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

                                                      S. Hrg. 114-484

                      IMPROVING VA ACCOUNTABILITY:



                               BEFORE THE

                              COMMITTEE ON
                          UNITED STATES SENATE


                             FIRST SESSION


                           SEPTEMBER 22, 2015


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                    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:
    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

                      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:


                      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.


    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 
[email protected] 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. 


    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 
    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 
    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.


    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 
    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 
    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) 
    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 
    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 
    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.


    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 
    Miss Rosayma Lopez, was issued a termination letter because 
she would not fabricate anything against me in her fact-
    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 
    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 
    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.


    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 
    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 
    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 
    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 
    Mr. Wilkes. Yes, sir.
    Chairman Johnson. To prevent you from and, by the way, 
prevent anybody else from coming forward, when you say damage 
    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 
    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.


    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 
    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 
    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 
    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 


    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 
    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 
    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 
    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 
    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 
    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 
    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 
    Chairman Johnson. Thank you, Senator Tester. 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 
    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.


    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 
    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 
    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 
    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.


    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 
    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 
    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 
    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.


    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 
    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 
    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 
    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 
    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 
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 
    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 
    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 
    Mr. Coleman. They protected me.
    Senator Carper. But they also can play a very valuable role 
    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.
    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.


    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 
    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 
    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.


    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.
    \1\ The prepared statement of Ms. Halliday appears in the Appendix 
on page 110.
    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 
    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 
    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.


    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.
    \1\ The prepared statement of Ms. Clancy appears in the Appendix on 
page 117.
    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 
    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 
    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 
    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 
    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 
    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 
    Ms. Halliday. I was not.
    Chairman Johnson. Were you aware it was being written and 
    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 
    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 
    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 
    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. 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    Senator Carper. [Presiding.] Senator Peters, you are next. 


    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 
    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.


    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, 
    Ms. Lerner. I think it is fair to say yes.
    Senator McCaskill. OK, and were those people fired, Dr. 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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 
    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, 
    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, 
    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 
    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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