be 
embraced,'' she said. She also pointed out that there is ``a culture of 
bullying employees. . . . It's just a culture of harassment that goes 
on if you report wrongdoing,'' she said.
    That culture doesn't appear to be limited to just one or two VA 
clinics. Some people, including former employees who are now beyond the 
reach of VA management, were willing to be interviewed by POGO and to 
be quoted by name, but others said they contacted us anonymously 
because they are still employed at the VA and are worried about 
retaliation. One put it this way: ``Management is extremely good at 
keeping things quiet and employees are very afraid to come forward.''
    This kind of fear and suppression of whistleblowers who report 
wrongdoing often culminates in the larger problems, as the VA is 
currently experiencing. By now it is well known that employees who 
recently raised concerns about veteran wait times faced reprisal. But 
whistleblower retaliation in the VA is nothing new. In 1992 a 
congressional report detailed the experiences of VA employees who were 
harassed or fired after reporting problems.\3\ Throughout the 1990s 
there were several congressional hearings conducted on the quality of 
care at VA hospitals and on reprisal against VA employees who exposed 
inadequate care.\4\ Despite then-Secretary Togo D. West's declaration 
that such reprisals would not be tolerated, a House hearing in 1999 
found that the reprisal problems still existed.\5\ A Government 
Accountability Report from 2000 found that many VA employees were 
unaware of their rights to protections against retaliation for blowing 
the whistle on wrongdoing.\6\ The report also found that the majority 
of employees feared retaliation and were therefore unwilling to report 
misconduct.
---------------------------------------------------------------------------
    \3\ Eric Lichtblau, ``VA Punished Critics on Staff, Doctors 
Assert,'' The New York Times, June 15, 2014. http://www.nytimes.com/
2014/06/16/us/va-punished-critics-on-staff-doctors-assert.html. 
(Downloaded April 10, 2015) (Hereinafter ``VA Punished Critics on 
Staff, Doctors Assert'').
    \4\  Government Accountability Office, Whistleblower Protection: VA 
Did Little Until Recently to Inform Employees About Their Rights, April 
14, 2000. http://www.gao.gov/archive/2000/gg00070.pdf (Downloaded April 
10, 2015) (Hereinafter Whistleblower Protection: VA Did Little Until 
Recently to Inform Employees About Their Rights).
    \5\ ``VA Punished Critics on Staff, Doctors Assert.''
    \6\ Whistleblower Protection: VA Did Little Until Recently to 
Inform Employees About Their Rights.
---------------------------------------------------------------------------
    The Office of Special Counsel (OSC) has been working to investigate 
claims of retaliation and get favorable actions for many of the VA 
whistleblowers who have come forward. Since April 2014, the OSC has 
successfully obtained corrective actions for over 25 whistleblowers.\7\ 
But the OSC still has over 100 pending VA reprisal cases to 
investigate, among the highest of any government agency, according to 
Special Counsel Carolyn Lerner.\8\ Although the VA has been cooperative 
with the OSC and their recommendations, merely addressing isolated 
incidents is not enough.\9\ The VA has been struggling with a culture 
problem for decades and something more must be done.
---------------------------------------------------------------------------
    \7\ Office of the Special Counsel, ``OSC Obtains Relief for More VA 
Whistleblowers,'' January 20, 2015. https://osc.gov/News/pr15-02.pdf 
(Downloaded April 10, 2015).
    \8\ Joe Davidson, ``Some VA whistleblowers get relief from 
retaliation,'' The Washington Post, January 20, 2015. http://
www.washingtonpost.com/politics/federal--government/some-va-
whistleblowers-get-relief-from-retaliation/2015/01/20/067dcd14-9da8-
11e4-bcfb-059ec7a93ddc--story.html (Downloaded April 10, 2015).
    \9\ Matthew Daly, ``VA settles more whistle-blower retaliation 
complaints,'' Associated Press, January 21, 2015. http://
www.azcentral.com/story/news/investigations/2015/01/21/va-settle-
complaints-whistleblowers/22108555/ (Downloaded April 10, 2015); Chris 
Hubbuch, ``VA to Investigate Overmedication, Retaliation Claims at 
Wisconsin VA,'' Military.com, January 16, 2015. http://
www.military.com/daily-news/2015/01/16/va-to-investigate-
overmedication-retaliation-claims-at.html (Downloaded April 10, 2015).

---------------------------------------------------------------------------
Oversight at Its Worst

    VA employees who have concerns about management or fear retaliation 
are supposed to be able to turn to the VA's Office of Inspector General 
(OIG). But whistleblowers have come to doubt the VA IG's willingness to 
hold wrongdoers accountable. Since 2014, the IG Office has not yet 
publically released any investigation into employee retaliation, making 
it difficult to assess how seriously the IG's office is taking this 
issue.
    Furthermore, the VA IG's office issued an administrative subpoena 
to POGO in May 2014 that was little more than an invasive fishing 
expedition for whistleblowers. The IG demanded ``All records that POGO 
has received from current or former employees of the Department of 
Veterans Affairs, and other individuals or entities.'' \10\ Though POGO 
did not comply with the subpoena, such an action was cause for concern 
for many of the whistleblowers who had shared information with us.
---------------------------------------------------------------------------
    \10\ Letter from the Project On Government Oversight to Richard J. 
Griffin, Acting Inspector General for the Department of Veterans 
Affairs, about the IG's subpoena for POGO records, June 9, 2014. http:/
/www.pogo.org/our-work/letters/2014/va-inspector-general-issues-
subpoena-for-pogo.html.
---------------------------------------------------------------------------
    POGO remains concerned that there is not a permanent VA IG in place 
and that the position has been vacant for over a year.\11\ Our own 
investigations have found that the absence of permanent leadership can 
have a serious impact on the effectiveness of an IG office.\12\ Acting 
IGs do not undergo the same kind of extensive vetting process required 
of permanent IGs, and as a consequence usually lack the credibility of 
a permanent IG. Acting IGs also often seek appointment to the permanent 
position, which can compromise their independence by giving them an 
incentive to curry favor with the White House and the leadership of 
their agency.\13\ Perhaps most worrisome, given the significant 
challenges facing the VA IG, a 2009 study found that vacancies in top 
agency positions promote agency inaction, create confusion among career 
employees, make an agency less likely to handle controversial issues, 
result in fewer enforcement actions by regulatory agencies and decrease 
public trust in government.\14\
---------------------------------------------------------------------------
    \11\  Project On Government Oversight, ``Where Are All the 
Watchdogs?'' http://www.pogo.org/tools-and-data/ig-watchdogs/go-igi-
20120208-where-are-all-the-watchdogs-inspector-general-vacancies1.html.
    \12\ ``Testimony of POGO's Jake Wiens on ``Where Are All the 
Watchdogs? Addressing Inspector General Vacancies,'' May 10, 2012. 
http://www.pogo.org/our-work/testimony/2012/go-ig-20120510-inspector-
general-testimony.html (Hereinafter Testimony of POGO's Jake Wiens on 
``Where Are All the Watchdogs?).
    \13\ Testimony of POGO''s Jake Wiens on ``Where Are All the 
Watchdogs?''
    \14\ Anne Joseph O'Connell, ``Vacant Offices: Delays in Staffing 
Top Agency Positions,'' Southern California Law Review, Vol. 82, 2009.
---------------------------------------------------------------------------
    It appears the VA IG may be subject to this dangerous lack of 
independence. For example, the VA OIG has failed to release the results 
of 140 healthcare investigations since 2006.\15\ Furthermore, the 
Department of Treasury IG sent a letter to this Committee just last 
month raising concerns about another VA IG investigation. After 
speaking to witnesses familiar with the situation, the Treasury IG 
concluded that their testimony, ``calls into question the integrity of 
the VA OIG's actions in this particular manner.'' The Treasury IG's 
investigation also found that multiple witnesses stated a VA employee 
boasted about his ability to influence the VA OIG's investigations.\16\
---------------------------------------------------------------------------
    \15\ Donovan Slack, ``VA doesn't release 140 vet healthcare probe 
findings,'' USA Today, March 8, 2015. http://www.usatoday.com/story/
news/politics/2015/03/08/probes-of-veterans-health-care-often-not-
released-to-public/24525109/ (Downloaded April 10, 2015).
    \16\ Letter from Eric M. Thorson, Department of the Treasury 
Inspector General, to the Hon. Jeff Miller and the Hon. Corrine Brown, 
Chairman and Ranking Member of the House Committee on Veterans Affairs, 
regarding the VA IG investigation, March 11, 2015. https://
veterans.house.gov/sites/republicans.veterans.house.gov/files/
Letter%20from%20Treasury%20Dept.%20IG--0.pdf (Downloaded April 10, 
2015).

---------------------------------------------------------------------------
Recommendations

    In POGO's 2014 letter, we recommended concrete steps for incoming 
VA Secretary McDonald to take in order to demonstrate an agency-wide 
commitment to changing the VA's culture of fear, bullying, and 
retaliation. Neither Acting Secretary Sloan Gibson nor Secretary 
McDonald have responded to our multiple requests for a meeting.
    Clearly, an important first step will be for the President to 
nominate a permanent IG for the VA. Hopefully strong and committed 
leadership in that office will correct its current course. POGO 
recommended that Secretary McDonald make a tangible and meaningful 
gesture to support those whistleblowers who have been trying to fix the 
VA from the inside. Once the OSC has identified meritorious cases, 
Secretary McDonald should personally meet with those whistleblowers and 
elevate their status from villain to hero. These employees should be 
publicly celebrated for their courage, and should receive positive 
recognition in their personnel files, including possibly receiving the 
types of bonuses that have been provided to wrongdoers in the past. 
Retaliation against whistleblowers is already a prohibited personnel 
practice, but it will be up to the senior-most VA leadership to ensure 
that this rule is enforced by the agency. This should not be an 
isolated event done in response to recent criticisms but an ongoing 
effort. Whistleblowing must be encouraged and celebrated or wrongdoing 
will continue.
    But it's not just the VA Secretary who can work to fix this 
problem. Congress should enact legislation that codifies accountability 
for those who retaliate against whistleblowers. The definition of 
``wrongdoing'' must include retaliation. The cultural shift that is 
required inside the Department of Veterans Affairs must be accompanied 
by statutory mandates that protect whistleblowers and witnesses inside 
the agency from retaliation. Legislation should ensure that 
whistleblowers are able to be confident that stepping forward to expose 
wrongdoing will not result in retaliation, and should provide a system 
to hold retaliators within the VA accountable.
    Congress should also extend whistleblower protections to 
contractors and veterans who raise concerns about medical care provided 
by the VA. POGO's investigation found that both of these groups also 
fear retaliation that prevents them from coming forward.
    While federal employees working at the VA enjoy whistleblower 
protections, contractors do not. Congress should extend the same 
protections to contractors in order to promote internal oversight in an 
increasingly contractor-heavy landscape.
    In addition, a veteran who is receiving poor care should be able to 
speak to his or her patient advocate without fear of retaliation, 
including a reduction in the quality of healthcare. Without this 
reassurance, there is a disincentive to report poor care, allowing it 
to continue uncorrected. Congress should extend whistleblower 
protections to veteran whistleblowers.
    The VA and Congress must work together to end this culture of fear 
and retaliation. Whistleblowers who report concerns that affect veteran 
health must be lauded, not shunned. And the law must protect them.

                                 

                 Statement of Kimberly Hughes Statement

    Thank you for the opportunity to submit testimony for the record to 
the Veterans Affairs' Subcommittee on Oversight and Investigations. I 
would especially like to thank Chairman Mike Coffman and Ranking Member 
Ann Kuster for providing a hearing Addressing Continued Whistleblower 
Retaliation within the Department of Veterans Affairs and a platform 
for whistleblowers to tell their stories.
    My name was first mentioned in the VA Whistleblower Hearing before 
the full committee on July 8, 2014 regarding Exposing Inadequate 
Service Provided to Veterans and Ensuring Appropriate Accountability, 
by Scott Davis, a fellow whistleblower at the Veterans Health 
Administration (VHA) Health Eligibility Center (HEC) in Atlanta, GA. 
The Atlanta Journal Constitution followed up with an article that told 
some of my story on August 15, 2014 and I applied for whistleblower 
protection from the Office of Special Counsel (OSC) in September 2014. 
My case is currently under review.
    The scandal is a year old and the news out of VA still has the 
power to stun average people. Some employees have committed suicide due 
to retaliation on top of the 22 Veterans a day that take their own 
lives.

A Little About Me

    For the record, I was hired by VA in 2004 as a GS-9 Presidential 
Management Fellow and promoted every year that I was eligible to the 
GS-14 level. My reputation was stellar and I was often sought after by 
other offices to either work for them or consult with them due to my 
knowledge, skills and abilities. I loved working for Veterans and 
during my career was given the opportunity to help formulate the 
healthcare budget in the VHA Office of Finance. My experience in that 
office was one of true admiration and respect for my chain of command. 
I would not trade that experience for any other inside or outside of 
VA.
    In 2005, I was the first VA employee ever allowed to work (via 
detail) at the Office of Management and Budget on a VA Congressional 
Justification (2007 Budget Request) with the President's budget 
examiners. I have been nominated for multiple awards related to my work 
including Employee of the Year in the VHA Office of Finance and a 
President's Quality Award while I was a Presidential Management Fellow. 
I was given outstanding performance ratings year after year and was 
honored to be selected as a participant in the prestigious Leadership 
VA Program in 2012--shortly after which my life and career were forever 
altered by retaliation.

Doing My Job

    I am the person that blew the whistle on the backlog of 900,000 
pending healthcare applications in the enrollment system to my chain of 
command in April 2012. I was the Associate Director for Informatics at 
HEC for three years and supervised a staff of analysts whose jobs 
included monitoring and reporting the status of many administrative 
data sets related to healthcare enrollment. In March 2012, it became 
clear to my staff and me that there was an alarming increase in the 
number of healthcare applications that were ending up in a pending 
status--both income and eligibility related--rather than being 
processed to a final enrollment determination. This is a kind of 
administrative limbo where the application can sit until someone acts 
upon it and applicants were never notified that their application was 
in this status which meant they could linger in it for days to years. 
We also identified 48,000 applicants as being deceased and in a pending 
status.
    As we dived into the data to find an explanation, it became clear 
that there was a relationship between the increase in long-term pending 
(>70 days) and the online healthcare application process which had been 
advertised since 2009 both by VA senior leaders and via VA website as 
``the fastest and easiest way to apply for healthcare.'' The enrollment 
data did not support this claim.
    In April 2012, this observation was elevated in a meeting with the 
Deputy Chief Business Officer for Member Services (DCBO, Senior 
Executive), Lynne Harbin, as well as HEC Director, Tony Guagliardo and 
HEC Deputy Director, Floretta Hardmon, and via an Excel table to the 
levels above DCBO including the VHA Chief Business Officer, Katie 
Shebesh and the VHA Deputy Assistant Secretary for Operations/
Management, Philip Matkovsky (who abruptly resigned in December 2014).
    The monthly meetings continued regarding pending applications 
beginning in April, 2012 until June, 2012. During the meetings, my 
staff and I received a great deal of push back from HEC management and 
DCBO including a ``negotiation'' where at first those in pending status 
for a year or less would be notified; then a second ``negotiation'' 
occurred where they would agree to go back two years and notify those 
applicants of their pending status; and a final ``negotiation'' was 
offered in that they would agree to go back three years and notify 
those applicants of their pending status--all three times we said that 
all applicants should be treated the same. The concern was then raised 
that if all pending applicants were notified that it would embarrass 
the Department and become public knowledge that they had been building 
up for years and Veterans would notify their Congressional 
representatives, creating a ``scandal'' for HEC management. The 
notification of applicants in a pending status was left unresolved.
    In the June 2012 meeting, it was determined that this project would 
be taken away from Informatics (me), and assigned to Floretta Hardmon, 
HEC Deputy Director by Tony Guagliardo, the HEC Director. To my 
knowledge, Ms. Hardmon never held another meeting or asked for any 
follow-up analysis or data related to her ``taskforce''. I continued to 
raise the issue in weekly Director's meetings but they were abruptly 
cancelled until further notice beginning in August 2012. The Director 
and Deputy Director continued to meet with other Associate Directors on 
a regular basis but I was ``frozen out'' of the front office. In 
October 2012, I was handed a memo by the HEC Director backdated to 
September 28, 2012 (a falsified document), notifying me that I was 
being detailed with no discussion or prior notice to a non-supervisory 
analyst position, working directly for the DCBO, Lynne Harbin. In 
December 2012, I was permanently demoted to the analyst position. 
Although I was becoming increasingly worried about management's actions 
towards me, I went to work in my new job and embraced my new duties. I 
was still analyzing data from the enrollment system but for the first 
time, also providing analysis of additional data sets in the 
organization which revealed more problems.
    In November 2012, during some routine analysis of the Veteran's 
Transportation Program data, I determined that the information being 
reported using the data set was so flawed that it could not be used for 
official reporting and notified my chain of command, Ms. Harbin and via 
a monthly report that was disseminated up to the Deputy Assistant 
Secretary for Operations/Management. At the time, the data was being 
used to justify funding for a program to transport Veterans to medical 
centers and clinics and was touted as saving the Department money as 
opposed to reimbursement for mileage. However, it was clear that 
savings could not be determined on a national level and the program did 
not have valid data to support such a claim. I was yelled at by Ms. 
Harbin that ``there has to be data to support the program!'' There was 
not.
    In January 2013, I was still monitoring pending applications and 
was stunned to learn from my former Informatics staff about a meeting 
with the Director, Tony Guagliardo and the Deputy Director, Floretta 
Hardmon where they were instructed to wholesale reject 600,000 pending 
healthcare applications in the enrollment system without concern for 
their true eligibility. They stated that the Director told them that he 
``didn't have the staff to work them'' and ``wanted to start fresh for 
Fiscal Year 2013.'' The Informatics staff refused to follow the orders 
and one person actually had to leave the meeting and find a subject 
matter expert on enrollment to tell the Director and Deputy Director 
that they did not have the authority for such action. I was horrified 
as this may be the most brazen and largest single attempt at fraud in 
VHA history. I now understood why I had been moved out of Informatics 
and promptly told Ms. Harbin about the meeting. She did not share my 
concern.
    Additionally, in January 2013, as I was analyzing data in the 
internal workload system at HEC--called WRAP--I came across a confusing 
set of three dates. The first column was the date the application was 
received (or uploaded via scanner). There was a second interim date in 
a second column and a closed date in a third column. This data was 
being used to compute the turnaround time for applications that were 
assigned to HEC employees to process. From what I could tell, the 
turnaround time was based on the second interim column and the closed 
column. I met with a subject matter expert on the WRAP system and asked 
him how the different dates were being used. He confirmed my suspicions 
that the interim date and the closed date were being used to calculate 
the official turnaround time for all of the applications. This meant 
that an application could be received in October 2012, ``opened'' by a 
HEC employee on December 12, 2012 and then closed on December 15, 2012 
and the turnaround time would be reported as three days. The received 
date was ignored in the calculation. Although the HEC Director was 
officially reporting a turnaround time of four days, I found nearly 
40,000 unprocessed applications in the workload system and some were 
nearly a year old. The majority category belonged to combat Veterans. I 
was again horrified and reported this to Ms. Harbin. She did not share 
my concern.
    As my analysis of the different data sets kept uncovering problems 
and it appeared that the healthcare application process was in at least 
a partial meltdown from the online application process to the internal 
processing of applications by HEC staff, I was told that the Office of 
Inspector General (OIG) was in the building so I put together a file 
for them assuming they would eventually meet with me. In the meantime, 
the retaliation was well under way.

The Cover-up and Retaliation

    Beginning in May 2012, I was subjected to ``pervasive and severe'' 
(VA's description) retaliation by Ms. Hardmon, Mr. Guagliardo and Ms. 
Harbin. The retaliation included false allegations of threats, being 
portrayed as ``difficult,'' ``disgruntled,'' ``inflexible,'' and 
``erratic'' (logically, the last two actually cancel each other out); 
told that I was ``too fact-based and relationships are what matter;'' 
detailed on the last day of the fiscal year (falsified) so that my 
supervisor, Ms. Hardmon would not have to provide an annual performance 
rating to me; eventually being demoted in December 2012; and put under 
surveillance with both a camera and microphone just outside of my 
office door and (I learned later) a wiretap on my personal cell phone. 
The environment became so hostile I was often ``baited'' by management 
and shunned by other employees who refused to speak to me or come into 
my office, left out of meetings and important e-mail strings related to 
my job duties and physically isolated in a suite of offices with one 
other person and Ms. Harbin.
    As I mentioned before, during the final months of my employment at 
HEC, OIG officials were in the building and, to the best of my 
knowledge, there to examine pending healthcare applications. It appears 
as though the backlog may have been reported to OIG sometime around 
August or September 2012 and the notification was sent to the HEC 
Director, Tony Guagliardo. This timeline also coincides with the 
escalation of the retaliation that I was subjected to and it is pretty 
clear that I was used as a scapegoat to deflect the accountability from 
his office to me.
    I was never interviewed by an OIG official regarding the healthcare 
applications although I should have been at the top of the list--both 
as the former Associate Director for Informatics and a current analyst. 
As it turns out, I was at the top of a ``hit list.'' Instead of meeting 
with me, I was subjected to hostility by the agents in the building. 
For example, when I entered the building, the security guard would pick 
up his phone and announce my arrival to someone else on the end of the 
line. I was warned by employees I didn't know from other offices while 
outside the building and near the elevators that ``loose lips sink 
ships'' and similar warnings. When I printed e-mails they now had a tag 
of ``Martinsburg'' in them which meant my computer was being monitored. 
I was lied to repeatedly by the HEC Director and HEC Deputy Director 
regarding the status of my 2012 performance evaluation which I did not 
receive until January 2013 (the standard is by the end of October 
2012). Withholding my evaluation meant that I would have difficulty in 
applying for a new position outside of HEC which essentially held me 
captive.
    Finally, after more than eight and a half years of service to VA, I 
resigned under extreme mental and emotional distress on January 24, 
2013. I have filed claims regarding my experiences of retaliation with 
VA and have yet to come to reconciliation although I have heard many 
promises of settlement and reinstatement over the last two years. VA 
did agree to mediation three times and backed out each time with no 
explanation.

What Has Happened at HEC?

    I was informed approximately three months after my resignation (and 
six months into OIG's ``investigation'') that my previous position had 
been reclassified by Ms. Harbin to a GS-15 (from a GS-14) specifically 
to reassign Mr. Guagliardo away from the Director of HEC. He was also 
reportedly given a slot at the Army War College and provided a Master's 
Degree in Strategic Studies by the taxpayers who paid him to attend 
college. Ironically, he had previously been caught including ``Master's 
Degree'' as a credential in a conference bio in September 2011 when he 
did not have one. Ms. Hardmon was promoted to a GS-15 by Ms.Harbin to a 
new position she created in her office shortly after his reassignment. 
Ms. Harbin has retained her position as Deputy Chief Business Officer 
although her defense of the healthcare application backlog has been 
completely discredited.

VA is a ``Bafflefield''

    Although OIG has been investigating disclosures made by multiple 
HEC employees for years, they have yet to issue a public report. 
According to news sources OIG was finalizing a report in October 2014, 
which includes at least five additional whistleblowers who applied to 
OSC for protection. A possible reason for the delay? One person 
reported in the media that OIG interviewed her eight times and she told 
them the same story eight times including what to look for and where to 
find it but they had not followed up on her disclosure.

The Way Forward

    I don't see how any of this costly drama--what I and scores of 
others have been subjected to--improves the culture of VA, attracts 
talent to federal service, or serves Veterans and taxpayers in any way. 
My wish is that the current fear-based management will no longer be an 
albatross around the necks of conscientious employees who are doing 
their best to fulfill the mission of the Department. Perhaps Bob 
McDonald is the right person for the job of Secretary; for the sake of 
the Veterans and employees, I hope he is.
    As to OIG, President Obama must nominate a permanent Inspector 
General to help ease the fear and retaliation of those whose life's 
work is to care for Veterans. The fact that this hearing is being held 
speaks volumes as to the importance of filling the vacancy. This will 
send a message to the Veterans and employees that the salad days of 
cover-up and retaliation are over.

                                 

                       Letter From: Mike Coffman

    To: Hon. Robert A. McDonald, Secretary,

    U.S. Department of Veterans Affairs,

    810 Vermont Avenue, NW., Washington, DC 20420

    Dear Secretary McDonald,

    Please provide written responses to the attached questions for the 
record regarding the Oversight and Investigations Subcommittee hearing 
``Addressing Continued Whistleblower Retaliation Within VA'' that took 
place on April 13, 2015.
    In responding to these questions for the record, please answer each 
question in order using single space formatting. Please also restate 
each question in its entirety before each answer. Your submission is 
expected by the close of business on Thursday, May 21, 2015, and should 
be sent to Ms. Bernadine Dotson at [email protected].
    If you have any questions, please call Mr. Eric Hannel, Majority 
Staff Director of the Oversight & Investigations Subcommittee, at 202-
225-3527. Sincerely,
    Mike Coffman, Chairman, Subcommittee on Oversight and 
Investigations

Questions for the Record From: Chairman Mike Coffman

    1. VA does not currently have a tracking system to determine the 
magnitude of or trends in employee misconduct cases and identify 
problem areas across the VA system. The only method for tracking 
disciplinary actions that may have occurred is by querying the 
Personnel and Accounting Integrated Data system, which only provides 
actions that resulted in loss of pay but does not provide details as to 
what the infraction was. So, VA lacks the resources to identify trends 
in misconduct across the VA system and prevent identified problems from 
recurring. Does the VA have a centralized database to track cases of 
misconduct, and what solutions has the VA implemented to identify 
systemic problems and prevent them from recurring?
    2. The Office of Special Counsel (OSC) has expressed disappointment 
that despite the numerous complaints it forwards to VA, the Office of 
Medical Inspector (OMI) seems to consistently take the position that 
patient health was never at risk. This approach hides the severity of 
systemic and longstanding problems, and has prevented VA from taking 
the steps necessary to improve quality of care for veterans. How has VA 
ensured organizational accountability for cases investigated by the 
OMI?
    3. VA does not collect and analyze aggregate data on the results of 
Administrative Investigation Board (AIB) investigations, which it uses 
to determine the facts surrounding alleged employee misconduct related 
to VA policies or procedures. AIBs do not determine disciplinary 
actions, but their results may be used to inform such actions. Having 
aggregate data could provide VA with valuable information to 
systematically gauge the extent to which matters investigated by AIBs 
may be occurring throughout the agency. What processes has VA adopted 
for collecting and analyzing aggregate data from AIB investigations?
    4. Have whistleblowers at the Health Eligibility Center (HEC) in 
Atlanta, who reported a backlog of 900,000 health care applications, 
experienced any retaliation for their disclosures?
    5. Whistleblowers at the HEC have provided the Committee with 
evidence that appears to show SES employees in the Chief Business 
Office misled veteran organizations about the pending problem, which 
may have been caused in part by an inability to upload DD-2 l 4s with 
an online application. Please explain if VA leadership and/or the OIG 
have looked into these allegations at the HEC and if so, what results 
and accountability measures have been or will be pursued?
    6. There is significant confusion among VA staff regarding how to 
deal with whistleblower disclosures. Managers need additional training 
to distinguish between insubordination and legitimate protected 
disclosures. What training does VA provide to managers on supervising 
whistleblowers, and how does VA measure the impact of any training that 
is provided?
    7. Regional counsels throughout VA handle the vast majority of the 
whistleblower retaliation caseloads internally. Because of the large 
and decentralized nature of VA, whistleblower complaints are often 
handled by these regional counsel offices. OSC staff have stated that 
regional counsels sometimes do not understand how to adequately defend 
their case against facility managers. What training does VA provide to 
regional counsels mediating whistleblower cases, and how does VA 
measure the impact of any training that is provided?

                                 

          Questions for the Record From: Chairman Mike Coffman

    1. VA does not currently have a tracking system to determine the 
magnitude of or trends in employee misconduct cases and identify 
problem areas across the VA system. The only method for tracking 
disciplinary actions that may have occurred is by querying the 
Personnel and Accounting Integrated Data system, which only provides 
actions that resulted in loss of pay but does not provide details as to 
what the infraction was. So, VA lacks the resources to identify trends 
in misconduct across the VA system and prevent identified problems from 
recurring. Does the VA have a centralized database to track cases of 
misconduct, and what solutions has the VA implemented to identify 
systemic problems and prevent them from recurring?

    VA Response: VA agrees that it is important to identify and track 
issues to determine how systematic they are, and identify trends that 
may help VA better address problems.
    VA has a centralized database that tracks disciplinary actions 
proposed and decided across the VA system. The system, which was 
created shortly after Secretary McDonald's confirmation, allows the 
Department to identify trends in the types of employee misconduct. 
Systemic problems may be mitigated through training to improve 
employees' awareness of rules and expectations, through clarifications 
in VA's Table of Penalties, or through other appropriate mitigation 
strategies.
    2. The Office of Special Counsel (OSC) has expressed disappointment 
that despite the numerous complaints it forwards to VA, the Office of 
Medical Inspector (OMI) seems to consistently take the position that 
patient health was never at risk. This approach hides the severity of 
systemic and longstanding problems, and has prevented VA from taking 
the steps necessary to improve quality of care for veterans. How has VA 
ensured organizational accountability for cases investigated by the 
OMI?

    VA Response: In Summer 2014, VHA's Office of Medical Inspector 
(OMI) was restructured to expand and intensify its focus on healthcare 
quality and patient safety. The Office of Special Counsel's (OSC) 
Carolyn Lerner recently expressed approval of this transformation, 
stating in her April 13, 2015, testimony to Chairman Coffman's 
Subcommittee, ``. . . in response to OSC's findings, VA overhauled the 
Office of Medical Inspector (OMI), and has taken steps to better 
respond to the patient care concerns identified by whistleblowers.'' 
Concerning a recent investigation led by OMI, she observed, ``While the 
facts of this case are troubling, the OMI response is encouraging. In 
an organization the size of the VA, problems will occur. Therefore, it 
is critical that when whistleblowers identify problems, they are 
addressed swiftly and responsibly. And OMI is an integral component in 
doing so.'' This positive view is confirmed by the fact that OMI 
continues to receive OSC cases for investigation. Since the 
restructuring, OMI has either completed or continues work on over 
twenty cases.
    All OMI investigations have adopted a more comprehensive approach 
that calls for this office to assemble and lead teams of persons from 
appropriate Program Offices and subject matter experts (SME) from 
across the Department of Veterans Affairs. These teams routinely 
include experts on human resources policies and procedures from the 
Office of Accountability Review (OAR) to address potential findings of 
individual wrongdoing, and to provide advice on personnel matters. Our 
joint efforts produce VA reports, vetted by VA's Office of General 
Counsel (OGC) for legal ramifications, OAR for employee accountability, 
and by other VA and VHA Program Offices, before being approved by 
leadership.
    OMI now meets regularly with OSC to review the status of 
investigations and discuss findings, schedules for reports, and 
progress. These meetings have improved communication between OSC and VA 
on investigations, ensuring complaints are thoroughly examined and that 
whistleblowers receive the protections to which they are entitled. The 
Department is committed to taking the steps necessary to ensure 
complaints are thoroughly examined and that whistleblowers receive the 
protections to which they are entitled.
    It is our hope and belief that OMI's restructuring has helped to 
ensure integrity and accountability across VHA's healthcare system. 
This improved cooperation is helping to overcome challenges in 
providing effective healthcare oversight, and is supporting efforts to 
restore the trust of Veterans and the general public.
    3. VA does not collect and analyze aggregate data on the results of 
Administrative Investigation Board (AlB) investigations, which it uses 
to determine the facts surrounding alleged employee misconduct related 
to VA policies or procedures. AIBs do not determine disciplinary 
actions, but their results may be used to inform such actions. Having 
aggregate data could provide VA with valuable information to 
systematically gauge the extent to which matters investigated by AIBs 
may be occurring throughout the agency. What processes has VA adopted 
for collecting and analyzing aggregate data from AlB investigations?

    VA Response: VA agrees that data-collection might be a helpful tool 
in learning from past investigations, and also assessing whether 
certain issues are systematic versus isolated. The Risk Analysis and 
Compliance Oversight Division of VA's Office of Accountability Review 
is exploring strategies to collect and analyze aggregate data from AIB 
investigations.
    4. Have whistleblowers at the Health Eligibility Center (HEC) in 
Atlanta, who reported a backlog of 900,000 healthcare applications, 
experienced any retaliation for their disclosures?

    VA Response: VA is dedicated to ensuring that all protected 
whistleblowers are treated fairly and in accordance with 5 U.S.C. 
Section 2302(b)(8), which prohibits retaliation against whistleblowers. 
VA will not tolerate retaliation or reprisal against whistleblowers, 
and we will continue to assess whistleblower activity to ensure no 
punitive actions occur. VA is aware of several whistleblower 
retaliation complaints filed with the Office of Special Counsel by 
Health Eligibility Center (HEC) employees. These complaints are 
currently under investigation.
    5. Whistleblowers at the HEC have provided the Committee with 
evidence that appears to show SES employees in the Chief Business 
Office misled veteran organizations about the pending problem, which 
may have been caused in part by an inability to upload DD-214s with an 
online application. Please explain if VA leadership and/or the OIG have 
looked into these allegations at the HEC and if so, what results and 
accountability measures have been or will be pursued?

    VA Response: The Department has been informed that the Office of 
Inspector General is reviewing these allegations.
    6. There is significant confusion among VA staff regarding how to 
deal with whistleblower disclosures. Managers need additional training 
to distinguish between insubordination and legitimate protected 
disclosures. What training does VA provide to managers on supervising 
whistleblowers, and how does VA measure the impact of any training that 
is provided?

    VA Response: Last summer, VA worked cooperatively with OSC to 
develop electronic training for supervisors on whistleblower rights and 
protections. All VA supervisors must complete this mandatory training 
on a biennial basis. The Department is also working with OSC to develop 
face-to-face training for VA supervisors that will cover, among other 
things, guidance on managing whistleblowers within the workforce.
    7. Regional counsels throughout VA handle the vast majority of the 
whistleblower retaliation caseloads internally. Because of the large 
and decentralized nature of VA, whistleblower complaints are often 
handled by these regional counsel offices. OSC staff have stated that 
regional counsels sometimes do not understand how to adequately defend 
their case against facility managers. What training does VA provide to 
regional counsels mediating whistleblower cases, and how does VA 
measure the impact of any training that is provided?

    VA Response: OSC recently met with VA OGC's senior leaders, 
including all Regional Counsel and Assistant Regional Counsel, to talk 
about the whistleblower retaliation complaint process and to clarify 
the parties' respective roles in mediating or adjudicating those 
complaints. The Department is working with OSC to develop additional 
training for Regional Counsel attorneys who handle these cases.

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