    [Senate Hearing 114-484]
    [From the U.S. Government Publishing Office]

                                                          S. Hrg. 114-484

                          IMPROVING VA ACCOUNTABILITY:
                        EXAMINING FIRST	HAND ACCOUNTS OF
                 DEPARTMENT OF VETERANS AFFAIRS WHISTLEBLOWERS

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

                                     HEARING

                                   BEFORE THE

                                  COMMITTEE ON
                   HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
                              UNITED STATES SENATE

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                               SEPTEMBER 22, 2015

                                   __________

            Available via the World Wide Web: http://www.fdsys.gov/

                           Printed for the use of the
            Committee on Homeland Security and Governmental Affairs

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            COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

                        RON JOHNSON, Wisconsin Chairman
    JOHN McCAIN, Arizona                 THOMAS R. CARPER, Delaware
    ROB PORTMAN, Ohio                    CLAIRE McCASKILL, Missouri
    RAND PAUL, Kentucky                  JON TESTER, Montana
    JAMES LANKFORD, Oklahoma             TAMMY BALDWIN, Wisconsin
    MICHAEL B. ENZI, Wyoming             HEIDI HEITKAMP, North Dakota
    KELLY AYOTTE, New Hampshire          CORY A. BOOKER, New Jersey
    JONI ERNST, Iowa                     GARY C. PETERS, Michigan
    BEN SASSE, Nebraska

                        Keith B. Ashdown, Staff Director
                             Kyle Brosnan, Counsel
                  Gabrielle A. Batkin, Minority Staff Director
               John P. Kilvington, Minority Deputy Staff Director
                 Brian F. Papp, Jr., Minority Legislative Aide
                         Laura W. Kilbride, Chief Clerk
                       Lauren M. Corcoran, Hearing Clerk

                                C O N T E N T S

                                     ------
    Opening statements:
                                                                       Page
        Senator Johnson..............................................     1
        Senator Baldwin..............................................    14
        Senator Tester...............................................    16
        Senator Ernst................................................    19
        Senator Ayotte...............................................    21
        Senator Carper...............................................    25
        Senator McCain...............................................    27
        Senator Peters...............................................    48
        Senator McCaskill............................................    50
    Prepared statements:
        Senator Johnson..............................................    61
        Senator Carper...............................................    63

                                    WITNESS
                          Tuesday, September 22, 2015

    Sean Kirkpatrick, Chicago Illinois...............................     3
    Brandon W. Coleman, Sr., Ph.D. (c), LISAC, Addiction Therapist,
      Phoenix VA Health Care System, Phoenix, Arizona................     5
    Joseph Colon, Credentialing Program Support, VA Caribbean
      Healthcare System, San Juan, Puerto Rico.......................     7
    Shea Wilkes, Licensed Clinical Social Worker, Overton Brooks VA
      Medical Center, Shreveport, Louisiana..........................     9
    Hon. Carolyn N. Lerner, Special Counsel, U.S. Office of Special
      Counsel........................................................    35
    Linda A. Halliday, Deputy Inspector General, U.S. Department of
      Veterans Affairs...............................................    37
    Carolyn Clancy, M.D., Chief Medical Officer, Veterans Health
      Administration, U.S. Department of Veterans Affairs;
      accompanied by Michael Culpepper, Acting Director, Office of
      Accountability Review..........................................    39

                         Alphabetical List of Witnesses

    Clancy, Carolyn:
        Testimony....................................................    39
        Prepared statement...........................................   117
    Coleman, Brandon, W.:
        Testimony....................................................     5
        Prepared statement...........................................    72
    Colon, Joseph.:
        Testimony....................................................     7
        Prepared statement...........................................    78
    Halliday, Linda A.:
        Testimony....................................................    37
        Prepared statement...........................................   110
    Kirkpatrick, Sean:
        Testimony....................................................     3
        Prepared statement...........................................    65
    Lerner, Hon. Carolyn N.:
        Testimony....................................................    35
        Prepared statement...........................................    97
    Wilkes, Sean:
        Testimony....................................................     9
        Prepared statement...........................................    82

                          IMPROVING VA ACCOUNTABILITY:
                        EXAMINING FIRSTHAND ACCOUNTS OF
                 DEPARTMENT OF VETERANS AFFAIRS WHISTLEBLOWERS

                                  ----------

                          TUESDAY, SEPTEMBER 22, 2015

                                         U.S. Senate,
                               Committee on Homeland Security
                                      and Governmental Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 9:34 a.m., in
    room SD-342, Dirksen Senate Office Building, Hon. Ron Johnson,
    Chairman of the Committee, presiding.
        Present: Senators Johnson, McCain, Ayotte, Ernst, Carper,
    McCaskill, Tester, Baldwin, and Peters.

                 OPENING STATEMENT OF CHAIRMAN JOHNSON

        Chairman Johnson. Good morning. This hearing will come to
    order. I want to welcome certainly our witnesses. Thank you for
    your thoughtful testimony.
        I am going to keep my opening statement very short because
    we have a lot of witnesses, two panels. I also want to make
    sure that the Committee Members understand we are going to keep
    questioning to 5 minutes as well--unless we have very few
    Senators, and then we might open it up again. But it sounds
    like we are going to have some pretty good attendance.
        I do ask that my written opening statement, be entered into
    the record,\1\ without objection.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Senator Johnson appears in the
    Appendix on page 61.
    ---------------------------------------------------------------------------
        As I read the whistleblower testimony as well as the
    testimony from representatives from the Department of Veterans
    Affairs (VA) and the agencies, and as we have held these
    whistleblower hearings, the question I have--coming from the
    private sector where, literally, I would be hanging a medal on
    individuals in my organization that would go through the layers
    of management to let me know what was happening on the shop
    floor, it is extremely difficult when you are the top of an
    organization to get that real information. Those people ought
    to be rewarded, not retaliated against. And the question that I
    will be asking everybody is: Why is retaliation so rampant
    within the Federal Government? We are focusing on the VA and
    the VA health care system here, but it is not isolated to the
    VA. And what is amazing to me is it seems pretty simple, pretty
    easy, unfortunately, for mid-level managers, within these
    agencies and the Department to retaliate and terminate
    whistleblowers, but then it is enormously difficult apparently
    for department heads, Secretaries, top-level management to hold
    those people that retaliate against whistleblowers accountable,
    much less potentially even terminate them.
        So, that is the problem, and from my standpoint, having run
    organizations, there is nothing more corrosive to an
    organization than when individuals within that organization get
    away with mismanagement, retaliation, and they are not held
    accountable. Nothing more corrosive. And we have a real problem
    with the VA health care system, problems that we all want to
    see fixed, and to me this is in many respects at the heart of
    those problems. If we cannot hold individuals in the VA health
    care system and, quite honestly, any manager within the Federal
    Government accountable, we are going to continue to have
    problems within all these agencies.
        So I do want to point out, because it also is somewhat
    baffling, we have had on the books whistleblower protection
    laws for decades. The first whistleblower protection
    legislation really was the Lloyd-La Follette Act of 1912,
    followed by the Civil Service Reform Act of 1978, followed by
    the Whistleblower Protection Act of 1989, followed by the
    Whistleblower Protection Enhancement Act of 2012. So this is a
    protection that has been well known for decades, really more
    than a century, and yet we still see retaliation against
    whistleblowers rampant within the Federal Government.
        So, the purpose of this hearing is to lay these issues on
    the table with some anecdotal stories here, some pretty
    powerful ones, to talk to the people in the agencies, and in
    good faith try and figure out a way to actually provide the
    whistleblower protection that will actually work so that we can
    get government to work more efficiently and effectively.
        One last thing I want to point out is that within our
    Senate office, because we value whistleblowers, they are
    essential, we have set up a website, and I want everybody to
    understand in the
    Federal Government you can come to our office by using
    whistleblower@ronjohnson.senate.gov. I encourage
    whistleblowers, if you feel uncomfortable talking to your
    Office of Inspector General, if you feel uncomfortable talking
    to your direct supervisor about these things, come to our
    Committee, and we will certainly hear your story and will offer
    whatever protection we certainly can.
        With that, our Ranking Member is going to be a little bit
    late. We will let him offer an opening statement when he gets
    here, probably between the panels. But it is the tradition of
    this Committee to swear in witnesses, so if you will all rise
    and raise your right hand. Do you swear that the testimony you
    will give before this Committee will be the truth, the whole
    truth, and nothing but the truth, so help you, God?
        Mr. Kirkpatrick. I do.
        Mr. Coleman. I do.
        Mr. Colon. I do.
        Mr. Wilkes. I do.
        Chairman Johnson. Thank you. Please be seated.
        Our first witness will be Sean Kirkpatrick. Mr. Kirkpatrick
    is testifying today on behalf of his late brother, Dr.
    Christopher Kirkpatrick. Dr. Kirkpatrick was a psychologist at
    the VA Medical Center in Tomah, Wisconsin, who raised concerns
    about patient overmedication. On the day of his termination,
    Dr. Kirkpatrick tragically committed suicide. Sean is joined in
    the audience this morning by his sister, Kathryn. Mr.
    Kirkpatrick.

          TESTIMONY OF SEAN KIRKPATRICK,\1\ CHICAGO, ILLINOIS

        Mr. Kirkpatrick. Thank you. My family would like to thank
    the U.S. Senate Committee on Homeland Security and Governmental
    Affairs for holding this hearing.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Mr. Kirkpatrick appears in the
    Appendix on page 65.
    ---------------------------------------------------------------------------
        It is an honor to be invited here to speak on behalf of my
    late brother, Dr. Christopher Kirkpatrick. On July 14, 2009,
    hours after being fired from the Tomah VA Medical Center, Chris
    committed suicide. Our family found out the next day that he
    was fired from the Tomah VA the morning he died. The reason
    they told us they fired him was for missing too many hours.
        Last winter, my family learned what really happened to
    Chris. Ryan Honl, a brave VA whistleblower and former Tomah VA
    employee, reached out to my family after he heard my brother's
    story from Lin Ellinghuysen, president of the American
    Federation of Government Employees (AFGE) in Tomah. Ryan put me
    in touch with Lin, who provided my family with documentation
    which proved Chris had raised concerns about possible
    overmedications and other issues affecting his patients while
    he was employed at the Tomah VA. If not for Ryan and Lin, my
    family would have no idea what the truth was behind the
    circumstances leading to his suicide.
        Chris was having difficulty treating patients in the post
    traumatic stress disorder (PTSD) and substance abuse programs
    he oversaw because they were unable to alert and engage in
    therapy due apparently to the high level and type of
    medications they were prescribed. Apparently, Chris had learned
    a physician's assistant had complained to the chief of staff,
    Dr. David Houlihan, that my brother was inappropriate in
    discussing medications that patients they both see are
    prescribed.
        In an email to his union representative written on April
    23, 2009, Chris addressed his concern that he was now in the
    cross hairs of the chief of staff for suggesting that patients
    may be overmedicated. He stated, ``I have had words with the
    physician's assistant about medications and possible side
    effect/adverse reactions patients were experiencing, but these
    conversations happened months ago. These situations put me in
    an ethical dilemma. Why this comes up as an issue now is open
    to interpretation. Based on what others have told me, I have
    every reason to be very afraid of Dr. Houlihan. I have
    sacrificed a lot to move up here and do the kind of work I
    excel at and help people. I need help.''
        Chris was subsequently reprimanded by his supervisor at the
    order of Chief of Staff Houlihan in the form of a written
    counseling on April 30, 2009. One of the points he made in the
    written counseling was that Chris should not be ``educating
    patients about what medications they are on, and that he should
    avoid advising on medications altogether.'' It is evident that
    those in charge were more concerned about disciplining my
    brother for questioning medication practices rather than
    properly investigating the problem of overmedicated patients.
        On July 14, 2009, 10 months after he was hired, Chris was
    directed to report to the human resources (HR) office. Chris'
    employment at the Tomah VA Medical Center was terminated during
    this meeting. Chris was told his services were no longer needed
    due to performance issues. Several frivolous allegations were
    made, all of which had no bearing. Chris stated, ``I know why
    this is happening. It is because of the note I put in the
    patient's chart. He was difficult and violent. He did not
    belong in this program. He stood at my office door and told me
    that he intended to do harm to me and my dog. I told you about
    this. The team decided this patient needed to be discharged and
    released from the program. On Thursday, July 9, he was still
    here. I charted this.''
        Please note that Chris took a vacation day on Friday, July
    10, and used a sick day on Monday, July 13, because that
    threatening patient was not discharged and still there. Chris
    was terminated that Tuesday, July 14.
        He was a recent graduate psychologist studying for his
    license with a full patient load, facilitating the group
    therapies on his own, hearing in great detail about horrific
    events experienced by his patients, but yet he had no guidance
    and support, despite going through the proper chain of command
    for assistance more than once. His life's goal of helping our
    Nation's veterans battle PTSD through innovative psychotherapy
    techniques was jeopardized because he questioned dangerous
    medication practices. He did what was ethical and right, but
    was only met with retaliation.
        My family began to have hope that Chris, would be
    vindicated after all these years since it seemed that the VA
    was now taking a serious look at the many cases of retaliation
    against Tomah staff and the dangerously high number of
    medications being prescribed to the veterans there. However,
    the Office of Inspector General (OIG) white paper report
    released this past June was nothing but slanderous toward my
    brother and insulting to my family. It suggested that he was a
    drug dealer and it did not take his death seriously.
    Apparently, the VA is still retaliating against Chris even to
    this day. For my parents to have to read this public document
    after everything they have been through is outrageous and
    unconscionable.
        Chris acted in the interests of the veterans at his own
    expense when he raised concerns about the overmedication of VA
    patients. His life was threatened by a hostile patient, and his
    superiors did not discharge the patient after he was told they
    would. His pleas for support and help managing the complex
    cases he had were never acted upon. Knowing this now leaves my
    family with the belief that the VA failed Chris. Furthermore,
    we learned that the VA never even did an investigation into the
    suicide of one of its psychologists.
        The last thing that Chris said to Lin as she walked him to
    his car after he was fired was, ``Try to get a support system
    so that no one else has to go through what I did! Will you
    please do that?''
        We are asking the same thing of this Committee. Thank you.
        Chairman Johnson. Thank you, Mr. Kirkpatrick.
        Our next witness is Brandon Coleman. Mr. Coleman is a
    Marine Corps veteran and addiction therapist at the Phoenix VA
    Healthcare System. Mr. Coleman raised concerns about improper
    care for suicidal veterans. Mr. Coleman.

      TESTIMONY OF BRANDON W. COLEMAN, SR., PH.D.\1\ (c), LISAC,
     ADDICTION THERAPIST, PHOENIX VA HEALTH CARE SYSTEM, PHOENIX,
                                ARIZONA

        Mr. Coleman. Thank you, Mr. Chairman. VA whistleblowers
    risk the destruction of their careers for simply telling the
    truth. During my time at the Phoenix VA, I have lost six
    veterans to suicide. Each one is like a punch in the gut. I
    have walked suicidal veterans to the Phoenix VA emergency room
    (ER) after hours only to have them not watched and walk away
    unaccounted for.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Mr. Coleman appears in the Appendix
    on page 72.
    ---------------------------------------------------------------------------
        In October 2014, Phoenix VA social worker Penny Miller
    admitted to improperly accessing my own Health Insurance
    Portability and Accountability (HIPAA)-protected Veteran
    Medical Records. This was only the start of improper and
    unlawful behavior that would persist over the following year.
        On December 6, 2014, I came forward to the Office of
    Special Counsel (OSC) regarding the unsafe treatment of
    suicidal veterans, along with my records being improperly
    accessed.
        On January 12 and 13, 2015, ABC 15 ran stories regarding my
    OSC complaints. On the 13, hospital director Glen Grippen held
    a meeting with leadership of the Phoenix VA, to include Chief
    of Staff Dr. Darren Deering and VA Legal Counsel Shelley Cutts.
    Grippen proposed to terminate me for being on TV. Cutts advised
    Grippen that it was illegal to remove me because of the
    Whistleblower Protection Act. But then Cutts stated, ``Brandon
    could possibly be removed for unrelated misconduct.'' The
    problem with her statement is I had an exceptional employment
    record.
        On January 20, my section chief, Dr. Carlos Carrera,
    questioned my mental health. Later that day, I had a social
    worker accuse me of threatening him. It was simply not true.
        On the 21st, Director Grippen met with me to share my OSC
    concerns. The director made an eerie comment. He stated,
    ``Brandon, I just want you to know you are not being terminated
    yet.'' He actually used the word ``yet.'' He admitted to saying
    this in his Equal Employment Opportunity Commission (EEOC)
    testimony.
        On the 23rd, Social Work Chief David Jacobson held a
    meeting for 15 to 20 employees. An employee made an audio
    recording. An ER social worker stated ``five suicidal vets had
    walked out of the hospital during the past week,'' and Jacobson
    responded, ``We have been really lucky that nothing bad has
    happened yet. It was sheer luck.'' This proved suicidal vets
    were walking out of the hospital.
        On February 2, I was placed on administrative leave for
    allegedly threatening other employees. The letter stated I
    could receive care as a vet, but I had to check in and out with
    the VA police. I immediately called the OSC to begin a
    retaliation investigation.
        On the 3rd, Grippen shut down my highly successful 52-week
    Motivation for Change treatment program. Seventy-one high-risk
    veterans no longer had long-term substance use disorder
    treatment. Those who are still alive still do not.
        On the 4th, employee Jared Kinnaman came forward to the OSC
    stating suicidal veterans were being mishandled.
        On the 26th, I attended a fact-finding regarding my
    placement on admin leave. I was personally escorted by VA
    police Lieutenant Robert Mueller. Lieutenant Mueller made me
    walk in front of him through the main hospital like I was a
    criminal. I was told by the fact finders after the meeting I
    would be cleared of any wrongdoing.
        On March 6, employee Lisa Tadano came forward to the OSC
    claiming suicidal veterans were being watched by janitors and
    volunteers. She learned employee Penny Miller had also accessed
    her treatment records without reason.
        On the 12th, I met with Secretary Robert McDonald when
    President Obama came to Phoenix. I told the Secretary it was
    highly questionable that I can have a one-on-one meeting with
    the most powerful man in the VA, yet if I go to the Phoenix VA
    for medical care, I have to check in and out with the VA
    police.
        On the 16th, the Veterans Benefits Administrator (VBA) said
    my service-connected injuries had improved and proposed to
    reduce my disability benefits by over $300 per month. The
    timing was highly suspect.
        On the 19th, I received a letter from Grippen stating I was
    no longer required to have a police escort. To date, I have
    never received a letter clearing me of wrongdoing.
        On April 9, I had a second sensitive patient access report
    (SPAR) pulled and learned two additional coworkers had
    improperly entered my medical records.
        On the 14th, I was walking through the VA hospital on my
    way to a 12-step meeting with friend and former Navy SEAL Carl
    Higbee. We were confronted by Grippen. I told Grippen what I
    was doing and went to attend the meeting that was open to the
    public.
        Six days later, on April 20, I received a ``gag order''
    from Grippen forbidding me from speaking to any other Phoenix
    VA employees but saying I could get medical care as a vet. How
    does a veteran get medical care without being allowed to speak
    to a VA employee?
        By the 24th, over a dozen media outlets contacted the
    hospital forcing Grippen to amend the letter acknowledging my
    right to free speech.
        On August 12, I pulled a third SPAR report and learned
    another administrative officer named Troy Briggs has accessed
    my records. I have not received care since January 2015 at the
    Phoenix VA when I got these eyeglasses, yet this employee was
    in my records on April 20, the same day Director Grippen placed
    a gag order on me. Mr. Briggs is even cc'd to the gag order
    letter. Why would he be in my record on this same date?
        In closing, it is a privilege to work for the VA, not a
    right. All employees, including directors, must be held
    accountable. Today I am calling on the Committee to ask for a
    Department of Justice (DOJ) investigation into the improper
    accessing of my HIPAA-protected veteran treatment records as
    retaliatory acts and as a criminal act. I am also asking the
    Committee to call for an investigation into Grippen's
    retaliation against me, including placing me on admin leave on
    baseless grounds, and for his attempting to manufacture grounds
    for my removal. His actions violated Federal whistleblower law.
        I find it sad that the only time Congress can get an honest
    answer from the VA is when whistleblowers are asked to testify.
    There is something deeply disturbing about that fact.
        Thank you for the allotted time today.
        Chairman Johnson. Thank you, Mr. Coleman.
        Our next witness is Joseph Colon. Mr. Colon is a Navy
    veteran and a credentialing support analyst at the VA Caribbean
    Healthcare System in San Juan, Puerto Rico. Mr. Colon raised
    concerns about unfair hiring practices, improper veteran care,
    and misconduct by upper management. Mr. Colon.

    TESTIMONY OF JOSEPH COLON,\1\ CREDENTIALING PROGRAM SUPPORT, VA
           CARIBBEAN HEALTHCARE SYSTEM, SAN JUAN, PUERTO RICO

        Mr. Colon. Good morning, Members of Congress. My name is
    Joseph Colon. I am a credentialing program support at the VA
    Caribbean Healthcare System in San Juan, Puerto Rico. I filed
    for whistleblower protection in August 2014, and my case
    settled in July 2015. Despite the above, retaliation against me
    and others similarly situated continues at that facility.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Mr. Colon appears in the Appendix on
    page 78.
    ---------------------------------------------------------------------------
        Before I provide my account of the events that have taken
    place with me, I would like to thank Senator Ron Johnson,
    Ranking Member Thomas Carper, and the Committee for their
    leadership and for allowing me the opportunity to be a part of
    the hearing and to explain what happens to a whistleblower that
    comes forward.
        The whistleblowers in Puerto Rico's facility really need
    the help from this Committee to ensure that whistleblower
    retaliation does not keep on happening at our facility and that
    the supervisors are held accountable. Unfortunately, our
    resident commissioner, Pedro Pierluisi, does not even issue one
    statement against whistleblower retaliation that occurs very
    often at this facility. Without proper oversight from our
    representative in Congress, it makes it even more difficult for
    us whistleblowers in Puerto Rico.
        There were numerous issues that I reported: a physician who
    killed a veteran while doing an authorized procedure that his
    spouse needed for her residency program; Mr. DeWayne Hamlin's
    arrest for drunk driving and having a controlled substance
    without a prescription; director absences; veterans mental
    health issues; chief of staff salary concerns; a physician that
    gave an improper dosage to a Veteran ordered the veteran's
    medical record be documented with incorrect information;
    physicians practicing with expired medical licenses and without
    clinical privileges; Legionella found in the physical therapy
    pool; community living center director, who was the direct
    supervisor of the area that was not helping elderly veterans
    with bathing, using the bathroom, feeding, and drinking, was
    promoted to associate chief of staff of geriatrics and extended
    care; registered sexual offender that provides disciplinary
    recommendations to management; unfair hiring practices, and
    limiting opportunities for veterans from outside the facility
    to apply for jobs; my immediate supervisor's fraud with the
    travel voucher program; the retaliation that I experienced from
    top levels of management at the VA in San Juan; investigated
    four different times for the same allegations; I was illegally
    placed on a permanent work detail on two different occasions;
    issued a proposed removal on two different occasions; received
    a 3-day suspension; no performance appraisal issued to me for
    the 20 months when I was on detail; non-selections when I
    applied for other positions in the hospital.
        The retaliation and harassment that I have experienced
    after the Office of Special Counsel settled my retaliation
    claim include: moved the Credentialing and Privileging
    Department from the fifth floor of executive suite to an office
    area with no windows on the third floor; the afternoon prior to
    me returning to my position, the Human Resources Manager Mr.
    Omar Ahmed issued an email warning his personnel that share the
    same lounge with me to not discuss any Human Resources business
    in the lounge area; no electronic email access for over 2
    weeks; no work assignments for 3 weeks; expired my high blood
    pressure refill medication without notifying me; not selected
    for the clinical administrative specialist position, even
    though I was the most experienced member of the Department. The
    two panel members that interviewed me are the same members that
    I reported wrongdoing about.
        Unfortunately, at the VA Caribbean Healthcare facility in
    San Juan, this is not the only incident of retaliation that has
    occurred under Mr. DeWayne Hamlin's and Miss Nayda Ramirez's
    and Dr. Antonio Sanchez's leadership. These three individuals
    are directly responsible for all cases mentioned in my
    statement.
        Miss Rosayma Lopez, was issued a termination letter because
    she would not fabricate anything against me in her fact-
    finding.
        Dr. Ivan Torres reported numerous concerns with the
    compensation and pension physicians who were not complying with
    the compressed time work schedule. Both cases are right now
    with the Office of Special Counsel.
        Management here in San Juan, Puerto Rico, actually reward
    people that actually help them build a case to fire a
    whistleblower.
        Miss Maritere Acevedo, who conducted the fact-finding
    against me, was rewarded as the quality management director,
    even though she stated in my fact-finding, ``In terms of Mr.
    Colon going over the chain of command and gathering
    information, this is seen as a pattern that does have an impact
    on the efficiency and effectiveness of his unit.'' She also
    believes there is a potential ethical issue for becoming a
    witness in a discriminatory case.
        Mr. Victor Sanchez was rewarded with a promotion as medical
    administrative supervisor in Mayaguez even though he sanitized
    and deleted a portion of the document that was used against me
    and he could not provide the original document when the
    investigator asked for it.
        As you can see, in Puerto Rico, both these people were
    rewarded with better positions, but Miss Rosayma Lopez was
    issued a termination letter. The difference is because Miss
    Rosayma Lopez was ethical and failed to do what management
    wanted her to do. There is no better example that shows
    management's unethical behavior and what levels they will go to
    fire the whistleblower. The Secretary of the Veterans Affairs
    must do the correct thing and place Mr. DeWayne Hamlin, Miss
    Nayda Ramirez, and Dr. Antonio Sanchez on detail until an
    accurate investigation is completed regarding their conduct and
    their behavior toward those who dare to bring into the light
    abuse and mismanagement.
        If the Secretary of the Veterans Affairs fails to do so, he
    actually is accepting that a whole executive team can
    participate in retaliation and he actually supports it. How
    many veterans are being hurt because employees live in fear of
    retaliation? How can you run a successful organization without
    accountability?
        It is easy to retaliate against someone when the supervisor
    does not have to pay for attorney fees, is not held
    accountable, and the American taxpayers foot the bill when
    compensatory damages are being paid.
        I truly believe that since the Secretary of Veterans
    Affairs has failed to impose discipline to his employees,
    Congress should give that authority to the Office of Special
    Counsel to discipline employees who are found to have
    retaliated against a whistleblower. It is time to really
    protect future whistleblowers and implement a zero tolerance
    policy in regards to whistleblower retaliation.
        Thank you again for this opportunity. I welcome your
    questions on the issues I have noted or any items I have
    submitted to the Committee.
        Chairman Johnson. Thank you, Mr. Colon.
        Our final witness on this panel is Shea Wilkes. Mr. Wilkes
    is an Army veteran and a licensed clinical social worker at the
    Overton Brooks VA Medical Center in Shreveport, Louisiana. Mr.
    Wilkes raised concerns about secret wait lists at his facility
    He is also the co-founder of the VA Truth Tellers, a group of
    VA employees nationwide who have suffered hardships since
    reporting wrongdoing within the VA. Mr. Wilkes.

     TESTIMONY OF SHEA WILKES,\1\ LICENSED CLINICAL SOCIAL WORKER,
        OVERTON BROOKS VA MEDICAL CENTER, SHREVEPORT, LOUISIANA

        Mr. Wilkes. Ladies, gentlemen, fellow Americans, I
    appreciate the opportunity to speak with you today in our great
    Nation's capital, a capital that symbolizes courage and a free
    way of life that so many have stood tall, strong, and given
    their life to protect.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Mr. Wilkes appears in the Appendix on
    page 82
    ---------------------------------------------------------------------------
        Your continued concern for the state of medical care being
    provided to our Nation's veterans is greatly appreciated. I
    thank everyone in this room for their continued efforts to
    right the faltering Department of Veterans Affairs.
        Throughout history, the success and failures of countries
    across the world have often balanced upon how that country has
    cared for those who have borne the battle. I believe all of us
    here today can agree a country that does not care for its
    veterans can quickly become a rudderless ship destined for
    disaster, for a country that will not live up to its promises
    made to its veterans willing to give everything to protect a
    way of life will quickly forget promises to its people.
        In our great Nation, there is an overwhelming support for
    our military and our veterans. From Bunker Hill to Helmand
    Province, Afghanistan, our Nation's veterans have faced what
    seemed to be insurmountable odds only to succeed time and time
    again in protecting a way of life preserved in a sacred
    document that resides a short distance from where we sit this
    very day.
        For some time, we the people have entrusted the caring of
    our Nation's veterans to the Department of Veterans Affairs.
    Unfortunately, reality here today is somehow this trust is
    being strained by what has become a bloated, unaccountable
    bureaucracy whose leadership is incompetent, often more
    concerned with its public image, and perpetrating its own
    existence than it is with providing first-rate medical care to
    our Nation's veterans, which they have earned and deserve.
        I am here today to fight for accountability, leadership,
    and competency in our VA health care system. I am here for
    those Truth Tellers who have shown integrity, despite knowing
    for certain that despicable and hateful retaliation will be
    imposed for coming forward. I am here for my brothers and
    sisters at arms, both past and present, and future, to assure
    our Nation does not forget where it comes from, who is
    protecting it today, and who is going to assure it is protected
    forever: veterans.
        What has happened to Shea Wilkes will not even be a
    footnote in history. However, I hope my voice will be heard by
    our leaders and the American people. I hope that you will hear
    VA Truth Tellers' voices within my voice and will unveil the
    truth hidden inside the walls and swept under the rugs of the
    VA system.
        I hope that our Truth Teller voices and your action will
    become a resounding chorus demanding and forcing change for our
    heroes.
        I was asked to tell you my story, but, no, I am not here
    for myself. If I were, my story would be of little interest. I
    can tell you that my story is not compelling because it has
    happened to Shea Wilkes; rather, it is compelling because it is
    a mirror image of how VA whistleblowers across this country
    have been treated.
        My situation, like other whistleblowers across this Nation,
    is a product of a contagious disease within the very fabric of
    the VA system itself. Whistleblowers are shunned, isolated,
    defamed, and accused of trying to destroy the VA. Those of us
    Truth Tellers that are also veterans have our VA personal
    medical records accessed and information in those records used
    in attempts to discredit us. We are placed in positions away
    from others, oftentimes below our ability levels. We are never
    given the same opportunities we once had.
        Truth Tellers are labeled problem children, troublemakers,
    crazy, and much more. We are put under criminal investigations
    for nonsense in an effort to scare and intimidate. Once a Truth
    Teller comes forward, they are alone, left gasping for air, and
    desperately trying to protect themselves from the good old boys
    of VA that have them in their cross hairs.
        I could continue, but we know the VA is still hiding issues
    and not being truthful. We know VA OIG has not been independent
    but yet working with the VA to damage control, whitewash, and
    intimidate Truth Tellers and potential whistleblowers. The VA
    OIG investigations have not been after the truth as they would
    attempt to make us believe. VA OIG investigations have been
    half-assed and shoddy. We could line whistleblowers up from
    around this country out this door and around this building and
    ask about the VA OIG. The overwhelming majority would answer:
    ``The VA OIG is a joke.''
        No longer are Truth Tellers allowing the VA OIG to dictate,
    intimidate, bully, and isolate, and they cannot stand it. VA
    Truth Tellers have the inside knowledge of how deeply embedded
    corruption is in the VA system, and we are going to continue to
    share it. VA Truth Tellers across the Nation are joining to
    have one voice, and it has made the knees of the VA giant
    shake.
        In closing, I say to those in this room, I say today the VA
    deception, deceit, and lies have gone on long enough. I speak
    to the leaders of Congress, OSC, new OIG leadership, VA Truth
    Tellers, potential whistleblowers, American taxpayers, and
    veterans, we must draw a line in the sand today and say, ``No
    more.'' No more will we allow VA leaders to take aim at
    whistleblowers brave enough to expose VA wrongdoings. No more
    will we allow the VA wasteful and fraudulent spending of
    American tax dollars. No more will we allow the VA to provide
    those that have borne the battle anything but the best care in
    this world. And no more will we allow the VA to chip away at
    the very foundation this country has stood on for generations,
    that our veterans have drawn a weapon to protect.
        The time has come for each of us in this room to stand
    together--E Pluribus Unum--and to tell the VA, ``No more.''
        Thank you for your time. May God bless each of you and may
    God bless the United States of America.
        Chairman Johnson. Thank you, Mr. Wilkes, and thank you all
    for your powerful testimony.
        I will start with you, Mr. Wilkes. In reading your
    testimony, the written testimony, I was struck by the criminal
    investigation, the intimidation. Can you just talk to me a
    little bit about exactly what you did? My understanding is you
    took--you understood the wait list, that veterans were waiting
    and obviously not getting the care they deserved. But you
    presented that to the Office of Inspector General, which would
    have been the proper venue. And then later on you were really
    the target of a criminal investigation. Is that true?
        Mr. Wilkes. Yes, sir. Let me state this: Wait lists are
    just one tool that was being used for manipulation of
    scheduling and numbers, and, I brought forward--I knew there
    were wait lists. I was actually, in mental health leadership,
    had done stuff for the directors, and I had heard about it in
    meetings, and I just kind of followed up with it and just kept
    seeing it. And probably about 10 months before hand, in June
    2013, 10 months before Phoenix came out, I reported it to the
    Inspector General (IG) and I never heard from it. Basically I
    was systematically removed from any leadership over time.
        Finally, when Phoenix came out, I said, ``You know what?
    This is my shot. This is another shot that I may get.'' And I
    did report that. After encouragement----
        Chairman Johnson. But, again, reported it to the Office of
    Inspector General.
        Mr. Wilkes. Yes, sir, again, and I reported it and went to
    the media. And when they came in finally about a month and a
    half after all this, they called, they said they wanted to meet
    with me. I said yes. They asked, ``Hey, you want to come off
    campus and meet?'' And I said, ``I am not bringing this list
    off campus.'' I said no. And I said, ``I have it here secured
    and everything. It is on my hard drive.'' And then what
    happened after that is they came up, we talked, they secured
    the list, and then it went--they said, ``We are going to go
    talk to people,'' which they ended up talking to basically
    those that, if there was a list, would have something to lose.
        Then we found out later about some of the questions. They
    came back. I was, like, oh, this does not make any sense. So at
    that time, I contacted my lawyer, and we were told, yes, there
    was an issue with how I got the list and of that such. And
    basically after that, they never really asked anything about
    that.
        Chairman Johnson. So, again, you were expecting the Office
    of Inspector General to come in and be shocked at this wait
    list. But instead what you found is the Office of Inspector
    General was basically coming in and kind of laying the
    groundwork for a potential criminal investigation against you
    for revealing the wait list.
        Mr. Wilkes. Right. My opinion----
        Chairman Johnson. So it is basically retaliation by the
    Office of Inspector General against you.
        Mr. Wilkes. Right. My opinion is they came in to basically
    damage control and scare the heck out of me and anybody else
    that knew about it and potentially--there are witnesses that
    know that it was there. There are witnesses that know they were
    going in and out of scheduling and doing that. But when they
    did that, everybody shut down. Stories changed.
        Chairman Johnson. So, obviously, one form of retaliation is
    intimidation.
        Mr. Wilkes. Yes, sir.
        Chairman Johnson. To prevent you from and, by the way,
    prevent anybody else from coming forward, when you say damage
    control.
        Mr. Wilkes. Yes.
        Chairman Johnson. Mr. Kirkpatrick, again, thank you for
    your powerful testimony. Were you aware, as you have gone
    through the records now and you have seen some of these things,
    were you aware--was your brother, Chris, ever given any warning
    before he was called in to that one meeting and fired?
        Mr. Kirkpatrick. Not to my knowledge, no. I think he kind
    of felt that that was a potential outcome, but I think he was
    surprised when he saw it that day. And I believe he contacted
    Lin Ellinghuysen right away saying he was concerned about this,
    and then she mentioned that, well, we should prepare for the
    worst, that it might be, your termination.
        Chairman Johnson. And the termination was predicated, the
    rationale was he missed a few days or abused some free time. I
    mean, that is basically what the termination was about?
        Mr. Kirkpatrick. Essentially, yes. One of the allegations
    was that he brought his dog into work one day, which they did
    not deny that he had permission to do so; but that when he
    stepped away, the dog, made a mess and somebody else had to
    clean it up. Other things they pointed out were that he was
    taking a lot of vacation time. I wanted to include that in my
    statement but for time reasons I did not, but his response was
    that for his own well-being he had to take additional days off
    because he did not have the support or anybody to talk to, and
    he was being overloaded. He was a graduate psychologist, and
    from what I can tell, I mean, he had a full caseload, very
    complex cases, and----
        Chairman Johnson. I am going to give you an opportunity
    right now to kind of lay out your recommendations based on
    that, but I just want to quickly drill down because I think it
    is tragic, quite honestly. It is to me just unbelievable. I
    come from the private sector. You always hear ``at-will
    employment.'' It is really not so. I mean, certainly as a
    private sector company, you have to go through a series of
    steps--warnings, counseling, talking to
    people--before you would even consider terminating someone just
    out of basic humanity, but also from a legal standpoint. And
    yet your brother was basically called into an office,
    terminated for what I would consider the flimsiest of reasons--
    and, again, from my standpoint, as a result it is obvious he
    was being retaliated against because he was raising the issue
    of drug overprescription resulting in real harm to our
    veterans.
        But in your testimony, you have a list of recommendations.
    Again, I think it is powerful testimony.
        Mr. Kirkpatrick. I do. Thank you.
        Chairman Johnson. I want everybody to read it, about the
    pressures that those individuals like your brother who are
    trying to help our veterans deal with some very difficult
    psychological and mental issues and addiction issues, the
    pressures they are under and how there is just not much help
    for them.
        Mr. Kirkpatrick. Thank you. I appreciate the time.
        Chairman Johnson. Please, talk a little bit about that and
    lay out those recommendations.
        Mr. Kirkpatrick. Well, we have quite a few here. I will
    just read through them. And let it be known, too, that I
    consulted with Lin Ellinghuysen again and to kind of see what
    she thought would also be the most effective recommendations.
        No. 1, we encourage--I am sorry. We urge Congress to
    mandate the development of a comprehensive support system for
    VA medical and mental health care professionals that provide
    needed consultation services with trained professionals as part
    of their employment and not to be seen as private treatment.
    These support services and consultations must maintain strict
    confidentiality. Currently, all that is offered at the Tomah VA
    are one or two sessions with a VA-provided counselor; after
    that, employees are left to manage these very intense job
    duties on their own without time to debrief, refresh, or
    regroup. Particularly, psychotherapy with veterans is difficult
    and draining and can take a great deal out of a clinician
    emotionally and physically.
        No. 2, if not licensed when hired, graduate psychologists
    are required to be licensed within 2 years. They are not given
    adequate time to prepare for the exam. Mentors could ensure
    that there is appropriate patient care assignments and time set
    aside for study. Note: Prep for exam requires 20 hours a week
    of study time for 3 to 6 months. And that recommendation
    actually came from somebody who has completed it.
        As a graduate psychologist, Chris was expected to counsel
    veterans with complex needs, facilitate group therapy,
    participate in care planning team meetings, along with all of
    the required reporting and documentation.
        No. 3, develop Veterans Health Administration (VHA)
    protocols for investigation of suicides of employees and
    recently terminated employees. The Tomah VA management and
    police did not investigate my brother Chris' death.
        No. 4, develop VHA protocols for addressing threats
    patients make against staff.
        No. 5, we also request that lawmakers investigate the
    pervasive use of extended temporary appointments within the VA
    health care workforce and the abusive use of terminations and
    other personnel actions against temporary and probationary
    employees and mandate additional protections, both statutory
    and administrative, for these most vulnerable employees who pay
    the heaviest price when they question the way of doing things.
        No. 6, we urge Congress to take steps to ensure greater
    accountability for VA front-line managers, mid-level managers,
    and upper management who engage in retaliation against
    whistleblowers and other front-line employees who speak up for
    veterans' needs.
        Seven, additionally, we urge Congress to review the current
    reporting structure for the chief of police at VA medical
    centers. Currently, they report to the medical center director
    rather than a separate entity that can address mismanagement or
    staff concerns without interference, such as the alleged
    illegal drug activity at Tomah.
        Eight, we are thankful the Senators and Congressmen are
    addressing and putting into place checks and balances that will
    ensure the safe ordering of opioids as well as the development
    of guidelines for the safe combining of opioids with other
    addictive drugs in an earnest effort to keep veterans safe.
        And I would like to point out, in addition to that, that
    Jason Simcakoski, who died last year from mixed drug toxicity,
    he died from essentially the same thing that my brother was
    addressing, and it is just beyond tragic.
        Last, but immensely important to our family, is our
    request--and this is a personal one--that Chris' Official
    Personnel File and all information be sent to myself, Sean
    Kirkpatrick. It is also requested that any and all Tomah VA
    supervisory notes, reports of contacts, et cetera, related to
    Christopher Kirkpatrick be sent to myself, Sean Kirkpatrick.
        Chairman Johnson. Thank you, Mr. Kirkpatrick.
        Mr. Kirkpatrick. Thank you.
        Chairman Johnson. Senator Baldwin.

                  OPENING STATEMENT OF SENATOR BALDWIN

        Senator Baldwin. Thank you, Mr. Chairman. I want to thank
    you and the Ranking Member, Senator Carper, for holding this
    hearing, and I especially want to thank the witnesses for their
    powerful testimony that will, I think, guide us in our future
    actions.
        As we have certainly seen in Tomah, Wisconsin, and, indeed,
    the rest of the Nation, the role of whistleblowers is
    critical--in fact, heroic--in running an effective
    organization. And agencies need to be much more open to
    accepting constructive criticism in order to improve an agency
    such as the VA, which has the tremendously important mission of
    taking care of our Nation's veterans.
        Mr. Kirkpatrick, I want to thank you so much for your
    attendance here today and also for mentioning Ryan Honl in your
    testimony.
        I also want to appreciate the fact that in your written
    testimony you shared the specific recommendations that you just
    outlined for the Committee that are really key. One that I
    would like to have you speak to a little bit more is the issue
    you raise about temporary or probationary workers.
        As we saw in Tomah with many whistleblowers it should not
    matter if an employee has been employed for 10 days, 10 months,
    or 10 years in terms of our treatment of them if they step
    forward to help veterans. I know this is a factor you have
    become aware of. We are working on legislation to address this
    issue. I very much appreciate your family's input but if you
    could speak more to the position that temporary or probationary
    workers are in when they come forward as whistleblowers.
        Mr. Kirkpatrick. Thank you, Senator Baldwin. I find it
    curious that, probationary and temporary employees--and I am
    really just drawing from my brother's experience, but the
    amount of responsibility that they are given and especially
    considering that they are lacking the support that I mentioned
    as well, that they can just be tossed aside really without any
    sort of third-party review, any sort of accountability. I mean,
    it is outrageous.
        In Chris' case, as Chairman Johnson pointed out, I think
    any independent person who would have looked at the reasons why
    they were terminating him would have come to the same
    conclusion, that these were ridiculous reasons and that it was
    clearly a case of retaliation. He was not afforded that
    protection because of his probationary status, and something, I
    think, needs to change with that.
        I think if we are going to--I mean, really, as, it was
    pointed out before, serving veterans is a privilege, and if we
    are going to put people in that position, a privileged position
    like that, we should provide them with the protections that
    they deserve, especially considering, a lot of these people, my
    brother included, he was not in the military, yet he was
    hearing firsthand accounts, from people with PTSD and hearing
    very hard things to hear for somebody, especially as a
    graduate.
        I think when you also add into the fact that to take that
    extra step and to point out what you see is wrongdoing and
    bring that to the attention of people, knowing that you do not
    have those protections, it takes a little more guts, I think.
    But that should absolutely be changed, and I do not see why
    anybody would disagree with that.
        Senator Baldwin. Thank you.
        Mr. Kirkpatrick. Thank you.
        Senator Baldwin. I want to note the repeated testimony we
    have heard today and on previous occasions about inappropriate
    access to whistleblowing employees medical records. We have
    heard such stories also at the Tomah facility regarding other
    whistleblowers who have stepped forward.
        I would like to ask Mr. Coleman and Mr. Wilkes whether
    there is an information technology fix in VA's recordkeeping
    systems that would make it more difficult for an employee to
    access a fellow employee's medical records. What action needs
    to be taken with regard to this pervasive problem?
        Mr. Coleman. I think, Senator, one of the things that can
    be done is to have maybe a two-party or two-employee system
    where, if there is a sensitive record like mine, because I am a
    Marine Corps veteran, that if an employee goes to get in the
    record, that another employee or a supervisor has to approve it
    for that to happen. The reason that would be important is this
    has happened four times to me, and when it has happened, I
    mean, I have heard excuses such as it was an innocent mistake--
    this is from the
    VA--or they were trying to get into a veteran's record with a
    similar name, and ``I do not recall being in the record.''
    Those were excuses that were actually given. And I do not know
    if any of the Senators have ever had a young puppy dog, but
    that first day when you leave a puppy dog in your apartment or
    your house and you go off to work and you come home and it has
    chewed up your shoes or it is wet on your floor, and you look
    at that puppy dog, and that puppy dog cowers like it has done
    something wrong, that is the same look that I got from Phoenix
    VA administrators after they gave me those excuses. They sat
    there quiet, all balled up, hoping that I would just stop
    talking about it and it would go away. It reminded me so much
    of a puppy I had one time, and that is what has to stop, ma'am.
        Mr. Wilkes. I have been fortunate to talk to 50-plus
    whistleblowers across the country, and 100 percent of those
    that are veterans have had their records accessed--100 percent,
    every single one of them. And, what can we do? There is no
    accountability. I was under investigation for a year, for
    having a list that was not supposed to exist, for possible
    privacy violations, but yet these people went into our records,
    and they face nothing. They do nothing.
        The whole thing with accountability, somewhere along the
    line there has to be accountability. And if you do it, there
    has to
    be--you have to say, ``Hey,'' and show those others that they
    are going to do something to them. There are ways that they
    have in place to say, hey, there is a big thing that pops up,
    this person is also an employee, so-and-so accessed--it tells
    them before they even go in there. I mean, 100 percent of
    whistleblowers/veterans that I have talked to have had their
    records accessed by people.
        Chairman Johnson. Thank you, Senator Baldwin. Senator
    Tester.

                  OPENING STATEMENT OF SENATOR TESTER

        Senator Tester. Yes, thank you, Mr. Chairman, and I want to
    thank Ranking Member Carper also for holding this hearing, and
    I want to thank you all for your testimony. I very much
    appreciate it.
        I just want to follow-up on Senator Baldwin's question with
    either you, Mr. Wilkes, or you, Mr. Coleman, and that is, why--
    and maybe I am just not seeing it. Why are they accessing your
    records? What are they doing?
        Mr. Coleman. What they do, Senator, is they access our
    records. Some of us have had mental health treatment after
    coming home from our time in the service. Really, it is none of
    their business to be in there. However, as Shea can tell you
    further about, what they do is they go into our records, and
    such as in my case, on January 20, when everything was kind of
    hitting the fan, I was called into a meeting with my section
    chief, who happens to be a psychiatrist, Dr. Carlos Carrera,
    and he asked me, he goes, ``I just want to find out about your
    mental health,'' and he started questioning me about my mental
    health. And I said it was highly suspect that he waited until
    after I was a whistleblower to ask me about my mental health.
    However, he never came to me after each of the six veterans
    committed suicide, he never once asked me about my mental
    health. So the timing is always highly suspect with these
    people.
        Senator Tester. But it is accessed to see if you have had
    mental health treatment? That is what they are doing.
        Mr. Coleman. I do not know, sir. I do not know exactly what
    they are getting at with that. I just know that they are
    violating HIPAA in doing it. But I know that they do use it
    against us, such as they have done with me.
        Senator Tester. By the way, I think your recommendation is
    well founded. I think it is a good recommendation.
        Mr. Coleman. I think it is a simple one.
        Senator Tester. Yes. Mr. Wilkes, would you----
        Mr. Wilkes. In my case, yes, I mean, I was brought in by my
    boss and sat down with him one on one, and he flat out asked
    me, ``Have you seen this mental health provider?'' And I had. I
    mean, I am an Afghanistan veteran, and, I had come back and I
    was seeing those, and I had quit sometime before, before I even
    came back to work at the VA from the vet center. And he
    basically told me, he said, ``Well, some of your colleagues are
    questioning your stability.''
        Senator Tester. And this was after you were a whistleblower
    they did that?
        Mr. Wilkes. This was after I had turned it in June 2013,
    yes. ``They question your stability and are saying you are
    unfit to lead.''
        Senator Tester. I got you. How long did you work for the VA
    before all this came down? I just want to try to get a timeline
    here.
        Mr. Wilkes. 2007.
        Senator Tester. 2007 you started, and you put forth some
    problems at what point in time?
        Mr. Wilkes. I had brought forth problems starting in 2012.
        Senator Tester. Got you. And they never talked about your
    mental health until after you brought forth problems.
        Mr. Wilkes. Until I reported it to the IG.
        Senator Tester. Cool. Not cool, but thank you.
        Mr. Kirkpatrick, I just want to say thank you for your
    recommendations. Oftentimes we get a lot of panelists in here,
    and to be proactive and talk about what you see as potential
    solutions is very helpful. So I want to just thank you for
    that.
        And this is for any one of you, Coleman, Colon, or Wilkes.
    What is the formal feedback mechanism for VA employees who want
    to bring forth a grievance to the attention of management? Is
    there a formal feedback mechanism? Go ahead, Shea, if you want.
        Mr. Wilkes. There is in place--I mean, they always want you
    to keep it and follow your chain of command, and they always
    suggest that you do that.
        Senator Tester. Yes.
        Mr. Wilkes. But, unfortunately, that is not working. And,
    unfortunately, when you report to the IG, if you take that
    step, the IG only takes a certain number of cases, and a lot of
    times they will send the report back to the Veterans Integrated
    Service Network (VISN), which goes back to the director, and
    then you are in trouble.
        Senator Tester. Right. So there is a mechanism. Are you
    told about the mechanism for grievances and are you told about
    whistleblower rights in any sort of training that the VA offers
    up?
        Mr. Wilkes. We do have a lot of Talent Management System
    (TMS) trainings, which is our online training system that we go
    through, and you do have classes on those. You do every year.
        Senator Tester. And it does cover whistleblower, it does
    cover how you report a grievance and all that? I am just
    curious.
        Mr. Wilkes. It does cover whistleblower. I am not sure
    about the union grievance process.
        Senator Tester. OK.
        Mr. Coleman. Can I add to that, Senator?
        Senator Tester. Absolutely.
        Mr. Coleman. The problem between our front-line supervisors
    and ourselves is that when all this happened with me, I told my
    front-line supervisor, because, once again, we are veterans, I
    believe in my chain of command.
        Senator Tester. Right.
        Mr. Coleman. It is just grilled into you. And when I came
    forward to my front-line supervisor, the first thing out of her
    mouth when I said I was coming forward regarding suicidal vets,
    she goes, ``That is how people get fired.''
        Senator Tester. Oh, my God.
        Mr. Coleman. Instead of suicidal veterans walking out of
    our hospital that everyone knew and we needed to fix it.
        The next time, I was walking through the hospital on my way
    to a meeting with the director when one of the assistant social
    work chiefs said, ``Do not rock the boat,'' as I walked by him.
    This is the kind of comments and wrongdoing that we are getting
    in our own hospitals by our front-line people that we are told
    to come through. That is where the disconnect is at, and that
    is the cancer that we have to fix within each of these
    facilities.
        Senator Tester. I agree. It makes me wonder what kind of
    training--other than professional training, what kind of
    training the VA does for your front-line supervisors.
        Look, mental health is a huge issue. You guys know that. I
    think every one of you are in that field, right? And you have
    come out of the military. You understand the impacts that are
    going on with the wars in the Middle East, how it is a
    signature injury coming out. But denial is not a solution, and
    so my time is up, but I just want to express my appreciation
    for you folks coming forward and bringing forth problems and
    solutions to those problems. I very much appreciate that. Thank
    you.
        Chairman Johnson. Thank you, Senator Tester. Senator Ernst.

                   OPENING STATEMENT OF SENATOR ERNST

        Senator Ernst. Thank you, Mr. Chairman. Thank you,
    gentlemen, so much for being here today.
        I will state again--I have said this many times in the
    short 8 to 9 months that I have been here--that this is one of
    my priorities, is working with veterans and mental health
    issues. The first bill I proposed was working with veterans
    that have mental health issues and allowing them greater
    access. And so I do want to thank you. My condolences on the
    loss of your brother, Sean. It is very sad.
        Mr. Kirkpatrick. Thank you.
        Senator Ernst. This is an issue I am extremely passionate
    about, and I think today's hearing just is reemphasizing to me
    that we have a corrupt and broken VA system. And when I hear
    that supervisors, other workers are more concerned about their
    own jobs than they are about the veterans, we have an issue. We
    have an issue, folks, that needs to be fixed. And I do not know
    how many hearings we are going to have until we get to actually
    addressing the situation. I hear a lot of talk, but we need to
    figure this out. So, again, I am very passionate about this
    issue, and thank you for coming forward, for being brave and
    doing the right thing.
        When it comes to accessing your health records, I just want
    to state, just for everybody, it does not matter what the
    reason is. They should not be accessing your health records.
    That would be like saying it is OK for us to access anyone here
    in the audience, their health records. It is wrong. It should
    never, ever occur. Never without your authorization. So I just
    want to emphasize that. It does not matter why.
        Mr. Coleman, do you believe there are many alternatives for
    veterans who feel they are not receiving timely or adequate
    mental health care at their local VA?
        Mr. Coleman. Thank you for asking me the question, Senator.
    I do not know if you read the article by Dave Phillips, the
    front page of the New York Times on Sunday. It was about the
    plight of Second Battalion, Seventh Marines, who have lost, I
    believe it is, 13 members to suicide after their deployments in
    Iraq and Afghanistan. The picture I have in front of me is me
    and my two Marine Corps sons. Not only am I a former Marine,
    but I make Marines. The one on the right is with 2-7 currently.
        In that article, they talk about how many of these veterans
    came to the VA for health care and were turned away. In one
    instance, they had a 22-year-old female social worker or
    whatever that told him that the loss of his buddies was like
    breaking up with a girlfriend and he just had to get over it.
    Well, we do not just get over it. And that is not right. And
    that is why I think that these guys and girls, when they come
    home from theaters of war, should have the right to go wherever
    they feel comfortable. We owe it to them to send them anywhere
    they feel comfortable. If it is a counselor in another town
    that they want to go to and they are going to open up and talk,
    then we should allow them to do that, because once they have
    committed suicide, it is too late. There are no second chances.
        Senator Ernst. That is right, and you do believe that
    opening up for greater access, whether it is at the VA or
    whether it is through a community clinic, peer-to-peer
    supports, those are ways to address it.
        Mr. Coleman. Any of those, ma'am. And the reason I do not
    agree with the number of 22 per day--I think that is a number
    of suicides--I believe that is a number fed to us in the hopes
    that we will all shut up and make it go away. That study was
    sponsored by the VA. It did not include the States of
    California, Texas, and Illinois. And I do not know about you
    folks, but when I was in the Marine Corps, over half of us were
    from California and Texas. Some of the guys written about in
    that article that have committed suicide are from California.
    They also do not count the phenomenon of suicide by cop. I have
    had two veterans that were killed by police officers. I am not
    saying it is the police officers' fault, but they pretend to
    have a weapon or they pull a weapon. The VA does nothing to
    report those as suicides. The number of 22 per day is
    inaccurate, and we need an independent third party to come in
    and do a complete study to show us what the real number is so
    we know. Once we get a real number, then we will know what a
    big deal it is, and then we can fight it together.
        Senator Ernst. And I use that 22-a-day number all the time,
    and I think that is appalling enough. But I think you are
    probably correct, Mr. Coleman, in your assessment.
        And for all of you, in your experience, do you believe the
    VA management takes seriously ideas for reform, the
    implementation of the IG recommendations, or recommendations
    from staff members when they are seeking to improve these
    services at the VA? Do you think they take them seriously?
        Mr. Wilkes. VA leaders, it is a system of cronyism that has
    gone on for so long, and they protect each other. Rules and
    regulations oftentimes, they do not care. They use them when it
    benefits them. And I will tell you, one of the reasons why is
    because nothing ever happens to them. Even if you catch them--I
    have put policies in front of folks and said, ``You cannot do
    this. This is the policy.'' They still do it. But nothing ever
    happens to them.
        And, the IG makes recommendations, but they do not have to
    hold--I mean----
        Senator Ernst. Who is holding their feet to the fire?
        Mr. Wilkes. Right.
        Senator Ernst. Right. We should be doing that. Thank you,
    Mr. Wilkes. Mr. Colon.
        Mr. Colon. I have always stated that it is great to have
    all these hearings, all new policies, all new recommendations
    and solutions. But since this scandal has broken, since
    Phoenix, we have not held one person accountable for any
    wrongdoing at the VA as far as whistleblower retaliation. The
    VA, what they do is the IG--I reported a couple things to the
    IG. The IG sent it back to the agency to investigate itself.
    And then they give it to the supervisor. The supervisor already
    knows who the whistleblower is.
        So what I always truly believe is that you cannot police
    yourself. It is not the solution that you should do it. Like I
    said, the key component that everything is failing to make the
    VA better and to do service for our veterans is start holding
    people accountable.
        Senator Ernst. Very good. Well, I know my time is up. Do
    you have any other comments? Please.
        Mr. Kirkpatrick. If I may, with regards to that, I know
    that the people who seem to have been responsible for
    retaliating against my brother, as far as I am aware, are still
    employed at the VA. I do not know if that is a pending
    investigation, but that is unacceptable.
        Senator Ernst. It is unacceptable.
        Mr. Kirkpatrick. And that is Dr. David Houlihan. And the
    human resources representative David DeChant.
        Senator Ernst. Thank you. Again, my condolences.
        Mr. Coleman, do you have any closing thoughts, very
    quickly?
        Mr. Coleman. Ma'am, really quickly, I was just going to say
    the retaliation investigations, I was removed on hearsay. I was
    on paid administrative leave for 206 days until I was ordered
    back into the same retaliatory environment on August 17, which
    I refused to go until it is safe. So they are able to remove me
    on hearsay; whereas, we have a sworn affidavit from the H.R.
    chief showing that the director held this meeting to propose to
    fire me on January 13, and he is still showing up to work every
    day. I love my job helping vets get clean and sober. I would do
    it for free. And they removed me from that or took me out of
    that position to investigate hearsay, which was proven untrue
    in late February.
        Senator Ernst. Thank you again, gentlemen.
        Thank you, Mr. Chairman.
        Chairman Johnson. Thank you, Senator.
        Let me assure everybody, Senator Ernst, all the witnesses,
    everybody in the audience, there is a process to solving a
    problem, and this is the first step. We have to properly define
    it. We have to lay these things out. We have to highlight these
    problems. And, of course, the purpose of these hearings we have
    been holding--and they have been multiple; we also have our own
    investigation under way with Committee staff--is to highlight
    the problem, to get agreement. And let us face it, what you are
    seeing is bipartisan agreement. These are problems that have to
    get fixed. So now that we understand and we have highlighted
    it, we will solve it. We will be introducing legislation
    certainly under the jurisdiction of this Committee. It will get
    reported out, and we will put pressure on the system to get the
    things passed. So this is not just talk. This will result in
    action, and your testimony is powerful and will result in that
    kind of action. And the fact that we have representatives of
    the VA here, as they were in Tomah when we held the hearing in
    Tomah, and we listened to the powerful testimony of the
    survivors of the abuse there, this is what will result in
    concrete action to start solving these problems. So, again,
    thank you all. Senator Ayotte.

                  OPENING STATEMENT OF SENATOR AYOTTE

        Senator Ayotte. Thank you, Chairman.
        Mr. Kirkpatrick, let me just add my condolences for the
    loss of your brother. And let me just say to all of you, in
    listening to the exchange you had with Senator Ernst, it is
    appalling, frankly, that they can retaliate against you for
    really doing the right thing for our country and coming forward
    with a focus on making sure that our veterans are served based
    on things like hearsay when you have at heart what we want to
    have in our VA, the best to serve those who have served us, and
    that the people who have done this to you are still merrily on
    their jobs. And so I think the accountability piece is the key
    to all of this, people who are not focusing on caring for our
    veterans and those--we need to reward people like you who want
    to serve our veterans. And those people who retaliated against
    you should be fired, and I think the problem we have seen with
    all that we have heard of the deaths of our veterans and our
    veterans who have suffered, there have been very few, if
    anyone, held accountable for it.
        And so within the organization it seems like the message
    being sent is, hey, keep covering everything up because, do not
    worry, you will keep your job; if you come forward, you are
    going to lose your job--which is the absolute wrong message.
        And so, Mr. Chairman, I hope that we make sure that the
    legislative tools are there and that we hold people
    accountable. So I just want to thank you all for being here and
    for your courage in what you have done.
        I also wanted to follow-up, just the one thing that many of
    us have focused on here is where is the priority. We have not
    even had a permanent Inspector General for the VA since
    December 2013. It has been 631 days. So if we look at where
    priorities are, it seems to me that that is being put low on
    the totem pole when we will not even put a permanent individual
    in that position. And many of us on this Committee--and I am
    going to do it again today--have called on the President,
    because he needs to appoint that individual and say this is a
    priority for our country.
        And I would like to ask all of you, what would you like to
    see--rather than the Inspector General, obviously we need to
    get someone there with the importance of it, of a permanent
    position and back that person up. But once those
    recommendations are made and the investigation is done, what
    more teeth can we give that process so it is not just turfed
    back to the same group of people in the VA where there may be a
    good investigation done, but nothing is followed up on it. So I
    wanted to get your thoughts on what could we do, ideas you have
    for us, to make sure there is more teeth in that process. I
    will turn it over to whoever wants to go first.
        Mr. Coleman. That is what we are here for today, is to get
    some teeth in the process, because like you have all stated, we
    continue to talk, and we all know there is a problem. However,
    they give their answers, and then we give them 3 more months,
    and then some new whistleblowers come back, and we do it all
    over again. The time for action is now.
        Senator Ayotte. Right.
        Mr. Coleman. We are here to help. I think being part of the
    process, the nice thing about it is you have some front-line VA
    employees here. I was a grunt in the United States Marine
    Corps. I know both----
        Senator Ayotte. Semper fi.
        Mr. Coleman. And I know that with some of these committees
    and stuff, such as Secretary Robert McDonald when he did the
    MyVA, a lot of these people that he selected--do not get me
    wrong. It is great, all these generals and stuff were there.
    But I have never seen a general have to use the VA for health
    care. I have never seen a general drive 150 miles and have an
    appointment canceled when he had to take a day off of work to
    feed his family. And no disrespect to the general and his
    service at all, but there needs to be more front-line people.
    There needs to be more grunts. There needs to be more, enlisted
    people involved in the process.
        Senator Ayotte. This has to be grassroots. They need to
    understand what is happening on the ground.
        Mr. Coleman. They do, ma'am. And what the problem is is
    they are not listening to us. We are talking, and we are all
    about respecting the chain of command. However, when there is a
    breakdown in the chain of command, that is where you all come
    in, and that is where we need your help. And I agree with you.
    We need a permanent IG. It needs to happen. But from the
    grassroots part of it, we allow them to have their own
    investigations. The VA gets to investigate itself, and there
    is--I am sorry to laugh, but it is just--it is a sad joke. We
    have an audio tape of them admitting five suicidal vets walked
    out of my hospital right after I came forward. Someone should
    have said, ``You know what? We messed up.'' They did not. They
    destroyed me when I told the truth. It played on CNN with Jake
    Tapper. It is just amazing.
        So how much more evidence do we need on these people before
    we are able to take action? And that is why I hope you all are
    upset and I hope you are able to take action, because it is
    enough. It is enough today.
        Senator Ayotte. I am upset, and I know that many on this
    Committee are upset.
        Mr. Colon. One of my recommendations in the statement that
    I provided, I think once the OSC concludes that a person
    retaliated, that they are given the authority to fire that
    person, because it seemed that the VA does not want to fire
    anybody.
        Another thing that Mr. Brandon Coleman had touched on, I
    requested through the Freedom of Information Act (FOIA) to see
    how many directors, deputy directors, and associate directors
    are actually veterans working in the VA. Seventy-six out of 479
    are veterans that are in executive positions for the VA, and
    that is a problem.
        I stopped getting care at the VA for one reason 3 years
    ago. Once I came forward, I knew the type of behavior I was
    dealing with. So the care that I earned, I stopped going there,
    because I know if they access my record or they did anything,
    that they would not be held accountable. But I think the IG
    should make recommendations. Maybe they should have the
    authority if they found somebody that has found misconduct,
    that they should be the ones that should issue disciplinary
    actions.
        One thing I have noticed through all this ordeal is the VA
    has failed to hold people accountable. And if that identity
    does not want to hold people accountable, then maybe we need to
    move forward with the IG and the OSC to start holding people
    accountable.
        Thank you.
        Mr. Wilkes. I will say this: The bottom line is the VA is
    going to have to start telling the truth, and somehow we have
    to make them do that. Their PR machine puts out more propaganda
    than the Republic of North Korea. I am serious about that. And
    the problem with that is they are not accepting any
    responsibility. It is still going on. The facility I work at
    told me there are no--after I came forward, no access to care
    problems. But in March of this year, I had a consult put in for
    my yearly eye appointment. They scheduled me an appointment in
    June. I did not even know about it. They did not offer me any
    kind of outside fee-based. I put in another one in May. They
    had canceled the one in June because the doctor had quit, moved
    it to August. Still nothing. I called down to the clinic, and I
    said, ``Are you all not going to offer me fee-based service or
    something?'' They said, ``Well, we do not do that. We do not do
    the Choice program.'' I said, ``Look, you do not know who I am,
    but I am very familiar with this stuff.'' I said, ``That cannot
    be right.''
        Now, I will give credit. When I called the chief of staff
    and the director, they got my appointment, and they said they
    were going to correct that. But it is still going on. It is
    still going on, and they are still putting out these numbers,
    and they say, ``Well, we have 97 percent new leadership.'' Yes,
    you moved this director from this hospital to this hospital,
    and this one here to here. That is the kind of numbers they put
    out. They are very misleading.
        Senator Ayotte. Unfortunately, I am hearing those stories
    from my constituents also.
        Mr. Kirkpatrick. Well, being the only civilian here, I do
    not really have a lot of personal insight but since I have
    learned a lot about this since my brother died, it seems very
    apparent that there is a lack of transparency, accountability,
    and in a way, it is like the ugly side of war, almost the
    ugliest side, is, the people who return from it broken. They
    have put their life on the line. They have paid the highest
    cost. And, they should be given everything from this country,
    to hear 22 people, and that is probably way underestimated, it
    is outrageous.
        It seems like the VA behaves as if it is above the law, and
    that is unacceptable. Personally, I have to say, this Committee
    is really the only entity out there that has taken my brother's
    case seriously, and I just want to let you guys know, on behalf
    of my family, we are eternally grateful for that. But, I hope
    at the same time that there is some power that you guys hold
    where, some change can be made here, a culture change or
    something. I mean, people's lives are on the line, and it gets
    swept under the rug. You do not hear about it, yet every day
    people are dying, people are suffering.
        So I do not really have anything specific to say, but I
    think it is worth pointing out.
        Senator Ayotte. What you said today has been heard, and it
    has been loudly heard, so we appreciate your being here.
        Mr. Kirkpatrick. Thank you.
        Chairman Johnson. Thank you, Senator Ayotte.
        The power we hold is the power of your testimony, and I
    just want to underscore the point of this is just a basic first
    step because we have to have a transparent and independent
    Office of Inspector General. That is just a basic first step.
    And, again, we do not have a permanent Inspector General. I
    wrote a letter to the President on January 22, 2015 asking for
    an appointment of a permanent one. Other Committee Members have
    asked for the same thing. We will ask again. We need a
    permanent Inspector General so we have a transparent and
    independent Office of Inspector General. That is just a basic
    first step.
        So, again, let me call on the President of the United
    States to, as quickly as possible, appoint an independent
    permanent Inspector General for the Veterans Administration. We
    need one, and we need one now. Senator Carper.

                  OPENING STATEMENT OF SENATOR CARPER

        Senator Carper. I want to thank each of you for being here
    today. I want to thank a number of you for wearing the uniform,
    and thank you for that service, and thank you for your
    continued service to our veterans.
        I spent 5 years in a hot war in Southeast Asia as a naval
    flight officer (NFO), and after that was over, I came back to
    the States and went to college on the GI bill. And the first
    week I was back in the States--I had moved from California to
    Delaware, and the first week I was back, I got in my Volkswagen
    Karmann Ghia with a rebuilt engine, and I drove from Newark,
    Delaware, to a VA facility in Elsmere, Delaware, about 12 miles
    away. And I had my DD214 with me, and I presented it to the
    folks there, and I said, ``I think I am eligible for some
    benefits.'' And they checked me out, and they said, ``Yes, you
    are. And if you will come back in a week, you are eligible for
    some dental benefits. You can have a checkup.'' And a week
    later, I came back, met a fellow, a dentist named Jerome
    Kayatta, and he took care of my dental needs. And at the end of
    my visit, he said to me, he said, ``This is not a very good
    health care facility. The morale is not good. The quality of
    the service is not good. If I were you, I think I would get my
    medical care from someplace else.''
        Ironically, 40 years later, he is still my dentist. He
    works part-time pro bono in the Delaware correctional system,
    providing dental care for folks that are incarcerated, some of
    whom are veterans. But I never thought of him as a
    whistleblower, but he did more to bring my attention to the
    need to make changes at that facility and health care provided
    for veterans all over our State. And I worked very hard to make
    sure that that was a hospital that we could be proud of, that
    they could be something closer to the gold standard than where
    they were in, gosh, 1973-74. And we have outpatient clinics--we
    only have three counties in Delaware, but we have VA facilities
    in all three counties. Do they provide perfect service?
    Absolutely right, no, they are not. None of us are perfect. But
    if you talk to the veterans in our State who use the VA, those
    outpatient clinics and our VA hospital--I call it the ``mother
    ship'' in Elsmere. I think for the most part they tell you that
    the people who work there are caring, dedicated men and women
    and dedicated to ensuring that veterans get the kind of service
    that they deserve. I would just sort of start off by saying
    that.
        The other thing I would say, we have a big air force base
    in my State, Dover Air Force Base. We are very proud of the
    work they do. They are an airlift base, have C-17s and C-5
    aircraft. They travel all over the world every day, delivering
    people and cargo wherever it is needed.
        They also have a special responsibility, Dover Air Force
    Base, because that is the mortuary for our country, and it is
    where the remains of our fallen heroes are brought throughout
    the year for years to Dover Air Force Base. It is a sacred
    mission. A sacred mission.
        About a half dozen years ago, we heard from a whistleblower
    at the mortuary at the Dover Air Force Base that some of the
    practices and procedures there were inappropriate. Things were
    happening that should not have happened in the carrying out of
    their responsibilities, and it indicated that there was a
    problem of leadership, leadership at the military level,
    colonel, full-bird, and at the civilian level, top civilian
    level leadership. And there were some people who thought, well,
    this person is just a malcontent. Well, as it turned out, there
    were a couple more people who came and shared their experiences
    with us. Our congressional office got involved, the
    congressional delegation got involved, and the
    Office of Special Counsel got involved. And the Office of
    Special Counsel--I think there is somebody here today from the
    Office of Special Counsel. They did a very good job.
        I once shared this with my colleagues. Two years ago, I was
    back--I go to the air force base a lot, but 2 years ago, I was
    back for a special visit and tour of the mortuary. I want to
    tell you, the hardest work I have ever seen anybody do in the
    military is in that mortuary, the people who deal with those
    remains and piece body parts back together. I mean, we think we
    have had tough jobs. Oh, my God, they have tough jobs, really
    tough jobs.
        But I went back, and it was interesting. They had a whole
    delegation of civilian and military folks there at the entrance
    to greet me. And foremost, right at the front of the group was
    Mr. Z, one of the original whistleblowers. Surrounding him were
    the other whistleblowers. And they were there to welcome me
    back. And do you know who was not there? The full-bird colonel.
    He was gone. And you know who else was not there? The civilian
    leadership of the mortuary. They were gone. And you know who
    was still there? The whistleblowers.
        So I just want to say sometimes whistleblowers were this
    Jerry Kayatta all those years ago in an unofficial role as a
    whistleblower, and more recently Dr. Z and the whistleblowers
    at the Dover Air Force Base. Sometimes--the parable of the
    seeds? Some of the seeds fall on the hard ground and in the
    thorns and so forth. Some of the seeds fall on fertile ground.
    In those cases, I think in Delaware, better things have
    happened.
        So I just wanted to share that with you. I have a couple of
    questions for you. We will maybe have a second round here, but
    I wanted to raise that.
        I also wanted to say as much as we appreciate your being
    here and look forward to hearing more from you today and I look
    forward to asking some questions, I just need to make a note
    that I have raised a concern of this at other hearings we have
    had for whistleblowers. I just think we need to respect the
    independent, objective process that Congress has set up in the
    Office of Special Counsel, which I have alluded to before, the
    Merit System Protection Board, and elsewhere.
        The last thing I want to say is this: Leadership. I wrote a
    note down here, and the Chairman looked at it. I wrote down the
    word ``leadership.'' The most important element in the success
    of any organization I have ever been a part of is leadership.
    Whether it was a military unit, a VA facility, here, business,
    even a sports team, leadership is always the key. And the guy
    that the President nominated to be the leader of the VA a
    couple of years ago is a fellow who was a West Point graduate,
    a fellow who was a Ranger, and who understands the military
    from the inside out. And what needs to happen at VA facilities
    across the country is the quality of leadership that I think
    exists at the top needs to permeate and come down to the local
    level.
        And I want to second again what the Chairman has said. We
    have sent many letters to this President saying we need more
    permanent IGs, Senate-confirmed IGs. And to the
    administration's credit, they have done a better job in the
    last year or two. And this IG has been vacant for almost 2
    years. Way too long. We have had an opportunity to meet just in
    the last week or so with the current leadership of the
    Inspector General's Office acting person. We need permanent
    Senate-confirmed leadership, and I would just urge our
    Committee to continue to write to the administration again and
    again and again, call and say this is a problem, this needs to
    be addressed.
        Thank you. I look forward to asking some questions in a few
    minutes. Thank you all.
        Chairman Johnson. Senator McCain.

                  OPENING STATEMENT OF SENATOR MCCAIN

        Senator McCain. Thank you, Mr. Chairman. I want to
    apologize for not being here for the entire hearing. I am
    chairing a hearing in the Armed Services Committee at the
    moment. But I wanted to come up here to mention my appreciation
    for the witnesses. I thank you. I thank you for your courage. I
    thank you for your steadfastness. And this is a very important
    hearing, and I want to thank the Chairman for having it.
        I also want to give a special thanks to Mr. Coleman. I want
    to thank him for his willingness to reach out to my office to
    share with me and my staff his experience at Phoenix as a
    whistleblower. We all know, Mr. Chairman, that this whole
    scandal began to unfold at the Phoenix VA where 50 of our
    veterans allegedly died because of a failure to receive--
    because of being on some kind of phantom waiting list.
        I think, Mr. Chairman, from what I have briefed, that we
    are finding out that there is a viewpoint or an environment in
    the VA that discourages and even punishes whistleblowers. Is
    that your conclusion? Then I would just like to ask the
    witnesses one question. What can we do to better protect you
    and others who are willing to come forward and willing to risk
    their careers in order to get better treatment or even in some
    cases treatment for our veterans who, in the view obviously of
    the treatment in the past has been less than acceptable? Maybe
    I can begin with Mr. Coleman and then you, Mr. Kirkpatrick, and
    then the others, Mr. Colon and Mr. Wilkes.
        Mr. Coleman. Senator McCain, I just want to thank you and
    your staff. They are amazing, and you guys have been with me
    from the beginning, from the first letter you wrote to the
    Secretary, and I just wanted to thank you for that in person.
        The word that comes to mind when you asked the question is
    ``accountability.'' When there is wrongdoing committed, it does
    not matter if the VA employee is a janitor or food service
    worker or a hospital director. When they are caught doing
    wrongdoing and breaking Federal law, they should be fired. When
    these employees----
        Senator McCain. And to your knowledge, there is none of
    that?
        Mr. Coleman. Senator McCain, the director had a meeting on
    the 13th of January asking to terminate me, was told he could
    not terminate me by legal counsel Shelly Cutts, and she said,
    ``But we can come up with other employee actions to get rid of
    him.'' On the 27th, I was taken out of my position. The H.R.
    chief, Laurie Butler, came forward and gave a sworn
    deposition--she is also a retired Navy officer, has no reason
    to lie; I never met her before in my life--showing that this
    meeting happened. We have asked for a full investigation into
    Director Glen Grippen's actions. It is amazing, the corruption
    that goes.
        So if you wanted an answer from me, my answer is
    accountability. When we catch these directors doing wrongdoing,
    they need to be fired, just like they do to us when we come
    forward.
        Senator McCain. And if they are not fired, then the
    leadership should be fired.
        Mr. Coleman. I agree. I agree, sir, because how can you
    trust your commanders in chief, all the way up the chain of
    command. These are not people you are ready to run into combat
    with, because they are out for themselves. So, all of us here,
    the three of us are all veterans. And I believe in my chain of
    command, and I also believe in good leadership, as you guys
    were saying before. There is not good leadership currently. We
    do not trust the leadership, because look at what they can do
    to us.
        Mr. Kirkpatrick. I would second what Mr. Coleman said. I
    think, accountability for the people who have been proven to be
    the problem is certainly what should happen.
        I also realize that this process here is a long, tedious
    one that requires gathering evidence, hearing testimony, as we
    are doing now. As I pointed out, the chief of staff at the
    hospital where my brother worked as far as I know is still
    employed by the VA, and it appears that he ran that hospital
    through intimidation, forced some good people out there--my
    brother, who really wanted to help people and sacrificed
    everything to be able to do that. It seems like the people who
    are the bad ones here, they lack that ingrained compassion and
    desire to help the veterans.
        It is difficult for me because, I am not a veteran myself,
    and I am speaking on behalf of my brother, who cannot speak for
    himself, but----
        Senator McCain. Well, could I just say to you, sir, that I
    know this Chairman and I know the Ranking Member, and I want to
    support them every way possible. We will do everything we can
    to hold them accountable. And what bothers us is that what
    happens to you is a strong disincentive for others to act with
    your courage. Is that right, Mr. Colon.
        Mr. Colon. That is totally correct, Senator. And, first of
    all, I want to thank you for your service.
        Senator McCain. Thank you.
        Mr. Colon. Like Mr. Brandon Coleman said and Mr.
    Kirkpatrick, there has been no accountability for the whole
    team that retaliated against me in San Juan, Puerto Rico.
        Another thing that I find astonishing, there is a table of
    penalties from a center memorandum that is a VA directive that
    States on page 38 to 42 that they can remove people for
    retaliation. But they failed to use their own table of
    penalties to hold executives or managers or supervisors that
    are retaliating against whistleblowers. So I find the main key
    thing, I think, to fix everything is to hold people that are
    found guilty of retaliation to be removed from the VA.
        Senator McCain. Thank you.
        Mr. Wilkes. Senator, it is good to see you again. I know we
    talked when you were in Shreveport with Senator Cassidy, and
    you had told me--and I think this is very telling. You said to
    me that day, when I said I am one of the whistleblowers, you
    said, ``Thank you.'' And you said, ``Do you know that I sat in
    front of that director, and they looked me in the eye, and they
    said nothing was going on'' ? And, if they will lie to you and
    try to cover this up, there is no accountability, and they do
    not fear it. You can just see that they do not fear that
    anything is going to happen to them because they have gotten
    away with it for so long.
        Until we are able to show that whistleblowers will be
    protected and that something is going to be able to be done,
    you are never going to know the depth of this corruption. There
    are people that want to come forward but are scared. They need
    their jobs. They come and they pull Brandon and me aside, and
    they say, ``Thank you for coming forward.'' And then, some of
    the schedulers said, ``Hey, you brought this forward, and, are
    they going to go back and change our evaluations? '' And I
    said, ``What do you mean? '' They said, ``Well, they marked us
    lower, and they told us, `You made this many appointments over
    14 days, and we are marking you down.' "
        And I want to tell them, ``Yes, they are,'' but I cannot
    because I know they are not. They want to come forward and
    say--they have told me, ``I would tell the IG if they came and
    asked me.'' The IG does not want to ask them.
        Senator McCain. Well, I thank you, and I thank you, Mr.
    Chairman, and Senator Carper for this hearing and your untiring
    efforts. We have to stop this. We just must stop it.
        I thank you, Mr. Chairman.
        Chairman Johnson. Well, thank you, Senator McCain. And just
    to kind of answer your question in terms of how rampant, it is
    almost epidemic proportions, but in subsequent testimony by the
    Office of Special Counsel, she is laying out the facts, that
    there are 4,000 prohibited personnel practice complaints in
    2015 to the Office of Special Counsel. Four thousand. That
    would be the retaliation complaints. Fourteen hundred of those,
    about 35 percent, come from the VA. So this is rampant, this is
    a problem, and it is a problem we are going to address.
        Let me just say we are going to have votes at 11, and I
    think what I will do, because the Ranking Member, Senator
    Carper, did not get a chance to ask questions, I will turn it
    over to him. He can ask questions. I would say, Senator
    Baldwin, if you would like to stay here and ask questions while
    I go vote--I am not going to recess. We will just keep this
    thing going. But then when I come back, we will seat the next
    panel. So if you guys want to take it from there and ask
    questions.
        Senator Carper. Thanks.
        Chairman Johnson. And, again, thank you. I will be back.
        Senator Carper. Thanks.
        Chairman Johnson. I heard there was one vote.
        Senator Carper. I think there are two.
        Chairman Johnson. OK. That will complicate things. I will
    still quickly vote, and we will get going.
        Senator Carper. [Presiding.] OK, good. Again, our thanks to
    you. Please bear with us as we try to do our jobs here and do
    our jobs voting. Sometimes it gets a little complicated.
        I believe one of the goals of this Committee needs to be
    understanding how the process really works for whistleblowers
    and what we can do to improve it.
        I would just ask each of you just one thing that is
    working, one thing that is working that you have seen working
    with respect to whistleblowers, whistleblower protection, and
    share a best practice with us. And if the answer is, ``I have
    never seen anything that works''--the Office of Special Counsel
    I am convinced works. We have seen it ourselves at Dover Air
    Force Base. But just share with me one thing, very briefly, one
    thing that you have seen work. And I do not care who goes
    first.
        Mr. Wilkes. With me, the Office----
        Senator Carper. I like to say: Find out what works. Do more
    of that.
        Mr. Wilkes. I think you are right. The Office of Special
    Counsel helped me. I would probably still have a looming
    criminal investigation over my head today if they had not
    stepped in when I filed my----
        Senator Carper. OK. Thank you.
        Mr. Colon. I just wanted to say one thing. I think it is
    the Office of Special Counsel--if it was not for the Office of
    Special Counsel, I would have been terminated. I think they
    worked. That is why I think we have to give them broader
    authority to hold these people who retaliate against us. And I
    would say just the Office of Special Counsel.
        Senator Carper. All right. Thank you, sir. Mr. Coleman.
        Mr. Coleman. Senator, I would echo their statements with
    the Office of Special Counsel when I came forward. What I would
    say is they need more help. The Office of Special Counsel I
    believe is overwhelmed, because I get, just like Dr. Katherine
    L. Mitchell, one of the whistleblowers from 2014, she and I
    speak just about every day, and I get anywhere from one to
    three calls from whistleblowers. I have had two since I have
    been in D.C. where I listen to these employees cry and tell me
    what is going on, and I always take that call, because I wish
    someone would have been able to do that for me.
        So I believe that the Office of Special Counsel needs more
    help, because I think some of these people that are coming
    forward, I just think it is an overwhelming task to ask the
    Office of Special Counsel to be able to help everybody. I do
    not think they have the manpower currently.
        Senator Carper. All right. Thanks so much. Mr. Kirkpatrick.
        Mr. Kirkpatrick. Unfortunately, I do not have the status of
    being a whistleblower myself, so I cannot really confidently
    comment on that. But I would say with the people that I know
    and have met, Ryan Honl, Noelle Johnson, and others, I think--
    and I know this may not be the answer you are looking for, but,
    they found sympathetic people within the media. They reached
    out to other whistleblowers, and as I stated before, I would
    not know any of what happened to my brother without Ryan and
    Lin, and that is really all I can say about that, and this
    Committee as well.
        Senator Carper. Thank you.
        Mr. Kirkpatrick. Thank you.
        Senator Carper. Let me just ask, for those of you who are
    whistleblowers, when you first thought you were being
    retaliated against, were you aware of your rights as a
    whistleblower and the processes and resources that were
    available to you? Mr. Wilkes, would you start with that?
        Mr. Wilkes. I had taken the trainings, and I was somewhat
    aware of it. But the overall process and how to do it and
    things like that, I have had to figure out on the go, who to
    file with, what you can file. A lot of times when you have a
    complaint in the VA, what I found is that you want to say,
    ``Hey, let us go to EEOC,'' or, ``Hey, let us go to Office of
    Special Counsel,'' or, ``Hey, let us go to the IG.'' I went to
    the IG first because I thought that is what to do. I never
    heard from them on the first one I did, and then the second
    one, it took them a month and a half after I reported it again.
        I went to the Office of Special Counsel after they told me
    that I was under investigation criminally, and I learned about
    that process. So I was not aware--it is a lot of steps to it,
    and that is kind of why we kind of started a support group, the
    Truth Tellers and stuff, to kind of help each other and share
    our stories with each other to let each other know exactly how
    to file, what you want to make sure, I mean, because it is very
    emotional, and you are isolated. I mean, they isolate you, and
    that is how they kind of keep you that way.
        Senator Carper. All right. Thank you.
        Mr. Colon, same question, please. Were you aware of your
    rights as a whistleblower and the processes and resources
    available to you?
        Mr. Colon. Negative, sir. But I was well aware that once I
    came forward that I would be retaliated against, because I had
    a good friend in 2010 that came forward about the reusable
    medical equipment that happened down in San Juan, Puerto Rico,
    and he was removed from his position. I do not think there is
    enough training of it. I know the American Legion visited our
    facility, and they found a bunch of posters that were up in the
    office that were never posted.
        When people come talk to me, I am very honest with them. I
    tell them, ``If you are willing to come forward, expect this to
    happen,'' because as long as--like, I keep on reiterating this
    famous
    word--there are two words, and I do not wear the ``I Care'' pin
    for two reasons, because I am an advocate, he is an advocate,
    he is an advocate for veterans, and we have become--look what
    they have done to us. And then they do not use the ``A'' for
    the accountability. So I will never wear that ``I Care'' pin
    until I see actual change. But there is nothing. They do not
    tell you how to do this. It is like the other fellow, a friend
    over here that just stated there is no training for us from the
    get-go.
        Senator Carper. OK. Thanks. Mr. Coleman.
        Mr. Coleman. I think, sir, even the training that there is
    limited, and it has changed so much in the last 2 years since
    this scandal has been going on.
        I think one thing that is important to point out is that we
    as whistleblowers, we should have the right to defend against
    retaliatory actions before the VA goes on the witch hunt. That
    is from the time that I came forward to the Office of Special
    Counsel regarding the systemic issues in early December, and
    then the retaliation was nonstop. However, the Office of
    Special Counsel was unable to take action until I was walked
    out from my employment on January 27th, crying. I had no one to
    call. I called the OSC attorney, David Tuteur, literally in
    tears. I did not know what to do, because I had just been taken
    out of a job that I loved. So, there is no way to defend
    ourselves, and the OSC, their hands are kind of tied as far as
    the retaliation goes until an act like that occurs, the overt
    acts of retaliation are going on every day. I asked for
    mediation on November 26th, because that is what I was told to
    do. My direct-line supervisor, who retaliated against me,
    waited until December 16 to get back to me, 20 calendar days. I
    know that is not right. It is my full written 188-page
    testimony that you have, sir.
        Senator Carper. All right. Thank you. Some of you have
    already answered this question, but I just want to throw it out
    there anyway. Based on your experience--and if you have already
    answered it, you do not have to answer it again. But based on
    your experience, what do you think could be done to make the
    information about whistleblowers' rights and the processes and
    resources available to whistleblowers, what could be done to
    make the process work better for future whistleblowers? And if
    you have already answered that, that is fine. But if you have
    just a nugget or two you would like to share with us, please
    do.
        Mr. Coleman. I think I would like to share on that,
    Senator, if I could. I think that not enough is being done to
    get the word out, and I do not know what the answer is, because
    I have thought about this. I enjoy helping veterans get clean
    and sober. That is what I think I was put on this Earth to do
    professionally. It is just amazing.
        Senator Carper. Isn't it great to know what you were put on
    this Earth to do? Isn't that great?
        Mr. Coleman. It is, and to actually get paid for it, that
    is the trick having a job you would do for free.
        However, I would say that I am very passionate about
    whistleblower rights, and it has kind of grown just because of
    what I have been through. I think more needs to be done. I do
    not think we can count on the VA to have us set up, but I think
    groups like the Truth Tellers, having ways to have
    whistleblowers available, because like I said, just getting
    these calls, these calls from other whistleblowers, is just
    heart-wrenching. And they have nowhere to go. And I am telling
    them to contact certain Senator or Representative's offices,
    sometimes out of their home State, because I have developed
    relationships with them, and I am telling them which media
    outlets to contact because the media is kind of your best
    friend in defending yourself. If it was not for the media and
    the Senate offices and the OSC, I would have been fired long
    ago? And so you kind of have to fight that battle, and each one
    of our battles, while they are so similar, are also so
    different, because like
    Shea--like Mr. Wilkes said, we are isolated. They isolate us. I
    had read all the articles from Tomah and, from Shreveport and
    from Puerto Rico, and I knew these guys existed. But I never
    knew that they went through the same thing as me, and that is
    where the power is, us coming together to be able to help
    future whistleblowers. There needs to be help there until we
    figure out a way to fix the VA. I do not know how long that is
    going to take, but there needs to be more to protect these
    people under Federal law when they are brave enough to come
    forward. That is what I think, sir.
        Senator Carper. Yes, the media can play a valuable role
    here. The media takes a lot of abuse. They hand out a lot of
    abuse.
        Mr. Coleman. They protected me.
        Senator Carper. But they also can play a very valuable role
    here.
        A real quick one, if I could, for Mr. Wilkes, and then the
    Chairman is going to come back and I am going to run over and
    vote, and we will play tag. I understand you are the founder of
    the group VA Truth Tellers. Could you just take a minute and
    explain to us what motivated you to get it started and how does
    it work?
        Mr. Wilkes. Basically it took off on its own. I kept
    reading, like Brandon said, these articles, and I am, like,
    ``Oh, my gosh, this is going on to a lot of us all over the
    country. And, like Dr. Mitchell and her thing, she had said
    that the IG was more worried about her making privacy things,
    and that was like me. They were more after me, investigating me
    for privacy violations.
        And I just started reading stories, and I reached out to
    Brandon and actually a lot of the media. And he is correct. The
    VA is more worried about their image, and that is one way that
    you can get the attention, is to try to tarnish their image and
    get your story out. And, actually, a lot of the media reporters
    got me in touch with all them, gave me their email addresses,
    gave me their phone numbers, and we started reaching out. And I
    had four. And then I met Germaine Clarno, and she had been
    trying to do the same thing on the other side. And it started
    out, we had 10 people, and basically it was in email. We were
    emailing just supporting each other.
        And, it kept growing, and people started coming in, and I
    was, like, ``Oh, my gosh,'' I did not expect it. And then we
    knew we had something. And then when those reports came out in
    Tomah and we had seen it and they whitewashed them and they
    started attacking whistleblowers, we had had enough. And I told
    the group and Germaine and I told them, I said, ``We got to do
    something about this.'' And then that is when we came out with
    the letter to the President about, the IG Director at the time
    we were calling for him to be dismissed. And that afternoon,
    after that letter, he announced his retirement that Saturday.
    And since then, it has kind of grown even more. I mean, every
    day Brandon--I get emails, text messages from whistleblowers
    all over the country and it is the same thing. It is the same
    story. It is absolutely amazing how each of our situations are
    unique, but how the retaliation is so similar. It is like the
    VA leaders have a book they developed on how to retaliate and
    this is how you do it, because it is the same.
        Senator Carper. Over the last, gosh, 40-some years, maybe
    50 years, in this country we have tried to figure out in a
    health care delivery system how do we get better results for
    less money, and for years we kept seeing the percentage of
    health care costs in this country as a percentage of GDP go up,
    up, up, up, double-digit increases in the rate of inflation in
    health care delivery, and not always with better results. A
    couple years ago, we had a situation where it was widely
    reported that about 100,000 people died in hospitals every
    year. It is not VA hospitals, but like hospitals across the
    country, which is a sad commentary. It is a sad commentary.
    Some people said we need to do health care reform in order to
    slow the growth of health care costs, and we did. Some people
    said we needed to do it in order to better ensure that we do
    not have 40 million people that go to bed at night without any
    health care coverage. We did. And we also said we had to get
    better results, and we do. And I think in some respects we are.
    The number of people without health care coverage is down from
    about 40 million to maybe closer to 10 million now, headed in
    the right direction. Health care costs as a planning of gross
    domestic product (GDP) is no longer going up double-digit rates
    of inflation. In fact, health care costs as a percentage of GDP
    are actually coming down now slightly. But we still have a lot
    to do in terms of getting better results for less money.
        I am going to run and vote; otherwise, I miss my chance.
    But I will be back, OK? Thank you. Thanks, Mr. Chairman.
        Chairman Johnson. [Presiding.] Thank you, Senator Carper.
        Again, I want to thank the witnesses for taking the time
    coming here, and let me underscore again that our ability--and
    you are seeing, I think, some bipartisan agreement, which is
    really what we need to do. Let us concentrate on the areas of
    agreement that unite us rather than exploit our division. So
    you are seeing some bipartisan agreement. Our ability to take
    action, to pass legislation, will be due in large part because
    of the courage of your actions and the power of your testimony.
        So, again, I want to thank all of you for coming forward.
    Obviously, we offer our condolences, Mr. Kirkpatrick, to you
    and your family. But, again, thank you for coming forward. We
    will act. We will act.
        Thank you. Let us seat the next panel now.
        [Pause.]
        Thank you. I appreciate your patience.
        As I said in the earlier panel, it is the tradition of this
    Committee to swear in witnesses, so if you will all rise and
    raise your right hand. Do you swear that the testimony you will
    give before this Committee will be the truth, the whole truth,
    and nothing but the truth, so help you, God?
        Ms. Lerner. I do.
        Ms. Halliday. I do.
        Dr. Clancy. I do.
        Mr. Culpepper. I do.
        Chairman Johnson. Thank you. Please be seated.
        Our first witness on the second panel will be Carolyn
    Lerner. She is Special Counsel at the Office of Special
    Counsel. Ms. Lerner.

       TESTIMONY OF THE HONORABLE CAROLYN N. LERNER,\1\ SPECIAL
                COUNSEL, U.S. OFFICE OF SPECIAL COUNSEL

        Ms. Lerner. Thank you, Chairman Johnson, Ranking Member
    Carper, and Members of the Committee. Thank you for the
    opportunity to testify today about the U.S. Office of Special
    Counsel and our work with VA whistleblowers. I also want to
    thank you or your work founding the Senate Whistleblower
    Caucus. OSC has already started to work with this caucus and
    looks forward to doing so more in the future.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Hon. Lerner appears in the Appendix
    on page 97.
    ---------------------------------------------------------------------------
        The Office of Special Counsel helps whistleblowers, and
    helps employees who make disclosures of wrongdoing and those
    who experience retaliation after doing so. There are separate
    processes for these two types of cases. I just want to go over
    them briefly.
        If an employee discloses a health or safety concern or a
    violation of law, rule, or regulation, and it meets a very high
    standard of review, I send the matter to the agency for
    investigation. After investigating, the agency must then
    provide an investigative report to my office. The whistleblower
    is given an opportunity to comment. I then determine whether
    the agency report contains the information required by statute
    and also whether the agency's findings appear reasonable. This
    includes whether appropriate corrective action, including
    discipline, has been taken. I then send the information and our
    findings to the President and Congress and post them on our
    website. That is the process for disclosures.
        OSC also protects Federal workers from prohibited personnel
    practices, especially retaliation for whistleblowing. Unlike
    disclosure cases where we do not have independent investigative
    authority, in retaliation cases OSC conducts the investigation
    and determines if retaliation occurred. We can get relief for
    the employee, including a stay of disciplinary action,
    reversing a termination, and damages for losses that are
    suffered as a result of the retaliation. So that in a nutshell
    is our process for we believe disclosures and retaliation
    complaints.
        Over the past 18 months, there has been a tremendous surge
    in cases from the VA. I will talk now about how our agency is
    addressing them, some signs of progress, as well as some areas
    of ongoing concern.
        OSC has about 140 employees with jurisdiction over the
    entire Federal Government. We are stretched pretty thin. But we
    have reallocated our resources to prioritize VA cases. Perhaps
    most significantly, we implemented an expedited review process
    for retaliation cases. This process allows OSC to present
    strong cases to the VA at an early stage, saving resources and
    getting quicker relief for employees.
        In the past year, we have obtained approximately 30
    corrective actions for VA whistleblowers through this expedited
    process, including a settlement on behalf of Mr. Joseph Colon,
    who testified just now. We also worked to secure relief for Mr.
    Ryan Honl of the Tomah VA.
        These are important victories for employees who risk their
    professional lives to improve VA operations and quality of care
    provided to veterans. My written testimony summarizes a number
    of other cases resolved through the expedited program,
    including an employee who was fired for requesting assistance
    from Congress.
        It is a sign of progress that the VA leadership agreed to
    the expedited review process. It has also agreed to resolve
    many more cases through regular processes, including mediation,
    through which we have gotten VA employees full or partial
    relief 84 times this year.
        On the disclosure side, our work has led to important
    improvements at the VA as well as discipline for 40 officials.
    This is an important step toward greater accountability and
    deterring future misconduct. However, our review of several
    recent disclosure cases indicates that disciplinary actions are
    being inconsistently imposed and are often of little
    consequence. The failure to take appropriate discipline where
    there is clear evidence of misconduct can undermine
    accountability, impede progress, and discourage whistleblowers
    from coming forward.
        I highlighted these concerns last week in a letter to the
    President and the Chairmen of the VA committees. I believe you
    all have that letter now. In the letter, I contrasted the lack
    of discipline in response to confirmed mismanagement at the
    Phoenix VA and other locations with the penalties imposed on
    whistleblowers for minor indiscretions. For instance, one
    whistleblower faced termination for eating a few expired
    sandwiches worth $5. I hope that VA leadership will review
    these cases and determine whether systemic changes to
    discipline could correct the inconsistent imposition of
    penalties.
        Based on the VA leadership's positive responses to prior
    recommendations, I am hopeful that they will work to address
    this problem. In fact, just last week, Deputy Secretary Sloan
    Gibson outlined a new process for responding to OSC
    whistleblower referrals. They will now be routed through the VA
    Executive Secretariat. This should ensure high-level review of
    all whistleblower allegations and investigations, and I am
    hopeful that the centralized process will help to address the
    concerns I outlined in my September 17 letter.
        Other ongoing issues of concern which I have previously
    noted include retaliatory investigations of whistleblowers,
    improper accessing of whistleblowers' medical records, the role
    of regional counsel, and the VA IG's unwillingness to provide
    OSC with information.
        In conclusion, we appreciate the Committee's interest in
    our efforts to protect VA whistleblowers and for all you are
    doing to advance whistleblower rights. The stories we have
    heard today from the four witnesses on the first panel are the
    stories that we hear every day at the Office of Special Counsel
    from hundreds of VA employees. We appreciate your support for
    our efforts.
        Thank you for the opportunity to testify, and I am happy to
    answer any questions you may have.
        Chairman Johnson. Thank you, Ms. Lerner.
        By the way, I think that is an extremely important point
    that we just had four stories but they are typical.
        Ms. Lerner. Hundreds.
        Chairman Johnson. They are not outliers. This is what you
    are dealing with, so I appreciate your efforts.
        Our next witness is Linda Halliday. Ms. Halliday is the
    Deputy Inspector General at the Department of Veterans Affairs
    Office of Inspector General. Ms. Halliday.

     TESTIMONY OF LINDA A. HALLIDAY,\1\ DEPUTY INSPECTOR GENERAL,
                  U.S. DEPARTMENT OF VETERANS AFFAIRS

        Ms. Halliday. Mr. Chairman and Members of the Committee,
    thank you for the opportunity to discuss the fundamental
    importance of whistleblowers to the VA OIG's mission and how
    the OIG works to protect and encourage Federal employees to
    come forward with allegations of waste, fraud, abuse, and
    mismanagement. I am accompanied by Mr. Quentin Aucoin, our
    Assistant Inspector General for Investigations.
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        \1\ The prepared statement of Ms. Halliday appears in the Appendix
    on page 110.
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        Whistleblowers are the lifeline of OIG organizations. Our
    OIG is committed to protecting their identities, understanding
    their concerns, objectively seeking the truth, and ensuring VA
    pursues accountability and corrective action for wrongdoing.
    Individuals who at times risk their reputations and careers to
    report suspected wrongdoing should be afforded all the
    protections available by law.
        Whistleblowers have played a vital part in revealing
    serious problems in need of corrective action at VA. For
    example, we recently acknowledged the instrumental efforts of
    whistleblowers who exposed extensive, persistent data integrity
    issues at the VHA's Health Eligibility Center and serious
    mismanagement and operational performance issues at the VA
    Regional office in Philadelphia.
        Federal laws dictate that veterans have both a right and an
    expectation that VA employees will not compromise the security
    of their sensitive personal information, even during the course
    of making a whistleblower disclosure. While we strongly
    encourage the reporting of wrongdoing, we equally encourage
    employees to do it in a responsible manner consistent with the
    applicable laws.
        After assuming the position of the Deputy Inspector General
    3 months ago, I made it my first priority to reinforce that the
    OIG values whistleblowers and that we are hearing and learning
    from the more recent complaints. We go to great lengths to
    protect their identity. We encourage them to report suspected
    wrongdoing to the IG. And any reprisal for doing so is
    absolutely unacceptable.
        I took steps to strengthen our Whistleblower Protection
    Ombudsman program and our internal whistleblower training
    program. OIG is also in the process of completing the U.S.
    Office of Special Counsel certification program which will
    ensure that all OIG employees can assist complainants in
    educating them on their right to be free from retaliation for
    whistleblowing.
        But our efforts to improve the OIG business processes and
    encourage whistleblowers to come forward do not stop there. I
    have also directed my staff to assess our own communications
    and feedback with individuals who report suspected wrongdoing,
    especially when the complaints involve complex and lengthy
    reviews, and to take action to update with VA their current
    policy on managing external referrals to VA. We are assessing
    opportunities to change our existing process for referring
    lower-risk complaints to VA that we lack the resources
    ourselves to do, to include assessing the feasibility of
    repositioning our resources to perform more reviews with our
    own resources rather than relying on a process that makes
    external referrals to VA. We want to provide greater assurance
    of confidentiality to whistleblowers and to enhance the quality
    of our own investigations and reviews performed.
        I have also reinvigorated the OIG rewards program, but make
    no mistake about it: We recognize the critical role
    complainants and whistleblowers play in exposing serious
    problems and deficiencies in VA programs and operations, and I
    will continue to review and evaluate ways in which OIG can
    enhance its interactions with complainants and promote greater
    confidence.
        In addition, I have done outreach to meet and establish
    strong relationships with several of the large Veterans Service
    Organizations to enlist their input on programs that may not be
    serving veterans' needs well. While we are thankful that the
    Congress has facilitated growth in OIG resources, I want to
    conclude by leaving the Committee with the understanding that
    there is a serious discrepancy between the size of our
    workforce and the size of our workload. The OIG is not right-
    sized to respond to all of the complaints we currently receive.
    We have approximately 660 multidisciplinary professional staff
    conducting criminal investigations, audit, health care and
    benefits inspections, and contract and financial reviews for an
    agency with more than 354,000 employees and $163.5 billion in
    their operating budget in Fiscal Year 2015. In fact, OIG's
    Fiscal Year 2015 budget is less than 1 percent of VA's budget.
    The resources pale in comparison to VA's massive decentralized
    and diverse facilities and the number of employees and the
    amount of funding needing regular oversight.
        Mr. Chairman, this concludes my statement, and I would be
    happy to answer any questions.
        Chairman Johnson. Thank you, Ms. Halliday.
        Our final witness is Carolyn Clancy. Dr. Clancy is the
    Chief Medical Officer at the Veterans Health Administration
    within the Department of Veterans Affairs. She is accompanied
    by Mr. Michael Culpepper, the Acting Director of the VA Office
    of Accountability Review. Dr. Clancy.

     TESTIMONY OF CAROLYN CLANCY, M.D.,\1\ CHIEF MEDICAL OFFICER,
      VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
      AFFAIRS; ACCOMPANIED BY MICHAEL CULPEPPER, ACTING DIRECTOR,
                    OFFICE OF ACCOUNTABILITY REVIEW

        Dr. Clancy. Good morning, Mr. Chairman and Members of the
    Committee. Thank you for inviting us here today to discuss the
    ways that Congress and VA can further encourage Federal
    employees to come forward with their concerns regarding quality
    of care, patient safety, and waste, fraud, and abuse.
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        \1\ The prepared statement of Ms. Clancy appears in the Appendix on
    page 117.
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        We exist at VA to serve veterans, and we depend on our
    front-line employees to serve veterans with dignity,
    compassion, and dedication. And I want to thank you and the
    Members of the Committee and other colleagues for recognizing
    just how passionate and dedicated the vast majority of our
    employees are.
        We depend on these same employees to be vigilant about
    actual and potential sources of harm to patients and to voice
    their concerns if a patient's safety is at risk. We recognize
    very clearly the important role that whistleblowing plays and
    addressing the express concerns in bringing issues to light.
        As the whistleblowers today have demonstrated, the
    Department has had problems with ensuring that whistleblower
    disclosures receive prompt and effective attention and that the
    whistleblowers themselves are protected from retaliation.
        Secretary Robert McDonald, Deputy Secretary Sloan Gibson,
    and other VA senior leaders, including myself, have made it our
    practice to meet with whistleblowers when we travel to VA
    facilities and to engage directly with those who have raised
    their hands and voices to identify problems and proposed
    solutions.
        For example, I am personally invested in ensuring that the
    quality of care at the Tomah VA is of the highest order and
    that any and all circumstances that led to problems at that
    facility have been diagnosed, addressed, with a sustainable
    path forward.
        Retaliation against whistleblowers who have demonstrated
    the moral courage and at great personal risk to share their
    concerns is unacceptable and cannot and will not be tolerated.
    We are making progress, and under Secretary Robert McDonald's
    leadership, we are confident we will reach our goal of ensuring
    that every employee feels safe in raising concerns and is
    protected from retaliation when they choose to do so.
    Monitoring the environment and whether people feel safe
    speaking up is something that we watch very, very closely.
        All health care systems require a wide array of feedback
    from multiple sources to ensure the best clinical outcome for
    patients. In addition to many formal mechanisms, the Department
    has taken several important steps in recent months to improve
    the way we address operational deficiencies and to ensure that
    those who disclose such deficiencies are protected. For
    example, we have communicated regularly to employees and
    managers about the importance of whistleblower protection. We
    track corrective actions, require annual training, and we have
    an online way to gather employee feedback and are now certified
    by the Office of Special Counsel.
        In addition, just over a year ago, the Secretary
    reorganized and assigned new leadership to VA's Office of the
    Medical Inspector (OMI). OMI moved quickly to establish clear
    policies to ensure that whistleblower allegations are
    investigated objectively, thoroughly, and promptly. Since that
    time, this office has completed 30 new whistleblower
    investigations and prepared more than a dozen supplemental
    reports to follow-up on earlier investigations.
        We have also improved our collaboration with the U.S.
    Office of Special Counsel, to step up to the challenge before
    us. We have collaborated with OSC to design and implement
    training for VA General Counsel and the Office of
    Accountability Review (OAR). This will eventually be rolled out
    across the Department, and as has been noted, last summer VA
    and OSC agreed upon an expedited process to speed corrective
    action for employees who have been subjected to retaliation. As
    of September 9, we had received 22 expedited cases and resolved
    11.
        We understand that we can improve on the timeliness of
    ensuring individuals found responsible for retaliation are
    disciplined appropriately and that deficiencies with programs
    and underlying issues are addressed.
        One approach that we do want to raise is for Congress to
    fund OSC at a level that enables that office to hire more
    investigators to complete this work. OSC has traditionally
    fulfilled this charge, and increasing their staffing to a level
    to assist VA in this endeavor would allow VA's limited
    investigative assets and resources to focus more in our area of
    expertise.
        To say it a different way, if we are successful in
    encouraging whistleblowers to step forward, we will have many
    more to deal with, and that is a good thing. That means that
    the people who are now currently fearful of stepping forward,
    as we heard from the first panel, will indeed feel that it is
    not only OK but a really great thing that they step forward and
    share their concerns. And it is anticipating that future that
    makes us raise this suggestion. It is very important that we
    hold individuals guilty of retaliation accountable for their
    actions and that we do so as timely as possible. And we welcome
    OSC's additional assistance on this front.
        The courageous and really heroic witnesses you heard from
    earlier today, and many, many others, underscore the importance
    of ensuring that all veterans receive the highest quality of
    medical care. I acknowledge today that VA is still working
    toward the full culture change we must achieve. We need to
    listen better the first time employees raise concerns. We need
    to ensure that all employees feel safe disclosing problems, and
    we need to guarantee that all supervisors who engage in
    retaliatory behavior are held promptly and meaningfully
    accountable. And, last, we need to work on establishing a
    culture where everyone recognizes that whistleblowing is not
    only beneficial, it is a gift to the organization.
        We continue to work with whistleblowers, OSC, and the
    Congress to resolve these issues and are very committed to
    these endeavors.
        Mr. Chairman, that concludes my testimony, and we look
    forward to your questions.
        Chairman Johnson. Thank you, Dr. Clancy.
        Now, you were all three sitting in the audience for the
    previous testimony, correct?
        Dr. Clancy. Yes.
        Chairman Johnson. I just want to ask each of you--and I
    guess we will start with Ms. Lerner--what was your gut
    reaction? What was going through your head? I mean, outside of
    your testimony, as you were listening to that testimony, what
    was going through your head? What was your initial reaction?
    Ms. Lerner.
        Ms. Lerner. I wish I could say that it was news, but it was
    not. As I said in my opening statement, the stories, several of
    them we have been working with, so we are very familiar with
    these gentlemen's stories. And as you said, they are not
    atypical. These folks are representative of the hundreds of VA
    employees who come to the Office of Special Counsel. We have
    hundreds of matters just like that that we are dealing with
    now.
        I think you may have been out voting when Senator Carper
    went down the line and said, ``What can we do? What is
    working?'' And each one of them said, I was very pleased to
    hear, that the Office of Special Counsel had helped them. So I
    was proud of that. I am really proud of my staff. Many of them
    are here today. They are doing, the Lord's work, really. They
    spend time on the phone with these folks who are in crisis, and
    they are doing an excellent job putting together reports of
    investigation that allow us to report to you and the President
    what is going on.
        We are building cases, which together are sort of--not to
    mix metaphors, they are all parts of the puzzle that we can see
    what is going on all over the country. And so my recent letter
    said, look, this is a pattern that we are seeing everywhere. We
    are seeing folks getting slaps on the wrist who are engaging in
    serious misconduct, not really being disciplined, all over the
    country. Compare that with the folks who are taking sandwiches
    or, sending out one email about doing taxes. They are facing
    termination. There is something wrong here.
        Chairman Johnson. Thank you again. I just wanted your
    initial reaction.
        Ms. Lerner. Sorry. It was a long answer.
        Chairman Johnson. Ms. Halliday, again, just initial
    reaction.
        Ms. Halliday. My initial reaction is I am really
    disheartened that VA is in the state of affairs it is in today.
    I have dedicated my entire career to serving veterans. The fact
    is if somebody brings an issue forward that can move positive
    change, why you would take actions against that individual is
    beyond me. When you do that, it is bad management.
        Chairman Johnson. OK. Dr. Clancy.
        Dr. Clancy. Profound appreciation for the individuals who
    were here before and the work they are doing to support others.
    A lot of pain listening to Mr. Kirkpatrick talk about his
    brother. And continued concern personally about the people who
    are fearful of speaking up even as we sit here today. And,
    frankly, a lot of impatience. We need to speed up our actions
    in terms of our disciplinary processes.
        Chairman Johnson. OK. I appreciate those answers.
        Ms. Halliday, you heard Mr. Wilkes in his testimony say
    that the VA Office of Inspector General is a joke. In your
    testimony, you said whistleblowers are a vital part, the Office
    of Inspector General values whistleblowers, reprisals are
    unacceptable. I want to talk about a white paper that was
    issued on really the investigation of this Committee and really
    the events that were revealed through press reports with the
    Tomah VA health care facility.
        Were you at all involved in the writing of that white
    paper?
        Ms. Halliday. I was not.
        Chairman Johnson. Were you aware it was being written and
    issued?
        Ms. Halliday. I was not.
        Chairman Johnson. It strikes me as, quite honestly,
    reprehensible. We issued a subpoena to the Office of Inspector
    General because we were not getting cooperation in this
    Committee's investigation of the events at Tomah and, quite
    honestly, as that blossomed with other whistleblowers, what is
    happening around this country in terms of opioid
    overprescription, drug diversion, retaliation, and we were not
    getting cooperation under the previous Acting Inspector
    General, so we had to issue a subpoena at the end of April.
        Now, the Office of Inspector General then issued this white
    paper a little more than a month later. Now, this is the same
    Office of Inspector General that basically deep-sixed 140
    reports and an Office of Inspector General that was so
    concerned, as am I, as is this Committee, about not releasing
    personal information, particularly health care records. And yet
    the Office of Inspector General issues this white paper, and I
    want to quote some of the more outrageous parts of this white
    paper. And this speaks, first of all, to the family of the
    Kirkpatricks.
        This is from the white paper: ``I strongly recommend a
    thorough review of the in-depth sheriff's report, a publicly
    available document that is included in the documents produced,
    records produced''--pages whatever--``with specific attention
    to the pages detailing the voluminous amounts and types of
    marijuana and what appears to be other illegal substances found
    in Dr. Kirkpatrick's residence, as well as other items
    including a scale and used devices containing marijuana
    residue.''
        I want that to sink in. This came from the Office of
    Inspector General who says whistleblowers are a vital part, the
    OIG values whistleblowers, reprisal is unacceptable. That
    sounds like a reprisal to me to a dead person. I want that
    sinking in.
        Second, in referring to another whistleblower, pharmacist
    Noelle Johnson said her termination was because she had poor
    interpersonal skills and was caustic with clinicians. Again,
    this is a white paper from the Office of Inspector General. I
    can only conclude from this white paper--by the way, this was
    also directed to this Committee's investigation, but I could
    care less. But I care deeply about the intimidation, the
    retaliation, the reprisal coming from the Office of Inspector
    General.
        So, listen, I appreciate the testimony. I appreciate the
    assurances that whistleblowers are a vital part, that the OIG
    values whistleblowers, that reprisals are unacceptable. But
    that is not the record.
        What will the Office of Inspector General, what will the VA
    do to make good on this, to make up for this reprisal, for this
    reprehensible reprisal? What action are you willing to take?
    And you heard Mr. Sean Kirkpatrick asking for the records for
    the family so that they understand what is happening. I want
    assurances that the VA will release those records to the
    family. I want assurances that this will be corrected, that
    amends will be made for this reprehensible reprisal. Ms.
    Halliday?
        Ms. Halliday. As I stated, I did not prepare that document.
        Chairman Johnson. Who did? Do you know the individuals
    within the Office of Inspector General that wrote this? Who did
    this? I want to know. This Committee wants to know who is
    involved in this.
        Ms. Halliday. The prior----
        Chairman Johnson. I want to know every individual who was
    involved in writing this report.
        Ms. Halliday. I would have to take that for the record.
        Chairman Johnson. We will leave that as an open question
    for the record.
        Dr. Clancy, what can the VA do to make amends for this?
        Dr. Clancy. I noted very clearly a number of very important
    suggestions that Mr. Kirkpatrick made, including the personal
    request about receiving his brother's official personnel file.
    I do not know and my colleague is not clear on whether we can
    do that, but if we can, we will certainly do so.
        Chairman Johnson. OK. Listen, let me apologize for showing
    such passion up here. Let me tell you what my gut reaction was
    in this hearing to these witnesses. I was upset coming in here,
    and you can tell I have become more upset. I think every member
    of this Committee has become more upset as we hear this.
        Ms. Lerner, you look like you want to say something.
        Ms. Lerner. The only thought I have is possible
    disciplinary action that might be taken against the person who
    is responsible. That is, I think, an avenue that could be
    explored.
        Chairman Johnson. Well, I will work with your office to
    find out exactly who those were and exactly what the proper
    accountability and the proper disciplinary action should be
    taken from those members in the Office of Inspector General,
    remember, that transparent, that independent watchdog over
    these agencies. My time has expired. Senator Baldwin.
        Senator Baldwin. Thank you, Mr. Chairman.
        First, a comment. On the situation in Tomah the Chairman
    has just discussed, the IG's various publications, I want to
    state for the record a conversation that we have had in
    delegation conference calls as well as private meetings on the
    importance of making VA' investigation into Tomah public. You
    can tell, by this hearing and the many other opportunities we
    have had to receive testimony that we have a greater ability to
    ask questions when we have a document we can read. I know you
    are working on that, but certainly we are very eager to see the
    work product; you have given us verbal assurances that you have
    spoken with each and every whistleblower whose name I have
    forwarded.
        Beyond Tomah and looking more globally, I have two
    questions. One relates to the testimony we heard earlier and
    what I have heard from whistleblowers at Tomah concerning the
    ability of veterans to look into medical records and use what
    they have found to publicly assail the credibility of a
    whistleblower.
        Based on the testimony that we are hearing, not only is
    this prevalent, but it sounds as though there have been
    virtually no instances of accountability for inappropriate
    access of those records. You have heard some fairly basic
    suggestions for how to make that right. One suggestion was that
    two parties have to be involved in accessing a record; another
    that we use information technology to uncover inappropriate
    access; and, third, that the folks who inappropriately access
    this data be held accountable. And I have not heard much of
    that.
        I would like to hear your comments on tangible things that
    we can do to put an end to this. It seems to me one of the more
    simple things that we can address in all of this.
        The other question I want to put out there--the testimony
    that we heard earlier suggests that it is really easy to fire
    somebody who is a whistleblower and really difficult to fire
    somebody who is the subject of a whistleblower complaint, to
    oversimplify the process. And the one thing that I want to make
    sure is, as we make it easier for the VA to hold people
    accountable, that we also do not make it easier for the VA to
    terminate the employment of those courageous individuals, some
    of them temporary employees or probationary employees.
        Those are two big questions I want to ask, especially with
    this illegal access to veterans' medical records in the context
    of whistleblowing. This seems like a straightforward fix. I
    would open it up to you to respond.
        Dr. Clancy. So as Senator Ernst said very clearly, it is
    illegal to do that. It is also painful to hear about,
    particularly when the issues related to discrediting a
    whistleblower around the issue of having sought care for mental
    health problems, if for no other reason than the stigma and the
    very fact that someone who works for us would be using that to
    discredit someone else at a time when we recognize that as a
    huge barrier to reaching all the veterans who need to be
    reached, is very painful for me to hear.
        Right now, veterans who are employees and use our system,
    as one of the earlier witnesses noted, their records are
    flagged. So there is no mistake if I stumble into a record of
    somebody with the same last name. This is not subtle. I am
    going to bring back and we will look into the issue of a two-
    step process. That seems to me to be potentially promising. But
    beyond that, it cannot be done, that is all, and it has to be--
    we can also track who accessed those records.
        Ms. Halliday. One of the challenges for the OIG is when
    information is inappropriately accessed, we always try to
    ensure the veteran's information is protected first, regardless
    of whether this is a whistleblower or an individual. In many of
    the cases that we have discussed and some of the cases that I
    have gone over the past year, veterans' information has been
    put at unnecessary risk for using outside systems to process
    veterans' personnel information and those inappropriate access
    to it.
        So I would think that a control that allows for a dual
    signature for when a medical record is being accessed would be
    very appropriate based on the need to have that information
    associated with doing their job.
        The second thing is the underlying controls within VA's
    system have to have the audit trails turned on, or you really
    cannot identify clearly who touched the record. And throughout
    many of the OIG reviews, we have found that key audit trails
    were turned off. They were turned off in Tomah. They were
    turned off in Phoenix. And we have told Office of Information
    Technology (OIT) officials they have to be on. You cannot
    monitor these 100 percent of the time. There is some
    responsibility for the Department to make sure those trails are
    in place. You just have to have that in this day when people
    can get access to records.
        Ms. Lerner. If I could just add a couple of things. In
    February, I first notified the VA that it needed to consider a
    systemwide corrective action to avoid these types of breaches.
    Through our disclosure process, 12 employees have been
    disciplined as a result. We have pending investigations in
    multiple cases where this is a problem. The VA's position that
    we have heard so far is that the searches were justified
    because they were just getting demographic information, things
    like mailing addresses from the files. Even if that is the
    case, the system is broken, and it should be a fairly easy fix.
    All they really need to do is make it harder to access these
    medical records, put a better lock on the system. Doctors need
    to have access to medical records, but colleagues and co-
    workers should not.
        The second thing is they are storing information right now
    so that medical information is commingled with demographic
    information. They are using the VistA system for both medical
    and personnel information, and that seems to me to be a pretty
    easy fix as well.
        Chairman Johnson. Thank you, Senator Baldwin. I just want
    to quickly follow-up. Isn't there an easier place to get
    addresses other than from medical records?
        Ms. Lerner. Well, they have a system for employees who are
    not also using the system for medical care, so you would think
    they could just use that system.
        Chairman Johnson. I mean, there is an alternate system you
    can get addresses from, which if you are looking for an
    address, you go to that system.
        Ms. Lerner. One would think.
        Dr. Clancy. There are many systems, and, in fact, right now
    there is a group pushing hard to get one reliable source so
    that we have contact with all veterans, period.
        Chairman Johnson. My point is that excuse I would term a
    lie. Senator Carper.
        Senator Carper. I want to thank all of you for joining us
    today. Carolyn, I do not know if you were in the audience when
    I talked about the whistleblowers at Dover Air Force Base and
    the great job that you and your team did there making sure that
    we found out the truth. And what do they say? The truth will
    make us free. As it turns out, you guys played an invaluable
    role, and we are grateful for that. I do not know if you were
    here when I asked the first panel maybe what is working and
    what we should do more of; find out what works and do more of
    that. And almost everybody mentioned the work that is being
    done in the Office of Special Counsel.
        Ms. Halliday, thank you for stopping by and visiting with
    me last week with some of your team and mine as well.
        Dr. Clancy, I spoke to you by phone this week. I would just
    say to my colleagues, we have something in Delaware called the
    Delaware Health Information Network, which is just a great way
    to get better health care results for less money. It encourages
    collaboration and sharing by all kinds of providers all over a
    State, and but for Dr. Clancy's support in the early days, that
    might not exist. So we thank you for that.
        Mr. Culpepper, I do not have anything good to say about
    you, but I am sure if I were to dig down, there is a lot I
    could say. I just do not know you. But we are glad that you are
    here.
        I think a lot of times in terms of shared responsibilities
    and who is responsible for fixing a problem. In most cases, it
    is a shared responsibility. And in our own VA health care
    delivery system in Delaware, which I talked about earlier,
    where the mother ship is the hospital and the nursing homes
    just outside of Wilmington, a town called Elsmere, and we have
    two outpatient clinics in our two southern counties. But
    sometimes the veterans will tell us when things do not go well,
    and I am in and out of our veterans' facilities throughout the
    year. My staff is as well. And there is a lot we can learn from
    those visits, and we need to do that. So just by our
    demonstrating by our presence, it sends a message to the folks
    that are running the VA in our States that we care about this.
        Families, family members, they contribute. Patients can
    tell us if things are not going well. They can tell our staff.
    I am going to be meeting with our Veterans of Foreign Wars
    (VFW) folks, representatives from Delaware, later this
    afternoon, and they are omnipresent, in and out of our hospital
    in Elsmere, Delaware. And they hear things that are going well
    and those that are not, and they can be very helpful in this.
        We have also as a Congress the opportunity through funding
    to make sure that we are funding VA health care, writ large,
    that we are funding your operation, the Office of Special
    Counsel, that we are funding the IG's office. And you have a
    huge burden to carry, also to make sure that you heard us
    talking about the Senate. We still have too many folks that are
    serving as an IG in an acting capacity. God bless you for those
    who are willing to do that, but we ought to have Senate-
    confirmed IGs, and we are going to keep pressing this
    administration until we do.
        We have a bunch of committees that have oversight over what
    is going on in the VA. We have a VA authorizing committee,
    Veterans Administration. We have an Appropriations Subcommittee
    whose focus is VA. This Committee is an oversight committee
    over the whole Federal Government. That is a whole lot to say
    grace over, so it is hard for us to cover every single piece of
    that. The Budget Committee has some jurisdiction over this. We
    are going to be going through in the next week or so a spending
    plan for our country, and the question is: Are we going to hold
    harmless the Department of Defense (DOD) budget and for the
    non-defense part of our Congress continue to expose many of
    those elements to sequestration? Is there some compromise
    there? Is there some way to do a deal?
        So we have plenty of opportunity ourselves here to try to
    effect a better outcome in the health care delivery system. And
    we have a bunch of watchdog organizations that have sort of
    popped up and are good enough to share information with us and
    with others. And then there is the media. So there is a lot of
    shared responsibility, and we need to take that seriously.
        Here is a short, easy question for each of you, and I will
    start with you, Mr. Culpepper, if you do not mind. But just
    give us one thing that you think could be done, should be done
    to ensure that whistleblowers--we will say just at the VA,
    whistleblowers at the VA--are better protected from
    retaliation? Either something we are already doing that we need
    to do more of, tell us what it is, or something we are not
    doing that we should be doing. Please, one thing.
        Mr. Culpepper. Thank you, Senator. I think really education
    of our workforce, especially our managers. So recently our
    Office of General Counsel and our Office of Accountability
    Review has actually gone over and got some training from OSC
    that we are looking forward very much to rolling out in a much
    more robust fashion than just the online training system you
    heard from the last panel. Education is key. It is no excuse
    for managers that retaliate. It is not tolerated. It will not
    be tolerated. But we do need to make sure they are educated so
    it happens less frequently.
        Senator Carper. All right. Thank you. Dr. Clancy.
        Dr. Clancy. I would not disagree with that. I do think that
    we need better training for front-line managers, and that is a
    pretty high priority for us at the moment.
        In addition to that, I think that we need to publicize and
    celebrate the good things that come out of people blowing the
    whistle. One of our former----
        Senator Carper. We did that. We did that, thanks to----
        Dr. Clancy. Yes.
        Senator Carper. That is what we did at the Dover Air Force
    Base.
        Dr. Clancy. And I have to say that Deputy Secretary Sloan
    Gibson this year, I believe, was the first time--I do not know
    if it was in history, but I think in many years; I have not
    been at the VA that long--actually attended the OSC Special
    Counsel's award ceremony for whistleblowers for VA, which I
    think is the right step.
        But in addition to that, I think we actually need to make
    it really clear: This person blew the whistle, here is what we
    learned, and here is why veterans are better off. Because
    without that, I do not think we get the cultural change. Other
    than that, it feels so uncomfortable that the instinctive
    reaction is to withdraw.
        Senator Carper. All right. Thanks.
        Ms. Halliday, just one example, please.
        Ms. Halliday. I think we need to spend our time on the
    education on the ranks of the people that are managing these
    whistleblower complainants. There is a lack of leadership.
    There are clearly problems with how they are addressing
    situations. Education there and an investment in how to
    properly lead is absolutely necessary.
        Senator Carper. All right. Thanks.
        Ms. Lerner, please, same question.
        Ms. Lerner. Everything they said, but since it has not been
    touched on and since it was the subject of my letter last week
    to the President and Congress, I think discipline is really key
    and has to be an area where we start shifting our focus. We
    have done a lot, we have seen a lot of progress, but the one
    area that I think remains to be really attacked is discipline.
    Senator Johnson said in his statement for this hearing the
    touchstone quality that makes any organization successful is
    accountability. And that is the missing piece, I think, right
    now.
        Senator Carper. [Presiding.] Senator Peters, you are next.
    Thanks.

                  OPENING STATEMENT OF SENATOR PETERS

        Senator Peters. Thank you, Senator Carper. And I would like
    to thank Chairman Johnson and Ranking Member Carper for holding
    this hearing, and I certainly appreciate the testimony from the
    witnesses. I think we all agree we heard some very disturbing
    testimony earlier this morning about the whistleblower process
    and the need to make some significant changes. Certainly as a
    country, we are all committed and have a solemn duty to take
    care of those who have taken care of us and who have kept us
    safe, and that duty certainly includes an obligation to take
    care of our Nation's veterans, and the 650,000 veterans that
    call my home State of Michigan their home.
        But we also have a responsibility to support the VA
    employees who serve our Nation's veterans honorably and those
    who are willing to come forward to identify problems, despite
    the risk. Apparently from what we are hearing, there are
    significant risks within the VA to come forward to identify
    those problems.
        So, with that in mind, Ms. Lerner, you stated in your
    testimony that complaints from VA employees make up between 35
    and 37 percent of the complaints that your office gets
    governmentwide. I mean, those are striking numbers, one agency,
    35 to 37 percent. So if you would tell this Committee--and I
    know you have mentioned some things, but elaborate--why you
    believe the VA accounts for such a large proportion of the
    complaints. And that certainly tells us an awful lot about the
    culture, but drill down a little bit for me and tell me why
    this is just an overwhelming number from the VA.
        Ms. Lerner. Sure. And, I think that there are a lot of
    possible reasons for the increasing number of complaints. Let
    me just give you a few.
        First, the VA is really big, and there are a lot of people
    who work there who are in health care facilities, so doctors,
    nurses, other health care workers who care really deeply about
    the mission of the VA, and because of the type of work that
    they are doing and because they are seeing people who are not
    getting the treatment that they need, they feel obligated to
    come forward. So it is an environment that is really ripe for
    disclosures.
        Second, I think employees may be feeling now in the last
    year or two that they could really make a difference, and we
    know that the No. 1 reason that whistleblowers do not come
    forward is not fear of retaliation, but it is because they do
    not believe that it is worth the risk if it is not going to
    make a difference. Why expend the time and energy and hope that
    goes into filing a complaint if you feel like it is going to
    fall on deaf ears?
        So if there is a silver lining to the increase in
    complaints, it may be that people feel that they are going to
    be heard and they believe that their disclosures are going to
    be acted upon. And OSC is really getting results. So a third
    reason is they are more familiar with my agency, with the
    Office of Special Counsel, and they know that they will be
    protected from retaliation if they come to us. We have been
    doing a lot more outreach and training, and the number of
    whistleblowers who are getting relief at our agency is at an
    all-time high. We have over 100 corrective actions for VA
    employees compared to about 29 cases over the entire government
    just 5 years ago. So there has been an exponential growth in
    the work that we have been able to do to help whistleblowers.
        So, in short, results matter. I think we are getting more
    of them. Whistleblowers know that they will make a difference
    when they come to us, and so I think it is a combination of
    those factors that is causing our increase in filings.
        Senator Peters. Thank you.
        Ms. Halliday, in your prepared remarks, you also cited some
    similar capacity concerns that Ms. Lerner mentioned in her
    testimony as well. In fact, you said, ``We receive far more
    allegations than we have the resource capacity to review, thus
    the OIG must be highly selective in the cases we accept.'' So
    could you elaborate for me how you prioritize those cases and
    exactly how quickly are they triaged? You obviously have to
    have some sort of management of those, and I would just like to
    get a sense of how that works.
        Ms. Halliday. Yes, I would. We get approximately 40,000 to
    42,000 complaints on our hotline annually. We are probably one
    of the largest hotlines in the Federal Government, most active.
    We look at those complaints. They come in to an intake group
    who triages complaint, whether they belong to Criminal
    Investigations, have a flavor that a crime has been committed,
    or fraud; or they will go to Health Care Inspections if it is a
    health care quality of care issue. It would go over to the
    audit groups or contract groups, depending upon what the nature
    of the complaint.
        At that point, the line offices take a very close look at
    whether the allegations are clear enough that we can do enough
    work to make a difference. In some cases, when a caller asks to
    be anonymous and they say, ``It is happening in my health care
    facility,'' you might only know where the facility is. You do
    not know if it is in surgery or how to drill down in the
    allegation. So we try to find enough information that we can
    review the complaints. We take all allegations against Senior
    Executive Service (SES), which are VA senior executives and
    your GS-15 levels, and we take the majority of the allegations
    when they have a high risk of financial risk or risk to patient
    safety, and it is triaged from that point. We are looking at
    that bottom group right now to see is there a way to take more
    of these.
        Senator Peters. All right. Thank you.
        Senator Carper. Thank you, Senator. Senator McCaskill.

                 OPENING STATEMENT OF SENATOR MCCASKILL

        Senator McCaskill. Thank you.
        I have a piece of legislation that would require the firing
    of anyone found to be retaliating against whistleblowers. Have
    either the Office of Special Counsel or the IG's office found
    that there has been retaliation within the Department of
    Veterans Affairs against whistleblowers? Have you found
    incidents of retaliation?
        Ms. Lerner. In our letter, we outlined a number of cases
    where employees who blew the whistle were subjected to
    disciplinary action, up to and including termination.
        Senator McCaskill. And you determined that was, in fact,
    retaliation?
        Ms. Lerner. I think it is fair to say yes.
        Senator McCaskill. OK, and were those people fired, Dr.
    Clancy?
        Dr. Clancy. Many were disciplined. I do not----
        Senator McCaskill. I did not ask that. Were they fired?
        Dr. Clancy. I think one person was fired?
        Senator McCaskill. Out of how many?
        Dr. Clancy. I would have to get you the numbers.
        Senator McCaskill. I need the numbers.
        Dr. Clancy. Sure.
        Senator McCaskill. I need to know if there is a
    determination either by the IG or by the Office of Special
    Counsel that retaliation has occurred. I need to know how many
    instances that determination has been made and someone was
    disciplined as opposed to fired. Do you believe if this bill
    passes and it requires the firing of someone who retaliates,
    that it would have the impact that we are looking for here in
    this very troubling area?
        Dr. Clancy. So knowing how much work probably went into
    developing this legislation, I would actually like to read it
    before rendering an opinion. And I am always----
        Senator McCaskill. It is simple. It just requires firing.
    What about the idea of requiring the firing of an employee who
    has been found to retaliate? Do you believe that idea--forget
    about the details of the legislation. It is pretty simple. Just
    assume it says just that. Do you believe that this is a good
    idea?
        Dr. Clancy. I believe in serious discipline. I worry a lot
    about more fear plummeted onto leaders who right now are
    feeling pretty fearful because what they feel like is if
    someone raises their hand or there is something that goes wrong
    at their facility, instead of saying, ``This is great that you
    brought it to me, bring it on, we can solve these problems.''
    They are worried that they are going to lose their job.
        Senator McCaskill. But isn't that a culture issue, Doctor?
        Dr. Clancy. It is a culture issue.
        Senator McCaskill. I mean, this is the problem.
        Dr. Clancy. Yes.
        Senator McCaskill. They are more willing to hide the
    problem because they are worried about their bonus or they are
    worried about how it is going to look to people above them than
    they are the problem.
        Dr. Clancy. I agree with you completely.
        Senator McCaskill. OK. That is why they have to be fired if
    they retaliate.
        Dr. Clancy. More firings I worry about. That was the reason
    I said reading the details would be helpful.
        Senator McCaskill. OK. And I will look forward to your
    input after you read it, but I would like the numbers. How many
    people who have been found to retaliate were fired?
        What if we had a clock, Deputy Inspector General Halliday?
    What if we had a clock that if the administration--this is
    putting you on the spot. Let me just put this on the record. I
    believe it is time to think about having a clock, and if the
    administration has not appointed an Inspector General after 6
    months at an agency that has 35 percent of the whistleblower
    complaints in all of the Federal Government, then Ms. Halliday
    gets the job. She becomes the Inspector General because the
    administration has failed to act.
        I do not know how else to do this. We went for months
    without an Inspector General at DOD, which really is a problem,
    a huge problem.
        Finally, let me just ask this on budgets. Budgets matter. I
    assume that if you said in your opening testimony, Ms.
    Halliday, that you are one percent of the VA budget, and I
    know, Ms. Lerner, your caseload has increased dramatically. I
    believe your caseload has increased over the last 5 years by 58
    percent. I guarantee you your budget has not increased by 58
    percent. I know we are looking at long delays in terms of these
    investigations because my office deals with whistleblowers
    every day and many of them have waited over a year to have
    their complaints looked at.
        Tell me what sequestration does to your budget, Ms. Lerner.
        Ms. Lerner. So right now I have about 140 employees. We
    cover the entire Federal workforce, all civilian workforce more
    or less, over 2.1 million employees. During sequestration last
    time, we went down to 104 employees. I had to let 15 people go.
        Now, I think if we tell Federal employees that they are
    going to be protected from retaliation if they come forward and
    make disclosures and that those disclosures are really
    important, we ought to be able to back that up. I personally
    feel really responsible for making sure that when people come
    to us, we are able to help them when they need help. It pains
    me when they have to wait and when we have to make triaging
    decisions about who are we going to help first.
        Senator McCaskill. I think we should have a buzzer, and
    every time anybody in the Senate talks about that, it is OK to
    go to sequestered levels of funding for the budget. We should
    ring the buzzer and talk about what comes out of the other side
    of their mouth about expecting you not to have any delays when
    someone comes forward and files a complaint. You cannot have it
    both ways. You cannot expect the VA to do its work well. You
    cannot expect the IRS to have customer service. You cannot
    expect Inspectors General to do their jobs thoroughly. You
    certainly cannot expect whistleblowers to have their cases
    adjudicated fairly and in an efficient manner if we are cutting
    the money that provides the necessary personnel to do the work.
        So I appreciate all of you very much, and I will look
    forward to getting the follow-up information from you. I have
    more questions for the record, but since we are voting right
    now and the vote is just about over, I will say thank you for
    your testimony today, and in particular, thank you to the
    whistleblowers on the first panel that I was unable to
    question.
        Senator Carper. Senator McCaskill, thank you so much.
        Senator Johnson is going to be back momentarily. He is
    voting, and I am going to recess the hearing for just a minute
    or two until he arrives.
        I again want to thank you all for joining us today, and it
    is especially good to see you, Ms. Lerner and Dr. Clancy. Thank
    you for the difference you have made in the State of Delaware.
    Thank you so much.
        Chairman Johnson. [Presiding]. Thank you, Senator Carper,
    for holding down the fort here.
        I have just got a couple more questions, and I will give
    everybody an opportunity at the very end to make a closing
    comment.
        Dr. Clancy, first of all, let me acknowledge, because this
    is true, I think the vast majority of people, doctors, nurses,
    administrators, from the lowest part of the organization all
    the way to the top, are definitely dedicated individuals doing
    everything they can to honor the promises made to the finest
    among us. I think that is just basically true, but we obviously
    have a systemic problem here, and the question I want to ask to
    you is: What is so difficult about holding the people that are
    retaliating, that are engaging in reprisals, what is so
    difficult about holding those people accountable? Because as
    you and I spoke yesterday in my office, there is nothing more
    corrosive to an organization than allowing bad apples to just
    get away with it and not being able to hold people accountable.
    So can you just kind of speak on why is it so easy, on the one
    hand, for the retaliators to retaliate and get away with it
    versus holding people accountable from the top of the agency
    down?
        Dr. Clancy. So I do not think it is that difficult. I think
    what is difficult is that it takes time to get all the facts
    together. It is rare that a story of retaliation is pure black
    and white. For example, people who are frustrated because they
    feel like they have been trying to make their voices heard and
    may not have been effectively doing so; people were not
    listening, their issues were blown off, may not always behave
    in a wonderful manner.
        Supervisors do retain a responsibility to hold people
    accountable for the various functions of their job. We have
    heard some examples today which I think are horrifying. I agree
    with you on that. But there are other times when it is a little
    bit harder to sort out the actual facts.
        So if there is a fair process, people should be held
    accountable, period. But I think the process needs to be fair,
    or people will be overwhelmed by fear.
        Chairman Johnson. Again, having managed people for 30-some
    years, I understand the gray areas and sometimes the difficult
    nature of getting to the truth. But do you believe that we are
    holding people properly accountable?
        Dr. Clancy. No. And we are taking too long to do it, and we
    are committed to doing better on that front.
        Chairman Johnson. Ms. Lerner, I would kind of like your
    assessment on that same question.
        Ms. Lerner. Well, the reason that I wrote this letter to
    the President last week is because of these very concerns. We
    have learned that even in cases where the VA has substantiated
    wrongdoing by officials that implicates patient health and
    safety issues, the VA has done very little to impose
    discipline. Sometimes, they will do a slap on the wrist or a
    written reprimand. But very little is done to those who are
    responsible.
        Chairman Johnson. But let me ask you, what is your
    assessment, your judgment of why that is? I know I am asking
    for an opinion here, but, why do you think that is?
        Ms. Lerner. I am speculating. It is hard----
        Chairman Johnson. I am asking you to speculate.
        Ms. Lerner. But, the folks who are in positions of power
    and authority are higher up along the food chain, and the folks
    who are getting the punishment and the discipline tend to be
    lower on the food chain. And I think that, there may be more of
    a reluctance and resistance to go after folks who are more
    powerful in the organization.
        I can tell you that headquarters VA, when I have had
    conversations with the Deputy Secretary and the General Counsel
    and the folks in Accountability and Review, the folks in D.C.
    really, I think, understand the importance of discipline and
    holding people accountable. They get it. The problem is it is
    down in the regions, and the regional counsel who have to
    enforce the disciplinary actions and bring them that are
    reluctant to do so. That is my sense, is that the problem is
    not at headquarters. It is really down at either the individual
    facilities or in the regions. And the regional counsel just are
    not willing to go after folks. But I do not have independent
    evidence of that.
        Chairman Johnson. And, again, I have had enough contact
    with Dr. Clancy, who I think is a very good person. I think
    your heart is in the right place. But it does speak--it really
    is a top management problem. I mean, top management is going to
    have to enforce that middle layer where we are not holding
    people accountable. That is what is going to be required. And,
    again, from my standpoint, it is going to require an
    independent and transparent Office of Inspector General to
    provide that information to the public, to Congress, to put the
    pressure so that actually happens. Dr. Clancy.
        Dr. Clancy. Yes, the one point I was going to add is I
    think one of the challenges we have, not just in this arena but
    in almost every aspect of what we do, is enormous variability.
    It is a huge system. We meet veterans' needs wherever they
    happen to choose to reside in this country and a few other
    places. And I think the issue of discipline is not different
    from other areas.
        So when then-Acting Secretary Sloan Gibson created the
    Office of Accountability and Review, a very, very big goal was
    to make sure that there was a far more consistent process. And
    I think that that is starting to work, but as I said, we need
    to pick up the pace.
        Chairman Johnson. Let me ask another question, because I
    think this is just a real problem. When somebody would come to
    me kind of leaping over layers of management with a complaint,
    it is difficult to deal with because how do you go and take
    care of it without kind of tipping off the manager who just
    might engage in retaliation? And certainly what we heard in
    testimony is that individuals have come to the Inspector
    General's office and/or the
    Office of Special Counsel, frequently those complaints are
    heard and then they are turned right back over to the agency,
    thereby--maybe not revealing the name, but, people are smart
    and they certainly can make assumptions.
        Ms. Lerner, I would like your assessment of to what extent
    that is a problem, and what can we do to correct that?
        Ms. Lerner. When whistleblowers come to us, they have the
    option of remaining anonymous. It is not as effective sometimes
    because we really like when we refer a case for investigation
    for the IG or the Office of Medical Inspector to actually
    interview the whistleblower. So it is not ideal when they stay
    anonymous. But they can. They can remain anonymous.
        Chairman Johnson. And then you do not go back to the agency
    or the department, correct?
        Ms. Lerner. No; we still do. We still do, absolutely. And
    you are right, sometimes they can still be identified, but not
    always. When we send our letters, when we send our referrals to
    the agency for investigation, we have language in there that
    specifically says we expect you to take steps to make sure that
    no retaliation occurs. And the minute we get a phone call from
    one of our whistleblowers saying, ``OK, they found out who I
    am, and I am being retaliated against,'' we then take action.
    We are on it. We do the best we can. And we can get stays of
    disciplinary action. We have been very active doing so, both
    informal stays and formal stays. Generally, if we contact the
    VA and let them know that someone is being retaliated against,
    they have been pretty good about holding off on taking
    disciplinary action. But it should not require the Office of
    Special Counsel to get involved.
        Chairman Johnson. Ms. Halliday, why don't you speak to that
    potential problem?
        Ms. Halliday. I consider one of the major risks to the OIG
    and to the Department is our ability not to take all of the
    complaints that come in and process them. I think that there is
    a fear with whistleblowers and a perception that VA will not be
    fair in the process as complaints are reviewed and fear of
    potentially disclosure of their confidentiality. We are
    probably in the best position to review but it is a resource
    issue given the volume that has come in post-Phoenix on these
    complaints.
        But I think that my executive staff clearly sees that as
    the major risk, and if we can work to get more controls over
    those more serious complaints that are coming into our office
    that absolutely need OIG's independent review, I think that it
    goes a long way to help the Department and it helps veterans.
        Chairman Johnson. So I appreciate Senator Ayotte coming
    here, but I will beg her indulgence for one final question,
    because you raised the issue that I wanted to ask this question
    about, the overwhelming nature of the volume of complaints
    coming in. How overwhelming is it? Ms. Lerner, you gave us some
    sense of that. But I would like both of you to kind of speak to
    the volume coming in, how you are trying to deal with it, how
    you try to prioritize the complaints, and what are you going to
    do with these? We will start with you, Ms. Lerner.
        Ms. Lerner. Sure. We are inundated and overwhelmed with
    complaints from the VA making up about 35 to 40 percent of our
    total caseload. As you said, we have gotten about 1,400
    prohibited personnel practice complaints, most of which are
    retaliation; about 2,000 disclosures from the VA. So we are
    overwhelmed.
        What we have done is set up our own sort of triage system.
    We have a senior counsel who is assigned to just the
    retaliation cases and working with the Office of Accountability
    Review at the VA to work on expedited settlements. We have
    worked with the VA to set up this expedited settlement process
    so that cases that have a lot of merit that we can identify
    quickly do not have to go through the full investigation
    process.
        We have a VA team at the Office of Special Counsel that
    meets once a week and talks about the VA cases. I get updates
    every week on every new VA retaliation case that is filed. So
    we are doing everything we can to make these a priority.
        That being said, we truly are overwhelmed and wish we could
    do a lot more.
        Chairman Johnson. And, again, you are just dealing with the
    retaliation on whistleblowers. Ms. Halliday, then your office
    is dealing with all the whistleblower complaints.
        Ms. Lerner. Well, we also deal with disclosures, too. So
    there are two tracks: one is disclosures of waste, fraud,
    wrongdoing, health and safety issues; and then also the
    retaliation cases.
        Chairman Johnson. OK. Ms. Halliday, tell me about the
    caseload that you are dealing with here.
        Ms. Halliday. The caseload now is about 40,000 to 42,000
    contacts a year. As I said earlier, the OIG VA's hotline, is
    one of the largest in the Federal Government, and the types of
    complaints that we get in are diverse. We have done exactly
    what OSC has done to perform better triage to make sure that we
    are gleaning out enough information at the complaint intake
    stage that we can understand the seriousness of the complaint
    so that we can process it effectively.
        Chairman Johnson. So how many of 42,000, how many do you
    view as serious enough to actually take action on?
        Ms. Halliday. The number is very low, and that is why I
    have asked my hotline team to divide up for me exactly what is
    in the 40,000 contacts so I can take a look at it by risk. I
    would say the last numbers I thought I saw was 3,200 or so
    complaints were actually taken in the last fiscal year. So you
    can see the delta is huge.
        Chairman Johnson. You have how many people adjudicating
    those complaints or looking into those?
        Ms. Halliday. Well, it is spread over three different
    directorates, depending upon if it is criminal, health care, or
    audit, and that would represent about 660 performing all OIG
    requirements.
        Chairman Johnson. OK.
        Senator Ayotte, I apologize, but you are up.
        Senator Ayotte. Thank you, Chairman.
        I wanted to, first of all, associate myself with the
    comments that Senator McCaskill made earlier. It is just absurd
    that it has been 631 days that we have not had a permanent
    Inspector General at the VA, and I will join--I have written
    numerous times to the President of the United States, but if
    the President really cares about getting this right, then he
    will nominate a permanent Inspector General. And I think it
    says a lot, unfortunately, that people on both sides of the
    aisle have asked him to do that, and we are 631 days into it,
    and I think our men and women in uniform deserve better than
    that so that you can have permanent leadership on this very
    important oversight issue.
        And I agree with Senator McCaskill. If the IG positions are
    going to go vacant, then, I previously also sponsored the
    Vacant IG Act that she and Senator Boozman have introduced that
    would put Congress in a position to actually nominate these
    positions if the executive branch abdicates its responsibility.
        I wanted to follow-up on the wait lists because, Dr.
    Clancy, the VA, of course, with what we went through last
    summer with the revelations of the wait list and the
    manipulated wait list and veterans literally who died waiting
    for care, and you talked about the fact that the VA is making
    progress. But as I understand it--there have been different
    estimates--only a handful of people have actually been fired as
    a result of what happened. And I regularly hear from veterans
    in New Hampshire who are really frustrated with the lack of
    action and accountability. And we heard that earlier with our
    panel of whistleblowers who felt that there was no
    accountability for the people who were not doing their jobs in
    serving veterans.
        What is being done in terms of this accountability issue?
    Why hasn't there been more accountability over the wait list
    manipulations?
        Dr. Clancy. So, first, I want to emphasize that since this
    whole scandal broke out, we have taken the issue extremely
    seriously and have literally for over a year sat down with the
    Deputy Secretary every single day of the week to go over data,
    to look at which facilities are having the worst time, and
    often bringing them in by videoconference to find out what is
    the problem, what is the barrier, how can we help and so forth.
    No senior leaders got bonuses. No one can have in their
    performance plan performance metrics related to wait times and
    so forth. And what we found was that we provided a lot more
    care, both within VA through extended hours and so forth, and
    also buying it.
        Senator Ayotte. But just so we are clear for the record,
    because I have a separate bill on this clawback of the bonuses
    issue, there were many people who received bonuses who are in
    positions where, unfortunately, they were engaged in this
    issue. And, obviously, they received them, and so that is why
    Senator McCaskill and I actually have a bill to claw that back.
    But please go on.
        Dr. Clancy. Yes. Well, I was speaking for 2014 because
    Secretary McDonald came in 2014, so that had been already
    declared by his predecessor, and Secretary McDonald carried
    that through. And, very importantly, I think the shift was
    toward do not hide this information, tell us. Tell us how we
    can help. Do you need more space? Do you need more people? How
    is it that we at headquarters can actually help you address
    some of these barriers and so forth? So we have seen facilities
    all across the system step up to this challenge, but we have
    also seen increasing demand as we have gotten better at getting
    veterans in to be seen. Either in our system, virtually by
    telehealth, or by buying care in the community, more and more
    veterans have come in. So we are still working this hard, and I
    have to say it is the No. 1 priority for our new Under
    Secretary, Dr. David Shulkin. So we are working that very, very
    hard.
        As you know, or I think are likely to be aware, there was a
    huge array of investigations brought. Some are still ongoing. I
    would have to get back to you with numbers so that I am really
    confident about how many senior leaders are still under
    investigation for wait list issues. It has taken quite a bit of
    time.
        Senator Ayotte. Well, I would appreciate it, and I think
    that for all of us, there is great frustration in not hearing
    the accountability. And so it is great to look at data.
        Dr. Clancy. Yes.
        Senator Ayotte. But real people were involved,
    unfortunately----
        Dr. Clancy. Absolutely.
        Senator Ayotte [continuing]. In manipulating these wait
    lists, and when you think about the people not being held fully
    accountable at all levels of the VA for this atrocity, what it
    does is it sends a message through the organization, through
    these other cases we have heard about, that is one, to Ms.
    Lerner's point, of not accountability at each level. And if you
    are not held accountable for what happened with these wait
    lists, I mean, what will people be held accountable for I think
    is a question. So I think all of us want to see more
    accountability and more people being held accountable, and, by
    the way, the people who are doing a good job rewarded, and
    instead of being in a position where they bring misconduct to
    light, supported by saying let us work to solve the problem
    that you brought to light, as we heard from our earlier panel.
        Dr. Clancy. Yes, and I was not, I hope, contradicting that,
    and we will get you an up-to-date accounting of where all this
    stands. I was just acknowledging that thorough investigations
    take time, and really our first priority was to make sure that
    veterans got seen as soon as possible--in other words, to
    address the patient care issue and then get into the
    accountability. And, frankly, how do we get there? The
    Secretary through his efforts has really led a number of other
    important areas, really strongly encouraging, actually
    requiring facility leaders to get out and talk to the clerks on
    a regular basis.
        Senator Ayotte. So I know my time has expired, but Ms.
    Lerner testified that, as I understand it, if I am correct in
    this, 35 to 40 percent of the complaints you receive just
    pertain to the VA?
        Ms. Lerner. That is correct.
        Senator Ayotte. And this is across the whole of government,
    correct?
        Ms. Lerner. Yes.
        Senator Ayotte. Well, that is a huge number. So I guess
    what I also want to understand is what are we doing in terms of
    looking at the number of complaints systematically in terms of
    what issues they repeatedly raise and making sure that there is
    systematic change being driven by the huge volume that clearly
    speaks for itself as you look at the whole of government for
    Ms. Lerner to be receiving 35 to 40 percent from, one agency.
        Dr. Clancy. Well, I think Ms. Lerner--and if I misquote
    you, please speak up--did acknowledge that there might be a bit
    of a silver lining there, and I would actually agree with that,
    if people actually do feel free to contact her office. But,
    ultimately, there are a lot of other ways that people can make
    their voices heard.
        Senator Ayotte. So, systematically, what are you doing with
    this? Let us say you have whatever percentage of whistleblower
    issues, of retaliation, whatever percentage in terms of waiting
    for care. I am just coming up with different categories. What
    is the VA leadership and at all levels doing to incorporate the
    complaints? Obviously, individually they need to be
    investigated, but systematically, how is that feedback being
    addressed by the VA?
        Dr. Clancy. Systematically, certainly we address the
    feedback once the whole set of investigations has been
    completed, but in addition to that, we are not waiting for
    that. We are also looking at data all the time. And we have
    identified a tool and built a tool to let supervisors and
    front-line managers as well as their directors know if there
    are scheduling irregularities. This is not saying that you are
    wrong. What it is saying is we are seeing something in the data
    that looks really funky here; you need to go look at it. And we
    are encouraging a lot of engagement with front-line employees
    so that we can hear from them directly.
        We also look at things as to whether people report issues
    of patient safety that do not actually go to the Office of
    Special Counsel. We have seen an increase in that this past
    year, which I actually think is a good thing if we are acting
    to follow-up on it and address those issues.
        Senator Ayotte. Well, Mr. Chairman, as you know, we could
    be on this topic for a long period, but this is something--I
    can think of no more important issue for this Committee to
    address in terms of more accountability, and obviously the
    issues we heard earlier with the panel on the whistleblowers as
    well and support for them within this organization. And so I
    look forward to working with you on this.
        Chairman Johnson. Thanks, Senator Ayotte.
        Again, I will give everybody an opportunity to make a
    closing comment. Before I do that, I do want to talk to Dr.
    Clancy. This is really a subject for another hearing, but I
    would be interested in Senator Ayotte confirming this as well.
    I am hearing repeatedly from veterans that their requests for
    the Veterans Choice Act are being denied. And, again, I just
    want to say I appreciate your willingness to take up a
    particular case. I cannot really reveal the individual's name.
    I am not sure we have the disclosure yet. But this is a Vietnam
    era veteran who early in August was diagnosed with Stage IV
    pancreatic cancer, really cannot travel the 120-plus miles to
    where the VA tells him he needs to get treated, and his request
    for treatment closer in a very high-quality private sector
    hospital in Green Bay is still being denied.
        It is an issue I am hearing repeatedly. They are
    adjudicating every one of these issues, but I really do want to
    make sure that you are aware that it is a real complaint I am
    hearing, but I truly appreciate you being willing to take a
    look at this one particular case, because this gentleman's time
    is precious, and it really does need taking a look at, so thank
    you very much for doing that. With that----
        Dr. Clancy. Let me just say very briefly, we have been
    buying more and more care in the community over the past 10 to
    12 years, and what we have gotten to is a place where we have
    six or seven different pathways to do that, including the new
    Veterans Choice Act. We will by November 1 be bringing a plan
    to the Congress to say we are integrating them all into one,
    which I think is going to be a very big step toward our
    becoming a high-performing network where VA focuses on what we
    do really, really well and relies on community partners to
    actually help us with those other issues.
        Chairman Johnson. And I do think that really should be the
    long-term direction. I realize this is not easy, but, again, I
    appreciate your efforts there.
        We will start with you, Dr. Clancy, if you would like to
    make a closing comment.
        Dr. Clancy. Again, I want to express profound appreciation
    because we need to hear from employees all the time. I think of
    whistleblowers as one end of the spectrum, and if they feel
    like they need to exercise that option, then we should take
    that with the utmost seriousness. We are, but we need to pick
    up the pace.
        But we also need to have many, many different outlets for
    employees and, frankly, we need to thank them when they speak
    up about those concerns and make that clear to others. We have
    started down this path. I am confident that we are going to get
    there, because I think Secretary McDonald and all of our
    leadership want nothing less.
        Chairman Johnson. Thank you, Dr. Clancy. Ms. Halliday.
        Ms. Halliday. Yes, I definitely am trying to change the
    culture within the OIG to make sure that we reward
    whistleblowers when they come forward. I see the risks to them,
    to their career, as significant. I know as an IG we have to
    look at all the underlying facts, weigh the evidence, but it is
    so important for us to do that. I want veterans, I want VA
    employees to have trust in the OIG. I know they come to us for
    help, and they deserve nothing less.
        Chairman Johnson. Well, I appreciate that.
        I also want to make sure that you look at this Committee as
    an ally in that type of transparency, trying to accomplish your
    task and making sure that whistleblowers are not retaliated
    against. Again, I would ask you to work with us in our
    investigation, complying with the subpoena that has been issued
    that is not
    yet--again, we are all concerned about private health care
    information. We are willing to work with you. But we really do
    need to get this information.
        Ms. Halliday. We are working it. Your suggestion to work
    with Mr. Michael Horowitz at DOJ was a very good one. I have
    followed through, and we have gone through several of the
    obstacles. There are still a few remaining. And I have no
    problem working with Mr. Brewer and his team.
        Chairman Johnson. To the extent of your good faith, I would
    say you still have a problem within the organization that
    continues to be a road block. That is just my honest assessment
    of it. Ms. Lerner.
        Ms. Lerner. We have heard some terrible stories today, a
    lot of negative information, but I wanted to say I feel very
    optimistic that we are on the right path forward. The message
    from the VA leadership over the last year and a half has been
    very consistently positive and supportive of whistleblowers.
    The Secretary and Deputy Secretary are meeting with
    whistleblowers when they go out to facilities, and I think
    those are really positive signs, and it is going to trickle
    down, I hope, to the regions and the facilities. And
    identifying the problem is really the first step. They say
    light is the best disinfectant, and shining light on the
    problem is terrific. Working in partnership with this
    Committee, I am really confident that we can solve this
    problem, and I look forward to working with you in doing so and
    working with the VA and doing so.
        Chairman Johnson. Well, thank you. One thing I always
    repeat--this is from my business background--is try and find
    the areas of agreement, and I think what you are seeing here is
    there is obviously enormous agreement that we have a problem
    here. There is also an enormous agreement that we do need to
    honor the promises to the finest among us.
        So working with this Committee, working with the Office of
    Special Counsel, the Office of Inspector General, and the VA
    system, we need to address this problem. We need to come up
    with solutions. We need to act. And so, again, the commitment
    from this Committee is to work with you in good faith to find
    those solutions to honor those promises. Let us, again,
    concentrate on the areas of agreement that unite us rather than
    exploit the division. So that is certainly my commitment.
        Again, I want to thank all of you, all the witnesses for
    their thoughtful testimony, their thoughtful answers to our
    questions.
        The hearing record will remain open for 15 days until
    October 7th at 5 p.m. for the submission of statements and
    questions for the record.
        This hearing is adjourned.
        [Whereupon, at 12:44 p.m., the Committee was adjourned.]

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