[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]




 
   LEARNING FROM WHISTLEBLOWERS AT THE DEPARTMENT OF VETERANS AFFAIRS

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

                                HEARING

                               before the

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 of the

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

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                         TUESDAY, JUNE 25, 2019

                               __________

                           Serial No. 116-22

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]        




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

             U.S. GOVERNMENT PUBLISHING OFFICE 
40-823                WASHINGTON : 2021         
        
        
                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

JULIA BROWNLEY, California           DR. PHIL ROE, Tenessee, Ranking 
KATHLEEN M. RICE, New York               Member
CONOR LAMB, Pennsylvania, Vice-      GUS M. BILIRAKIS, Florida
    Chairman                         AMATA COLEMAN RADEWAGEN, American 
MIKE LEVIN, California                   Samoa
MAX ROSE, New York                   MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire          DR. NEAL DUNN, Florida
ELAINE G. LURIA, Virginia            JACK BERGMAN, Michigan
SUSIE LEE, Nevada                    JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina       ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR.,           DAN MEUSER, Pennsylvania
    California                       STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota        CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN,      GREG STEUBE, Florida
    Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
                 Ray Kelley, Democratic Staff Director
                 Jon Towers, Republican Staff Director

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                 CHRIS PAPPAS, New Hampshire, Chairman

KATHLEEN M. RICE, New York           JACK BERGMAN, Michigan, Ranking 
MAX ROSE, New York                       Member
GILBERT RAY CISNEROS, JR.,           AUMUA AMATA COLEMAN RADEWAGEN, 
    California                           American Samoa
COLLIN C. PETERSON, Minnesota        MIKE BOST, Illinois
                                     CHIP ROY, Texas

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

                            C O N T E N T S

                              ----------                              

                         Tuesday, June 25, 2019

                                                                   Page

Learning From Whistleblowers At The Department Of Veterans 
  Affairs........................................................     1

                           OPENING STATEMENTS

Honorable Chris Pappas, Chairman.................................     1
Honorable Jack Bergman, Ranking Member...........................     3

                               WITNESSES

Dr. Katherine Mitchell, VA Whistleblower, VISN 22: Desert Pacific 
  Healthcare Network.............................................     5
    Prepared Statement...........................................    35

Mr. Jeffery Dettbarn, VA Whistleblower, Iowa City VA Health Care 
  System.........................................................     6
    Prepared Statement...........................................    48

Dr. Minu Aghevli, Ph.D., VA Whistleblower, Veterans Affairs 
  Maryland Health Care System....................................     8
    Prepared Statement...........................................    53

Ms. Rebecca Jones, Policy Counsel, Project On Government 
  Oversight......................................................    20
    Prepared Statement...........................................    54

Mr. Tom Devine, Legal Director, Government Accountability Project    21
    Prepared Statement...........................................    61

Ms. Jacqueline Garrick, Founder, Whistleblowers of America.......    23
    Prepared Statement...........................................    67



   LEARNING FROM WHISTLEBLOWERS AT THE DEPARTMENT OF VETERANS AFFAIRS

                              ----------                              


                         Tuesday, June 25, 2019

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 10:03 a.m., in 
Room 210, House Visitors Center, Hon. Chris Pappas [Chairman of 
the Subcommittee] presiding.
    Present: Representatives Pappas, Rice, Cisneros, Peterson, 
Bergman, Radewagen, Bost, and Roy.

          OPENING STATEMENT OF CHRIS PAPPAS, CHAIRMAN

    Mr. Pappas. The hearing will come to order. Today's hearing 
of the Oversight and Investigation Subcommittee is entitled 
``Learning from VA Whistleblowers.'' Our Committee is 
constantly exploring ways to improve the accessibility, 
quality, and safety of veterans' health care, create a more 
timely and accurate review of benefit applications, and reduce 
instances of waste, fraud, and abuse in the department.
    One of the best sources of information and ideas is the 
VA's 370,000 employees. The people at the front lines for 
delivering services for veterans. Unfortunately, VA seems to 
have a culture problem. In some instances, VA leadership and 
supervisors have turned a blind eye to those in VA's workforce 
that have pointed out serious problems or attempted to expose 
bad actors that have abused their positions or broken laws.
    In even more concerning examples, VA leadership and 
supervisors have actively worked to stamp out these voices. As 
you will hear from one of our witnesses today, VA informed her 
just yesterday of its intention to terminate her employment. 
The timing of VA's notice, just one day before this hearing, is 
suspicious at best and at worst reeks of retaliation.
    Make no mistake, this Committee believes in the importance 
of having people who are brave enough to stand up and blow the 
whistle on missteps and misdeeds within the Department of 
Veterans Affairs. Anyone involved in the veterans' policy arena 
will recall the difference that can be made by whistleblowers 
if they think back 5 years.
    In 2014, a group of people working for the Phoenix VA 
Medical Center exposed the existence of a secret waiting list 
of veterans in need of medical care. Thousands of veterans were 
waiting months upon months for appointments. However, as was 
later revealed in an independent VA inspector general audit, 
more than 70 percent of the veterans who were waiting for care 
from the Phoenix VA were excluded from the VA's official count.
    Worse, the Phoenix VA leadership actively worked to hide 
the exorbitant wait times. And it turned out that such 
practices were occurring at VA facilities nationwide. The 
coverup was extensive and deliberate. And the health and well-
being of veterans were at risk.
    Congress became involved passing laws to stop secret lists 
and requiring that the wait times faced by veterans will be 
published online for everyone to see, but there was a cost.
    As you will hear from a number of today's witnesses, the 
Phoenix VA employees who blew the whistle in 2014 have faced 
retaliation. Their jobs were threatened, and they faced a 
hostile work environment. Despite our witness' initial success 
in obtaining protection and reinstatement as an employee, she 
is once again facing retaliation.
    Fortunately, VA whistleblowers continue to come forward. 
Just last month, journalists reported about a whistleblower 
with evidence suggesting VA is still hiding veterans' wait 
times. This Subcommittee is currently conducting his own 
investigation to examine the facts surrounding these new 
allegations. Whistleblowers are too important a resource to 
ignore. Their rights must be protected so that future 
whistleblowers will have confidence that their stories will be 
heard and assurance that their allegations will be investigated 
without reprisal.
    There are several institutions in place to help protect 
whistleblowers. Most recently in 2017, Congress and VA 
established a new office of accountability and whistleblower 
protection. And two years' later, it is time to see if this new 
VA office is effective. Unfortunately, as you will hear from 
our first panel, there is evidence suggesting that problems 
continue.
    Let me be clear. As this Subcommittee's Chairman, I will 
fight for the rights of whistleblowers. The work of the VA is 
too important to ignore those pointing out the missteps and 
misdeeds. I also want to say that there are some examples of VA 
eventually successfully listening to whistleblowers without 
retaliating against them.
    At the Manchester VA Medical Center in my district, Dr. Ed 
Kois and his colleagues saw serious problems threatening the 
health of veterans. At first, he went to his supervisors, but 
Dr. Kois was ignored. He continued pressing these issues to 
higher and higher authorities within the VA. He was still 
ignored. Finally, he went to the Boston Globe's investigative 
journalism team, and to Congress. And finally, the VA took his 
allegations seriously and began working to address the patient 
safety and quality of care concerns that Dr. Kois and his 
colleagues identified.
    This is good news that Dr. Kois says he has not experienced 
retaliation as a result of speaking out. And I urge the VA to 
follow the path of New Hampshire's example when other 
whistleblowers express their concerns. Let's not be naive, 
however. The success story we saw in my home state is not 
always what happens. That is why this Subcommittee will take a 
long, hard look at current VA policies and Federal institutions 
intended to protect whistleblowers.
    We will also hear testimony from a set of experts that work 
closely with hundreds of people who similarly raise concerns 
and face retaliation from the department. I look forward to the 
testimony of today's witnesses. And with that, I would like to 
recognize Ranking Member Bergman for 5 minutes for any opening 
comments he may have.

       OPENING STATEMENT OF JACK BERGMAN, RANKING MEMBER

    Mr. Bergman. Thank you, Mr. Chairman. Good morning, 
everyone. As an aviator, I know firsthand how vital it is that 
all team members at every level of an organization feel 
empowered to bring problems forward. When I climbed into an 
aircraft, I trusted that everyone, from aircraft maintenance to 
my most junior ground crew and flight crew members, to my co-
pilot, that they would alert me to any concerns they had. All 
of our safety, my safety and the safety of the crew in the 
cargo depended on a deep level of trust and communication.
    Similarly, as a leader of Marines, I needed all my units to 
be empowered to raises concerns because of the health and 
safety of troops, and the mission demanded it. The Department 
of Veterans Affairs is no different.
    As we saw with the Phoenix wait time scandal in 2014, and 
Dr. Mitchell, who is here with us today, was an important voice 
in that disclosure, VA employees had the courage to sound the 
alarm and potentially save lives. Leadership must create an 
environment where such alarms are taken seriously, investigated 
thoroughly, and prompt remedial action is taken when necessary.
    Today, the Subcommittee will receive testimony from 
whistleblowers and organizations that represent them in an 
effort to better understand the current state of whistleblowing 
protections and accountability in the VA. In addition to 
Congress, whistleblowers have three main venues to raise 
concerns: the Office of Special Counsel, the Office of 
Inspector General, and the Office of Accountability and 
Whistleblower Protection or OAWP.
    Employees can blow the whistle in one or all three of these 
venues. I would like to hear from the whistleblowers about 
their experience with each of these offices with three separate 
organizations potentially performing the same investigation. I 
am interested in the witnesses' perspectives on the differences 
and relevant strengths and weaknesses of each office and any 
suggestions that they may have for improvement.
    From the organizational witnesses, I would like to hear 
their opinion concerning the elements of a sound whistleblower 
program. I am interested in understanding which Federal 
agencies they believe have a good whistleblower program, and 
what constructive and concrete actions VA could take to improve 
its program.
    In the written testimony, the witnesses described several 
incidents of retaliation and reprisal. There was no question 
that the state of whistleblower protections in the VA reached a 
low point several years ago. This important issue, overlooked 
for so long, finally attracted widespread attention.
    During the 115th Congress, we passed, and President Trump 
signed into law several enhancements to the VA's whistleblowing 
program, chiefly the VA Accountability and Whistleblower 
Protection Act of 2017, and the Dr. Chris Kirkpatrick 
Whistleblower Protection Act of 2017, which mandated tough 
penalties for supervisors retaliating against whistleblowers. I 
need to hear from you how well these reforms are working.
    I am under no illusion that everything is perfect, and that 
work remains to be done. It is important that this Congress, 
that we evaluate whether the last Congress' enhancements have 
improved the process.
    Originally, the Government witnesses who could provide that 
information were scheduled to testify in July, but their 
testimony has now been delayed until September. This is 
unfortunate because the Committee would greatly benefit from 
hearing from VA and the other Government witnesses about the 
current state of whistleblowing program.
    This hearing was presented to me as the first hearing to 
help members understand the whistleblowing process and show the 
depth and complexity of the process, in other words, a non-
political educational hearing.
    However, on Saturday, USA Today published a story on 
today's hearing, identifying the witnesses without comment from 
the other governmental organizations. Then yesterday evening, 
the Chairman's staff advised my staff that one of today's 
witnesses received a notice of her proposed removal and is 
concerned that this is reprisal.
    Mr. Chairman, as you will learn of this Congress, the VA 
does not work that fast. Mr. Chairman, the Committee received a 
letter, which I have here, from Secretary Wilkie this morning. 
On this hearing, I ask unanimous consent that it be included in 
the record.
    Mr. Pappas. Without objection.
    Mr. Bergman. Yes. Mr. Chairman, pursuant to Committee Rule 
3 and the House Rule 11, Clause 2, I request the right to call 
minority witnesses before the close of this hearing. Those 
witnesses should include VA, the VA inspector general, the 
Office of Special Counsel, and the Merit Systems Protection 
Board. I believe that it is imperative to receive testimony 
from these witnesses as soon as possible, while today's 
testimony is still fresh in the minds of members because 
whistleblowers deserve it.
    I would like your commitment to hold this hearing either 
this week or at least the first week we return. Whistleblowers 
provide an important service to the country, however, the way 
this hearing has evolved has the potential to create the 
perception that complaints fall on deaf ears. If whistleblowers 
do not have confidence in the system, we are putting patient 
health and safety at risk. With that, I yield.
    Mr. Pappas. Well, thank you, Ranking Member Bergman. And I 
want to give you my commitment that we always intended to do a 
second hearing and we are eager to work with you, the majority 
and minority staff together, to call witnesses and ensure that 
this happens as soon as possible, and hold a hearing that also 
includes the VA. So if you want to take that commitment, we are 
going to be happy to work with you, you know, shortly after 
this hearing concludes on setting a timeframe for that.
    Mr. Bergman. Well, you know, unfortunately, this town has a 
very short memory and unless we can condense it so we can get 
that full perspective. Because as Oversight and Investigation, 
as you very well know, we have to look at it from 360 degrees 
and the information has to be fresh and correct, and I 
appreciate that.
    Mr. Pappas. Thank you. I will now recognize our first 
witness for the panel. First, we have Dr. Katherine Mitchell, a 
physician who has worked with the VA for more than 20 years. 
This Subcommittee thanks you for appearing with us today. Dr. 
Mitchell, you have 5 minutes.

                STATEMENT OF KATHERINE MITCHELL

    Dr. Mitchell. Thank you, sir. By nature, I am a very 
private person. I was ethically compelled to become a public 
whistleblower only because there were no other avenues to keep 
veterans from dying. My disclosures on access and poor quality 
care had national VA implications and encouraged a wave of VA 
employees to speak up about serious VA problems.
    As a result, I received the 2014 Federal Employee of the 
Year Award. The VA entered into a settlement agreement with me 
and gave me a patient care oversight position. I have been 
described by the VA as a whistleblower success story and as 
definitive proof that the VA embraces whistleblowers. However, 
nothing could be further from the truth and I am here to set 
the record straight today.
    In 2014, I testified at this Committee's groundbreaking 
whistleblower hearing that finally brought VA retaliation into 
the spotlight. I had hoped my 2014 testimony would help 
jumpstart positive change so that all employees could report 
problems without fear of retaliation. Unfortunately, VA 
administrators today still continue to retaliate. The only 
change I have seen is that since 2014 is that administrators 
are now much more skilled at weaponizing investigation boards 
and manufacturing charges.
    In my case, I have experienced ongoing retaliation that 
started shortly after signing a 2014 retaliation settlement 
agreement. For example, for nearly 5 years, I have been 
prohibited from performing every major duty listed in the 
written job description that was given to me as part of the 
legally binding settlement agreement.
    For about 2 years, I was banned from initiating contact 
with all VA medical center staff in my region. From 2014 until 
2018, I had no regular assignments. Although I am highly 
trained as a VA quality scholar, I am excluded from almost 
every oversight activity and I am not officially allowed to 
intervene in patient care problems. I have not been silent 
about this retaliation, but I cannot seem to make it stop. 
There are no easy avenues to obtain relief from VA retaliation 
and VA administrators know it.
    Since 2015, I have intermittently notified my chain of 
command, to no avail. In 2016, I contacted the Office of 
Special Counsel, or OSC, to get help with the broken settlement 
agreement. The OSC agreed to informally work with the VA, but 
the VA declined to respond or participate. At that time because 
of OSC backlog, my only option was to file another 
whistleblower retaliation complaint and wait my turn in line. 
It was a wait that would be 15 months long before the OSC had 
time to review my case.
    In 2017, I also contacted several congressional offices, 
but merely was referred to the Office of Accountability on 
Whistleblower Protection, or OAWP. I initiated contact with the 
OAWP twice in 2017 and requested to file a claim. I then waited 
about 16 months before I got an OAWP response back that merely 
asked me if I was still interested in filing a claim.
    At that time, the self-described OAWP procedure for 
investigation was so alarming to me that I opted not to use its 
services. In 2017, I also sent the VA a legal formal notice of 
breach of settlement agreement. In response, I received and 
accepted an offer for short-term assignment with a potential 
for a longer term position. However, the VA suddenly cancelled 
the offer without explanation shortly after I gave a public 
interview about escalating levels of VA retaliation.
    I subsequently sent a second legal notice to the VA, but 
the VA just ignored it. I never received a response. In 
approximately October 2018, the OSC conducted a preliminary 
investigation and found ample evidence of retaliation against 
me. I subsequently agreed to mediation with the VA to resolve 
the issues quickly. Unfortunately, once again, the VA no longer 
has the expedited mediation process that was available in 2014. 
As a result, I have remained in mediation for 9 months and 
counting with absolutely no end in sight.
    This delay is primarily due to VA responses that are 
extraordinarily slow, piecemeal, and on one occasion so 
disturbing that it felt like it should be counted as 
retaliation in itself. In my opinion, the VA's callous approach 
to mediation illustrates the degree to which the agency 
devalues whistleblowers and tries to avoid institutional 
accountability for the retaliation.
    I am definitely not the only prominent whistleblower 
treated this way. Dr. Christian Head of the Greater Los Angeles 
VA and Scott Davis of a national VA office are still 
experiencing extreme, ongoing retaliation ever since testifying 
with me in that fateful 2014 whistleblower hearing. Frankly, if 
the VA has no qualms about aggressively targeting well-known 
whistleblowers, it stands to reason that lesser known 
whistleblowers will be targeted with even more enthusiasm and 
absolutely do not stand a chance alone.
    Ultimately, whistleblowers are not guilty of anything other 
than reporting serious problems that leadership wants to 
camouflage. Until leadership culture improves, whistleblowers 
will serve as a vital, necessary safety net for veterans. 
Whistleblower retaliation threatens that safety net and 
eminently jeopardizes the health and safety of every veteran in 
the system. Thank you so much for your time. I look forward to 
answering your questions.

    [The prepared statement of Dr. Katherine Mitchell appears 
in the Appendix]

    Mr. Pappas. Thank you very much, Dr. Mitchell, for your 
work, for your courage in appearing here today, and for looking 
out for our veterans.
    I will now recognize or second witness, Jeff Dettbarn. He 
is a registered radiologic technologist, who has worked at the 
VA for more than 14 years. Mr. Dettbarn, you have 5 minutes.

                   STATEMENT OF JEFF DETTBARN

    Mr. Dettbarn. Thank you. I am a 14 year employee at the 
Iowa City VA Medical Center. I have been a radiologic 
technologist for over 29 years. I became a whistleblower out of 
concern that the veterans were being placed at risk of not 
receiving the care they desperately needed and the unnecessary 
risk to patient care presented by non-medical personnel 
practicing as physicians.
    I observed the first improper cancellation of a radiology 
order in February 2017. A veteran presented for a CT of the 
chest for a lung cancer screening, but the order had been 
improperly cancelled by the radiology service secretary. I 
later discovered that the administrative officer and 
secretaries were risking patient lives by overriding crucial 
physician orders.
    I immediately alerted supervisory chain, but no one would 
listen. Nobody seemed to care. In June of 2017, I persistently 
reported the problems in radiology. False complaints were made 
about my job performance. The complaints came at approximately 
the same time of my first disclosure to Senator Grassley. 
Management misled Senator Grassley with bogus excuses about one 
patient's cancelled imaging order when there had been actually 
12,660 orders cancelled.
    I would be more than happy to expound on the VA's deception 
if asked during the question and answers. In July of 2017, my 
banishment from the hospital began and continues today. Once I 
was removed from the main facility, others, afraid to speak 
out, told of secret lists of veterans who had not received the 
imaging for their specialty clinic appointments. Imaging 
essential for doctors to accurately diagnose and treat life 
threatening conditions. I reported this to the OIG.
    In August of 2017, I was targeted by a rigged AIB 
investigation. There was no charge letter. I was only informed 
that they were addressing issues in radiology. It became clear 
from the accusatory nature of the questions I was the target.
    Senator Ernst' office has connected me with the OSC, and I 
have filed disclosure and retaliation complaints. I also filed 
with the Office of Accountability and Whistleblower Protection. 
I sent them countless emails attempting to get a progress 
report about my case. They never bothered to address me.
    In November 2017, a baseless patient abuse allegation was 
manufactured, prompting my removal from direct patient care. 
December of 2017, the chief of staff, Stanley Parker, proposed 
my termination on charges cooked up from the AIB. The clearly 
fabricated testimony of witnesses and management in the AIB 
prompted me to seek legal assistance with the process of 
blowing the whistle.
    I have experienced another common VA retaliation tactic, 
malicious complaints to my licensing agencies: twice to the 
American Registry of Radiologic Technologists; and once to the 
Iowa Department of Public Health. These overt attempts are to 
blacklist me from both Iowa and national licensing. For every 
person who wants to speak up, there are thousands that have 
tried, only to be removed, demoted, or intimidated into 
silence.
    The process of seeking a whistleblower assistance is 
confounding to me. Do I file with OIG, OSC, OAWP, the list goes 
on. Although I have navigated to this point, not everyone is 
that fortunate. After 23 months, my current situation is 
horrendous. The VA has mothballed me into a makeshift position 
as a records requester. I have not had a performance appraisal 
in three years. I am forced to forego merit increases and about 
one-third of my salary. But worst of all, the VA has ripped my 
patients away from me.
    Whistleblowers are essential to ensure the best quality 
care our veterans need and deserve. If not for the veterans, I 
would not be a whistleblower. The veterans I am trying to 
protect, and help have become an extended family to me. As I 
have continually stated throughout this process, they are 
someone's mother, father, sister, brother, husband, wife. 
Taking care of the patients and ensuring the best possible care 
for the veterans is why I am here. Taking care of people is 
what I do.
    At this point in time in my life, I haven't much to lose or 
anything to gain. However, the veterans that I am here for, 
stand up for, and am a voice for do have a lot to lose, their 
lives. Thank you.

    [The prepared statement of Jeff Dettbarn appears in the 
Appendix]

    Mr. Pappas. Thank you very much for being with us and for 
caring for our veterans. We appreciate it.
    I will now recognize our third witness, Dr. Minu Aghevli. 
She is a clinical psychologist who has worked at the VA for 
more than 15 years. Dr. Aghevli, you have 5 minutes.

                   STATEMENT OF MINU AGHEVLI

    Ms. Aghevli. Thank you. My name is Dr. Minu Aghevli and I 
am the program coordinator of the opioid program at the VA 
Maryland health care system in Baltimore. I have a Ph.D. in 
clinical psychology, and I have been with the VA for almost 20 
years, my entire career. I even did my externship, internship, 
and post-doc there.
    Back in 2013, as the opioid epidemic was getting going, we 
found ourselves unable to keep up with the demand for treatment 
and we had to start a wait list. Management almost immediately 
started pressuring me to reduce the size of our official wait 
list in various ways that I felt were improper: such as 
removing people from the unofficial wait list by scheduling 
them fake appointments at an imaginary clinic.
    I felt these things were wrong and I protested. I went up 
through my official chain of command in the facility. I 
eventually went all the way to the secretary of the VA, 
actually two secretaries. I came to the OIG repeatedly and I 
spoke to Members of this Committee.
    After I started voicing my concerns about our improper wait 
list practices, the agency threatened to remove me as 
coordinator of the program and transfer me to a different area 
of the hospital. I went to both the OIG and the OSC. The 
transfer was rescinded in the end, but not until the last 
possible minute before it went into place.
    Over the last 5 years, this pattern of retaliation and 
threats has continued. It doesn't matter that my performance 
evaluations have been uniformly outstanding. I have experienced 
constant harassment, scrutiny, and frivolous investigations. 
Management has stripped me of authority in ways that have been 
humiliating. I am exhausted.
    Last year, I reported concerns about a patient death, and I 
was threatened with a reprimand. Earlier this year, I had 
expressed concerns about a serious patient safety concern and 
two months ago yesterday, the agency told me that they were 
summarily suspending my clinical privileges. The stated reason 
for this was that I had gone to visit a high risk patient in a 
community hospital after he had overdosed, been treated in our 
emergency room, and then discharged.
    While I was visiting him, the veteran also told me that he 
had attempted suicide after leaving the hospital. Since my 
privileges have been suspended for the last two months, I have 
been forbidden to talk to any patients or engage in patient 
care. And I have been assigned menial administrative tasks in a 
situation that seemed chosen to be as stressful and publicly 
humiliating as possible.
    A couple weeks ago, I informed my supervisors that I was 
going to testify at this hearing. I sent them a copy of the 
invitation. Yesterday, I was informed that they were starting 
the process to remove me under the Whistleblower Protection Act 
provisions.
    This feels obviously retaliatory. But worse than that, I 
feel like I am being used as a threat against other employees 
who might think about speaking up--I am sorry--about patient 
care concerns and I resent that. I do not want to be used as a 
pawn.
    I have gone repeatedly to the OSC for help with retaliation 
over the last 5 years, but the OSC has continually let me down. 
The process can take years. My last complaint took almost 3 
years to resolve. Also, they have not been able to help me 
because they have told me that when the VA has threatened me 
with actions, but then not followed through, or even when they 
have followed through but then reversed course, the OSC does 
not consider this a personnel action that they can remedy.
    Even when my privileges were suspended, the OSC told me 
that this was not considered a personnel action. I do not 
understand this because I know that under the statute, threats 
against whistleblowers are not permitted. They are prohibited. 
And honestly, suspending someone's privileges is worse than 
taking a disciplinary action because even if somehow my 
termination is stopped, I will still have to put down that my 
privileges were suspended every time I renew my license or if I 
ever apply for a job for the rest of my career. So it is kind 
of like having an arrest record I can't ever expunge.
    Finally, I just want to say that the way the VA is allowed 
to retaliate against whistleblowers, it has a terrible effect 
on veterans. I have taken care of some of my patients for 
almost 20 years. I see some of them every day when they come 
into the clinic. They are like my family. It has broken my 
heart to not see them during this past two months.
    Sometimes, I am once of the most stable people in their 
lives. And so when I abruptly disappear, it affects them. 
Recovery from addiction is so difficult already. And it is hard 
to do. It is easy to give up on yourself if you don't think you 
are worth fighting for.
    Many of our patients don't have people in their lives who 
advocate for them and sometimes that is the role we play. We 
advocate for our patients and we tell them that they are worth 
it, and they matter. And if our colleagues see people 
retaliated against for trying to stand up for our veterans, 
that will have a chilling effect and our veterans will suffer. 
And I am asking this Committee to please expand protections for 
people like us because we need to shift the culture of the VA 
from one that tells us to be quiet and keep our heads down when 
we see something that is wrong, to a place that values speaking 
up for what is right. Thank you.

    [The prepared statement of Minu Aghevli appears in the 
Appendix]

    Mr. Pappas. Thank you very much for your strength in 
appearing here and for your comments today. Thank you to each 
of our witnesses for being a part of this hearing.
    We will now begin the question portion of the hearing for 
the first panel and I will begin by recognizing myself for 
questioning for 5 minutes. And I want to voice my appreciation 
again for all of you for appearing here today. I think the 
testimony we just heard makes it clear that stepping forward as 
a whistleblower is difficult. It is frustrating. It is time 
consuming. And becoming a whistleblower has major personal 
consequences.
    Dr. Aghevli, if I could start with you. As you mentioned, 
you were notified yesterday that the VA intends to terminate 
your employment. I am wondering if you could describe a little 
bit more to the Committee what the notice will mean for you, 
even if you were able to gain protection as a whistleblower.
    Ms. Aghevli. Do you mean if I am actually terminated or-
    Mr. Pappas. Well, just the fact that notice has been served 
to you. What does that mean for you going forward as you 
grapple with this and, you know, seek to be protected?
    Ms. Aghevli. Well, it was devastating to receive because 
like I said, I have never worked anywhere else than the VA. So 
I feel like that is my whole world.
    I had filed with OSC already, so I am hoping that they can 
offer me some protection, but it is very stressful.
    Mr. Pappas. Well, I can only imagine what you are going 
through and I think it is a little suspicious that the VA chose 
to communicate its intent to terminate Dr. Aghevli the day 
before this hearing, and just a couple of days after an article 
was published, and a few weeks after you gave your intent to 
your supervisor to appear here and to speak truth about some of 
the things that you are seeing at the VA.
    And I think we need to give you our commitment that we are 
going to do everything we can to protect folks who are in your 
position. We can't allow individuals to be intimidated who are 
coming forward with important information.
    Dr. Mitchell, I am wondering if I could ask you a question. 
Your testimony describes a story that would seem in one sense 
successful because you blew the whistle in 2014 about wait 
times and people heard your story. Congress took action, 
hearings were held, and eventually it led to new laws. And for 
you personally after going through the long and arduous 
whistleblower process, you were reinstated, yet you said today 
that you still face retaliation.
    And as I understand it, the Office of Special Counsel, the 
independent Federal agency that investigates whistleblower 
retaliation has found this to be the case. Dr. Mitchell, do I 
have it correct that you are once again under retaliation and 
could you comment on what this means for your ability to do 
your job at the VA?
    Dr. Mitchell. The retaliation never stopped. The only 
difference is the way the retaliation is occurring has changed. 
Before, it was making me work unlimited hours without 
compensation or dropping my performance evaluations. Now, it is 
basically excluding me from any opportunity that I have to 
oversee patient care and address the problems.
    My title is Specialty Care Medicine Consultant. I am 
supposed to be allowed, by my job description, to oversee 
patient care, to be involved in risk management and utilization 
review. I have been excluded from all of those activities. I 
cannot verify that the VA has improved things when issues have 
come up.
    I can tell you that in the last 5 years, I have seen 
tremendous strides in patient care and access across the VA in 
general. I am proud to send my family members to the VA. I 
believe the VA provides millions of high quality episodes of 
care every year in a manner that in many ways is superior to 
private sector. But I am not allowed to help improve that care 
at all. It is incredibly frustrating and devastating as a 
physician.
    Like so many of us, we are rather high performing and we 
are our work. And not to be able to do that work is 
psychologically incredibly difficult.
    Mr. Pappas. And Mr. Dettbarn, we just have a few seconds 
left, but you described a very difficult personal process that 
you have gone through as a result of blowing the whistle. And I 
am wondering if you could comment on why you continue as a 
whistleblower and why you haven't given up.
    Mr. Dettbarn. The patients, the veterans. That is what we 
are here for. As I stated, we take care of people and these are 
family. We know their names, their histories, their loved ones. 
You are taking care of a family. It is not just a person. They 
are a family.
    Mr. Pappas. Thank you very much for your response. I would 
now like to recognize General Bergman, the Ranking Member, for 
5 minutes.
    Mr. Bergman. Thank you, Mr. Chairman. Dr. Mitchell, in your 
testimony, you recommend that OAWP speed up the intake and 
triage process, and improve transparency. Can you tell me what 
your expectations are as it relates to the timeliness and 
transparency of the OAWP? Can you give me some examples?
    Dr. Mitchell. Yes. You are referring to my written 
testimony, Section 4 and 5. There are a couple of things. First 
of all, when I contacted the OAWP, I asked if the documents I 
was going to provide to the OAWP would be shared with my 
supervisors. The first time the lady spoke with me offline on 
the telephone to let me know that, yeah, they probably could. 
The second time, I actually got email confirmation that if I 
submitted documents, it would go to my--in the process of 
investigation, it could go to my supervisors. That would be the 
very first thing I would stop with the OAWP. If there is going 
to be an investigation, whether they do it themselves or they 
refer to the VISN or the facility to do it, the employee needs 
to know that their documents will be held confidential. That is 
very important.
    There are some other things. I don't know what is a 
reasonable timeliness period, but I do know 16 months is not. 
Others have told me it has been a year. If you are talking 
about a major action where an employee is suffering risk of 
termination or demotion or suspension, those actions can occur 
within a week or two. The OAWP should have processes in place 
to be able to mobilize quickly, to go in and examine whether or 
not those personnel actions are appropriate in the context.
    Mr. Bergman. Okay. Thank you. Thank you. Mr. Dettbarn, in 
your written testimony, you state that both the process of 
seeking assistance as a whistleblower was ``truly 
confounding,'' and that you did not know how any employee would 
know who to contact.
    It is my understanding that the No Fear Act of 2002 
mandates that Federal agencies provide employees annual notice 
of certain Federal laws, including the whistleblower laws and 
training on such laws, no less frequently than every two years. 
Have you taken that training and are you saying that the 
training is inadequate? How could VA improve on that training 
to make it easier for all employees to understand and not be 
confounded?
    Mr. Dettbarn. Yes, I have taken the training. Everyone 
takes it. The problem is that we don't have the support from 
our agencies when we do finally figure out who to report to. 
And then we are turned over to the agency for their own 
investigation. So the training looks great on paper. Everybody 
did it. But when you try to actually go about the process, 
going online to the OIG site or OSC site, wherever, if you are 
not a computer savvy person, it is mind boggling.
    Mr. Bergman. Okay. So basically, it is online training.
    Mr. Dettbarn. Correct.
    Ms. Aghevli. Could I add to that?
    Mr. Bergman. Go ahead.
    Ms. Aghevli. I feel like I could teach the No Fear training 
at this point and the problem is that it is not true. So in the 
No Fear training-
    Mr. Bergman. Well, first of all, what is not true?
    Ms. Aghevli. Well, so they state that, you know, bullying 
is prohibited, and harassment is prohibited. But I have filed 
with the OSC now three times and they are very lengthy 
applications. You have to describe the entire history of your 
retaliation. So I have gone back 5 years. But then what I have 
been told is bullying is not covered as a prohibited personnel 
practice that the OSC can help me with.
    So it feels frustrating because I take that training every 
time and I think, ``I wish I could get help with this.'' My 
life would be much better if I could get help with this.
    Mr. Bergman. Okay. Well, thank you. I see that my time is 
running short, so I will just yield back the 30 seconds, Mr. 
Chairman.
    Mr. Pappas. Thank you very much. I would now like to 
recognize Mr. Cisneros for 5 minutes.
    Mr. Cisneros. Thank you, Mr. Chairman, and thank you all 
for being here today and having the courage to come forward.
    I was just wondering, and any of you could answer this, or 
all of you could answer this. But what is the messaging that 
the VA gives you as far as coming forward to whistleblowing to 
reporting incidents, to reporting something that you see that 
is wrong, and contrast that with the reality for me.
    Dr. Mitchell. The VA administration does very good public 
relations as far as stating that they will not tolerate 
retaliation. They are actually trying to become what is called 
a high reliability organization. It is a new initiative where 
it is a culture of safety. Everyone is supposed to be 
encouraged to speak up.
    Although I have had supervisors who are excellent 
supervisors, very ethical, in general, when you bring up a 
problem to the VA, you risk your professional reputation, your 
credibility. And if they go after you as viciously as they have 
been, you risk your ability to support yourself and your 
livelihood because as Mr. Dettbarn said, they will maliciously 
manufacture things and report you to your license or licensing 
agency.
    I know of at least five physicians who have spoken up, who 
were fired or had to leave, and could not get a job for at 
least a year, sometimes two years, and in one case, five years. 
This is a radiologist, radiation oncologist, internal medicine 
physician, highly skilled surgeon.
    This retaliation, I know some people think that it is 
office politics, it is not. This is a vicious, relentless 
assault on everything that is important to you. It drives 
people to the edge. Chris Kirkpatrick was driven to the edge. 
He was the psychologist out at Toma who committed suicide. 
Frankly, this is my tenth year of retaliation. It started 5 
years before the access scandal.
    I am a well-rounded woman. I am intelligent. I have a great 
support system. I would have successfully committed suicide a 
while ago because the retaliation is so severe. I don't say 
that to shock you but to open your eyes that this retaliation 
is vicious. This is at a level that you can't imagine, and it 
is destructive to everyone and endangers veterans because 
anyone with a reasonable mind would not speak up in this 
culture.
    People tell me things so I can report it because they are 
too afraid of what will happen to them.
    Mr. Cisneros. And any of you can answer this second 
question as well. But when you have come forward to report the 
incidents or the wrongdoing that you saw, did anybody come and 
visit you to discourage you to retract your statement? And who 
was this? Is it junior personnel, junior supervisors, or is it 
coming from higher ups within the VA facilities or even higher 
up than that?
    Ms. Aghevli. I think in my case, people have expressed 
concern for me that something will happen to me if I say 
something.
    Mr. Cisneros. Were those friends or were they, like, 
supervisors that came-
    Ms. Aghevli. Both. I mean, I was advised at one point that 
I would probably need to change jobs or leave. And look at what 
is happening. I am now sitting in a congressional hearing and I 
have been proposed for removal. So I guess that was good 
advice.
    I mean, I totally agree with Dr. Mitchell. I think there is 
a culture of like we do not air our dirty laundry. And it is 
very destructive because it means that instead of being able 
to, you know, look at things that didn't go as well as they 
might, and learn from mistakes, and problem solve, it is just a 
stone walling.
    Mr. Cisneros. Mr. Dettbarn, did anybody encourage you to 
kind of retract your statements or anything that you saw?
    Mr. Dettbarn. No one encouraged me to retract my statement, 
but I think I came across strong enough at the beginning that I 
wasn't going to back down from this. This is an important issue 
and veterans' health care is at stake.
    They tote the I Care, No Fear. We have to take these online 
courses every year and it is exactly the opposite of what these 
courses teach us that we are confronted with from management in 
the VA.
    Mr. Cisneros. All right. With that, thank you very much for 
your testimony here today and for coming forward. And Mr. 
Chairman, I yield back my time.
    Mr. Pappas. Thank you. I now recognize Ms. Radewagen for 5 
minutes.
    Ms. Radewagen. Thank you, Mr. Chairman. I want to thank the 
panel for being here today. My question is for all three of 
you. What are some specific actions that Congress could take 
right now to improve protections for whistleblowers? If I could 
get maybe one or two answers from each of you, please, briefly.
    Dr. Mitchell. There are two things: The Merit Systems 
Protections Board is backlogged 2,000 cases in 4 years because 
there is no three person quorum. If there could be a bipartisan 
effort to make sure that whatever is done is taken, or whatever 
needs to be done is taken, to make sure there is a three person 
quorum.
    I don't care what the political party is, I just need those 
people. There are 2,000 people waiting with potentially 
improper personnel actions. The other thing is the OSC was 
grossly understaffed for many years. Their budget is one 
percent less. They are backlogged 2,600 cases. They found a way 
to hire 11 people by redoing their lease. But I would go to 
them and say, ``What kind of monies do you need?''
    They are getting historic levels of employees coming to 
them and a huge portion are from the VA. They do excellent work 
when they have enough staffing. But when they don't have enough 
staffing, they cannot do the work they intend to do.
    Ms. Aghevli. Yes, I would add a similar thing. I think 
cases need to be processed quicker because if you wait years, 
you are in a limbo. The way adverse actions and personnel 
actions are defined seems very, very narrow to me. You know, 
proposing actions and then pulling them back at the last minute 
over and over again is exhausting. That is threatening. I think 
in a lot of other workplaces, that would constitute harassment 
and intimidation.
    And then in my case, you know, if I didn't have a pending 
case before the OSC, I would have 7 days to deal with this huge 
evidence file and mount some sort of defense. And if I didn't 
have a lawyer to help me, I don't know what I would do. So the 
way the removal process goes now under the law is very 
difficult for most people to handle.
    I think we need a little bit more protection for--I mean, 
if you are about to be removed. It seems like you need a little 
bit more in place to help you. I agree when people are bad 
actors and they have done something wrong, obviously they need 
to be able to be removed, but if you are facing reprisal, that 
is a very thin margin.
    Mrs. Radewagen. Mr. Dettbarn?
    Mr. Dettbarn. This sounds very simple, but listen to the 
whistleblower and instead of acting--there was so much money 
and time wasted in the disagreement of what I was--or the 
rebuttal to my disclosures, the problem could have been fixed 2 
years ago when it was brought up, but instead of listening and 
trying to fix it, all we got was excuses of why it was 
happening.
    I believe that when the OAWP was put into process there 
were 1800 people terminated within the first year, only 15 were 
supervisors, management positions. The fact that 1700 people 
that were environmental services, nurse's aide, food service 
workers, I don't think that is who our problem is.
    Ms. Aghevli. Can I add to that? I feel like when I read 
these OIG reports--I am not an expert and I don't pretend to 
know about other facilities, but I feel like often they will 
identify a major problem like, you know, there is improper 
management of a wait list, and what they will focus on is the 
front-line staff, like all of these front-line staff are 
scheduling improperly, but they will fail to look at whether 
this is being directed in some way.
    And even if it isn't one person saying you do this, is 
there a culture at that facility that is influencing people to 
do these things, and I think over and over again we are not 
looking at that as a system. We are just picking off the people 
at the very bottom, like the low-hanging fruit, and so it keeps 
happening.
    Mrs. Radewagen. Thank you.
    Mr. Chairman, I yield back.
    Mr. Pappas. Thank you very much.
    I now recognize Miss Rice for 5 minutes.
    Miss Rice. Thank you, Mr. Chairman. I'm sorry, I thought 
there was someone else before me.
    First, I would like to thank all three of you for 
testifying here today about your experience as whistleblowers. 
Your dedication to serving our veterans is not only exemplified 
by the work that you have done, but through your decision to 
continue working at the VA despite the challenges and the 
intimidation tactics that you have faced.
    I am sure I speak for everyone on this Committee when I 
express my deep concern about the instances of ongoing 
retaliation that you have shared with us today. This is 
completely unacceptable. We cannot allow individuals who are 
brave enough to come forward about threats to veterans' health 
and safety, and who are perfectly, more than good at their 
jobs, to be pushed out of their positions, while those 
responsible for actual wrongdoing are not held accountable. The 
fact that all three of you reported misconduct at the VA 
regarding wait times and backlogs, some of which occurred, you 
know, as far back as 2014, and only a couple of weeks ago as 
well there was another whistleblower report about the same 
exact issues and subsequent retaliation for reporting it, 
points to systemic cultural problems within the VA management 
that this Committee simply cannot ignore. I mean, it is not as 
if every whistleblower is talking about a new problem, we're 
talking about the same things happening; clearly, they are not 
being fixed.
    Mr. Dettbarn, can you just talk a little bit more, because 
this gets to the heart of whenever we have had management 
before us in hearings, I have always focused on how far up the 
chain goes, where is the accountability. If someone becomes a 
whistleblower--and this is to the point that you were making, 
Mr. Dettbarn--they don't--out of 1800 people who were fired, 
none of them were executives or very few at the top who were 
actually responsible for addressing the issues that all of you 
have exposed.
    So if you can just talk a little bit more about your 
perception of how, you know, their willingness to hold people 
at lower levels accountable for problems that are far more 
systemic than just, you know, a one-off, so to speak.
    Mr. Dettbarn. The people that are being held accountable, 
the lower-level echelon, if you want to call us that, we were 
instructed to do this by management. This came down, we were 
constantly told a directive, the DUSHOM directive gave us 
authority to cancel these orders. What DUSHOM directive? Show 
me that directive. If you are going to tell me to cancel a 
patient's order, you better have it in writing of what I am 
supposed to do.
    The directive that gave them the authority to cancel orders 
with all of the stipulations wasn't signed until September of 
2017. They started canceling, the first patient showed up 
February 22nd, 2017, months before the directive was ever even 
signed. And we--the lists that were given out to subordinates 
by management, it came from the chief of staff to my 
administrative officer, who then doled out the lists of orders 
to be canceled.
    So, if your boss tells you to do something, you would hope 
that it wasn't illegal, and you sure don't expect to get in 
trouble when you question, what are we doing? You can't do 
this. And then you end up like the three of us.
    And something that you said, Miss Rice, that I thought was 
very inspiring: we choose to stay at our positions, and we 
choose that because we care, we truly care about the veterans 
and our patients and their families.
    Miss Rice. Well, that is very obvious, that is very 
obvious.
    So one of the things that I like about this Committee is 
that we don't--it is not a political committee, all we care 
about is making sure that our veterans, our brave men and 
women, are served. And these complaints, this horrifying 
treatment of whistleblowers was--Obama was President when you--
Dr. Mitchell, when you had your whistle--in 2014, and some has 
been under the Trump administration. I think this agency 
suffers from, especially over the past 2 and a half years, of 
being completely rudderless; there is no one at the top, there 
is no accountability.
    But that is not to say that the problems with 
whistleblowers only have existed over the past 2 and a half 
years. Even when there was a dedicated, Senate-confirmed 
Secretary of the VA, the problems with whistleblowers existed 
too.
    So I am just trying to figure out what is at the core of 
this problem. Is it because there is no leadership at the top? 
Is it because the culture is just so--this corrupt--because 
that is what it is--this corrupt culture is just so embedded in 
the agency?
    And this is for all of you, if we could start with you, Dr. 
Mitchell.
    Dr. Mitchell. Yes. The agency is 89 years old; I have been 
working in it for 30 years either as a student or a nurse or a 
physician, and the culture of leadership has been malignant 
even back in 1989 when I started. This has nothing--
    Miss Rice. But why, why? Why do you--
    Dr. Mitchell. I don't know what started it originally, but 
what happens is that leadership people promote people that are 
like them. So, bad promoted like, and that is very common. So 
you have a culture of people that are all like-minded.
    I will tell you, I don't want to paint all leadership with 
a broad brush, because I have known some very ethical, very, 
very good people, supervisors, administrators, who are 
wonderful. The problem is there are only two types of 
administrators or leaders in the VA, those that wield power 
unethically and retaliate, and those that wield power 
ethically, but don't have the power to address and stop the 
retaliation.
    I have had my supervisors, I had two of them who were very 
sympathetic that I wasn't allowed to do anything in my job 
description, but they said they couldn't overcome politics. I 
don't blame them, because they too would have been targeted and 
they would have been fired.
    And, again, this has nothing to do with who is in office. 
Things got worse 2 years ago because the media's attention 
turned off whistleblowers and turned on to other politics and 
other things. It has nothing to do with who is in the 
President's office or who controls Congress. This is a 
malignant leadership culture that will outlast us all unless 
someone has the courage to break rank in leadership and finally 
change it.
    Mr. Pappas. Unfortunately, we are out of time here.
    Miss Rice. I apologize, Mr. Chairman.
    Mr. Pappas. That is quite all right. I appreciate your 
response.
    And I want to recognize Mr. Roy for 5 minutes.
    Mr. Roy. Thank you, Mr. Chairman. I couldn't agree more 
than my colleague Miss Rice about the extent to which this is 
clearly a bipartisan problem.
    I just want to thank you guys for standing up, having the 
courage to stand up, and just know that--at least I am going to 
speak for myself and I think, you know, my colleagues that we 
have your back. This is not the way things should operate and I 
really want to thank you for doing what you are doing; it is 
important and it means a lot, it means a lot to the veterans 
who are not receiving the service they should and it means a 
lot to the country that you would have the courage to do this. 
So, thank you.
    I have a couple quick questions. Dr. Mitchell, you describe 
administrative investigative boards and professional standards 
boards as being weaponized. What sort of oversight exists, if 
you could give any help on this, what sort of oversight exists 
for these boards?
    Dr. Mitchell. There is no oversight. Officially, human 
resources is supposed to be in charge of it. What happens is 
that the rules are complex, but there are some basic things 
about giving a charge letter, basically telling a person they 
are being investigated, rules of evidence, procedure, making 
sure that it is neutral people on the panel.
    What they do by weaponizing, they used to just do one or 
two things, now they do all of them. They make sure that the 
people on the panel are either cronies of the person who is 
doing the retaliation or are too afraid to stand up to that 
person to go against what the retaliator says.
    When they give a packet of evidence, it used to be a few 
sheets of paper and there was missing pieces. Now what they do, 
especially for physicians, is they will go back through every 
case the physician has ever done, pull up 30 or 40 cases, give 
pieces of information, even though the physician didn't do 
anything wrong, put it in a packet, jumble them up, and then 
give the person 7 days to respond.
    Another thing is that they don't give them a list of their 
rights.
    What they need to do is develop a standard operating 
procedure and a checklist, and make sure that--get your best 
and brightest HR people, make sure you have the rules. There is 
a step-by-step procedure, so it is AIBs and standard 
professional boards are done the same way at each facility, 
there is a checklist that is electronically signed off, and 
then if anyone deviates from that checklist, they are held 
immediately accountable and responsible.
    I can tell you right now, that alone would stop a huge 
amount of these frivolous AIB boards.
    The other thing is the fact-finding investigations. Fact-
finding investigations are basically fishing expeditions. They 
are not a full AIB, but what they do is they go to your 
colleagues or to people in your area and say, you know, Dr. So-
and-So is doing this, or Nurse So-and-So is doing this, can you 
tell me about that? And they kind of feel out about which 
employees they can get to give reports of contacts that are 
false.
    Another thing they do is if you are--there is a chief of 
staff out of Dublin, the Dublin VA, Carlene Bapttiste-Downie, 
in her AIB none of the affidavits were signed and, more 
importantly, a lot of them were from employees that she had 
legitimately given disciplinary action because they were 
substandard performers. Administration went to those people and 
got them to say that she was creating a hostile work 
environment.
    The credibility was questionable to begin with. The 
techniques of weaponizing these AIBs are very good, very 
effective and, once it is done, it takes the employee literally 
years to reverse it. And that has to stop, that tool has to be 
taken away.
    Mr. Roy. Well, I don't even know where to begin. I mean, I 
would like to dive into that and, you know, sit here for--but I 
have got 5 minutes, but I want to know more about that.
    Dr. Aghevli, thank you. I know it is a pretty tough week 
for you, but, again, we are here, and we are listening. Just 
what parts of the Whistleblower Protection law are not being 
followed, in your observation?
    Dr. Aghevli. I mean, I think more than anything, like I 
said, I don't feel like the things that have made my life 
miserable in the last 5 years have been acknowledged when I 
went for help. I feel like the ways I have been harassed and 
intimidated when I went to try to get help from the OSC, I have 
been told over and over again that those were not things that 
they could intervene in.
    And it has been confusing because, like we talked about a 
couple of minutes ago, when I take the trainings on things like 
No FEAR, I would understand that those are things that are 
prohibited. So I have ended up feeling kind of like anything 
could be done to me. I mean, in a way, I am almost relieved, I 
was relieved to get that letter, because it felt like the other 
shoe dropping.
    Mr. Roy. Mr. Chairman, if I might ask one more question? I 
know I am over my 5 minutes.
    Thank you for that and, again, I would like to go and 
explore that further. The fact that you are describing 5 years' 
public service is miserable and for you personally is really 
troubling.
    Dr. Aghevli. Well, I love--but I should say, I love my job.
    Mr. Roy. Yep.
    Dr. Aghevli. And, you know, it is scary to just feel like 
at any moment I could come into work and something else is 
going to happen.
    Mr. Roy. Mr. Dettbarn, quickly, you said for every person 
who gets to this point of being a whistleblower, there are 
thousands that have spoken up only to be removed, that is a 
staggering number. Where do you get that number? Is that kind 
of hyperbolic or is there any kind of assessment to that 
number?
    Mr. Dettbarn. No, there is no assessment, that is just my 
experience with the people that I have had to deal with. I have 
had many, many coworkers feeding me information since this 
whole cancellation of orders fiasco began. So, once somebody 
gets--once you get to this point, there are a lot of people 
that are willing to help and fight for the veterans, and that 
is where I get that number is the number of people that have 
reached out to me to try to get their voice heard.
    Mr. Roy. Well, God bless you all. Thank you for what you 
are doing.
    Mr. Pappas. Well, thank you. And before we close out this 
panel, I just wanted to recognize Ranking Member Bergman for a 
brief statement.
    Mr. Bergman. Yeah, thanks, Mr. Chairman. And, truly, thank 
you to all of you. As I listened to all of the questions and 
all your responses, this is not a simple matter, it is a very 
complex one that has occurred and built over time and over 
decades. This did not just occur in the last couple of years, 
is what I heard you saying. This has been building for a while 
and through previous administrations, whatever that might mean.
    So I just wanted to acknowledge your selflessness in coming 
here and I thank you very much.
    And I yield back.
    Mr. Pappas. Thank you. And, once again, thank you to our 
first panel for joining us here today. We really appreciate 
your time, your thoughts, and your strength, and all the work 
you do for our veterans. So, you are now excused.
    [Pause.]
    Mr. Pappas. And I would like to call up our second panel.
    [Pause.]
    Mr. Pappas. Welcome today. Good morning.
    I would like to recognize our first witness for the second 
panel. First up we have Ms. Rebecca Jones, she has Policy 
Counsel at the Project On Government Oversight.
    And, Ms. Jones, I would like to recognize you for 5 
minutes.

                   STATEMENT OF REBECCA JONES

    Ms. Jones. Chairman Pappas, Ranking Member Bergman, and 
Members of the Subcommittee, thank you for the opportunity to 
testify today on the vital role of whistleblowers at the 
Department of Veterans Affairs.
    I am Rebecca Jones, the Policy Counsel at the Project On 
Government Oversight. Since 1981, POGO has worked to strengthen 
the effectiveness and accountability of the Federal Government 
through independent investigation, analysis, and policy reform.
    VA whistleblowers put their careers on the line every time 
they speak truth to power to ensure the best possible care for 
those who put their lives on the line defending our country. In 
that way, VA whistleblowers are heroes saving heroes. Their 
disclosures save patients' lives by identifying barriers to 
timely and effective medical care due to negligence or 
intentional misconduct. In the process, whistleblowers expose 
officials who have perpetuated a culture of abuse for decades 
and free up misused taxpayer dollars that can instead go toward 
providing resources and care. And yet, even though 
whistleblowers are legally protected, they often face 
retaliation.
    The Office of Special Counsel reports that 30 percent of 
their intake comes from VA employees alone. This is partly 
because the VA is a massive agency, but it is also because of 
the overwhelming culture of intimidation and retaliation that 
has persisted for decades, forcing whistleblowers to seek 
relief when they are retaliated against.
    In 2014, alarmed by the Phoenix VA wait list scandal, POGO 
and the Iraq and Afghanistan Veterans of America invited VA 
whistleblowers to make secure disclosures to us online, so that 
we could better understand the prevalence of retaliation at the 
VA. In just a month, we received disclosures from an 
unprecedented 800 VA employees, contractors, and veterans who 
had lost faith in the agency.
    The theme was clear: whistleblowers were terrified of 
speaking out for fear of losing their livelihood.
    Shortly thereafter, POGO was wrongfully subpoenaed for 
those disclosures by the VA Inspector General. Although we have 
refused to comply and that subpoena was later dropped after 
Members of Congress stepped in, we nevertheless learned for 
ourselves that the VA's retaliatory culture permeates the very 
top levels of the institution.
    The Office of Accountability and Whistleblower Protection 
was created in part to address that culture by holding senior 
VA officials accountable. The office is a central point of 
contact for all matters related to whistle blowing, including 
disclosures and acts of retaliation. It acts as an ombudsman 
and an investigator, depending on the issue at hand.
    While the impetus behind the office is sensible, POGO 
expressed initial concerns that creating such an office within 
the agency itself would cause more harm than good. We worried 
that the internal office would become a clearinghouse used to 
identify and retaliate against whistleblowers, and that it 
wouldn't be effective at holding senior officials accountable 
because of its lack of independence.
    Unfortunately, the problems we most feared seem to have 
become a reality. Last year, both the GAO and the OAWP itself 
released reports that demonstrate an agency unprepared and 
unwilling to handle whistleblower investigations in good faith.
    For example, OAWP noted that the VA's Office of General 
Counsel is conducting legal reviews of proposed disciplinary 
actions against senior VA officials. This is not only a glaring 
conflict of interest, it is contrary to the VA Accountability 
and Whistleblower Protection Act, OAWP's authorizing statute.
    Second, GAO found that employees accused of misconduct are 
participating in the investigations into their own behavior, 
including managers investigating themselves for misconduct.
    To make matters worse, the decision of whether to implement 
proposed disciplinary action isn't being appropriately elevated 
to a more senior office. As a result, an individual can act as 
both the proposing and deciding official in certain cases.
    And, finally, senior officials are not being held 
accountable for their actions, making up only 0.1 percent of 
disciplinary action taken in the office's first year, 
maintaining the level since 2014.
    VA whistleblowers, many of whom are veterans themselves, 
blow the whistle because they are honor-bound to speak up when 
they witness violations of the country's trust, or individual 
suffering caused by negligence or corruption. Unfortunately, VA 
whistleblowers are ten times more likely than their peers to 
face retaliation, according to the GAO.
    Strengthening opportunities for whistleblower disclosures 
benefits us all, but it is vital that we be willing to quickly 
change laws that carry unintended consequences for those they 
were meant to protect. We ask that you consider amending the 
structure and work of OAWP to increase its independence, so it 
can better serve whistleblowers and veterans.
    Thank you for the opportunity to testify today and I look 
forward to any questions you may have.

    [The prepared statement of Rebecca Jones appears in the 
Appendix]

    Mr. Pappas. Thank you, Ms. Jones.
    I will now recognize our second witness, Mr. Tom Devine, 
Legal Director of the Government Accountability Project.
    Mr. Devine, you have 5 minutes.

                    STATEMENT OF TOM DEVINE

    Mr. Devine. Thank you. This hearing is timely and 
necessary, because the DVA remains a free speech Death Valley 
for Government whistleblowers. The agency produces from 30 to 
40 percent of whistleblower complaints nationally in the 
executive branch, the same as GAP's docket has been for the 
last few years. This is extraordinary for one agency in the 
nearly 2-million-person executive branch workforce. And if 
there were any hope that it has learned its lessons, the agency 
dashed them this month in a media policy to all employees that 
imposed blanket prior restraint for all communications. This 
not only violates the Constitution, but three provisions of 
Federal law, including two in the unanimously-passed 
Whistleblower Protection Enhancement Act.
    Hopefully, this hearing will lead to the DVA respecting the 
rule of law, at least in terms of official policy.
    Today's whistleblower testimony is not about an aberration, 
it is about a way of life. I will share the nightmares of 
others who risked their professional lives to save the lives of 
America's veterans.
    Consider Mr. James Hundt. The secret waiting list scandal 
horrified the Nation and sparked a serious corrective action 
effort that was leading to significant progress, but over the 
last 2 years the agency has gutted it by replacing virtually 
the entire team of 175 seasoned professional career employees 
with a green crew of a buddy-system contractor. The civil 
service team initially had received agency commendations, but 
they were all replaced after a reorganization illegally planned 
and controlled by the buddy contractor. It reversed internal 
agency recommendations, violated basic contracting and spending 
laws, and since the purge on-site inspections have been 
replaced by an honor system in the VA's hospitals.
    Mr. Hundt, the team's Associate Director, persistently blew 
the whistle on this sellout. The agency then opened retaliatory 
investigations and fired him on pretextual grounds, amazingly, 
for him seeking personal gain on government time, although he 
had checked and received prior approval for the same actions 
that non-whistleblowers engaged in and received promotions.
    Or consider Krod Rodriguez, one of the key pioneers who 
broke the secret waiting list scandals. He disclosed that the 
agency incorrectly scheduled 400 patients in Phoenix with 
another 8,000 awaiting appointments; he disclosed to Congress a 
list of 38,000 veterans nationally waiting over 280 days; and 
he also disclosed the tragic medical consequences, including 
patient deaths.
    In response, agency managers moved him to a small, 
windowless office without air conditioning in Arizona; placed 
him under surveillance, eliminated his supervisory authority; 
actively recruited mobbing allegations against him; lowered his 
performance appraisals; referred to him as a ``rat'' and a 
``media whore''; subjected him to an AIB proceeding; failed to 
respond to death threats against him; and placed him under 
criminal investigation.
    Or there is Daniel Martin, the Chief of Engineering 
Services of Indiana VA facilities, where he also supervised 
over 100 employees. He disclosed contractual bribery, including 
for the water purification system essential for the 
sterilization of medical equipment and safe drinking water for 
patients. He later learned and disclosed evidence that the 
Indiana abuses reflected corruption occurring nationally.
    In response, the agency stripped Mr. Martin of his duties; 
assigned him to an isolated office, unheated in winter and not 
air conditioned in summer; had him perform menial chores under 
the supervision of a junior staffer; exposed him to asbestos, 
which is already having destructive medical impact; placed him 
under three retaliatory investigations, primarily for an 
altercation that his so-called victims denied was more than a 
conversation. The third probe was conducted by an AIB that 
denied him access to or even the identities of his accusers.
    The agency initially refused an OAWP-mediated solution to 
move him to Seattle, Washington, where management said they 
would welcome him. Despite canceling his duties, Indiana 
officials said they could not spare Mr. Martin.
    It appears he will finally be allowed to work in Seattle, 
but over the last 3 years his life has been a professional 
nightmare.
    Why didn't OAWP stop these abuses? Its authority to grant 
temporary relief initially had an outstanding impact, but 
despite genuine commitment from some leaders it has become a 
threatening force of frustration for whistleblowers as a rule 
and an effective remedial agency as an exception. The causes? 
Lack of structural independence; cultural bias from 
investigators whose careers have been based on retaliatory 
investigations; lack of enforcement teeth for permanent relief; 
effectively, inexplicably canceling its effective whistleblower 
mentoring program, which defused conflict and shrank litigation 
by finding whistleblowers a fresh start; and operating on an ad 
hoc basis without accountability to regulations. This maximizes 
confusion and enables arbitrary action.
    To illustrate, the Senior Executive Association has 
detailed how OAWP conducted several lengthy, draining 
investigations of a manager that led to a 5-day suspension, 
only made possible by removing exculpatory evidence from the 
file. This is the same outfit that doesn't have time to return 
whistleblowers' calls.
    Mr. Chairman, we have got 19 recommendations from the 
bipartisan, trans-ideological Make It Safe Coalition, whose 
mission is supporting whistleblowers. I hope that we can work 
with your Committee on these, because both this Committee and 
the whistleblower community are committed to making 
Whistleblower Protection Act rights a reality at DVA; however, 
our work is far from finished.

    [The prepared statement of Tom Devine appears in the 
Appendix]

    Mr. Pappas. Thank you, Mr. Devine.
    I would now like to recognize Ms. Jacqueline Garrick, 
Founder of Whistleblowers of America, for 5 minutes.

                STATEMENT OF JACQUELINE GARRICK

    Ms. Garrick. Thank you. I am truly grateful to be here 
today, because it could not have happened without the support 
from this Committee over my fraud, waste, and abuse disclosures 
with Defense suicide funds and VA contracts. Since then, I have 
experienced several forms of retaliation, including threats to 
stop speaking out.
    It was a frightening and lonely time, until I compared 
notes with other employees. When we realized the potential 
conflicts and favoritism in contracts, we jointly filed with 
the DoD and VA OIG on Veterans Day 2016, because the lives of 
my fellow veterans' matter. But other than VA case numbers, 
nothing, until the OIG came to my home a day after this 
Committee got involved. I gave them documents, emails, and 
witnesses. I believe investigations are still ongoing.
    As VA underperforms in high-risk areas, veterans are dying 
by suicide, denied benefits, benefits take years to adjudicate, 
staffing shortages continue, while money is misspent, ill-
managed, or stolen. Reporting is asking to have your career 
killed and your life threatened; that is unfair.
    Whistleblowers of America, founded in 2017, has heard from 
almost 200 VA employees who suffer retaliation, harassment, or 
discrimination, similar to the 33 percent of the VA workload at 
OSC.
    OAWP has not acted in the way we thought to assist, 
support, and guide whistleblowers through a protected process 
and provide a decision algorithm for reporting. Instead, VA 
employees are ignored, attacked, or regulated to obscurity when 
they try to engage in process improvements, seek ethical 
decisions, protect funding, and solve patient care challenges.
    A closer look shows that whistleblowers experience 
violence, gas-lighting, mobbing, shunning, marginalizing, 
devaluing, double-blinding, blackballing, and accusing. These 
toxic tactics are features of workplace traumatic stress and 
can lead to PTSD, depression, and suicide. Employees are going 
to OAWP hoping for protection; instead, it causes more harm 
because of deficiencies in timeliness, unfair processes, and 
improper staffing.
    OAWP has not published a policy. It asks the same chain to 
investigate the wrongdoing it has been accused of. 
Investigations are weapons for gathering information for later 
legal action. AIBs are often conducted by untrained coworkers, 
at times the investigator and the proposing official is the 
same, or the deciding official was named in the complaint.
    Doctors who are reported to the National Practitioner Data 
Bank, even when no charges have been substantiated, have no 
recourse. Practitioners leave the VA out of fear. Vet Centers 
staff were reminded that President Trump curtailed their due 
process rights and can be fired at any time.
    Instead, OAWP should be focused on advocacy and a duty to 
assist by protecting veteran employees over denials, privacy 
invasions, restrictions from treatment, and disability 
compensation targeting. No settlement should contain a non-
disclosure agreement; transactions involving taxpayer money, 
Government resources, and the welfare of veterans should remain 
in the public domain. It should require union reps be 
consulted, since not every employee even knows they are covered 
by a bargaining agreement.
    It should clarify its website data. How are whistleblowers 
being assisted? How many adverse actions involve veterans?
    The Kirkpatrick Act mandated agencies report employee 
suicides; however--Mr. Bergman, you asked about this--OSC says 
none were made. If suicide prevention is the number one VA 
priority, then shouldn't it care about its own workforce?
    There are three main options for OAWP improvement: publish 
a policy and transparent data; utilize independent, unbiased 
staff, and sanction retaliators; or abolish it and transfer the 
resources to OSC, or allow VA employees to take their cases to 
civilian courts.
    OIG. There are no mandates for OIG findings. Guilty 
managers are not held accountable. Examples, OIG found that 
$11.7 million of VBA money inappropriately went to Calibre, but 
no action was taken to reclaim any of those funds or hold 
managers accountable for wasteful spending. Or what happened to 
the $6 million that went unspent for suicide prevention?
    Senior executives with pecuniary responsibility must pass 
background checks and hold security clearances. OIG should 
oversee spending accountability, as with the $25 billion VECTOR 
IDIQ with 68 companies performing management initiatives. How 
is that going to be monitored?
    Congress should expand penalty payments to the judgment 
fund. Whistleblowers are out of pocket while wrongdoers are 
defended by the Government at taxpayer expense. This is not 
common sense. Legal aid authority could be expanded to support 
VA employees. There has been a history of animosity between the 
OIG and its leadership through criticism, intimidation, and 
outside influence. We are concerned that emails outside of 
official VA sources would not be accessible during discovery.
    Whistleblower feedback is informative, but fear of reprisal 
causes many to remain bystanders and not veteran advocates. 
They suffer workplace traumatic stress, while senior officials 
travel to Europe, attend NASCAR, and curry favor with 
contractors. That is unfair.
    To reduce stigma, Congress should authorize VA to host an 
annual whistleblower award and highlight right-doing, and 
should consider a national whistleblower memorial on the 
grounds of the Capitol that demonstrates the lamplit pathway 
many have taken in exercising their First Amendment rights.
    That concludes my statement. I welcome your questions.
    And I also just want to say hello to my USC social work 
students who have been assigned to watch this testimony today. 
So, thank you.

    [The prepared statement of Jacqueline Garrick appears in 
the Appendix]

    Mr. Pappas. And I am sure they are still tuning in. I 
appreciate your testimony, Ms. Garrick, and thank you to our 
panel.
    And I would like to now transition to the questioning 
period of this and I will start by recognizing myself for 5 
minutes.
    You all referenced that complicated landscape that exists 
for individuals who are whistleblowers, because there are a 
variety of agencies across our government that are involved in 
receiving information and investigating Federal employee 
whistleblower disclosures. I am wondering, given that current 
landscape, what can be done to more clearly and effectively 
communicate to VA employees the best ways for them to disclose 
instances of mismanagement, and to protect themselves from 
retaliation and be able to identify retaliation in the first 
place.
    And that is for the entire panel.
    Ms. Garrick. So I think that the idea that OAWP was 
supposed to be set up for that, or that is how many of us 
perceived it, they were going to be the source that helped 
somebody walk through this process. As you have heard, you can 
go to OAWP, I think Ms. Cloud in her testimony, her written 
statement, describes 11 different opportunities to engage 
internally before even going to OSC, MSPB, EEOC. There is no 
decision tree algorithm that helps you walk through that. So 
even though there is No FEAR Act training, it is--by no means 
explains any of those processes to you.
    So, again, I think we need a better understanding of what 
OAWP is supposed to be doing--they need a policy--or we just 
need to bolster up OSC and let them do their jobs by helping 
whistleblowers from outside the agency.
    Mr. Devine. Mr. Chairman, I think to kind of summarize the 
themes and 19 of our coalition recommendations, one would be to 
close the loopholes in reprisal protection, such as AIB 
proceedings or referrals to licensing boards that can cause 
blacklisting.
    A second is to restore due process in internal proceedings. 
The idea was to eliminate roadblocks to accountability, but 
actually it has backfired, and the lack of due process is being 
used to railroad whistleblowers out of the agency.
    The third is to provide enforcement teeth and abolish the 
conflicts of interest for the agency's checks-and-balances 
institutions. That is kind of the core causes behind our 
frustration.
    Ms. Jones. And I would just add, I think, to your note of 
ensuring that employees know about the different channels and 
how they interact, I think there is massive confusion and I 
think that is evident from the first panel, that employees 
simply don't understand the different lines between the IG, the 
OSC, and the Office of Whistleblower Protection.
    And I would also just add that ensuring that the VA and its 
IG are both certified under the Office of Special Counsel's 
certification program, that is a separate program at the OSC 
that allows--or that trains and ensures that training within 
each agency is up to par, and my understanding is that they are 
not currently certified.
    Mr. Pappas. Okay. And I was going to follow up about 
training by OAWP and how important of a tool that can be once 
that matures, and I'm wondering if you can comment on the need 
to ensure that is fully implemented.
    Ms. Jones. Sure, absolutely. I believe when the Full 
Committee heard from OAWP or the VA last year on the 1-year 
anniversary of when the office was created, my understanding 
from that was that they hadn't yet implemented all the training 
requirements in the authorizing statute; that they had trained 
certain HR professionals, but that the broad training had yet 
to be implemented. And I would just again point out that they 
are not--the VA, nor the IG, are not certified under the OSC's 
program.
    Mr. Devine. Mr. Chairman, there very much needs to be 
training of OAWP in the Whistleblower Protection Act. There 
doesn't seem to be a practice consistently familiar with its 
provision. So many of the staff have come from institutions 
where they spent their entire lives on assignment to conduct 
what turned out to be retaliatory investigations against 
whistleblowers. This accumulated a real bias. That doesn't 
change with a new location and a new job description. They need 
to get it.
    Mr. Pappas. Thank you. Ms. Garrick, I don't know if you 
want to respond to that; if not, I have another one.
    Ms. Garrick. No, I think they covered it.
    Mr. Pappas. Okay, thanks.
    Just real quickly, we have been hearing a lot in other 
areas of the VA about the need to have a steady hand at the 
ship, ensure that we have permanent officials in place at 
senior leadership positions. Right now, 48 percent of the 
senior leadership positions within the VA are held by 
individuals serving in interim or acting roles. In your 
experience, does this have an impact on the picture around 
whistleblowers and a culture of retaliation?
    Ms. Jones. I mean, I would just say, you know, a high 
turnover rate can be troubling for many reasons and one of them 
is sort of a lack of institutional buy-in at the top about 
changing the culture of retaliation, ensuring that the people 
who are leading agency are determined to make the change. Where 
there is a high turnover, I mean, that becomes less clear if 
who they are placed with will really understand the underlying 
culture of retaliation and whether they would be, you know, as 
determined as others to ensure that there is reform.
    Mr. Devine. Mr. Chairman, the lack of permanent 
appointments certainly has had a destructive impact, but the 
problems go long before that current phenomenon.
    I would say there are three basic causes that we have 
identified. The first is that this agency has an almost 
uniquely feudal structure, kind of bureaucratic barons have far 
too much authority, and the national office has been frustrated 
when it tried to do the right thing.
    Second, there is a culture that allows those barons to put 
their own personal self-interest above the agency's mission of 
patient medical care or the rule of law.
    And, finally, there has been a conflict of interest in 
almost all of the agency's institutional mechanisms to hold 
itself accountable. And those are three strikes against an 
effective mission.
    Mr. Pappas. Thank you.
    Ms. Garrick. So, if I may? I have listened to this 
Committee and I have attended a couple of hearings over the 
last few months, and it just strikes me that when you don't 
have the right leadership or you have inexperienced leadership, 
or you have a revolving door of leadership, what you are losing 
is expertise and a commitment to the right-doing part of all of 
this.
    And I wish Miss Rice was here, because she asked a really 
good question about the why. The why comes down to the money 
and, if you can't follow the money and you don't know how to 
manage the money, I mean, that is the trickle down. That is 
where these contracts, this IDIQ, this enormous amount of 
money, where is it all going to go? How do you follow it? How 
do you put something on contract?
    I mean, I have heard this talk about when you obligate 
money, execute money, budget money, those are all different 
things and they mean different things in the world of 
government contracting. And, I mean, I have spent 16 years, a 
lot of that in a management position at VA, at DoD, up here 
with the congressional staff, I understand how the money flows. 
And if you don't understand the difference between an award, a 
deliverable, a sole source, a sub and a prime, a purchase 
order, all of those things are how the money gets manipulated 
and, trust me when I tell you, there is your reason for 
whistleblower retaliation.
    The panel that was up here, they are at the bottom 
receiving end of when this money trickles down and when it 
doesn't trickle down, and that is the incentive to cover all 
this up, that is the incentive to retaliate, follow that money.
    Mr. Pappas. Thank you very much.
    I would now like to recognize General Bergman, the Ranking 
Member, for 5 minutes.
    Mr. Bergman. Thank you, Mr. Chairman, and thanks to the 
panel for being here. You bring very broad and unique and 
necessary insights to the process.
    The first couple questions are going to be simple yes or 
no. So we are going to start with Ms. Jones, walk across, you 
know, yes or no.
    Whistleblowers can file separately with the Office of 
Special Counsel, OAWP, and the IG, so three different ways. 
This has the potential to cause duplicative work and delays 
work on other disclosures. For each of these organizations, do 
you agree or not that with multiple offices potentially 
investigating the same event this may not be very efficient or 
effective?
    Ms. Jones. Yes.
    Mr. Devine. Yes, I do, sir.
    Ms. Garrick. I agree.
    Mr. Bergman. Okay, the second question. Again, just simple 
yes or no. Have you met with the Assistant Secretary Bonzanto 
in OAWP to share your ideas for improving the whistleblower 
process?
    Ms. Jones. No.
    Mr. Devine. Yes, before she received that current job 
officially.
    Ms. Garrick. I did in February.
    Mr. Bergman. Okay, very good.
    Ms. Jones--the yes-or-nos are over, okay? We don't have to 
go down the line. Ms. Jones, in your written testimony you 
reference OAWP statistics concerning the disciplinary rates of 
senior executives and senior leaders compared to the GS-1 
through GS-6 category to suggest that the distribution is 
inequitable against the lower grades. What specific 
distribution of discipline does POGO believe would demonstrate 
equity and how did you arrive at that number?
    Ms. Jones. Well, I mean, I can't state a number 
specifically, but that is--I would love to work with the VA in 
terms of figuring out best practices and how we can get there, 
and with this Committee as well, but my priority would have 
been any change between 2014 and now.
    So my understanding and part of the reason of standing up 
this office within the VA was to change those numbers, to 
ensure that senior leaders were held accountable, but 
unfortunately, based on the numbers that you quoted, there 
hasn't been that change. And I believe that 0.1 percent 
represents only seven individual cases of discipline against 
senior officials.
    Mr. Bergman. Well, you know, as we struggle with numbers, 
because sometimes you can look at total numbers or percentage 
of the population, and it's kind of like in some cases, you 
know, apples and oranges. So, you know, you have got--I think 
at the SES level, you have got like 630 SES positions, so that 
is about two tenths of a percent of the workforce, whereas the 
G-1s through 6s I think are roughly 54 percent of the 
workforce.
    So we want to make sure that, if we look just at a raw 
number as opposed to a percentage, try to get, you know, a 
relative perspective on that, is there an inequity or is there 
not.
    And also, again, Ms. Jones, you described what you referred 
to as a toxic culture in your dealings with former Acting 
Inspector General Richard Griffin in 2014. The current 
Inspector General, Michael Missal, who has appeared before this 
Committee several times, assumed the office in May of '16. What 
are your observations about the IG's conduct in the handling of 
Whistleblower Protection under Inspector General Missal, and do 
you believe that the IG has improved under his leadership? And 
feel free to expand on that.
    Ms. Jones. Sure, absolutely. I was heartened to see the 
Inspector General willing to push back in access to documents 
from OAWP. You may recall there was a bit of a public spat that 
went on between the IG and the Secretary that I believe has 
since resolved. That is the kind of push-back that POGO likes 
to see from IGs, those who are independent and willing to 
investigate properly to make sure that things are operating as 
they should be.
    I understand that there is--there has been recent 
complaints from whistleblowers about--I am not sure if those 
are from the IG specifically or whether it is more broadly at 
the VA, but the IG may well be involved--that those 
whistleblowers have had their identities revealed to the 
agency. Now, I am not sure of the IG's involvement in those 
cases. I think it would be--
    Mr. Bergman. Well, your articulation of that, you know, 
again, when you have multiple agencies to report to, to 
interact with, it can be confusing at times. And, anyway, thank 
you for your answers.
    And, Mr. Chairman, I yield back.
    Mr. Pappas. Thank you.
    I now yield 5 minutes to Mr. Cisneros.
    Mr. Cisneros. Thank you, Mr. Chairman. And then you all for 
being here today.
    Ms. Jones, I want to kind of follow up on something you 
said regarding senior leadership and their disciplinary 
actions. I believe you said that senior leaders are permitted 
to investigate themselves and make their own determinations on 
those investigations whether they are guilty or not. Is that 
true at all facilities, you know, whether it be a hospital, any 
VA facility, or is it--I mean, does it differ anywhere?
    Ms. Jones. Well, that information comes from the GAO's 
report that came out I believe last year that looked at all VA 
whistleblower conduct, and it looked specifically at what has 
happened since OAWP has been stood up, the Office of OAWP. I 
can't speak to whether it is happening everywhere, but, I mean, 
the line managers investigating themselves to misconduct, I 
mean, obviously that should be of a huge concern to veterans, 
to this Committee, and to the taxpayers, to be perfectly frank, 
in how rigorous those investigations are.
    Mr. Cisneros. Ms. Garrick, you were kind of shaking your 
head as a yes there. I mean, can you add to that answer?
    Ms. Garrick. So, as she is talking, just example after 
example is sort of popping into my head about people who have 
told me just that same thing, where they have gotten either the 
proposing official is the same person and the deciding official 
has been labeled in the corruption charges in the first place. 
So we don't see a lot of unbiased, independent investigations; 
these things all happen within the same chain of command. OAWP 
sends the letter to do the investigation right back to the 
facility.
    And this is--we have been talking a lot about the medical 
centers, this happens at the regional offices and at VBA as 
well. I mean, I see the same thing that from the top down it 
ends up going right back into the lap of the supervisor who has 
been the--more likely than not the perpetrator of the 
wrongdoing. So that is not fair and unbiased.
    Mr. Cisneros. All right. Ms. Garrick, I have a question for 
you, something that you said in your testimony. You said the 
OAWP has no whistleblower policy; can you expand on that?
    Ms. Garrick. Correct. So near as we have seen, and we have 
asked a few times now, to see a published policy, a policy 
statement, an employee handbook, something that delegates the 
roles and responsibilities, and we have not been--nobody has 
shared that with us anyway. So, if there is one, I am unaware 
of it. But really something like a standard operating 
procedure, an SOP, that outlines roles, responsibilities, and 
helps to even manage some of these expectations.
    My understanding in like some of the data they reported 
that I have questioned is they say about 50 percent of the 
people that come to this office aren't whistleblowers. Well, 
who are they? Are they veterans? Are they, you know, vet 
patients, are they family members? Are they volunteers? Who is 
that 50 percent? We have no key for that data to know even what 
they are reporting on. It just makes no sense. And they are not 
reporting on how they assist or what kind of retaliation they 
are documenting. I mean, there is a laundry list of things I 
would love to see in a policy.
    Mr. Cisneros. Okay. And my last question is, what agency or 
government department out there would you say has a good, 
strong whistleblower program that the VA could probably emulate 
out there? Is there one?
    Mr. Devine. Sir, we represent whistleblowers throughout the 
executive branch, and I am not aware of such an animal. I 
believe the Office of Special Counsel has been making a good 
faith effort, but it is a relatively small office, just over a 
hundred employees to guide the system for the whole executive 
branch, and all they can do at most is kind of make a point in 
cases that are cut-and-dried, kind of low-hanging fruit, to 
send a message to the rest of the labor force. They don't have 
the resources to be a reliable source of protection. They are 
independent and we haven't seen a conflict of interest there 
like all the internal VA structures.
    But we need a safety valve where whistleblowers at the VA 
and throughout the executive branch can have the same rights as 
corporate employees who blow the whistle on abuses of the 
public trust, to go to court and defend themselves in a jury 
trial against retaliation.
    Mr. Cisneros. All right. With that, I yield back my time. 
Thank you for your testimony.
    Mr. Pappas. Thank you.
    I now recognize Mrs. Radewagen for 5 minutes.
    Mrs. Radewagen. Thank you, Mr. Chairman.
    Mr. Devine, in your testimony you refer to OAWP's mentoring 
program. How can this program help whistleblowers if it is 
reinstated? And, conversely, how can this type of mediation 
potentially fall short? I believe you referenced the cases of 
Mr. Rodriguez and Mr. Wilkes as examples in your testimony.
    Mr. Devine. The mentoring program either delivered some 
partial results or made a best effort to in a number of the 
cases that I discussed. The idea behind it is that, as an 
alternative to litigation, OAWP would search out fresh starts 
for whistleblowers with managers who would welcome their 
perspective instead of being threatened by it. And it really 
has some very effective initial results and we don't know why 
OAWP canceled it, but I think it is very unfortunate.
    Our frustration with the mediation process has been at the 
Office of Special Counsel, which has tried to resolve disputes 
through negotiation, and I think the reason that it hasn't 
worked is that the Office of Special Counsel doesn't have the 
resources to hold those agencies accountable when they play 
games rather than in good faith trying to discuss a resolution. 
And so we have had too many experiences where they just kind of 
string out the process for 6 months to years in bad-faith 
negotiations that prevent the whistleblowers from actually--the 
OSC from investigating the wrongdoing or the whistleblowers 
from having a day in court.
    So instead of being a constructive alternative to conflict, 
it has ended up just sustaining it and spreading it out. There 
really needs to be accountability for this agency.
    Ms. Garrick. So, ma'am, if I can add to that. 
Whistleblowers of America is a peer-support program that I 
started because I was an Army social work officer, we have used 
peer support very successfully with dealing with combat vets, 
PTSD, suicidality. And so when I started Whistleblowers of 
America it is using some of those evidence-based strategies to 
deal with these kinds of issues, building resilience, problem 
solving, that I think a mentorship program could really, really 
help VA employees work their way through this process. And 
maybe eliminate some of the stress, what I call workplace 
traumatic stress, it could be really eliminated, and some of 
the damages that you are hearing people talk about that have 
happened to their psycho-social life I think are the things we 
can maybe do a better job of as well and mitigate through a 
more organized, structured program.
    Mrs. Radewagen. Thank you, Mr. Chairman. I yield back.
    Mr. Pappas. Thank you.
    I now recognize Miss Rice for 5 minutes.
    Miss Rice. Thank you, Mr. Chairman.
    So I believe the statistic that, Mr. Devine, you might have 
said, that 30 to 40 percent of all whistleblower claims come 
from the VA.
    Mr. Devine. Yes, ma'am.
    Miss Rice. So I think this kind of takes off on what my 
colleague Mr. Cisneros was asking, who does it right? Who 
handles whistleblowers in the right way? Is there any Federal 
agency that does? Or are they all handled the same way, through 
the same pipeline?
    Mr. Devine. The structural problem is that whistleblowers 
in the civil service are primarily dependent upon remedial 
investigative agencies that don't have the resources to provide 
consistent relief. They can have--maybe do an in-depth 
investigation over a period of 1 to 2 years for 10 percent or 
less of the complaints that come in and that is just a token 
compared to the extent of retaliation. We need to restore 
credible due process rights.
    And the Merit Systems Protection Board, the administrative 
body that defends the merit system, currently is not functional 
and it is many, many years from getting--from healing. They 
haven't had a board that could issue final decisions in 3 
years--
    Miss Rice. Why is that?
    Mr. Devine [continued]. --in over 2 years--
    Miss Rice. Why?
    Mr. Devine. That is because the Senate blocked confirmation 
of appointments during the end of the Obama administration and 
the Trump administration didn't make them. We finally--
    Miss Rice. But that is a fix, that is a potential fix that 
could be made.
    Mr. Devine. Oh, it has just paralyzed enforcement of the 
merit system. We are on the verge of getting a board again, but 
they have a 2,000-case backlog in the interim over that 2 and a 
half years, and even that board is just--it is really kind of 
minor league due process compared to the access to court in 
jury trials that corporate whistleblowers have in every 
corporate whistleblower statute that has been passed in America 
since 2002.
    So we really have second-class enforcement. And even 
agencies like the Office of Special Counsel that I believe are 
making best efforts can only have token impact.
    Miss Rice. So would it be appropriate to put a time frame 
on how long a whistleblower investigation should take?
    Mr. Devine. I'm sorry?
    Miss Rice. How long--you are saying these drag on and on, 
these investigations, when a whistleblower makes a claim. I 
mean, what is the optimum period of time that an investigation 
like this would take?
    Mr. Devine. Well--
    Miss Rice. Because it seems like the insinuation is that 
they drag it out and they drag it out for their own purposes 
and keep all of the whistleblowers in a state of perpetual 
limbo.
    Ms. Garrick. But I think they do that on purpose.
    Miss Rice. Well, that is what I am asking.
    Ms. Garrick. I mean, it is intentional to drag it out, even 
though there are--you know, there are things that say there are 
180 days or 240 days. They will go beyond that--
    Miss Rice. So those are routinely being violated? There is 
no time frame--
    Ms. Garrick. Oh, absolutely.
    Miss Rice. Yeah.
    Ms. Garrick. Because here is the rub: The Government has 
all the time in the world, their attorneys are on--
    Miss Rice. Yeah, yeah, yeah--
    Ms. Garrick [continued]. --you know, they hire their own 
attorneys--
    Miss Rice. --they are on staff; they are on staff.
    Ms. Garrick [continued]. --they are on staff.
    Miss Rice. Right.
    Ms. Garrick. I mean, I went to an MSPB hearing, five 
Government people showed up and one guy pro se. Most of the 
people I deal with end up pro se, because it costs hundreds of 
thousands of dollars to go out and hire a really good attorney.
    Miss Rice. Yeah, yeah. No, it is totally skewered. There is 
no--can I just ask you another question, Ms. Garrick? It seems 
to me crazy that--
    Ms. Garrick. Yes.
    Miss Rice [continued]. --these--that the potential 
wrongdoers are the ones that ultimately are making the decision 
as to what happens with the whistleblowers?
    Ms. Garrick. Correct, and they are--
    Miss Rice. How can that be?
    Ms. Garrick [continued]. --by the Government--
    Miss Rice. How can that--I mean, it seems to me like there 
should be a separate track of supervisors that assess a 
situation we are not intimately involved in and don't have a, 
quote-unquote, ``dog in the fight.'' Although you could argue 
that anyone at VA has a dog in the fight of keeping this 
information from whistleblowers hidden.
    But how can we make that better? Because that is just a 
perversion of the whole system, it seems to me.
    Ms. Garrick. Well, and that is where I do believe there 
needs to be a lot more independence. And, I mean, if you look 
at the budget for OSC versus OAWP, just OAWP's budget and you 
compare it to the OSC budget, you will see they are about the 
same when OSC has the workload for the entire Federal 
Government. So there is this disparity in how things get funded 
across the Government, whether it is at the OSHA budget, the 
EEOC budget.
    So there is a lot of disparities in how the Federal 
Government funds these programs that are supposed to help all 
these whistleblowers. And there is no algorithm that says go 
here or go here, as opposed to sending you to three and four 
different places while you are out-of-pocket--
    Miss Rice. Yeah.
    Ms. Garrick [continued]. --and you are on your own time, 
because you can't whistle blow on the Government's dime, so--
and there is very little help and support for that.
    Mr. Devine. Congresswoman, the conflict of interest is 
perhaps most fundamental with OAWP. They should be an 
independent watchdog within the agency, but in practice their 
decisions are controlled by the Office of General Counsel; its 
mission is to defeat whistleblower claims. The conflict of 
interest could not be more hopeless and OAWP needs to be freed.
    Miss Rice. These are all really great suggestions. I want 
to thank Mr. Chairman for holding this hearing and I want to 
thank all of you. We need to get this right, because this is 
just--there are so many wrongs that are glaring and there is no 
reason why we can't fix them.
    So, I just want to thank you all, and I yield back.
    Mr. Pappas. Thank you.
    Well, I do want to thank each Member of our panel for 
sharing their perspective with us today. It was really 
illuminating testimony that I know we have to continue to 
contend with as we move forward as a Subcommittee, so I really 
appreciate your time.
    I do want to recognize General Bergman for a closing 
statement.
    Mr. Bergman. Well, I want to thank everybody for coming and 
the testimony, the questions and the answers. This is an 
extremely important issue that we are dealing with here to keep 
the environment open to make sure that good people can get 
their voices heard and not be limited or inhibited.
    And I just wanted to, you know, thank the Chairman for 
keeping the hearing open and in recess at our request, the 
minority's request. And there is just the letter--you know, the 
no job is complete until the paperwork is filed, but I just 
wanted to thank you in advance, and we have procedurally here 
to make sure that we get the second panel in here as soon as 
possible. And, again, I thank the Chairman for his agreeing to 
do that.
    And I yield back.
    Mr. Pappas. Well, thank you, General Bergman. And I 
absolutely agree, it is clear that this can't be the end of the 
conversation and we need to move forward expeditiously to 
continue it, and I am committed to doing that.
    I would like to underscore the bipartisan nature of the 
work of this Committee and the issues regarding whistleblowers. 
The Subcommittee will hold additional hearings on the need for 
VA to listen from whistleblowers and protect their rights and, 
as I alluded to earlier, we will hold this hearing open. I 
think it is clear today that all the whistleblowers who have 
stepped forward are doing an incredible service to our 
veterans. So, on behalf of the Subcommittee, I want to thank 
the three individuals who appeared on the first panel for all 
of their work and for being with us here today.
    Under the Committee Rule 3(c)(F)(5), the minority witness 
panel will appear subject to the call of the chair. The 
Committee will remain in recess until such time.

    [Whereupon, at 11:56 a.m., the Subcommittee adjourned 
subject to the call of the chair.]




                            A P P E N D I X

                              ----------                              

            Prepared Statement of Dr. Katherine L. Mitchell
                        Section I: Introduction
    My name is Dr. Katherine L. Mitchell. I am a board-certified 
internist who is currently employed at the Veterans Integrated Service 
Network (VISN) 22 office in Arizona as a Specialty Care Medicine 
consultant. My VA professional career has spanned 21 years in various 
roles including staff nurse, emergency department staff physician, 
emergency department director, and post-deployment clinic medical 
director. In 2017 I also completed the 2 year VA Quality Scholars 
program wherein I learned the fundamental basics of quality management, 
research design, project implementation, and change theory.
    I became a nationally known VA whistleblower in May 2014 because I 
was the first, actively-employed VA front-line staff member to speak 
publicly regarding the Phoenix VA waiting list manipulation, lack of 
timely Phoenix VA primary care appointments, substandard Phoenix VA 
triage nursing care, and other health and safety issues which were 
potentially applicable to the entire VA system.
    I initially testified in front of the House Committee on Veterans' 
Affairs (HVAC) in a ground-breaking July 2014 hearing regarding VA 
whistleblower retaliation. I subsequently testified three additional 
times in front of congressional committees regarding various topics 
including my analysis of Phoenix VA patient care deaths on the waiting 
list, national VA health care and oversight issues, and subsequent 
improvements at the Phoenix VA Medical Center.
    Since the VA access crisis was identified, I have seen great 
strides made in VA access and patient care. Although remaining cracks 
in the VA system must be addressed, I strongly believe the VA currently 
provides millions of high quality patient care episodes every year in a 
manner that in many ways is superior to private care.
    I had hoped my July 2014 HVAC testimony would help jumpstart a 
fundamental shift in VA culture wherein all employees would be 
encouraged by VA leadership to identify problems without fear of 
retaliation. Unfortunately, I believe VA leadership at all levels still 
continue to perpetuate a culture of whistleblower retaliation even as 
the VA publicly decries such tactics and rolls out new initiatives to 
encourage more employees to speak up about VA problems.
    Specifically, in my case the VA whistleblower retaliation against 
me has continued for most of the last 5 years despite signing a 
September 2014 settlement agreement intended to resolve such unjust 
treatment. Although I have made multiple direct and indirect attempts 
to fight the retaliation, I have not yet found any successful method to 
stop it.
    Available avenues to formally address VA whistleblower retaliation 
have been exceptionally slow and thus not able to provide any prompt 
relief.
    In October 2018, after the Office of Special Counsel's preliminary 
investigation found credible evidence of the ongoing whistleblower 
retaliation against me, I entered into mediation with the VA via the 
OSC alternative dispute resolution process (ADR). That mediation is 
still ongoing because the VA no longer has an expedited mediation 
process in place.
    In the remainder of this written testimony I will outline examples 
of ongoing VA whistleblower retaliation against me since signing a 
September 2014 settlement agreement, briefly describe my attempts to 
stop such retaliation, and discuss my concerns regarding the VA Office 
of Accountability and Whistleblower Protection (OAWP). I will also 
propose potential remedies for assisting VA whistleblowers, positively 
influencing VA culture, and strengthening federal whistleblower safety-
nets.
    Please note that I am not the only nationally prominent 
whistleblower experiencing persistent retaliation after congressional 
testimony. Dr. Christian Head who testified with me in the July 2014 
whistleblower hearing has had ongoing, severe VA retaliation against 
him since appearing in front of the HVAC and other congressional 
committees.
    If the VA has no qualms about subjecting prominent national 
whistleblowers to further retaliation, it stands to reason that the VA 
could target lesser known local whistleblowers with even more 
enthusiasm. Since Dr. Head and I have been unable to get relief from 
retaliation in the last 5 years, I believe most other whistleblowers 
will not fare any better.
 Section II: Whistleblower Retaliation against Dr. Mitchell - Examples 
                         from 9/2014 to present
Pertinent Background:

      In September 2014 I signed a settlement agreement with 
the VA in order to resolve the whistleblower retaliation against me. As 
part of the settlement agreement process, I was offered a new position/
training as Specialty Care Medicine consultant at a VA Veterans 
Integrated Service Network (VISN) office in Arizona and allowed to 
enter the 2-year VA Quality Scholars program.
      As per the job description given to me as part of the 
settlement, the Specialty Care Medicine consultant position/associated 
on-the-job training would allow me to directly influence the quality of 
patient care by participating in the oversight of quality assurance, 
risk management issues related to poor quality care, and utilization 
review at multiple facilities within a 3 state region. The VA Quality 
Scholars program would enable me to learn the basics of quality 
management, research design, quality project implementation, and change 
theory.
      The VISN office has 3 main divisions: medicine/CMO (Chief 
Medical Officer), quality/QMO (Quality Management Officer), and 
business/DND (Deputy Network Director). My Specialty Care Medicine 
position fell under the VISN medical/CMO division. Although the VA 
Quality Scholar position was unique in that it was not assigned a 
division, it clearly aligned with VISN quality/QMO division activities.
      When I started working at the VISN office, I hoped I 
could resume my VA professional career trajectory without the 
institutional stigma of being a whistleblower. I immediately observed 
that staff were very distant and rarely spoke to me. Although several 
communicated privately to tell me they were glad I brought attention to 
VA issues, I believed my whistleblower status was causing most staff to 
be inappropriately apprehensive. I decided the best course of action 
was to consistently demonstrate my professional expertise, work ethic, 
and interpersonal skills. By doing so, I hoped I could develop 
effective collegial relationships and reassure staff that I was a 
trustworthy, reliable individual who would be a valuable asset to the 
VISN office.
      By early 2015, after realizing VISN leadership was not 
enthusiastic about my presence in the VISN office, I was not surprised 
by their subsequent retaliatory behaviors towards me. In 2016, when 
VISN-level retaliation against me never abated, I tried to obtain an 
alternative VA position outside the VISN office. In the process of 
searching for a new position in 2017, it became evident that the 
retaliatory actions against me were also occurring at the level of VA 
Central Office (VACO).

Examples of Ongoing VA Retaliation against Me:

    For purposes of brevity, I have summarized only a few episodes of 
the countless episodes of whistleblower retaliation I experienced from 
late 2014 through March 2019. These examples are provided in rough 
chronological order, not in order of severity.

    1. From 2015 through the date of this testimony VISN leadership has 
prohibited me from performing the primary duties of my Specialty Care 
Medicine job description which was provided to me as part of the 
September 2014 settlement agreement with the VA.

    I signed the settlement agreement and specifically accepted the 
position based on the official duties contained in formal ``position 
description''. However, VISN leadership has never allowed me to 
officially perform any of primary duties listed on the job description 
that was provided as part of the legally-binding 2014 settlement 
agreement.* Those primary duties included coordination of and 
involvement in quality assurance, risk management, utilization review, 
and clinical cost analysis.
    *Note: Since 2014, even though I have been prohibited from 
officially performing risk management activities, I have nonetheless 
addressed reports of patient care problems that have been brought to my 
attention privately by hospital employees who felt confident I would 
not disclose their names. Those employees contacted me because they did 
not feel comfortable reporting their concerns using facility chains-of-
command or the OIG because the employees feared whistleblower 
retaliation.
    Responding to such informal reports clearly fell within my 
Specialty Care Medicine duties even though leadership would not 
officially allow me to officially perform those duties. Each time I 
received an employee's report, I maintained employee confidentiality, 
remotely researched the patient care chart to gather data, analyzed the 
data to determine if the employee's concerns were valid, and wrote a 
formal summary listing concerns/conclusions about patient quality. I 
electronically provided each summary to the VISN leadership for further 
follow-up. Though leadership almost never provided me any updates and 
were not always pleased with my activities, I believe my findings did 
receive VISN attention. I am aware from subsequent conversations with 
involved hospital employees that my efforts have resulted in 
significant changes in policy, consult processes, and even the removal 
of a grossly substandard physician.

    2.In December 2014 after I found gross factual errors in a 
facility's response to an Office of Inspector General (OIG) inquiry, 
VISN leadership never allowed staff to share OIG inquiries/facility 
responses with me again.

    In December 2014 a VISN QMO staff member need the assistance of a 
physician to review the accuracy of a small batch of facilities' 
responses that appeared to be problematic. Because I was the only 
physician on-duty that day, the VISN staff member asked for and 
subsequently received my assistance. Although the majority of responses 
to each OIG inquiry were accurate, I found one facility response which 
was clearly contrary to facts documented in the patient's chart. I 
summarized my findings in writing and forwarded them to the QMO 
division and QMO staff member.
    Since that time I have never been allowed to review any facility 
OIG responses even though review of such responses falls within the 
Specialty Care Medicine consultant position description I received when 
I signed the settlement agreement. The QMO employee was told not to 
share OIG hotline responses with me again.

    3.From 9/2014 through 2018, various VISN leadership actively 
discouraged staff from associating with me.

    From conversations with VISN co-workers I learned VISN division 
supervisors would tell each other which VISN staff were seen speaking 
with me. Two division supervisors openly instructed staff not to 
provide any information of any type to me, even if that information was 
just routine, common knowledge. One staff member who persisted in 
speaking with me was moved to an office far away from my cubicle.

    4.In FY17 now-former VISN 22 leadership significantly prevented me 
from obtaining the full benefit of my VA Quality Scholar (VAQS) 
training program for 17+ consecutive weeks.

    Although other VISN staff did not have to have prior approval for 
projects, I was not allowed to start VAQS projects examining the 
quality of patient care without submitting a project proposal and 
obtaining approval from senior VISN leadership. In a VISN office where 
leadership routinely made decisions within a matter of days on any 
subject, 2 senior leaders deliberately impeded my progress in the VAQS 
program by taking an extraordinarily long time (11+ weeks) to consider 
one of my VAQS project proposals before rejecting it. It was not until 
1/25/17, 11+ weeks after my proposal submission, I was told my project 
proposal was rejected because ``it was not a VISN priority'' even 
though the project was based on a high priority VA directives to 
address women's health care in VA emergency departments.
    At any time during that 11+ weeks those senior leaders easily could 
have informed me that my VAQS project was denied and allowed me the 
opportunity to present another project. However, they inexplicably 
chose to ignore my email requests for follow-up on my project proposal. 
Because I could not get approval for my VAQS project from VISN 
leadership, I missed 11+ consecutive weeks of opportunity to be working 
on a patient care project or projects that would have allowed me to 
work at my full potential as a VAQS and Specialty Care Medicine 
consultant.
    On the date I was told my project was rejected, I was also told I 
was being removed from the VAQS program because I had not provided my 
confidential settlement agreement to VISN senior leaders. It would take 
another 6 weeks to be reinstated to the VAQS program through the 
intervention of the Office of Special Counsel.

    5.In violation of the 2014 settlement agreement, in January 2017 
now-former VISN leadership suddenly removed me from the VAQS program 
because I declined to provide a confidential copy of my 2014 VA 
settlement agreement which the VISN Director had inappropriately 
requested.

    On 1/25/17 now-former VISN leadership informed me that I was being 
removed from the VAQS program by VISN leadership because I refused to 
provide a copy of my confidential 2014 settlement agreement wherein the 
VAQS program eligibility was discussed. I was told by the VISN director 
that since I had refused to provide the settlement agreement, she had 
no ``proof'' that I was still eligible to be in the VAQS program.
    I immediately stated I could ask the Office of Special Counsel 
(OSC) to contact her immediately to verify my eligibility, but she 
declined and stated again that I was prohibited from further 
participation in the VAQS program. As a VISN director, she should have 
known the process to get verification of my VAQS status from VA Central 
Office/VA legal counsel and the restrictions on demanding a copy of a 
confidential OSC settlement agreement.
    The VISN director never told me prior to 1/25/17 that she required 
me to establish my eligibility. If she had communicated that to me 
prior to 1/25/17 I would have contacted the OSC to intervene to provide 
the appropriate verification of my VAQS eligibility.

    6.A now-former direct supervisor gave me impossible performance 
goals in January 2017. Although I formally voiced objections, he still 
did not provide timely revisions to those impossible goals for 2 
months. Unfortunately, many of the revisions were inadequate and 
rendered most goals essentially impossible for me to achieve within the 
remaining FY17.

    I was first notified of the FY17 performance goal criteria by my 
supervisor on 1/20/17. The deadline for completing all criteria was 9/
30/17. The fiscal year 2017 (FY17) performance goals I was initially 
given were completely unrealistic/unachievable. (Note: Performance 
goals are different than the annual proficiency criteria on which I am 
rated.)
    Among the mandatory requirements to which I would be held in order 
to be viewed as fully meeting performance goals included publishing a 
minimum of 5 peer reviewed journal articles in the timespan between 1/
20/16-9/30/17 (a standard to which no other VISN staff in the nation is 
held to and which would not be possible even for a full time academic 
researcher working alone), improving the access SAIL scores by a full 
quintile in 5 VISN facilities (an achievement that the entire VA using 
all available resources for the past 2 years had not been able to do in 
any VISN in the entire country), and improving the health care 
associated infection SAIL metrics a full quintile simultaneously in all 
8 VISN facilities (an equivalent achievement never done in any VISN in 
the whole country since SAIL began).
    The VISN management repeatedly insisted in the 1/25/17 meeting that 
the performance goals were reasonable even though anyone with basic 
knowledge of SAIL data/publications would know that the performance 
goals grossly violated VA Handbook 5013, Performance Management 
Systems. Although VISN management eventually stated I could submit 
suggestions for alternative performance goals, the CMO quickly sent me 
new performance goals which were only minimally changed. I sent an 
informal grievance on 1/31/17 to VISN leadership. Subsequent 
performance goals were eventually modified in approximately March 2017 
but still were not achievable before the deadline of 9/30/17.

    7.During FY17, VISN 22 administration refused to assign me to 
relevant committees/workgroups pertinent to my quality activities or my 
role as VISN 22 Specialty Care Medicine consultant.

    My job title is VISN 22 Specialty Care Medicine consultant. 
However, when VISN 22 reorganized its committees in mid-2017, VISN 22 
management did not inform me that it had restarted the Specialty Care 
Committee. Management chose not to appoint me to this committee. I only 
learned of the committee's existence in January 2018 when I was doing 
research on starting a VISN-level committee for specialty care.
    Although my physician experience includes 9.5 years in a VA 
Emergency Department, in 2017 and 2018 I have been excluded by VISN 22 
administration from any membership on the VISN 22 workgroup to improve 
Emergency Department flow throughout VISN 22 facilities. (It was not 
until 2019 that I would be assigned to an Emergency Department project 
to improve such flow.)
    After completing a self-developed project that identified VISN 22 
facilities' interfacility specialty care consult (IFC) processes and 
points of contact (POC) for each step, I inexplicably was excluded from 
membership on the workgroup looking at these processes even though they 
were relying on my self-developed project materials to address IFC 
problems.

    8.At the end of FY17 I was told by my now-former direct supervisor 
that she was not authorized to rate me any higher than ``fully 
satisfactory'' on my end-of-year appraisal rating. Her statement was 
illogical because, based on the definitions printed on the appraisal 
rating form, I met the all the criteria contained in the definition for 
``excellent'' and my VA Quality Scholar work supported a rating of 
``outstanding''.

    Not only did I meet all the criteria listed by the form for the 
category of ``excellent'', my supervisor was also aware that I had 
received an ``outstanding'' performance rating from my VA mentor in my 
0.75 FTE VA position as VA Quality Scholar. My now-former supervisor 
inexplicably stated she was not allowed to consider such outstanding 
performance when providing a summary rating me as a full time VA 
employee even though I occupied a 0.75 full-time VA position as VA 
Quality Scholar and only 0.25 full-time VA position as Specialty Care 
Medicine consultant. She stated I would have to submit a 
reconsideration (formal complaint) of her summary rating of ``fully 
satisfactory''. Although she was the primary rating official, she 
inexplicably told me that she did not ``have the power'' to change my 
rating. (I do not think she was retaliating against me but rather was 
following retaliatory orders from more senior VISN leadership who did 
not want me to be rated higher.)
    I filed a formal complaint within the VISN office and eventually 
was granted a rating of ``Excellent''.

    9.In October 2017, shortly after a Washington Post reporter 
submitted to VACO my statements about ongoing VA whistleblower 
retaliation, the VA suddenly withdrew its offer of a short-term 
assignment to the Office of Accountability & Whistleblower Protection 
(OAWP) without providing any explanation.

    In an August 2017 telephone meeting for 1.5-2 hours with a now-
former OAWP Executive Director I was informed that the VA Deputy 
Undersecretary of Healthcare Operations and Management (DUSHOM) had 
recommended an OAWP assignment for me because the OAWP had no 
physicians assigned to it and was in great need of such medical 
expertise to investigate cases involving physicians. During that 
meeting I was offered me a 4-month assignment to the OAWP with the 
ability to extend the detail. I accepted.
    Because the OAWP Executive Director stated he wasn't sure how to 
initiate the necessary paperwork for me to have the assignment, I told 
him I would do the research to find out how to expedite it. Within 3 
days on 8/25/17 I sent him an email telling him I was excited about the 
opportunity to work with the OAWP and that I created the necessary HR 
documents (attached to the email) in order to expedite the detail. He 
replied on 8/25/17 ``Thank you for getting the process started. Since 
this will be a unique detail, I'll work it with [VA Deputy 
Undersecretary of Healthcare Operations and Management]''.
    In September 2017, a Washington Post reporter was working on a 
story regarding increasing VA whistleblower retaliation. When he 
interviewed me, I told him VA retaliation was worsening. The reporter 
subsequently submitted my comments about ongoing/worsening VA 
whistleblower retaliation to VA Central Office (VACO) as part of 
routine investigative process in order to get a response from VACO. 
(The reporter's final article appeared on 10/30/2017.)
    Shortly after the timeframe that the VA would have received 
notification of my specific comments by the reporter, I received a curt 
2 sentence email dated 10/25/17 from that same OAWP Executive Director 
stating that he would ``not be moving forward'' with the OAWP detail. 
This OAWP Executive Director never responded to my subsequent email 
requesting an explanation of why the detail was suddenly cancelled.
    Because the OAWP had ongoing significant need for medical expertise 
in investigations, I believe the assignment offer was withdrawn because 
VACO was displeased with my comments about VA retaliation. Since the VA 
DUSHOM had recommended me for the position and since the VA DUSHOM 
never again contacted me, it would have taken a senior VACO leader to 
reverse the DUSHOM's recommendation for an OAWP assignment, stop DUSHOM 
interactions with me.

    10.In a January 2018 news article the VA falsely portrayed itself 
as continuing to work on my case even though it has persistently 
ignored my genuine attempts since 2016 to resolve its breach of 
settlement agreement and had broken off all contact with me since 
October 2017.

    In a USA Today article published 1/16/18, the VA falsely contended 
it was ``still working'' on my case. In fact, from October 2017 through 
the time the VA entered mediation with me in October 2018 the VA 
Central Office had no direct or indirect contact with me.
    The VA has persistently ignored my attempts to resolve the breach 
of settlement agreement. After it became evident that the VA materially 
breached the 2014 settlement agreement, I tried to resolve the issues 
informally via the Office of Special Counsel starting in approximately 
mid-2016. After the VA stopped responding to the OSC in Spring 2017, on 
6/23/17 I sent (via email delivery) a 6/23/17 formal ``Notice of Breach 
of Settlement Agreement'' with a 30 day deadline for response to the VA 
DUSHOM. The DUSHOM informally acknowledged receipt of this document in 
an email dated 6/27/17. In the formal notice I requested a new position 
to resolve the breach.
    The follow-up communication I received was a brief email dated 7/
19/17 from the DUSHOM asking for my resume and indicating he was 
``pursuing a couple possibilities'' for me. I promptly provided my 
resume via email. Although I subsequently was offered a short-term OAWP 
assignment with a potential for a longer position, that assignment 
offer was later withdrawn.
    Because I received no formal response from the VA to the initial 
Notice of Breach of Settlement Agreement and because the material 
breach continued/worsened, on 11/15/17 I subsequently submitted (via 
email delivery) a second document entitled ``Second Formal Notice of 
Breach of Settlement Agreement'' to the VA DUSHOM. This notice was read 
by the DUSHOM on 11/15/17. This document gave a 30 day deadline for VA 
response. The 30 day deadline passed on 12/15/17 with no formal or 
informal response from the VA. As of June 2019, the VA has never 
provided any informal or formal response of any kind to my ``Second 
Formal Notice of Breach of Settlement Agreement''.

    11.In January 2018, after I publicly stated I had been offered an 
Office of Accountability and Whistleblower Protection (OAWP) short-term 
assignment which had inexplicably been withdrawn, VACO countered with 
an inaccurate public statement claiming that I had never been 
officially offered a position with the OAWP.

    In a nationally circulated January 17, 2018 USA Today article 
wherein I stated I had been offered an OAWP position which was 
subsequently withdrawn, the VACO inexplicably contended that I had not 
ever been officially offered any type of position with the OAWP. VACO's 
statement was not consistent with the conversation or emails from the 
OAWP Executive Director with whom I had arranged the short-term 
assignment.

    12.From 2017 through 2018, even though I was assigned 
responsibility for the Healthcare Associated Infections (HAI) at all 
VISN 22 facilities, various VISN leadership would not include me in the 
HAI communication loop between the facilities and VISN 22, provide 
access to the facilities' HAI improvement action plans, or actively 
involve me in ongoing HAI projects.

    In early 2017 I was specifically assigned by the VISN 22 CMO 
division to monitor the prevention of HAI in VISN facilities by 
tracking trends and following up with front-line staff who would be 
most familiar with root causes and interventions. However, in February 
2018 I learned via emails that I had not been included the 
communication loop between the VISN 22 DND and the facilities regarding 
HAI. I learned of the communication loop only after receiving an email 
wherein a facility questioned why it was being asked to do ``double-
work'' by providing HAI action plans to VISN 22 DND and separate 
documents to me. Although I sent multiple emails to my chain-of-command 
to be included in the activities/information flow, I was never allowed 
to participate. HAI responsibility was removed from my responsibilities 
in FY19.

    13.Contrary to multiple OPM regulations, VISN operating procedures, 
and VISN business needs, in late 2018 VA Central Office (VACO) 
reportedly was able to deny me the ability to participate in medical 
review of local VISN-level consult issues even though it is highly 
irregular for VACO to be involved in such matters.

    In 2018 I was struggling to fill my 40 hour workweek with 
activities because the duties I was allowed to perform did not consume 
all my duty time. In late 2018 I learned the business division of my 
VISN was experiencing consult problems which could be resolved by 
physician review. After briefly speaking to my supervisor, I 
subsequently submitted an email to that supervisor formally requesting 
the ability to have some of my work time assigned to the business 
office to assist with these consult problems. Several months later I 
learned my request had been inexplicably denied even though such duties 
would clearly fall under the Specialty Care Medicine role and were 
within my scope of practice as a board-certified internist.
    In 2019 I inadvertently learned from an extremely reliable source 
that my request had been forwarded to VACO for review and that VACO had 
denied the request. Because it is extremely irregular for VACO to have 
any input on the routine local assignment of a temporary job duty for a 
local VISN-level employee, I believe I was being treated differently 
because of my whistleblower status. I am extremely concerned that VACO 
has been surreptitiously dictating my VISN job duties, or lack thereof, 
since beginning my VISN position in 2014.
 Section III: Lack of Timely Avenues to Stop Whistleblower Retaliation 
                          against Dr. Mitchell
    During these last 5 years, I have not been silent about the 
retaliation against me. Although I have made multiple direct and 
indirect attempts to fight the retaliation, I have not yet found any 
successful method to stop this unjust treatment.
    Since 2015, I have notified my immediate chain-of-command several 
times in an attempt to obtain relief. Although 2 of my immediate 
supervisors were blatantly retaliatory against me, I could not elevate 
the existence of the retaliation to the chain-of-command because the 
VISN Network Director, the top supervisor in the VISN chain-of-command, 
had also taken retaliatory actions against me. I spoke with 2 of my 
subsequent supervisors about VISN-level retaliation. However, although 
they were sympathetic to my plight, they informed me that they could 
not overcome VISN-level ``politics'' that were successfully blocking me 
from performing any of the duties of the Specialty Care Medicine 
consultant position or participating in VISN-level projects that were 
in the scope of Specialty Care Medicine duties.
    In late 2016 I contacted the Office of Special Counsel or OSC, 
explained the retaliation, and asked if it could help me obtain a new 
VA position. The OSC tried to resolve the problem by informally 
engaging the VA, but the VA declined to participate. Because the OSC 
was so backlogged, I was told the only way to receive further OSC help 
was to file another whistleblower retaliation complaint and wait my 
turn in line, a line that ultimately was about 15 months long.
    In 2017 I also contacted several congressional offices and was told 
they were referring all VA whistleblower matters to the new VA Office 
of Accountability and Whistleblower Protection (OAWP). I contacted the 
OAWP twice in 2017. When I submitted my request for OAWP assistance, I 
even cc'd the now-former Secretary of the VA, an individual with whom I 
had exchanged several patient care-related emails. I waited again - it 
was a wait that would last 16 months to get a follow-up response from 
the OAWP. The now-former Secretary of the VA never responded.
    In June 2017 I also sent the now-former VA Deputy Undersecretary 
for Healthcare Operations and Management (DUSHOM) a formal legal notice 
citing settlement agreement breach and clearly outlined the 
whistleblower retaliation against me. In the document I requested 
assistance with obtaining a new position. I was elated when the DUSHOM 
asked for my resume. As a result of his actions, I subsequently 
received and accepted an offer of a new short term VA assignment with 
the OAWP with the potential for a permanent position. Unfortunately, 
the VA suddenly withdrew the offer after I gave a national newspaper 
interview about ongoing VA retaliation. In November 2017 I sent the 
DUSHOM a second formal legal notice of breach. Although the email read 
receipt confirmed the DUSHOM read the notice, I never received any type 
of VA response to my formal legal notice.
    In October 2018, after the OSC's preliminary investigation found 
credible evidence of ongoing whistleblower retaliation against me, I 
readily entered mediation with the VA. That mediation is still ongoing 
as of June 2019 because the VA no longer has an expedited mediation 
process in place.
    Please note: In 2014 the VA had an expedited mediation process for 
OSC cases wherein credible retaliation was found. Although I am not 
privy to the details of that confidential process or the rationale for 
discontinuing it, that 2014 VA expedited mediation process was 
successfully used to address the whistleblower retaliation against me 
and other VA employees.
Section IV: Whistleblower Vulnerabilities when Interacting with OAWP - 
  General concerns & specific examples based on Dr. Mitchell's 2017 & 
                            2019 experiences
    In this section I describe my Office of Accountability and 
Whistleblower Protection (OAWP) interactions in 2017 and 2019 and 
explain how those interactions reveal weaknesses in OAWP processes. 
Although the OAWP has recently come under new leadership, I remain 
concerned the OAWP does not yet seem to have any effective processes in 
place to ensure the complainants are not subjected to further 
retaliation for using OAWP services. Further development and 
transparency of OAWP processes would help address the concerns 
discussed below.

    1)Prior to the filing of an OAWP complaint, the OAWP triage intake 
staff fails to communicate key information to complainants about the 
potential for the complainant's supervisor and facility leadership to 
obtain unredacted complaints/associated unredacted documents.

    Based on my OAWP experiences described below and intermittent 
conversations with other whistleblowers who have contacted the OAWP, 
the OAWP intake staff routinely do not disclose to whistleblowers that 
any documents submitted can potentially end up in the hands of the 
whistleblowers' supervisors/facility leadership if A) the OAWP 
initially deems the complaint not to meet the criteria for 
whistleblower retaliation, B) the OAWP directly does an investigation, 
or C) the investigation is referred by the OAWP to the VISN/VISN 
facility associated with the whistleblower.
    My OAWP experiences: On 9/8/17 I sent an email to the OAWP 
notifying it that I was experiencing whistleblower retaliation. In the 
9/13/17 email response the OAWP triage specialist wrote ``To ensure 
your whistleblower disclosure and subsequent retaliation is addressed 
appropriately, please respond to this email with information...'' She 
then listed the information to include events, witnesses, and 
documented evidence such as emails. She did not inform me whether or 
not those documents could be shared with my supervisor/leadership.
    Because the 9/13/17 OAWP email did not disclose the OAWP processes 
for handling my complaint, I sent a follow-up email dated 9/13/19 
seeking more information/explanation about those processes. I asked if 
my supervisor, VISN office, or general VA leadership would have access. 
I also inquired as to whom would be investigating the retaliation.
    I received the OAWP triage specialist's partial response to those 
questions on 9/15/17, but the triage specialist did not state who would 
have access to my complaint and supporting documents. Because the 
triage specialist did not answer that question, I replied on 9/15/17 
asking her to confirm who would have access. In a 9/18/17 email, the 
triage specialist sent me her phone number and subsequently spoke off 
the record with me. In our conversation she vaguely indicated the 
documents might be shared, but she would not officially confirm it.
    In 2019 I received written confirmation from an OAWP staff member 
that all whistleblower evidence documents could be shared with a 
complainant's supervisors/facility leadership and that even previously 
redacted information could be unredacted/given to VISN leadership (and 
to the facility if the VISN requests that the facility investigate). In 
a 2/5/19 email to the OAWP I wrote ``Can you verify that my chain of 
command within VISN 22 (supervisor/VISN 22 leadership) would not have 
access to the documents I submit to you?'' In a 2/5/19 email response 
an OAWP staff member informed me in writing that ``[she] cannot confirm 
that they will not see the documents .documents can be shared as the 
investigation proceeds'' in retaliation cases.
    I was also informed via the same 2/5/19 email response that 
redacted information could also be given to the VISN when there were 
disclosures of violations, gross mismanagement, waste of funds, abuse 
of authority, or specific danger to public health or safety. OAWP staff 
member wrote in such cases ``.the investigative party (OAWP or VISN) 
may be provided with copies of the redacted information''.

    2)Prior to the filing of an OAWP complaint, the OAWP triage intake 
staff apparently fail to communicate key information to complainants 
about the investigative process and the potential to have the 
investigation conducted by the VISN or by the complainant's facility if 
the OAWP declines to conduct the investigation using its own staff.

    Based upon my OAWP experiences described below and intermittent 
conversations with other whistleblowers, the OAWP intake staff do not 
fully explain the process of investigation and do not routinely 
disclose to whistleblowers that any complaints not meeting the initial 
definition of whistleblower retaliation are forwarded to the employee's 
VISN for subsequent investigation and/or subsequent delivery to the 
complainant's facility to investigate.
    My OAWP experiences: In a 9/15/17 I was informed by an OAWP triage 
specialist that the OAWP investigates matters involving ``all VA Senior 
Leaders'' and refers any other matters not involving senior leadership 
``to the appropriate entity to investigate''. The triage specialist did 
not specify which entities would be involved.
    In 2019 an OAWP case manager wrote that the investigative party for 
allegations other than retaliation would be the ``OAWP or VISN''. 
However, she did not offer any specific information on what might 
happen if a retaliation complaint was deemed not to rise to the level 
of whistleblower retaliation.
    Because it took 17+ months for the OAWP to respond to my 2017 
initial intake disclosure, I asked the same case manager about the 
timeliness of any future investigative processes. The OAWP triage case 
manager told me she could not ``clarify the OAWP timeframe for taking 
action or the investigation process. Each case is will be [sic] handled 
on a case by case basis.'' I was surprised because I assumed the OAWP 
would have processes defining the average/desired timeframes for 
investigations.

    3)The OAWP does not appear to have any processes in place to ensure 
that the content of any referred complaint is handled by a neutral 
party at the complainant's VISN office or facility.

    Anecdotal OAWP information: I have been told by VA staff who wish 
to remain anonymous that the OAWP will forward those complaints deemed 
not to be retaliation to the regional VISN with only general 
instructions to address the complaint. The OAWP does not appear to take 
any steps to ensure the content of the complaint is handled by a 
neutral party at the VISN.
    I have been told that OAWP complaints are often forwarded by the 
VISN to the complainant's facility (enabling the facility to 
investigate itself) because the VISN does not have the staffing to 
investigate. (This is similar to how the VISNs commonly handle OIG 
hotline complaints that are referred to VISNs.)
    I do not have any information on whether or not the OAWP does 
follow-up of forwarded complaints to determine if resolution is 
achieved.

    4)The OAWP intake processes appear to be extremely slow with gaps 
of up to 1+ years for initial intake.

    When talking to another VA whistleblower (Dr. Christian Head) who 
also testified at the 2014 HVAC hearing, I learned that he never 
received any contact from the OAWP despite having filed a complaint 
more than 1+ year earlier.
    My OAWP experience: In 2017 I was told by several congressional 
offices that they refer all potential VA whistleblower retaliation 
cases to the OAWP. After learning that I could not receive 
congressional help unless I first went through the OAWP process, I 
contacted the OAWP to file an initial complaint. In September 2017 I 
sent the initial email to make a disclosure and ask if the OAWP could 
help. I subsequently sent a December 2017 email to the VA 
Accountability Team and the now-former Secretary of the VA wherein I 
stated ``I would like to file a case with the OAWP'' and provided a 
succinct synopsis of the retaliation I experienced. Unfortunately, I 
did not receive any OAWP response until January 2019 (1+ year later) 
asking me if I ``still wish to file a disclosure''.

    5)The OAWP appears to be subject to internal pressure from VA 
Central Office (VACO) senior leadership.

    My OAWP experience: In late August 2017, after I had notified the 
now-former VA Deputy Undersecretary of Healthcare Operations and 
Management (DUSHOM) in June 2017 about ongoing whistleblower 
retaliation against me, the now-former OAWP Executive Director 
contacted me at the request of the DUSHOM regarding a short-term detail 
position to the OAWP as a physician investigator with the potential for 
a longer assignment. I accepted the detail. Because that OAWP Executive 
Director was uncertain how to initiate the detail paperwork, I drew up 
the appropriate paperwork and forwarded it to him. He sent me an email 
8/25/17 which thanked me ``for getting the processes started'' and 
stated he would ``work it with [the DUSHOM]''. In late September/early 
October 2017 I gave an interview to the Washington Post wherein I 
stated that the VA retaliation against whistleblowers like myself had 
worsened. Although the article did not appear until 10/30/17, the VA 
was notified of my comments in advance as part of the standard 
procedure for journalists. Shortly after the time the VA was initially 
notified, I sent an inquiry to that OAWP Executive Director asking for 
an update on the detail position because I had not heard from him after 
waiting the expected 4-5 weeks it takes to get detail approval. In a 2 
sentence email he replied he was not moving forward with the detail for 
me. He did not respond to my subsequent email politely asking for an 
explanation.
    In January 2018 VACO publicly denied in a 1/17/18 USA Today article 
that I was offered an OAWP position despite those emails to/from the 
now-former OAWP Executive Director which are described above. Although 
I do not have direct evidence of VACO's interference with my detail, it 
seems logical that only VACO senior leadership would have the power to 
not only cancel the detail that had been arranged by the DUSHOM but 
also deny such a detail position offer ever existed.

    6)The OAWP is inappropriately asking for complaint details/
documentation which could logically interfere with a potential/pending 
OSC investigation.

    My OAWP experience: On 1/25/19 I was contacted via email by an OAWP 
triage case manager to determine if I still wanted to file a complaint 
based on my 2017 correspondence with the OAWP. At the time of contact I 
was already in the OSC's Alternative Dispute Resolution (ADR) process 
with the VA because a Fall 2018 preliminary OSC investigation found 
credible evidence of whistleblower retaliation against me. I explained 
this and asked ``would there be any purpose in engaging the OAWP now?''
    Per a 1/30/19 email, the OAWP case manager responded that the 
``OAWP would still conduct their investigation despite OSC involvement 
(provided we have all supporting documentation).'' This statement is 
extremely concerning to me. Because the VA has no expedited mediation 
process in place, my ADR with the VA has been ongoing since October 
2018. If the mediation process ultimately is not successful, then it 
will terminate.
    If the current ADR process fails, then the OSC would conduct a full 
investigation of the VA retaliation against me. In the event of a full 
OSC investigation, if the VA were to be given advance access by the 
OAWP to my complaint and all my supporting documents, I fear there 
would be a significant risk intimidation of/retaliation against my 
witnesses or other interference with the OSC investigation of my case.
 Section V: Potential Remedies to Assist VA Whistleblowers, Positively 
  Influence VA Culture, & Strengthen Federal Whistleblower Safety-Nets
    Because many ingrained root causes contribute to VA whistleblower 
retaliation, I do not know of any single method which could effectively 
obliterate retaliation in the VA system overnight. However, I believe 
there are potential remedies which, if done concurrently, realistically 
could address immediate whistleblower concerns, facilitate reductions 
in VA retaliation events, positively influence VA culture so all VA 
employees could identify safety issues without fear of retaliation, and 
systematically strengthen federal whistleblower safety-net resources. I 
have listed a few of those remedies in this section.
    Note: Some of the recommendations listed below include references 
to 3 VA initiatives: High Reliability Organization (HRO), Just Culture, 
and Servant Leadership. In theory, each of these initiatives can 
positively influence VA culture. However, 2 initiatives (Just Culture & 
Servant Leadership) have not been consistently operationalized in a 
manner conducive to substantially influencing the sprawling VA culture. 
The remaining initiative (HRO) has not yet been implemented though its 
eventual success will be extremely limited if Just Culture & Servant 
Leadership are not already strategically in place.
    The HRO initiative is a 3-pronged approach to achieve 
organizational health care excellence by fostering a workplace culture 
of safety, dedication to continuous improvement, and leadership 
support. The ``culture of safety'' has techniques/guidance that empower 
every employee to verbalize safety concerns and potential solutions 
without fear of retaliation. As part of that culture, every level of 
leadership expects/actively encourages employees to verbalize 
legitimate concerns and take action to prevent patient harm. The 
emphasis on a culture of safety and continuous improvement are 
tantamount.
    The Just Culture initiative must be present to have an effective 
roll-out of HRO. ``Just Culture'' involves implementing an 
institutional culture wherein there is balanced assignment of 
accountability for designing safe processes/systems and for addressing 
any occurrence of negative health care/safety outcomes. That 
accountability is shared by both the individual employee and the 
institution. If a problem/negative outcome occurs, the event is 
analyzed to assign individual and institutional accountability. This 
analysis also determine how the problem/negative outcome can be 
prevented in the future by addressing employee-level issues as well 
institutional-level issues that contributed to the event. Just Culture 
also effectively reverses the present VA ``culture of blame'' wherein 
staff are penalized for admitting mistakes.
    The Servant Leadership initiative essentially encourages leaders to 
promote collaboration/teamwork, trust, and ethical behaviors among 
themselves and employees to meet the needs of the organization and its 
staff. In its simplest form, Servant Leadership is the ethical use of 
leadership power.

Recommendations for the Department of Veterans Affairs

      Reinstate a VA expedited mediation process (similar to 
what was present in 2014) for OSC cases wherein credible whistleblower 
is found and there are no confounding factors.
    Although it may be unintentional, the current extreme delays in VA 
mediation responses imply the VA devalues whistleblowers to the point 
that it is not even willing to provide adequate resources or expedited 
processes to ensure those suffering credible retaliation are treated 
promptly and fairly.
    If the Office of Special Counsel (OSC) has determined credible 
evidence of retaliation exists and there are no confounding employment 
factors, there is no reason for the VA to delay implementing the 
remedies to reverse the unfair/unjust personnel actions and 
appropriately address the effects the whistleblower retaliation has had 
on the employee. (I am defining ``confounding factors'' as substandard 
employee performance/conduct that normally would justify a major 
adverse personnel action as defined by as defined by VA Directive 5021/
17, Employee/Management Relations. Per that VA Directive, major adverse 
actions are ``suspension, transfer, reduction in grade, reduction in 
basic pay, and discharge based on conduct or performance''.)
    In 2014 the VA had an expedited mediation process for OSC cases 
wherein credible retaliation was found. Although I am not privy to the 
details of that confidential process or the rationale for discontinuing 
it, that 2014 VA expedited mediation process was successfully used to 
address the whistleblower retaliation against me and other VA 
employees.
      Discard the practice of removing/firing probationary 
employees who have become whistleblowers and who have displayed good 
work performance/competence during their VA probationary employment.
    The purpose of the probationary period is to determine if an 
employee is a good fit for the VA position and can function 
appropriately with other VA team members. If an employee has displayed 
good work performance/interpersonal skills at his or her position, that 
employee should be welcomed into the VA system because the VA workforce 
would benefit from the employee's presence.
    In the past, the VA has fired probationary employees after they 
become whistleblowers even though there were reportedly no red flags in 
the employees' VA work performance. While technically any employee can 
be fired without cause in the probationary period, the spirit of the 
applicable regulation/law is to help weed out poor performers including 
those with poor interpersonal skills and NOT to weed out those with the 
integrity to speak up about VA problems jeopardizing Veterans' care or 
agency mission. In addition, while there are legitimate red flags in 
probationary period performance that would necessitate firing a 
probationary employee whether or not the employee was a whistleblower, 
the VA should not use very minor issues that can be easily corrected 
with training or instruction as a trumped up excuse to fire a 
whistleblower when the VA would not use those same issues to fire a 
non-whistleblower in the probationary period.
      Ensure that all VA facility Administrative Investigative 
Boards (AIBs) and Professional Standard Boards (PSBs) are no longer 
weaponized as tools of retaliation.
    In the VA system, AIBs and PSBs have been weaponized to retaliate 
against whistleblowers. Unethical use of AIBs and PSBs involve 
deviating from prescribed regulations for committee set-up and 
functioning, providing the whistleblower with only limited information/
time to address allegations, stacking AIB/PSB committee membership in 
favor of the retaliator, and drawing conclusions that are not based on 
the objective evidence. There appears to be almost no accountability 
for AIB/PSB committee members who act in bad faith.
    The VA must ensure that all AIBs/PSBs are conducted in a 
standardized fashion according to appropriate regulations. However, 
AIB/PSB regulations can be complex and not all facility HR personnel 
are familiar with requirements. While there are several approaches to 
ensuring AIB/PSB standardization, some measures include 1) creating a 
system-wide universal standard operating procedure for all AIB/PSB 
phases that includes rules of procedure, 2) developing a mandatory AIB/
PSB checklist that must be completed/signed by committee members and 
verified by Human Resource staff as being accurate, and 3) holding any 
AIB/PSB committee member (as well as facility HR personnel) immediately 
accountable for deviating from the SOP/checklist.
      Revise VA leadership/supervisor training on whistleblower 
retaliation to ensure the content is comprehensive, impactful, and 
reflects real-world concerns of whistleblowers.
    Although I do not recall the exact date, sometime in the last 2 
years I was listening to a virtual presentation wherein leadership was 
receiving training on whistleblower retaliation. Although the training 
content was technically accurate, it fell far short of discouraging 
retaliation. The emphasis appeared to be on improving documentation of 
poor employee performance so that substandard employees could not hide 
behind ``whistleblower'' status to avoid accountability for poor 
performance. While I agree that employees should have appropriately 
applied accountability for their poor performance, I vehemently 
disagree with the inference that the vast majority of whistleblowers 
are just poor performers who became whistleblowers to shirk 
responsibility for their otherwise substandard performance.
    The training would have been much more useful it had identified 
examples of the commonly used HR tools surreptitiously used as 
retaliation, the reasons why those uses violated VA policy/ OPM 
regulations/federal law, and how misuse of those HR tools would not be 
tolerated within the VA system. The training certainly would have been 
more impactful if it identified 1) actual examples of consequences for 
leadership who deliberately misused such HR tools and 2) actual 
examples of the manner by which VA whistleblowers positively impacted 
agency operations/mission. The training should have also highlighted 1) 
ways in which to encourage all employees to identify VA problems 
without fear of retaliation and 2) methods for leaders to respond to 
reports of VA problems.
    In addition to seeking HR specialist/VA leadership perspectives on 
content development, VA whistleblower input on/evaluation of training 
content would help ensure the training addresses whistleblower concerns 
and is truly tailored to preventing whistleblower retaliation.
      Incorporate more effective means to encourage leadership 
to routinely recognize VA employees/whistleblowers who have alerted the 
chain-of-command about problems jeopardizing Veterans' care or agency 
mission.
    Recognizing employees who identify problems and/or solutions to VA 
operations and safety issues should be incorporated into standard VA 
workflow. Providing such recognition should be a substantially weighted 
expectation included in leadership's annual performance evaluation. In 
addition, the weekly national VHA call, monthly VISN Executive 
Leadership Council meetings, and other similar calls/meetings should 
have a recurring segment in which there is informal & formal 
recognition of leaders who have encouraged employees to speak up about 
problems negatively impacting VA operations and how identification of 
those problems will positively impact agency operations/goals.
    Unfortunately, VA leadership in many places do not routinely offer 
formal/informal recognition if an employee identifies problems and/or 
solutions to issues negatively impacting VA operations in any setting. 
Leadership do not follow the guidelines which are published Handbook 
5017/1, Employee Recognition and Awards.
    Although the current VA initiatives of ``Servant Leadership'', 
``Just Culture'', and ``High Reliability Organization'' theoretically 
would encourage positive leadership behavior and incorporation of 
employee recognition into standard VA workflow, those initiatives' 
principles have not been effectively operationalized.
      Revise Just Culture training/forms and then roll out 
``Just Culture'' to more VA facilities so that all VA employees will be 
encouraged to proactively identify and report patient health and safety 
concerns.
    If effectively implemented, the Just Culture initiative replaces a 
``culture of blame'' with balanced accountability for staff and the 
institution whenever negative outcomes occur. The Just Culture approach 
should significantly alleviate fear of retaliation/unjust treatment for 
identifying and reporting issues that negatively impact a facility's 
operations and safety.
    I recently reviewed some forms used by large VA facility to promote 
``Just Culture'' when assigning accountability to adverse patient 
safety events. I was appalled to see the forms neglected to formally 
evaluate/document whether institutional factors (e.g., short staffing, 
lack of proper process, lack of resources, etc.) contributed to the 
negative outcome. While the form did list some employee factors that 
would mitigate the type of accountability attributed to the employee, 
the document essentially still resulted in unilaterally assigning blame 
and instituting a punitive approach to address employee behavior.
    That punitive approach is not consistent with Just Culture 
principles. I am concerned that employees will not readily identify 
health and safety issues in such a punitive environment. If the Just 
Culture principles are being incorrectly applied in one large VA 
facility, I am concerned that Just Culture is being incorrectly 
operationalized at other VA facilities.
      Emphasize proper execution of Peer Review/Root Cause 
Analysis (RCA) to include the need to formally consider/document/report 
all institutional factors contributing to negative outcomes.
    While processes for Peer Review and RCA theoretically should 
include institutional factors/accountability for negative outcomes, in 
the VA such consideration is not consistently/objectively performed or 
documented. For each case/event being reviewed, there should be an 
enforced requirement for every Peer Review committee and Root Cause 
Analysis committee to formally solicit/document information on whether 
there were institutional processes that failed and/or otherwise 
contributed to the negative case/event outcomes. There should be a 
standard operating procedure in place for the Peer Review committee/RCA 
committee to ensure that institutional accountability is assigned and 
institutional deficiencies are proactively addressed so the risk of 
future negative outcomes can be reduced.
    While there are many ways to emphasize such institutional analysis, 
one potential way would be to develop a standardized reporting form 
which each involved employee would be required to complete and every 
committee would be required to consider. In addition to filling out a 
``blank'' section describing his or her account of the event/case, the 
employee would also be given the option to complete the pre-printed 
form questions including, but not limited to, 1) ``Are there pertinent 
facility factors (e.g., lack of resources/inadequate standard operating 
procedures/understaffing or other issues) that you believe contributed 
to the outcomes in this incident? If so, please explain.''; 2) ``Have 
you previously reported institutional factors you believe contributed 
to this negative outcome or could have prevented this negative outcome? 
If so, please explain.''; 3) ``Can you identify any facility process 
improvements or potential equipment/resources that could prevent this 
incident from re-occurring in the future? If so, please explain.''
    Emphasis on analyzing institutional/facility factors and 
appropriately assigning institutional accountability is consistent with 
the VA initiative of ``Just Culture'' and ``High Reliability 
Organization''.

Recommendations for the Office of Accountability & Whistleblower 
    Protection

    Note: I only have very limited recommendations for the OAWP because 
its processes are not transparent to me. I am proposing the following 
remedies based on my experiences detailed in Section IV of this written 
testimony.
      Speed up the time for triage intake/follow-up of OAWP 
complaints.
      Foster transparency in OAWP procedures so that 
complainants filing with the OAWP are aware exactly where their 
documentation/complaint will be forwarded at each step of the OAWP 
process and are informed of the approximate timelines for each OAWP 
process step.
      If referral of a complaint is necessary, establish 
processes to ensure the content of any referred complaint is handled by 
a neutral party at the complainant's VISN office or facility. (Ideally 
no referrals of whistleblower complaints would occur.)
      If not already doing so, based on the nature of the 
whistleblower retaliation allegations that are received, make ongoing 
content recommendations for real-time field updates and training 
pertaining to the prevention of VA whistleblower retaliation.
      If not already doing so, if the OAWP has inadequate 
resources, consider narrowing the scope of investigations conducted 
directly by OAWP staff to emphasize its current strengths (speed and 
agility) to address major adverse actions against whistleblowers.

    Although I do not have official data, I have anecdotally been told 
that a number of claims submitted to the OAWP are either for 
allegations completely unrelated to whistleblower retaliation or 
allegations in which the retaliation is not classified as a major 
adverse action by VA Directive 5021/17. (Per that VA Directive major 
adverse actions are ``suspension, transfer, reduction in grade, 
reduction in basic pay, and discharge based on conduct or performance.)
    While any type of credible whistleblower retaliation is 
unacceptable, the OAWP likely does not have the manpower resources or 
processes to personally investigate every allegation of whistleblower 
retaliation.
    If not already doing so, assuming OAWP resources are so limited 
that it must prioritize its activities, the OAWP should consider 
concentrating its available OAWP manpower on 4 activities 1) 
determining whether SES executives are facilitating retaliation, 2) 
determining if there are credible allegations of whistleblower 
retaliation in situations where the whistleblowers are facing unjust 
major adverse actions, 3) quickly reversing major adverse actions that 
reasonably appear to be stemming from whistleblower retaliation on 
investigation, and 4) monitoring/tracking data pertinent VA 
whistleblower retaliation.
    (Note: If the OAWP is not already doing so, the minimum pertinent 
OAWP data to monitor would include frequency of allegations of VA 
whistleblower retaliation, types of personnel actions that are reported 
in allegations of whistleblower retaliation, facility/service line 
implicated in allegations of whistleblower retaliation, and number/
facility/service line/major adverse action in substantiated 
whistleblower retaliation cases. That data could help the VA monitor 
whistleblower retaliation, identify trends, and proactively address 
areas where there are concerns about retaliation and/or indications of 
a need for facility/service line cultural change.)
    When conducting OAWP investigations involving SES executives or 
major adverse actions, the OAWP may choose to use its own employees for 
the investigation or obtain the assistance of non-OAWP VA subject 
matter experts. However, to avoid bias and potentially increasing the 
risk of further retaliation against the whistleblower, the OAWP should 
never delegate the primary investigative process back to the facility 
or the facility's VISN office if the case involves SES executives or 
major adverse actions against complainants.
    If the OAWP is referring any retaliation complaints to the VISN/
facilities, then it must establish standardized processes to ensure the 
content of any referred complaint is handled by a neutral party at the 
complainant's VISN office or facility.

      Take appropriate steps to ensure OAWP decisions are not 
influenced by internal pressure from VA Central Office.
      Do not solicit case documents when a potential 
complainant is already in the OSC investigative stage or mediation 
process.

Recommendations for Congress

      Consult with the Office of Special Counsel (OSC) to 
determine what additional budget allocation would enable the OSC to 
effectively manage its entire caseload and backlog in a timely manner 
and meet projected caseload needs.

    In general, the largest portion of OSC claims are filed by VA 
employees. At the end of 2018, the OSC had a backlog of over 2,600 
cases while still receiving new claims at historic levels. The general 
budget request for the OSC is 1% lower than last year. The OSC recently 
was able to hire 11 additional staff due by lowering its financial 
lease obligations, which will improve its ability to handle its 
caseload. However, additional budgetary monies may still be required to 
enable it to address all new and backlogged claims in a timely fashion 
and proactively address projections on the numbers of claims which will 
be filed in the coming fiscal year.
      Use bipartisan influence to ensure that a 3 member Merit 
Systems Protection Board quorum is immediately established.
    The MSBP is the safety net for all federal employees who have 
legitimate claims of adverse/unfair personnel actions including those 
who are VA whistleblowers. The MSPB has not had a quorum for over 2 
years. Without a quorum no MSPB appeals can be decided. As a result 
there is a backlog of over 2,000 petitions and other cases - each day 
of delay for each case has potentially significant negative impact on 
an employee's career, livelihood, and psychosocial well-being.
    Although 2 MSPB nominees have been approved in committee, they have 
not been submitted for full vote because there is a wait for select a 
3rd nominee. (Of the 3 nominees originally selected, 1 nominee withdrew 
his name from consideration.)
    (An employee can choose to bypass the MSPB delays by filing 
directly in federal circuit court. However, this option is out-of-reach 
for many federal employees because it is extremely cost-prohibitive and 
lengthy.)
      Allocate sufficient budgetary monies for the Merit 
Systems Protection Board (MSPB) to fulfill its mission requirements in 
a timely manner and recruit additional staff to replace pending 
retirements.
    The budget request for the MSPB is 10% lower than last year. The 
MSPB had stated the budget cut will significantly impact multiple 
operations and also affect its ability to address staffing needs for 
pending retirements. The MSPB is a major safety net for federal 
employees and should not be jeopardized.

                                 
                 Prepared Statement of Jeffery Dettbarn
    Chairman Pappas, Congressman Bergman, and distinguished members of 
the Subcommittee, it is my honor to appear before you today to testify 
about my experience as an employee and whistleblower at the Department 
of Veterans Affairs. My name is Jeffery Dettbarn, I have been employed 
for over 14 years at the Iowa City VA Medical Center, with an 
unblemished record before blowing the whistle on the improper mass 
cancellation of what turned out to be tens of thousands of radiology 
orders. I have been a Registered Radiologic Technologist for over 29 
years. After receiving the Mallinckrodt award for the highest 
achievement in my radiology school class, I went on to my first job as 
an X-ray Technologist, learning general ultrasound, echo cardiography 
and carotid doppler sonography. I took a position approximately 2 years 
later doing Mobil Computerized Tomography which also allowed me the 
opportunity to learn to drive a Semi truck and trailer. I later worked 
at the University of Iowa working as a Cardiac Cath laboratory 
technologist and in Orlando Florida, where I spent 11 years working in 
many facets of radiology as a supervisor. In 2005, I returned to Iowa, 
taking the position of Radiology Supervisor at the VAMC Iowa City. 
After 3 + years as a supervisor, I stepped down to the role of CAT Scan 
Technologist and that was what I did and loved every work day until I 
blew the whistle two years ago and was quickly banished to non-patient 
care duties, where I have remained to the present date.
    Over the years I have developed a strong rapport with many of my 
patients, but NEVER have I had such an over whelming feeling of loyalty 
as I do to our Veterans. The comradery, compassion, and loyalty these 
men and women have to their Family, Flag and Freedom is phenomenal. It 
is also infectious. In my heart, the Veterans and I are family because 
of the relationships I have cultivated over the past 14 years of caring 
for them. I have been called ``Brother,'' by countless numbers of our 
Veterans, which to me shows their confidence, faith, and trust in me. I 
have not served but I SERVE them, and they are my extended family.
    I came forward and became a whistleblower out of concern that 
Veterans were being placed AT RISK of not receiving the care, and 
follow-up care, they desperately needed, and because of the unnecessary 
risk to patient care presented by non-medical personnel practicing as 
physicians. Since then, the VA has banished me from the hospital for 
two years, away from the greatest job ever-taking care of Veterans, cut 
my pay by a third, targeted me with an Administrative Investigation 
Board, proposed my removal, and subjected me to unbelievable physical 
and emotional stress,
    My present saga began in early to mid-2016, when the CT area began 
experiencing issues with management's implementation and attempted 
implementation of bogus policies and Standard Operating Procedures that 
did not undergo the proper approval and implementation process. These 
``policies'' included email instructions for technologists to 
``protocol'' exams and to fill out, and complete with the Veteran the 
required Patient Consent forms. Protocol sheets are forms used to 
specify EXACTLY what type of scan a Veteran is to receive based on a 
diagnosis. For example, a chest CT may require the use of intravenous 
contrast, resulting in the need for a kidney function test, when ruling 
out cancer, or it may be done without contrast when looking for a 
calcification of the lung. Instructing a technologist to ``protocol'' 
an exam was entirely beyond the technologist's ``scope of practice,'' 
and something that only a physician should do.
    Another bogus policy involved the execution of the Patient Consent 
form-normally only executed by the Veteran together with the 
RADIOLOGIST when the use of intravenous contrast is necessary, yet the 
Veteran has some contraindication for NOT being a perfect candidate for 
contrast. All risk factors would be discussed by the radiologist and 
the Veteran, and the Veteran's informed consent would be obtained. This 
consent must include a consult with the radiologist for it to be 
effective, and instructing the technologist to execute the Patient 
Consent form was also out of the technologist's ``scope of practice.''
    Upon my questioning of many of these ``new'' rules, I was met with 
great hostility and anger. No matter who I tried to contact locally for 
assistance, someone in a higher position seemed to be blocking anyone 
who was willing to help me with the issues I had reported. The 
hostility I was met with paved the way for the barrage of retaliation I 
have endured since making my disclosures to numerous agencies, such as, 
OIG, OAWP, OSC, and including Senators Grassley and Ernst.
    The big reveal of the impact of improper cancellations of radiology 
orders came on February 22, 2017, when a Veteran presented for a CT of 
the chest for a LUNG CANCER screening. There was a history of smoking 
since age 13. That cancelled order would eventually be found to have 
been improperly cancelled by the Radiology Service Secretary-only the 
Physician who ordered it should have cancelled it. This order had been 
cancelled 19 days prior to the appointment, meaning that the mysterious 
cancellation had not been adequately reviewed for nearly three weeks 
and suggesting that it had been part of a ``block'' or ``mass'' 
cancellation.
    The lead technologist at the time, when attempting to register what 
should have been an active order, inquired ``why can't I register this, 
there is no order.'' Upon investigation, I realized there was an issue 
due to the original order having been cancelled by the Service 
Secretary, who is not a licensed practitioner. This violation of policy 
was magnified when the lead technologist then took it upon himself to 
``Reorder'' the Veteran's exam, in effect acting as the Veterans care 
provider. This is completely beyond the Scope of Practice of a 
Radiologic Technologist. Orders are only valid when initiated by a 
Licensed Independent Practitioner. The lead technologist went on to 
hide what had been done by destroying the ``New'' order and passing off 
the paperwork for the cancelled order as bona fide, stating to a co-
worker, ``This one is ready,'' and implying that the Veteran was ready 
for a valid exam, properly ordered by a Licensed Independent 
Practitioner. This is when I knew something was wrong.
    I informed my co-worker of the issues and specifically instructed 
him to ``hang on to that paperwork, this is going to come back 
around.'' I had no knowledge at the time this was anything other than 
an Iowa City issue, but it has since become an ongoing national 
investigation of improper radiology cancellations by the VA Inspector 
General. Some 12,660 orders were cancelled at the Iowa City VA Medical 
Center alone, according to the sworn testimony of our Administrative 
Officer.
    My co-worker at the time voiced his concerns of these unprecedented 
actions to management, and I voiced mine to Patient Safety. In no realm 
of health care is this practice of cancelling a physician's order 
acceptable. Normally, only the physician who placed the order would 
cancel the order. Every day for the months to follow, my co-worker and 
I would uncover multiple scheduled patients with their orders cancelled 
by management and ancillary staff. In the weeks to follow I would again 
contact patient safety officers, compliance officers, AFGE, and the 
Joint Commission (JACHO) Readiness Manager with my concerns of the mass 
cancellations we were seeing in radiology.
    Anyone trying to assist me or make their own disclosures was met 
with every roadblock you can imagine, from sham Administrative 
Investigation Board investigations, to blatant retaliation by not only 
management, but other employees recruited by management. The harassment 
caused a co-worker to leave the VA entirely.
    By June of that same year, I was informed that one of the staff 
radiologists was now complaining of my job performance. This complaint 
came at approximately the same time of my first disclosure to Senator 
Grassley. Months later, as I reviewed the testimony and documents used 
by the Administrative Investigation Board to justify my removal, I 
became aware that just days after I submitted an Electronic Patient 
Safety Report on June 22, 2017, the Administrative Officer solicited 
others in the department to forward to her any adverse reports on me 
that they could come up with. These false allegations were exactly the 
pretext upon which the VA proposed my removal six months later, and 
included, ``Failure to follow hospital Policy and procedure, failure to 
follow standard operating procedure, failure to assist a radiologist 
during a contrast reaction, and failure to follow physician instruction 
on patient positioning.''
    During that same timeframe, ironically, I was also nominated for 
and awarded a ``Good Catch Award,'' submitted to the agency by a co-
worker for my actions regarding a Veteran's poor renal function. After 
discovering the potential for complications due to an order for 
intravenous contrast, I alerted the proper staff to ensure the 
Veteran's care and treatment were NOT jeopardized by the contrast. Only 
by accident was I made aware of this award the day after I was to have 
received it at the All Employee Forum from our Medical Center Director, 
Judith Johnson Mekota. After that, it would take me almost four months 
of continually asking the director and her aid, before finally 
receiving my pin and certificate via interoffice mail. Because I was 
later banished from the main facility, the award was forwarded to me by 
a co-worker; it had been sent to the Radiology department and placed in 
my mailbox which had been stripped of my name.
    On July 12, 2017, while a Joint Commission Survey Consultant was at 
the facility reviewing numerous processes in the CT area, my co-worker 
and I disclosed to the consultant many of our concerns, including 
technologists being instructed to act outside the scope of their 
practice. The consultant later confirmed that the ordering and 
``protocoling'' of exams by CT technologists was improper and must 
cease. Yet, as I have heard from others to scared to come forward, the 
cancellations have continued.
    During this entire time while I was questioning the improper 
cancellation of orders, management at the Iowa City VA consistently 
referenced the ``DUSHOM directive,'' Outpatient Radiology Scheduling 
Policy and Interim Guidance, VAIQ 7722255, of August 12, 2016, as 
justification. This directive begins with the declaration that ``orders 
can be placed as much as 390 days in advance,'' yet management was 
cancelling orders as ``expired'' that were within days of the date the 
Veteran was scheduled to appear for care. This is but one example of 
management's flawed and twisted interpretation of this directive.
    Later, after the VA detailed me out of the main facility, I learned 
from others to afraid to speak up that numerous specialty clinics where 
keeping secret lists of Veterans who would present for their 
appointments and NOT have received the prior imaging required for that 
appointment. A case manager of the Urology clinic informed me of this 
practice, and upon investigation and questioning, other case managers 
and Nurse Practitioners from Urology, Pulmonary, Ear, Nose and Throat 
(ENT) Hematology and Oncology all admitted to having similar lists. 
Upon learning of these lists, I contacted OIG, with the permission of 
the case managers and Nurse Practitioners to release their names, and 
reported that ``they would gladly speak with an OIG official,'' should 
they be asked. To my knowledge, there has been no follow up from OIG 
regarding my complaint.
    On July 27, 2017 I was summoned to the Chief of Imaging Service 
office. This was to be the beginning of my ``Banishment,'' from the 
hospital setting. I was given a ``not to exceed 120 days'' detail 
letter and told to immediately report to the Federal Building. No 
specifics of why I was being detailed were given. I was handed a piece 
of scratch paper with ``Post Office,'' and ``Find Savanah,'' written on 
it. Upon my arrival at the partially abandoned post office building in 
downtown Iowa City, I found the building locked with an access control 
system and I had not been given the code. There were no signs or 
identifiers to guide me once inside the building, but this was just an 
introduction to the types of retaliation I have encountered over the 
past 2 + years of being a whistleblower by the Agency.
    Following my detail to the partially abandoned federal building, I 
was targeted by a sham AIB investigation. In August 2017 I was told to 
appear for testimony before the AIB, but I was not given a charge 
letter, only informed that the AIB was addressing ``issues in 
radiology.'' Soon after I began to testify, it became clear from the 
accusatory nature of the questions, that I was the target.
    At that same time I had again contacted Senator Grassley, and I 
continued to contact Senator Ernst, whose office got me in contact with 
the OSC disclosure unit. I then began the tedious process of filing 
Forms 11 and 12 with OSC. I was also given contact information for OAWP 
and in December of 2017, I formally filed with them after a telephonic 
conversation with a triage case manager. This would lead to my sending 
hundreds of emails and skype messages to OAWP, attempting to get any 
information or progress reports about my case. I do not recollect ever 
being contacted by OAWP, I had to initiate all communication. In the 
meantime my detail was extended-``not to exceed'' 120 days, again.
    In November 2017, prior to the release of the AIB report, and after 
my initial contact with the intake and the retaliation unit lawyers of 
OSC, I was made aware that I had been the target of a patient abuse 
allegation which is what prompted my removal from direct patient care. 
On December 28, 2017, the Chief of Staff, Stanley L. Parker, proposed 
my termination. It was at this time that I was given the testimony and 
exhibits from the sham AIB investigation. After reviewing the entire 
4000 plus pages and prompted by the amount of false testimony it 
contained and the apparent attempt by management to cover up the 
wrongdoings at the VA Medical Center Iowa City, I sought assistance 
with the process of ``Blowing the Whistle.'' I had been referred to as 
being ``Toxic,'' and ``Bi-Polar'' by the JACHO Readiness Manager and 
Administrative Officer of Imaging Services, and it had been reported to 
me that the Imaging Supervisor had warned co-workers, ``not to let Jeff 
get his hooks into them.''
    It wasn't until I reviewed the testimony and exhibits that I became 
aware of the numerous Reports of Contact aimed at me and submitted by 
the recently assigned Cat Scan Supervisor who had been promoted twice 
with a year, likely rewarding him for his willingness to retaliate 
against me. It is my belief that I was targeted for this barrage of 
Reports of Contact because of my whistleblowing and part of the effort 
to have me dismissed from my position. That Cat Scan Supervisor also 
made several attempts to discipline me for bogus and unfounded 
allegations, alter the scope of my duties, or simply harass me only to 
be blocked or reversed with help from AFGE.
    Beginning in July 2017, VA employees retaliated against me by 
filing multiple bogus complaints with the Iowa Department of Public 
Health and the American Registry of Radiologic Technologists, the 
national association that maintains my certifications. All of these 
allegations have been investigated and dismissed as having no merit and 
no action is needed but this particular retaliation is incredibly 
hurtful and could result in the loss of my livelihood.
    The process of seeking assistance as a whistleblower was truly 
confounding. Do you file with EEO, OSC, OAWP, OIG, ORM, or JACHO? How 
would anyone know who to contact? Sometimes you contact the wrong 
agency, not knowing which way to go with no guidance or assistance. 
Although I was lucky enough to have two good intake lawyers at OSC, not 
everyone is that fortunate. For every person who gets to this point of 
being a whistleblower there are 1000 that have spoken up only to be 
removed, demoted, or intimidated into silence. After finally getting in 
touch with some of these remedial agencies, I was occasionally 
confronted with downright hostility, making the whistleblower feel as 
if ``they'' are the problem, or that their disclosure is not relevant 
or important. After that, I sat for months before finally prodding a 
response from OAWP, or subsisting on the minimal correspondence from 
OSC and OIG. During this ongoing two years of exile away from my 
patients, the VA has forced me to forego about one-third of my salary, 
shutting me off from ``on-call'' pay.
    I have endured both physical and mental stress over the past 2 + 
years of retaliation and whistleblowing, including Major Depressive 
Disorder and Social Anxiety Disorder. I have sought psychiatric 
counselling and started on medication for both disorders. I have had to 
endure multiple regimes of different drug combinations to find one that 
will afford me enough relief to allow me to function despite the 
depression. I also have had to start on medication for chronic stomach 
pain and discomfort caused by stress and nervousness. I am reluctant to 
attend any type of function outside of my home, because of the risk of 
a panic attack-I was forced to leave my nephew's wedding because of 
one. My social life has become non-existent and the headaches, nausea, 
stomach cramps, and diarrhea are at times debilitating.
    My current professional situation, after 22 months, is unbearable. 
The VA has placed me in a fabricated position as a ``records 
requester.'' I am NOT receiving approximately $20,000-$30,000 per year 
of ``on-call'' pay which is specifically stated in my job description 
and represented about one-third of my annual income. I have not had a 
performance appraisal for over three years. The mobbing and harassment 
continues, ranging from fabricated allegations against me, to the 
clothing I wear to my detailed position in the partially abandoned 
federal building.
    A truly accountable upper-level management would have easily 
rectified the mass cancellation problem in its earliest stages by 
admitting there was a problem and mustering all-hands to correct it. 
But instead, they chose to blatantly fabricate excuses and present 
incorrect DUSHOM directives, trying to pass them off as permission to 
continue illegal activity. They then fabricated and pursued egregious 
accusations against me, the person who spoke up for the core VA values 
and our Veterans. Some of my co-workers who were similarly committed to 
high-quality patient care chose to leave the VA rather than endure the 
toxic leadership.
    There is a culture of fear and retaliation that the VA uses as the 
weapon to silence the whistleblower. I am the prime example that the 
Iowa City VA has made to silence all employees. I have heard everything 
from ``look at the trouble Jeff is in,'' to ``you don't want to end up 
like Jeff,'' but I feel the worst is to have been asked ``what did you 
do?'' And the answer is, ``I TOLD THE TRUTH.'' Other employees can see 
what happened to me, the VA destroyed my career because I told the 
truth. They will not speak up.
    I am concerned about the lack of accountability for those 
responsible for the mass cancellations. I have been banished for 2 
years, away from patient care, with no end in sight, while the 
Administrative Officer who was responsible for the cancellations and 
the direction to cancel the orders for those needed exams has faced no 
repercussions. Likewise, the Cat Scan Supervisor, implicated in the 
cancellations and the retaliation was returned to duty promptly after a 
120-day detail. There has been absolutely NO discipline for those who 
broke the rules and retaliated against me for speaking the truth. Where 
is our SPEED OF TRUST, I CARE, and NO FEAR that is constantly touted by 
management? Where is the accountability preached by OAWP, where is the 
TRANSPARENCY everyone speaks of? The only information I received on 
OAWP was an email from the AFGE president stating that one particularly 
sensitive email that I provided to OAWP was forwarded to hospital 
management and then thrown in the union representative's face to be 
used against me as evidence of my not being a team player.
    One of the most important questions I have for the committee is who 
will stand up for the best quality CARE our Veterans need and deserve? 
If not for the VETERAN, I would not be a whistleblower, I would not be 
needed. When I think of why I am doing all of this, I think of my 
brother, a medically retired Chief Warrant Officer 4, who served 20 
years before a life-threatening accident in Iraq that took him out of 
the military. The thought of him needing any type of care and it being 
jeopardized by individuals who are not qualified to cancel, alter, or 
order a life-altering test is unfathomable to me. I have other 
immediate family members, father and uncles, that also receive their 
care at the VAMC. The Veterans I am trying to protect and help have 
become an extended family to me. I know hundreds of them by name, their 
histories, their family scenarios, and their loved ones. As I have 
continually stated in this process: This is someone's Mother, Father, 
Son, Daughter, Husband or Wife.
    Taking care of my patients and ensuring the best possible care for 
our Veterans is why I am here and it is what I love. At this point and 
time in my life I haven't much to lose or anything to gain. I am 51 
years old, and my life has been very good. However, the Veterans that I 
am here for, to stand up for, and be a voice for, DO have a lot to 
lose. THEIR LIVES.
    Thank you.

                                 
                 Prepared Statement of Dr. Minu Aghevli
    Thank you for having me today. It's an honor to be here.
    I am the program coordinator of the opioid agonist treatment 
program at the VA Maryland Health Care system in Baltimore, Maryland. 
We provide medication assisted treatment for over 400 opioid dependent 
veterans. I've been with the VA almost twenty years, and in this role 
for over ten. Throughout my career, I have consistently received 
outstanding ratings on my performance evaluations, and I have been 
awarded multiple Gold VA Pins for excellent customer service. Our 
program treats one of the most vulnerable and stigmatized group of 
veterans in the VA system, who are at an extremely high risk for 
overdose, suicide and other deaths. Many are indigent. I love my job 
and the veterans that I treat. I have spent years developing 
relationships with my patients and have earned their trust and respect. 
I can't imagine any job I'd rather do. But for the past five years, the 
VA has consistently impeded my ability to provide care to veterans who 
need it the most, at the expense of those veterans, and in order to 
prevent me from speaking out about patient care issues.
    Most recently, on April 24, 2019, the Chief of Staff and Medical 
Center Director summarily suspended my clinical privileges under 
circumstances which could only lead to the conclusion that they were 
revoked because I blew the whistle. I have not been able to provide 
care to veterans since then and there is no available recourse for me.
    By way of background, for approximately five years, the VA has 
engaged in continuous retaliation against me, in what appears to be a 
concerted, systematic effort to oust me from the Agency. The 
retaliation started when I first reported concerns about the improper 
practices for maintaining a waitlist for veterans waiting to receive 
care for opioid treatment. Specifically, in the spring of 2014, 
following a nationwide Agency scandal concerning lengthy patient wait 
times, VA management began to convey to me that our waitlist was too 
long and they were concerned the waitlist would draw scrutiny from VA 
leadership and Congress. In order to reduce the waitlist, I was 
instructed to improperly remove veterans from the electronic waitlist 
by scheduling fake appointments for them in an imaginary clinic. This 
clinic was not tied to any provider or location, nor did it actually 
correspond to any real visits and accordingly, the veterans scheduled 
for these fictitious appointments were not actually receiving VA care.
    The VA also pressured me to artificially reduce the number of 
patients on the waitlist through other improper means. This included 
making minimal efforts to contact indigent patients and then coding 
them as ``care no longer needed'' without confirming that care was, in 
fact, no longer needed; as well as scheduling patients for appointments 
without telling them, and then coding them as ``no show'' when they did 
not appear for the appointments about which they had not been notified. 
I was repeatedly pressured to make these changes, and I protested. I 
went through my chain of command including the
    Deputy Director and Director of Mental Health, the head of my 
facility and ultimately to the Secretary of the VA. I also repeatedly 
communicated my concerns to Office of Inspector General (``OIG'') and 
to this Committee. For example, in September 2015, the VA received a 
Congressional suspense asking about wait times for treatment. Due to 
our inappropriate removal of patients from the electronic waitlist, the 
official numbers were significantly less than the actual numbers of 
veterans waiting to receive care. When the VA deliberately sent these 
incorrect numbers to Congress, I again contacted OIG and also got in 
touch with this Committee.
    For the past five years, VA management has made my life a nightmare 
and interfered with my ability to perform my duties but the Office of 
Special Counsel (``OSC'') has repeatedly told me that the VA's actions 
are just not bad enough for them to take any action. Approximately one 
month after I complained of the improper waitlist practices, I was told 
that I would be summarily transferred out of my coordinator role and 
moved to an entirely different area of the hospital, where I would be 
performing work unrelated to substance abuse treatment or the area in 
which I had expertise. I filed with both OIG and OSC, and the transfer 
was rescinded at the last possible minute before it became effective. 
During the month that I was awaiting that transfer, I lost twenty 
pounds and almost had a nervous breakdown. However, OSC told me that 
since the VA had reversed the transfer, there was no adverse personnel 
action for them to address. Since then, I have been routinely 
reprimanded and subjected to fact findings about various frivolous and 
inappropriate things. I have been excluded from meetings, subjected to 
scrutiny and oversight that my colleagues are not, my functional 
statement has changed, and I have been stripped of many duties which I 
previously performed. In June 2016, I was informed that I would be 
detailed to work in the Mental Health Executive Suite and prohibited 
from engaging in patient care. The VA did not provide any legitimate 
justification for its decision. I retained counsel and was ultimately 
reinstated to my position. I was again unable to obtain redress through 
OSC, who closed my case earlier this year, finding that the details did 
not constitute a prohibited personnel action.
    Most recently, shortly after OSC closed out my earlier case, VA 
management again removed me from clinical care, this time also formally 
suspending my privileges. As a result, I am currently not able to 
provide care to veterans and am instead assigned to perform basic, data 
entry work. The letter that I received from the Medical Center Director 
stated that the suspension was because I visited one of our high-risk 
veterans at a community hospital after he had overdosed and then 
subsequently attempted to commit suicide. This reason is simply 
nonsensical and cannot be the true reason for the suspension of 
privileges. I had visited the veteran with the approval and 
authorization of the attending physician and the Director of the ICU at 
the hospital where the veteran was located. I have contacted the 
Maryland Psychological Association's Ethics Committee, and numerous 
other highly respected psychologists and physicians, all of whom agree 
that there are no concerns with my conduct. According to a Maryland 
Psychological Association Ethical Consult, the only ethical issue is 
the fact that the VA is forcing me to me abandon my patients. My 
actions were also in line with the VA's policies on assessment and 
follow up of suicide risk and providing mental health care to high risk 
veterans, an issue I am grateful this Committee has devoted a lot of 
attention to.
    Since the suspension, I haven't been allowed to speak to any of my 
patients, plan for coverage of the program, or even sign my chart notes 
from the day that my privileges were suspended.
    Despite the fact that I have been unnecessarily unable to provide 
care to high-risk veterans for two months, OSC has again proven to be a 
futile option. On June 4, 2019, OSC issued a preliminary determination 
letter stating that ``[t]he suspension of privileges is not a personnel 
action covered by 5 U.S.C. Sec.  2302.''
    In sum, the VA has been relentless in threatening me with action, 
taking limited action against me, and then evading any liability by 
reversing course. The constant harassment has ruined my life and 
impeded my ability to provide care to veterans. When I turned to it for 
help, OSC refused to take action and left me vulnerable to the Agency's 
sanctioned retaliatory actions.
    Ultimately, the way the VA treats whistleblowers affects veteran 
care. I have taken care of some of my patients for close to twenty 
years. I see many of them every single day and as their therapist and 
the program coordinator, I am often one of the few constants in their 
lives. Every time I've abruptly disappeared, it is traumatic for them 
as well. After my suspension, I was not even allowed to visit a patient 
dying from cancer in our hospice unit to say goodbye, or call his 
family to offer my condolences after his death. These are certainly 
adverse outcomes. I've been punished for speaking up for a group of 
people who are often stigmatized, and that isn't right. They deserve 
better. Many of the veterans we treat, especially in substance abuse, 
don't have a lot of support in their lives or people who are advocating 
for them and letting them know they are worth fighting for. It's 
important to me to speak up when they are not receiving the treatment 
they deserve, because we need to convey a message that our veterans, 
and their treatment, are worth standing up for. I ask you to please 
join me in standing up for these underserved veterans and expand 
protections for whistleblowers so that we can continue ensure that 
these veterans receive the care to which they are entitled, without the 
VA undermining us by circumventing current law.

                                 
                  Prepared Statement of Rebecca Jones
    Chairman Pappas, Ranking Member Bergman, and members of the 
Subcommittee, thank you for the opportunity to testify today on the 
vital role of whistleblowers at the Department of Veterans Affairs 
(VA), and on the steps you can take to protect those brave 
whistleblowers. I am Rebecca Jones, a Policy Counsel at the Project On 
Government Oversight. POGO is a nonpartisan independent watchdog that 
investigates and exposes waste, corruption, abuse of power, and when 
the government fails to serve the public or silences those who report 
wrongdoing. We champion reforms to achieve a more effective, ethical, 
and accountable federal government that safeguards constitutional 
principles.

The Role of Whistleblowers at the Department of Veterans Affairs

    Whistleblowers at the Department of Veterans Affairs put their 
careers on the line every time they speak truth to power to ensure the 
best care possible for those who put their lives on the line to defend 
our country. In that way, VA whistleblowers are heroes serving heroes.
    Disclosures by VA whistleblowers save patients' lives by bringing 
to light barriers to timely and effective medical care due to either 
negligence or intentional misconduct, exposing officials who have 
perpetuated a culture of abuse for decades, and freeing up taxpayer 
dollars that are being misused and that instead can and should go 
toward providing resources and care.
    We've seen firsthand the profound and immediate impact 
whistleblower disclosures can have on quality of care at the VA. Many 
are familiar, for example, with the wait lists at Arizona's Phoenix VA 
Health Care System brought to light by VA whistleblowers. While the 
system's computer records falsely indicated that vets were getting 
timely medical appointments, a secondary and accurate wait list 
reflected the actual prolonged wait times that veterans were 
experiencing. That secondary list showed that approximately 1,400 
veterans were waiting months to meet with a doctor. At least 40 of 
those veterans died waiting in the backlog tracked by the accurate 
list. \1\ To add insult to injury, this wait-list scheme didn't just 
hide the magnitude of the problem from Congress and the public, it 
likely ensured that high-level officials received personal performance 
bonuses. \2\ The VA inspector general found in 2014 that the way the VA 
cooked the books made it seem that the system operated efficiently. 
Taking advantage of this appearance, ``leadership significantly 
understated the time new patients waited for their primary care 
appointment in their [leadership's] FY 2013 performance appraisal 
accomplishments, which is one of the factors considered for awards and 
salary increases,'' \3\ according to the inspector general.
---------------------------------------------------------------------------
    \1\ Scott Bronstein, Drew Griffin and Nelli Black, ``Phoenix VA 
officials put on leave after denial of secret wait list,'' CNN, May 1, 
2014. http://www.cnn.com/2014/05/01/health/veterans-dying-health-care-
delays/
    \2\ Chelsea J. Carter, ``Were bonuses tied to VA wait times? Here's 
what we know,'' CNN, May 30, 2014. https://www.cnn.com/2014/05/30/us/
va-bonuses-qa/
    \3\ Department of Veterans Affairs Office of Inspector General, 
Veterans Health Administration - Interim Report - Review of Patient 
Wait Times, Scheduling Practices, and Alleged Patient Deaths at the 
Phoenix Health Care System, May 28, 2014. https://www.va.gov/oig/pubs/
VAOIG-14-02603-178.pdf
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    Unfortunately, the misconduct in Phoenix was not an isolated 
incident. Complaints of inaccurate VA wait lists can be traced back 
over a decade and all over the country, \4\ and even after the Phoenix 
scandal, the abuse persisted. And whistleblowers continued to be 
essential in bringing those abuses to light.
---------------------------------------------------------------------------
    \4\ Rich Gardella and Talesha Reynolds, ``Memos Show VA Staffers 
Have Been `Gaming System' for Six Years,'' NBC News, May 13, 2014. 
https://www.nbcnews.com/storyline/va-hospital-scandal/memos-show-va-
staffers-have- been-gaming-system-six-years-n104621
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    For instance, in 2015 the VA inspector general released a report in 
response to this committee's request to investigate a whistleblower's 
disclosure of mismanagement at the Veterans Health Administration's 
Health Eligibility Center. \5\ The inspector general substantiated many 
of the whistleblower's disclosures, finding that the Chief Business 
Office, the central authority for determining VA benefits eligibility 
and enrollment, had ``not effectively managed its business processes to 
ensure the consistent creation and maintenance of essential data.'' \6\ 
That mismanagement included deleting 10,000 or more unprocessed 
applications, and employees hiding applications in their desks. The IG 
noted that in the instance of employees intentionally hiding 
applications, the VA neither reported the incident to the VA inspector 
general, nor did it discipline the employees responsible because 
leadership had played a part in the situation. \7\
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    \5\ Department of Veterans Affairs Office of Inspector General, 
Veterans Health Administration, Review of Alleged Mismanagement at the 
Health Eligibility Center, September 2, 2015. https://www.va.gov/oig/
pubs/VAOIG-14- 01792-510.pdf (Hereinafter, IG Report)
    \6\ IG Report, p. ii.
    \7\ IG Report, pp. 14, 17.
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    In 2017, two whistleblowers disclosed that a secret wait list in 
Omaha hid the fact that 87 veterans faced inordinate delays for mental 
health appointments. Congressional attention and pushback helped to 
highlight this incident, but no employees were terminated from 
employment. \8\
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    \8\ Steve Liewer, ``Nebraska-Western Iowa VA kept secret waiting 
list for some mental health appointments,'' The World Herald, October 
16, 2017. https://www.omaha.com/news/military/nebraska-western-iowa-va-
kept-secret- waiting-list-for-some/article--c428a382-320c-560d-bbee-
eb0a40ee6b23.html; Steve Liewer and Joseph Morton, ``Secret waitlist 
delayed care for 87 veterans at VA hospital in Omaha, led to departure 
of 2 employees,'' The World Herald, October 31, 2017. https://
www.omaha.com/livewellnebraska/health/secret-waitlist-delayed-care-for- 
veterans-at-va-hospital-in/article--5048df5a-bb65-11e7-932b-
af5b8746deef.html
---------------------------------------------------------------------------
    And just this month, a whistleblower came forward alleging that, 
yet again, VA facilities are secretly keeping separate, miles-long wait 
lists-three times the size of the public lists-to conceal long delays 
in care. As you know, this committee and its counterpart in the Senate 
sent a letter to the VA seeking an explanation. \9\ Now, the 
whistleblower who exposed the wait list is claiming that he is being 
retaliated against professionally for his disclosure. \10\
---------------------------------------------------------------------------
    \9\ Letter from Chairman Mark Takano of the House Committee on 
Veterans' Affairs, and Ranking Member Jon Tester of the Senate 
Committee on Veterans' Affairs to Robert Wilkie, Secretary of the U.S. 
Department of Veterans Affairs, on veterans' access to timely health 
care, June 4, 2019. https://www.dropbox.com/s/4gcsnmq3d8aq9qe/
2019.6.4%20Takano%20and%20Tester%20Wait%20Times%20Lett er.pdf?dl=0
    \10\ Joe Davidson, ``Does VA have a secret wait list for health 
care? Key members of Congress want to know,'' The Washington Post, June 
5, 2019. https://www.washingtonpost.com/politics/does-va-have-a-secret-
wait-list-for- health-care-key-members-of-congress-want-to-know/2019/
06/04/28d149e2-8717-11e9-a491- 25df61c78dc4--story.html
---------------------------------------------------------------------------
    In all these instances, it took whistleblower disclosures for the 
public to learn what happened-a nearly universal truth across the 
federal government.
    And yet, across the federal government, blowing the whistle 
continues to be a risky business: Even though federal employees are 
legally protected for exposing wrongdoing, they're likely to face 
retaliation for doing so. A 2010 survey revealed that about one-third 
of federal employee whistleblowers say they experience ``threats or 
acts of reprisal, or both.'' \11\ And potential whistleblowers are 
discouraged from making disclosures at every turn, whether directly by 
their supervisor or indirectly by seeing their co-workers retaliated 
against for speaking out for what's right. All the while, retaliating 
supervisors go unpunished, or worse-get rewarded. The adage that no 
good deed goes unpunished is profoundly true for VA whistleblowers.
---------------------------------------------------------------------------
    \11\ Merit Systems Protection Board, Blowing the Whistle: Barriers 
to Federal Employees Making Disclosures, November 2011, p. i. https://
www.mspb.gov/mspbsearch/
viewdocs.aspx?docnumber=662503&version=664475&application=ACROBAT
---------------------------------------------------------------------------
    In 2014, POGO investigated problems at the VA by inviting VA 
whistleblowers to make secure disclosures to us online. Working with 
the Iraq and Afghanistan Veterans of America, we received disclosures 
from approximately 800 VA employees, contractors, and veterans in just 
a month's time. The disclosures were diverse in both the problems they 
exposed and the employees making them. Disclosures ranged from a 
pharmacy technician who faced retaliation for repeatedly reporting 
missed, late, and expired doses of medication administered to patients, 
to a nurse being forced out of her job after speaking up for her 
patients whose injuries were being severely neglected. \12\
---------------------------------------------------------------------------
    \12\ Testimony of Lydia Dennett, Project On Government Oversight, 
before the Senate Committee on Appropriations Subcommittee on Military 
Construction, Veterans Affairs, and Related Agencies, November 6, 2015, 
pp. 1-2. https://www.appropriations.senate.gov/imo/media/doc/110615-
Dennett-Testimony1.pdf (Hereinafter Dennett Testimony)
---------------------------------------------------------------------------
    In reviewing the disclosures, the theme was clear: VA 
whistleblowers were terrified of speaking out for fear of losing their 
livelihood. ``Management is extremely good at keeping things quiet and 
employees are very afraid to come forward,'' one whistleblower 
explained. \13\ Worse, not only were whistleblowers being attacked by 
their employer, the VA inspector general investigating their 
disclosures or retaliation claims was often worsening the situation by 
exposing the whistleblowers' identities. POGO soon experienced this 
toxic culture for ourselves, as the then-acting VA inspector general, 
Richard Griffin, attempted, unsuccessfully, to force us to hand over 
the database of VA whistleblower complaints we'd complied. \14\
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    \13\ Dennett Testimony, p. 3.
    \14\ Letter from Richard Griffin, then-Acting Inspector General, 
Department of Veterans Affairs, to Project On Government Oversight, 
regarding subpoena to POGO, May 30, 2014.
---------------------------------------------------------------------------
    In 2018, after a change in inspector general leadership, then-
acting VA secretary Peter O'Rourke tried to intimidate the VA's newly 
Senate-confirmed inspector general, Michael J. Missal, in an attempt to 
kill an inspector general investigation. \15\ Missal raised the alarm 
when his office wasn't getting requested information and documentation 
from the agency about the Office of Accountability and Whistleblower 
Protection-documents that the inspector general is entitled to under 
the Inspector General Act. \16\ In what seemed like a desperate attempt 
to get the inspector general off his back, the acting secretary wrote, 
``You are reminded that OIG [Office of Inspector General] is loosely 
tethered to VA and in your specific case as the VA Inspector General, I 
am your immediate supervisor. You are directed to act accordingly.'' 
\17\ Of course, the idea of an inspector general being subservient to 
an agency head is wholly contrary to both the spirit and the design of 
federal inspectors general. Nonetheless, the VA apparently felt 
entitled to lash out against the independent investigation.
---------------------------------------------------------------------------
    \15\ Joe Davidson, ``As inspectors general are celebrated, VA tried 
to intimidate its IG,'' The Washington Post, July 10, 2018. https://
www.washingtonpost.com/news/powerpost/wp/2018/07/10/inspectors-
generals-are-celebrated-as-va- tried-to-intimidate-its-ig/ 
(Hereinafter, IG Intimidation)
    \16\ The Inspector General Empowerment Act of 2016 added clear 
access to agency records for inspectors general. Public Law 114-317, 
Sec. 5. https://www.congress.gov/114/plaws/publ317/PLAW-114publ317.pdf
    \17\ Letter from Peter O'Rourke, Acting Secretary of Veterans 
Affairs, to Michael Missal, Inspector General, U.S. Department of 
Veterans Affairs, about access to documents concerning the Office of 
Accountability and Whistleblower Protection, p. 2. https://
assets.documentcloud.org/documents/4529198/Letters-Between-Missal-and- 
O-Rourke.pdf
---------------------------------------------------------------------------
    Thanks to this committee's leadership \18\ and that of its 
counterpart in the Senate, \19\ the backlash against O'Rourke was swift 
and bipartisan. But the lesson is clear: The modus operandi at the VA, 
starting at the top of the agency, is to quash investigations and 
dissent by bullying investigators and retaliating against 
whistleblowers-all to the detriment of veterans and taxpayers.
---------------------------------------------------------------------------
    \18\ House Committee on Veterans Affairs, ``RM Walz Responds To 
Unprecedented Attack By Acting VA Secretary O'Rourke On VA Inspector 
General,'' June 18, 2018. https://veterans.house.gov/news/press-
releases/rm-walz- responds-unprecedented-attack-acting-va-secretary-o-
rourke-va-inspector
    \19\ IG Intimidation

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The Office of Accountability and Whistleblower Protection

    In April 2017, the Office of Accountability and Whistleblower 
Protection (OAWP) was created through Executive Order 13793, \20\ which 
was later codified and expanded upon by Congress when the VA 
Accountability and Whistleblower Protection Act was passed into law. 
\21\
---------------------------------------------------------------------------
    \20\ Executive Order 13793, ``Improving Accountability and 
Whistleblower Protection at the Department of Veterans Affairs,'' April 
27, 2019. https://www.federalregister.gov/documents/2017/05/02/2017-
08990/improving- accountability-and-whistleblower-protection-at-the-
department-of-veterans-affairs
    \21\ Public Law 115-41, Codified at 38 U.S.C. Sec.  323.
---------------------------------------------------------------------------
    A merging of VA's Office of Accountability Review and the Central 
Whistleblower Office, the OAWP is an internal fact-finding body that:

    serves to improve the performance and accountability of VA senior 
executives and employees through thorough, timely, and unbiased 
investigation of all allegations and concerns. Where these actions are 
found factually true, OAWP will provide recommended actions related to 
the Senior Executive or other senior leader's removal, demotion or 
suspension based on poor performance and/or misconduct. Additionally, 
OAWP provides protection of valued VA whistleblowers against 
retaliation for their disclosures under the whistleblower protection 
provisions of 38 U.S.C. section 714. \22\
---------------------------------------------------------------------------
    \22\ Department of Veterans Affairs Office of Accountability and 
Whistleblower Protection, Report to The Committee on Veterans Affairs 
of the Senate And The Committee on Veterans Affairs of the House of 
Representatives On the Activities of the Office of Accountability and 
Whistleblower Protection, June 2018, p. 3. http://
federalnewsnetwork.com/wp-content/uploads/2018/07/ANNUAL-REPORT-Office-
of-Accountability-and- Whistleblower-Protections-Activities.pdf 
(Hereafter, OAWP Report)

---------------------------------------------------------------------------
    The office is broken into six sub-offices:

      Executive Office of the Director, the overseer and 
liaison between OAWP and VA leadership;
      Triage Division, the first point of contact for 
whistleblowers both in making initial disclosures and in reporting 
retaliation, and the overall case manager that sends intake to 
different offices, depending on content;
      Investigations Division, the office that conducts 
investigations into whistleblower retaliation and senior official 
misconduct allegations when referred to them by the Triage division;
      Advisory and Analysis Division, which recommends 
corrective action to senior VA leadership based on OAWP investigations, 
and trains VA leadership on the Accountability Act;
      Knowledge Management Operations, which maintains and 
creates structural databases for OAWP's work, and;
      Human Resources and Office Support, which provides 
support to OAWP staff, and conducts external affairs.

    As of last year, OAWP was supported by 73 employees. \23\
---------------------------------------------------------------------------
    \23\ OAWP Report, p. 6.
---------------------------------------------------------------------------
    In order to be resolved, all VA whistleblowing disclosures must now 
go through OAWP at some point. Even those that an employee files with 
the Office of Special Counsel or the VA inspector general must 
eventually go through the Triage Division for processing. \24\
---------------------------------------------------------------------------
    \24\ OAWP Report, p. 8.
---------------------------------------------------------------------------
    While the office has now been in operation for about two years, 
there is very little evidence to indicate that it's functioning as 
intended. In June 2018, the OAWP released its first annual self- 
assessment report, as required by statute. While it's clear from the 
report that the office was still being stood up, it nevertheless saw a 
predictably huge amount of intake, reporting having received ``nearly 
2,000 submissions'' from whistleblowers in its first year. \25\
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    \25\ OAWP Report, p. 9.
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    Unfortunately, despite the office's mission, that large intake does 
not seem to have translated into any significant trend of disciplinary 
actions against senior VA officials found to have retaliated against VA 
whistleblowers. From OAWP's own reporting, senior executives and senior 
leadership made up only 0.1% of disciplinary actions taken during 
OAWP's tenure. That 0.1% maintains the average levels seen since 2014 
and, in fact, is actually a decrease from recent years. The total 
number of disciplinary actions taken from June 2015 to June 2016, for 
example, was 15 cases, and from June 2016 to June 2017 there were just 
9. In OAWP's first year, June 2017 to June 2018, there were only 7. 
\26\
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    \26\ OAWP Report, pp. 27-28.
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    Instead, during OAWP's existence, 36.4% of disciplinary actions 
were taken against GS rank 1 through GS rank 6 employees. \27\ Based on 
that reporting, it's difficult to conclude that OAWP is succeeding in 
its mission of holding VA senior executives accountable for their 
actions. It reads, instead, like they're maintaining the status quo of 
focusing disciplinary action on lower level employees.
---------------------------------------------------------------------------
    \27\ OAWP Report, p. 30.
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    The Government Accountability Office (GAO) released a review in 
July 2018 of the VA's employee misconduct procedures and practices, and 
provided more insight into what is causing this imbalance. \28\
---------------------------------------------------------------------------
    \28\ Government Accountability Office, Department of Veterans 
Affairs: Actions Needed to Address Employee Misconduct Process and 
Ensure Accountability, July 2018. https://www.gao.gov/assets/700/
693268.pdf (Hereafter, GAO Report)
---------------------------------------------------------------------------
    The GAO reported that senior officials engaging in misconduct are 
not being consistently held accountable at the VA. When a retaliation 
claim was substantiated and investigators proposed disciplinary action, 
the VA didn't always follow through with that recommendation. GAO found 
that the VA failed to discipline senior officials in 5 out of the 17 
cases with substantiated misconduct. \29\ Information from OAWP seems 
to explain why: The agency's own attorney is pre- reviewing 
disciplinary decisions before they're finalized. \30\ Such a review 
indicates that the agency's attorneys could reject proposed 
disciplinary action, and it risks exposing the identity of the 
whistleblower to senior agency executives.
---------------------------------------------------------------------------
    \29\ GAO Report, introduction.
    \30\ GAO Report, p. 94.
---------------------------------------------------------------------------
    Although OAWP's authorizing statute rightfully forbids the Office 
of General Counsel's (OGC) involvement in whistleblower claims, \31\ 
OGC is nevertheless heavily involved. Once OAWP's advisory and analysis 
division completes their disciplinary proposal based on the underlying 
investigation, they send that proposal to the OGC's office for legal 
review. \32\ Although the OAWP and the OGC are both housed within the 
VA, their interests are not the same. The OGC's mandate is to represent 
the best the interests of its client: the VA. Repeated disciplinary 
actions taken against VA senior officials is not in the VA's best 
interests. It could affect public perception of the VA's work, future 
funding, and individual jobs. The OAWP, on the other hand, is in charge 
of fact-finding and analysis independent of any ulterior motivation to 
keep the agency out of legal trouble. Allowing agency attorneys to 
provide legal analysis or review of a proposed disciplinary action is 
akin to a judge allowing the defense attorney in a criminal case to 
overturn the judge's decision against a defendant. It's highly 
unethical for OGC to weigh in on a whistleblower retaliation complaint, 
because OGC's sole interest is the legal representation of the agency.
---------------------------------------------------------------------------
    \31\ The VA Accountability and Whistleblower Protection Act of 2017 
Sec.  323(e): The Office shall not be established as an element of the 
Office of the General Counsel and the Assistant Secretary may not 
report to the General Counsel. https://www.congress.gov/115/plaws/
publ41/PLAW-115publ41.pdf
    \32\ GAO Report, p. 94
---------------------------------------------------------------------------
    GAO also found that employees who stand accused of whistleblower 
retaliation are reviewing, and sometimes even participating in, their 
own misconduct investigation due to the VA's systematically weak 
internal controls to monitor who is involved in an investigation and 
lax enforcement of the controls that do exist. \33\ This practice 
leads, according to the GAO, to confusion about the role of OAWP and 
about the office's responsibilities, and could make whistleblowers feel 
``uncomfortable or intimidated.'' \34\ GAO found instances, for 
example, where managers ``investigated themselves for misconduct.'' 
Further, the GAO explains in its report, the VA lacks the oversight 
measures necessary to ensure that misconduct allegations are 
investigated by an entity separate from the control or influence of the 
office accused of misconduct. \35\
---------------------------------------------------------------------------
    \33\ GAO Report, introduction.
    \34\ GAO Report, p. 55.
    \35\ GAO Report, introduction.
---------------------------------------------------------------------------
    GAO also found that VA officials were not following separation-of-
duty policies. Such policies require that a final decision on 
disciplinary action against an individual found to have engaged in 
whistleblower reprisal be made by an official at least one rank higher 
than the individual or team who proposed the discipline. This is to 
ensure multiple levels of review and to preempt any undue influence 
that someone charged with misconduct might have on the individual or 
office proposing the discipline. Unfortunately, GAO's report indicates 
that this is not happening consistently at the VA. Instead, the 
individuals recommending whether officials should be punished or not 
were also the individuals deciding whether or not to implement that 
recommendation. GAO found that 73 VA officials ``acted as both the 
proposing and deciding official'' in cases involving removal for 
employees who engaged in misconduct. GAO followed up on 29 cases of VA 
officials who violated a separation of duty policy at least twice, and 
not a single one had been disciplined. \36\
---------------------------------------------------------------------------
    \36\ GAO Report, pp. 44-45.
---------------------------------------------------------------------------
    GAO's report, combined with OAWP's own first-year numbers, do not 
paint a promising picture of solving the whistleblower retaliation 
problem within the VA. OAWP's existence hasn't led to greater 
accountability of senior officials, and hasn't led to greater safety 
for VA whistleblowers when they disclose abuse.

Fixing a Culture of Retaliation

    The problems uncovered by the GAO that relate to OAWP are 
consistent with what we have seen in other attempts to internalize 
whistleblower investigations within an agency. This is why POGO 
recommended increased structural independence for the office in 
previous Congressional testimony. \37\ The OAWP is fighting an uphill 
battle because it is trying to solve individual claims while 
simultaneously combating a persistent culture of whistleblower 
retaliation from within the agency itself. And this concept of a 
retaliatory culture is no mere speculation: The GAO found that VA 
whistleblowers are ``10 times more likely than their peers to receive 
disciplinary action within a year of reporting misconduct.'' \38\
---------------------------------------------------------------------------
    \37\ Liz Hempowicz, ``POGO Testimony on VA Accountability and 
Whistleblower Protection Act,'' May 17, 2017. https://www.pogo.org/
testimony/2017/05/pogo-testimony-on-va-accountability-and-
whistleblower-protection-act/
    \38\ U.S. Government Accountability Office, Fast Facts on 
``Department Of Veterans Affairs: Actions Needed to Address Employee 
Misconduct Process and Ensure Accountability,'' https://www.gao.gov/
products/GAO-18-137
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    Instead of changing the culture of whistleblower retaliation, 
keeping investigations under the wing of the larger agency creates an 
internal clearinghouse used to silence employees speaking out. \39\ 
According to recent reports from VA whistleblowers, several individuals 
who have contacted the office have had their identities exposed. As a 
result, the VA inspector general is currently conducting its own 
investigation into this issue. \40\
---------------------------------------------------------------------------
    \39\ Daniel Van Schooten, ``POGO and Others Oppose `Trojan Horse' 
Office for VA Whistleblowers,'' September 30, 2016. https://
www.pogo.org/analysis/2016/09/pogo-and-others-oppose-trojan-horse-
office-for-va-whistleblowers/
    \40\ Eric Katz, ``New Whistleblower Protection Office Is Under 
Investigation for Retaliating Against Whistleblowers,'' Government 
Executive, April 16, 2019. https://www.govexec.com/oversight/2019/04/
new-whistleblower-protection- office-under-investigation-retaliating-
against-whistleblowers/156314/
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    The VA's stated vision is to ``to provide veterans the world-class 
benefits and services they have earned-and to do so by adhering to the 
highest standards of compassion, commitment, excellence, 
professionalism, integrity, accountability, and stewardship.'' Based on 
the information available, it's hard to draw any conclusion other than 
that the agency is failing to make this vision a reality and has been 
for some time. While OAWP may have been created out of a desire to 
shift the retaliatory culture, it lacks the structural independence it 
needs from an agency stymied by a pervasive internal culture of 
whistleblower retaliation, so the cards were stacked against it from 
the outset.
    Recommendations for Reform
    Changing the culture of whistleblower intimidation and retaliation 
at the VA isn't an easy lift, but it would surely have profound impacts 
for the veterans who rely on the VA's care. Holding senior officials 
accountable for their actions is vital for lasting change. It is also 
essential that the agency work to prevent retaliation in the first 
place by ensuring independent, comprehensive, and swift investigations, 
and providing quality training for employees on their rights. In doing 
that, the VA will demonstrate that they take whistleblower allegations 
seriously and will show employees that it's safe to come forward.
    The first step toward improving the functionality of OAWP is 
ensuring that the office has the independence necessary to analyze and 
thoroughly investigate both whistleblower retaliation complaints and 
allegations of misconduct by senior officials. While the best course of 
action would be to remove OAWP's investigative functions from within 
the agency's structure entirely, we understand that such a sweeping 
reform may be a longer-term goal.
    To immediately make the office more independent, Congress should 
mandate that the OAWP have its own office of legal counsel, 
circumventing any need to refer matters to the VA's Office of General 
Counsel. OAWP concurs with this recommendation, noting that relying on 
the OGC creates the appearance of a conflict and creates delays in 
resolving cases. \41\
---------------------------------------------------------------------------
    \41\ OAWP Report, p. 22.
---------------------------------------------------------------------------
    To further increase independence, Congress should consider 
mandating more guidance and oversight from the U.S. Office of Special 
Counsel (OSC) and OAWP. Such guidance and oversight should include OSC 
review of OAWP's final recommendations for disciplinary action of 
senior-official misconduct as a means of quality control. This will 
also end reliance on agency officials, such as those in the agency's 
Office of General Counsel, who should be conflicted out of reviewing 
OAWP decisions.
    Congress should mandate that OAWP develop and oversee a 
comprehensive and transparent system to ensure that those who are the 
subject of an investigation, and their immediate office, are not able 
to influence the investigation into their own behavior. Such a system 
must also ensure that separation of duty policies are upheld in 
practice. Individuals found to have knowingly and willfully violated 
these policies should face mandatory disciplinary action. As a part of 
this, OAWP should better track department-wide disciplinary action, so 
that they can follow up on whether senior officials are actually being 
disciplined, while ensuring the protection of the whistleblower 
involved.
    Further, OAWP should implement robust, updated training regarding 
the options available to employees for reporting disclosures or 
whistleblower reprisal, the connection between OAWP and other 
investigative entities such as the U.S. Office of Special Counsel and 
the VA Office of Inspector General, and the rights of whistleblowers to 
make disclosures anonymously, as well as training on how a 
whistleblower's information is to be shared between investigative 
entities. At the time of OAWP's first report, they had yet to 
disseminate updated training materials. \42\
---------------------------------------------------------------------------
    \42\ OAWP Report, pp. 20-21.
---------------------------------------------------------------------------
    Congress should also consider broader reforms to the Whistleblower 
Protection Act to address issues that plague not just VA 
whistleblowers, but all federal employees who can claim protection from 
retaliation under the law. First, Congress should amend the law to 
include retaliatory investigations as a ``prohibited personnel 
practice'' in order to combat one of the most common forms of 
whistleblower retaliation used to intimidate and stifle those who speak 
out.
    While the Whistleblower Protection Enhancement Act expanded 
protections for federal employees in 2012, employers responded to the 
stricter law by opening retaliatory investigations as a means to 
distract from the underlying disclosure without technically committing 
an actionable offense. \43\ By reforming the law to include these 
investigations as a prohibited practice, whistleblowers would be 
protected from the outset of the retaliation, rather than having to 
wait for suspension or termination from their job.
---------------------------------------------------------------------------
    \43\ Government Accountability Project, ``Ban the Criminalization 
of Whistleblowers!'' https://www.whistleblower.org/truthjailing/
---------------------------------------------------------------------------
    Second, Congress should extend the right to a federal jury trial to 
federal employees who blow the whistle. Given prolonged delays in 
access to justice for whistleblowers who have been retaliated against, 
federal jury trials would ensure an expeditious, independent forum for 
whistleblowers to seek relief.
    VA whistleblowers blow the whistle because they're honor bound to 
speak up when they witness violations of the country's trust or 
individual suffering caused by negligence or corruption.
    Creating or empowering independent oversight bodies that help 
whistleblowers make disclosures benefits us all, but it's vital that 
Congress be willing to quickly amend laws that carry unintended 
consequences for those they were meant to protect. POGO thanks this 
Subcommittee for taking the next steps in investigating protections and 
processes at the VA for whistleblowers and we urge you to take action 
to expeditiously fix this broken system.

                                 
                  Prepared Statement of Thomas Devine
    MR. CHAIRMAN:

    Thank you for inviting testimony from the Government Accountability 
Project (GAP). This hearing is timely and necessary. Despite repeated 
legislation, a presidential Executive Order and national media 
scandals, the Department of Veterans Affairs (DVA) remains a free 
speech Death Valley for government whistleblowers. This is not 
surprising. Retaliation is ingrained in the culture of the DVA. It will 
take years of aggressive oversight and accountability before this 
agency respects the First Amendment or the Whistleblower Protection Act 
(WPA) in practice, rather than empty rhetorical promises. This 
conclusion reflects the bitter experience of whistleblower rights 
lawyers from all perspectives. Two of today's witnesses are from GAP's 
docket of ten DVA clients, representing 40% of the 25 whistleblowers 
whom I represent. That ratio is consistent with the U.S. Office of 
Special Counsel's (OSC) experience. This is an extraordinary record for 
one agency in the nearly two million Executive branch work force. 
Forty-percent of whistleblowers is an extraordinary number for an 
Agency that comprises less than 20% of the Executive branch work force. 
Our experience is consistent with that of attorneys at the Senor 
Executive Association (SEA) who represent management whistleblowers. 
Their disclosures are the highest stakes exposure of mission breakdowns 
threatening the health of America's veterans.
    GAP is a nonprofit, nonpartisan, public interest organization that 
assists whistleblowers, those employees who exercise free speech rights 
to challenge abuses of power that betray the public trust. GAP has led 
or been on the front lines of campaigns to enact or defend nearly all 
modern whistleblower laws passed by Congress, including the 
Whistleblower Protection Act of 1989, the 1994 amendments and the 
Whistleblower Protection Enhancement Act.
    Over nearly 40 years we have formally or informally helped over 
8,000 whistleblowers to ``commit the truth'' and survive professionally 
while making a difference. We have been leaders in campaigns to pass 35 
whistleblowers laws ranging from Washington, DC to the recently-enacted 
European Union Whistleblower directive, which created enforceable free 
speech rights in 28 member nations. This testimony shares and is 
illustrated by painful lessons we have learned from this experience. We 
cannot avoid gaining practical insight into which whistleblower systems 
are genuine reforms that work in practice, and which are illusory.
    Our work for corporate whistleblower protection rights includes 
those in the Sarbanes-Oxley law for some 40 million workers in 
publicly-traded corporations, the 9/11 law for ground transportation 
employees, the defense authorization act for defense contractors, the 
Consumer Product Safety Improvement Act for some 20 million workers 
connected with retail sales, the Energy Policy Act for the nuclear 
power and weapons industries, and AIR 21 for airline employees, among 
others. Last year GAP was counsel for an amicus curiae brief filed by 
Representative Speier, as well as Senators Grassley and Johnson, which 
successfully defended the WPA burdens of proof for analogous corporate 
whistleblower statutes.
    We teamed up with professors from American University Law School to 
author a model whistleblower law approved by the Organization of 
American States (OAS) to implement at its Inter American Convention 
against Corruption. In 2004 we led the successful campaign for the 
United Nations to issue a whistleblower policy that protects public 
freedom of expression for the first time at Intergovernmental 
Organizations, and in 2007 analogous campaigns at the World Bank and 
African Development Bank. GAP has published numerous books, such as The 
Whistleblower's Survival Guide: Courage Without Martyrdom. We have also 
published law review articles analyzing and monitoring the track 
records of whistleblower rights legislation. See ``Devine, The 
Whistleblower Protection Act of 1989: Foundation for the Modern Law of 
Employment Dissent, 51 Administrative Law Review, 531 (1999); Vaughn, 
Devine and Henderson, The Whistleblower Statute Prepared for the 
Organization of American States and the Global Legal Revolution 
Protecting Whistleblowers, 35 Geo. Wash. Intl. L. Rev. 857 (2003); The 
Art of Anonymous Activism (with Public Employees for Environmental 
Responsibility and the Project on Government Oversight)(2002); and The 
Corporate Whistleblower's Survival Guide: A Handbook for Committing the 
Truth (2010).The latter won the International Business Book of the Year 
Award at the Frankfurt Book Fair. This spring, with the Project on 
Government Oversight (POGO) and Public Employees for Environmental 
Responsibility (PEER), we co-authored a survival guide for anonymous 
whistleblowers: Caught Between Conscience and Career: Expose Abuse 
without Exposing your Identity.
    Along with POGO, GAP also is a founding member of the Make it Safe 
Coalition, a non-partisan, trans-ideological network of 75 
organizations whose members pursue a wide variety of missions that span 
defense, homeland security, medical care, natural disasters, scientific 
freedom, consumer hazards, and corruption in government contracting and 
procurement. We are united in the cause of protecting those in 
government who honor their duties to serve and warn the public. Our 
coalition led the citizen campaign for passage of the Whistleblower 
Protection Enhancement Act (WPEA). The Coalition includes organizations 
for better government ranging from the Center for American Progress, 
the National Taxpayers Union and Common Cause, environmental groups 
from Council for a Livable World, Friends of the Earth and the Union of 
Concerned Scientists, conservative coalitions and organizations such as 
the Liberty Coalition, Competitive Enterprise Institute, American 
Conservative Defense Alliance and the American Policy Center, to unions 
and other national member based groups from American Federation of 
Government Employees and the National Treasury Employees Union, to the 
National Organization for Women. But the coalition itself is only the 
tip of the iceberg for public support of whistleblowers. Some 400 
organizations with over 80 million members joined the petition for 
passage of the WPEA.
                           ILLEGAL GAG ORDERS
    If there were any hopes that the DVA has learned from years of 
scandal and remedial legislation, the agency dashed them this month. On 
June 13 the DVA officially reaffirmed its illegal intolerance for 
freedom of speech by whistleblowers. The attached memorandum on media 
policy to all employees from the Acting Deputy Under Secretary for 
Health Operations and Management imposed the following policy:
    Queries that may yield negative coverage or are controversial in 
nature must immediately be forwarded for review to the appropriate 
regional Office of Public and Intergovernmental Affairs (OPIA) staff 
and VISN public affairs contacts . to generate an approved response..
    Regardless of subject, any query from national outlets also 
requires the same review. This includes outlets such as the Associated 
Press, Reuters, New York Times, Los Angeles Times, Wall Street Journal, 
Washington Post, Newsweek, USA Today, Huffington Post, National Public 
Radio, TIME magazine, CNN, and the network news and magazine programs 
of ABC, CBS, Fox, NBC and PBS.
    While the memorandum further orders employees not to communicate 
with the media as government representatives on official time, there is 
no clarification that they have that right speaking as free citizens on 
their own time. As a result, on its face this prior restraint violates 
three provisions of federal law, including two in the unanimously-
passed Whistleblower Protection Enhancement Act of 2012. (WPEA) - 5 
U.S.C. Sec.  2302(b)(13) and Sec.  114 of the WPEA, as well as a 
longstanding appropriations law provision. As explained in the attached 
legal memorandum, both the WPEA and an annual appropriations rider 
since FY 1988 require that any nondisclosure policy contain a 
clarifying addendum with the following message: rights in federal 
whistleblower laws trump its restrictions. This agency policy is very 
clear about its free speech restrictions, and silent on employees' 
legal rights. Hopefully this hearing will lead to the DVA respecting 
the rule of law, at least in terms of official policy.
                              CASE STUDIES
    Government Accountability Project's best contribution today will be 
sharing the nightmares of DVA whistleblowers who risked their 
professional lives to save the lives of America's veterans. 
Illustrative examples from our docket are below.
                              James Hundt
    The 2014 ``secret waiting list'' scandal for Department of Veterans 
Affairs (DVA) hospital care horrified the nation, and sparked a serious 
corrective action effort that was making significant progress at ending 
both the backlog and the deception. Unfortunately, over the last two 
years the Veterans Health Administration (VHA) has gutted the effort by 
replacing virtually the entire team of over 175 seasoned, professional 
career employees at its Veterans Engineering Resource Center (VERC) 
with the green crew of a buddy system contractor. The civil service 
team had been aggressively imposing, working closely with hospitals to 
implement and inspect, corrective action. Its effective efforts 
initially led to agency commendations.
    But they were all replaced in favor of a buddy system contract. The 
switch was accomplished through a reorganization illegally planned and 
controlled by the favored contractor. It reversed Commission on Care's 
internal agency recommendations and violated basic contracting and 
spending laws. To illustrate, the agency allowed the prospective 
contractor to draft a reorganization plan that would replace the civil 
service professionals with unqualified, completely inexperienced 
contractor staff. Since the civil service employees have been purged, 
on-site inspections have been replaced by an honor system in which 
facilities certify completion of various tasks. This helps to explain 
other testimony today such as Mr. Dettbarn's, concerning the 
persistence of secret waiting lists.
    VERC Associate Director James C. Hundt persistently blew the 
whistle internally to challenge the reorganization. The agency then 
opened illegal retaliatory investigations on Mr. Hundt, using it to 
fire him on pretextual grounds after he challenged the reorganization. 
He led a group of staff whistleblowers, the most active ones receiving 
the same treatment. In a stunning display of pretextual double 
standards, the agency fired Mr. Hundt for seeking personal gain on 
government time, although he had checked for prior approval of the same 
actions that non-whistleblowers engaged in and received promotions.
    This case of whistleblowing and reprisal calls for intensive 
congressional oversight to restore progress addressing the most serious 
challenge in recent years both to the DVA's integrity and the health of 
America's veterans. After initial support, since last year the U.S. 
Office of Special Counsel's efforts have become dormant, leaving the 
whistleblowers unemployed and further corrective action dysfunctional 
for the waiting lists. It also severely challenges respect for 
Congress' mandate in the Patient Protection Act, the Dr. Chris 
Kirkpatrick Whistleblower Protection Act and other recent statutory 
efforts against DVA whistleblower retaliation.
                     Kuauhtemoc ``Krod'' Rodriguez
    Mr. Rodriguez is an Iraq war veteran and former infantry officer 
who was serving as a Management Analyst in the agency's Phoenix, 
Arizona Health Care System when he began blowing the whistle to the 
OIG, to Congress and to the media about what has since been recognized 
as the agency's worst facility. He was one of the key pioneer 
whistleblowers who broke the secret waiting list scandals. In addition 
to challenging the Agency's gross waste of funds and cronyism, as an 
advanced computer expert he disclosed that the agency incorrectly 
scheduled approximately 400 patients, while another 400 patients had 
been waiting over 120 days for an appointment and over 8,000 
appointments were waiting to be scheduled. He later disclosed to 
Congress a list of 38,000 veterans waiting over 280 days for specialty 
care clinic appointments. He tracked how the agency was covering up the 
secret waiting lists. Using his computer skills, he has traced for 
Congress how the secret waiting lists were exponentially more severe 
than the agency had publicly conceded, and how the secret waiting lists 
extended well beyond Phoenix. Mr. Rodriguez not only disclosed the 
deception, but the tragic medical impacts including patient deaths.
    In response, agency managers moved him to a small, windowless 
office without air conditioning in Arizona; placed him under 
surveillance; eliminated his supervisory authority; actively recruited 
mobbing allegations against him; lowered his performance appraisals, 
referred to him as a ``rat'' and ``media whore''; failed to respond to 
death threats against him; placed him under criminal investigation; and 
subjected him to an AIB proceeding.
    Thanks to intervention from the agency's Office of Accountability 
and Whistleblower Protection's mentoring program, Mr. Rodriguez has 
been placed in a new location where the harassment has subsided. But 
his career has been paralyzed by denial of promotions for which he is 
eminently qualified, and the agency has denied all misconduct in WPA 
proceedings.
                             Daniel Martin
    Mr. Martin was the Chief of Engineering Services at the Veterans 
Affairs Northern
    Indiana Healthcare System (``VANIHCS''). He oversaw engineering 
operations at VANIHCS's two campuses (in Marion and Ft. Wayne, 
Indiana), and the nearby Marion National Cemetery, where he also 
supervised over 100 employees. After refusing attempted inducements by 
a contractor, he disclosed evidence to the DVA OIG that his superiors 
were engaged in illegally accepting gratuities, including at least free 
meals and entertainment, and possibly cash bribes from the VA 
contractor, in exchange for steering and awarding illegal sole source 
contracts to that contractor in violation of long-established anti-
bribery statutes and procurement regulations. One of the suspect 
contracts concerned the water purification system that is essential for 
sterilization of medical equipment and safe drinking water for 
patients. He later learned and disclosed evidence that the Indiana 
contracting abuses were not aberrations, but reflected corruption 
occurring nationally with contracts.
    In response, the agency stripped Mr. Martin of his duties, assigned 
him to an isolated office that was unheated in winter and not air-
conditioned in summer, and had him perform menial chores under 
supervision of a junior staffer. He was exposed to asbestos that he 
believes already is having a destructive medical impact. He was placed 
under three retaliatory investigations, primarily for an 
``altercation'' that his so-called victims denied was more than a 
conversation. The third probe was conducted by an AIB that denied him 
access or even the identities of adverse witnesses.
    Active intervention by OAWP, combined with GAP's Whistleblower 
Protection Act (WPA) appeal, prevented the agency from terminating Mr. 
Martin. But the Agency refused an OAWP-mediated solution to move him to 
Seattle, Washington, where the management said they would welcome him. 
Despite canceling his duties, Indiana officials said they could not 
spare Mr. Martin.
    During his WPA appeal, Government Accountability Program 
depositions of the officials who retaliated against Mr. Martin 
established that they knew of his OIG disclosures when they acted, 
which they previously had denied under oath during an inquiry by the 
Office of Accountability and Review (OAR). It appears that Mr. Martin 
may finally be allowed to work in Seattle and stop being a prisoner of 
those he blew the whistle against. But for over three years his 
professional life has been a nightmare, because he challenged 
corruption that could threaten the lives of DVA patients and staff.
                      Christopher ``Shea'' Wilkes
    Shea Wilkes is another pioneer VA whistleblower for exposure of 
secret waiting lists at VA hospitals in 2014. The OSC found there was a 
``substantial likelihood'' that his wait list disclosures were correct, 
but the Special Counsel later lambasted the VA Inspector General and 
the VA Office of Accountability Review for an obvious whitewash of this 
breakdown in their subsequent report on patient care.
    While his disclosures sparked a national spotlight on the VA's 
deadly neglect of veterans, Mr. Wilkes faced serious reprisal after 
blowing the whistle. Ten days after his disclosure to Congress and the 
VA Inspector General, he was placed under criminal investigation 
regarding his access to and the source of the secret lists. He was also 
stripped of his duties, denied any new training, and steadily harassed 
in a hostile workplace environment. After four years of steady 
hostility, an OAWP mentoring effort helped relieve the pressure on Mr. 
Wilkes. He is currently working for a new hospital director and 
attempting to resolve an active complaint at the Office of Special 
Counsel.
    Following his disclosures, Wilkes co-founded the 50+ member ``VA 
Truth-Tellers'' organization, one of the most effective whistleblower 
self-help groups currently operating today.
                           Dr. Nishant Pavel
    Dr. Patel is a psychologist with the Department of Veterans Affairs 
(VA) in New York whom the agency is gagging from attempting to help 
asylum seekers. For the last few years, he has volunteered with Weill 
Cornell Medical Center for Human Rights, an organization at Cornell's 
medical school that helps those individuals. He has assessed the mental 
state of numerous asylum seekers, and in six cases submitted affidavits 
on their behalf in immigration proceedings. No objection was ever 
raised by the Department of Homeland Security (DHS) or the VA to his 
submission of these affidavits. His work with the Center is pro bono.
    Last year Dr. Patel planned to offer expert testimony on behalf of 
another asylum seeker. As with his previous work, he would receive no 
compensation for his testimony, nor would he be identified as a VA 
employee during the proceedings. Before he was able to testify, 
however, attorneys for the Department of Homeland Security (DHS) 
asserted that he could not testify without permission from the DVA.
    Dr. Patel duly sought permission from his DVA superiors to testify, 
but was denied. The only explanation provided was that the VA would 
need permission from the Department of Justice (DOJ) but would not be 
able to get it. His supervisors also threatened him with criminal 
liability under 18 U.S.C. Sec.  205 if he testified. That statute bars 
government employees from acting as attorneys or agents for those in 
lawsuits against the United States.
    The newly-created objections are a shameless legal bluff that defy 
well-established case law interpreting the First Amendment and 5 CFR 
Sec.  2635.805, which governs outside activities of government 
employees. The threat of criminal liability is particularly baseless. 
There is no hint in statutory language of this extended application for 
Sec.  205, which repeatedly has been rejected in court. Nonetheless, 
the DVA has refused to eliminate the gag order, and if he resumes 
helping asylum seekers Dr. Patel will risk termination and prosecution.
         OFFICE OF ACCOUNTABILITY AND WHISTLEBLOWER PROTECTION
    OAWP enjoys a legislative and presidential mandate to help 
whistleblowers to make a difference and defend themselves against 
retaliation. Its authority to grant temporary relief against 
retaliation initially had an outstanding impact, and is unprecedented. 
It made a difference in several cases described above. Unfortunately, 
despite genuine commitment from some leaders and an impressive initial 
track record, it has become a threatening source of frustration for 
whistleblowers as the rule, and an effective remedial agency as the 
exception.
    This submission will not duplicate the in-depth analysis of my 
colleagues today on OAWP. However, it would be irresponsible not to 
share lessons learned about the basic causes of this frustration. Most 
basically, the Office lacks structural independence. In practice it 
cannot act without approval by the DVA Office of General Counsel, whose 
mission is to defeat whistleblower cases. This is a hopeless structural 
conflict of interest.
    On a cultural level, the OAWP staff lacks empathy and 
whistleblowers frequently complain of hostility. Many of its 
investigators come from offices where they accumulated anti-
whistleblower bias by spending their careers conducting retaliatory 
investigations of them. That does not end with a new duty station and 
job description.
    OAWP lacks enforcement teeth for permanent relief. Agency officials 
have the discretion to defy it with impunity. For example, early in the 
Dan Martin case it negotiated a transfer to Seattle. But the same 
Indiana manager who refused to give Mr. Martin any duties defied the 
resolution on grounds that he could not be spared.
    The Office inexplicably canceled its effective mentoring program. 
This effort had successfully defused conflict and shrank litigation by 
finding whistleblowers a fresh start with offices that would welcome 
their commitment to the agency mission, instead of being threatened by 
it.
    Most fundamentally, OAWP operates on an ad hoc basis, without 
accountability to regulations. This maximizes employee confusion and 
enables arbitrary actions in any given case, and permits inexcusable 
wastes of resources that exhaust targeted employees. To illustrate, the 
Senior Executive Association has detailed how OAWP conducted seven 
lengthy, draining investigations of a manager that resulted in a five 
day suspension, only made possible by removing exculpatory testimony 
from the evidence file.
    In short, without serious oversight, training and structural 
reform, this remedial office will degenerate into a Trojan horse for 
whistleblowers.
                            RECOMMENDATIONS
    It is clear that changing the DVA's repressive way of life will 
require marathon persistence, both in terms of oversight and stronger 
legal controls based on lessons learned. Based on these experiences, 
GAP has teamed up with our colleagues today and Public Citizen to share 
the following recommendations to keep pace with circumvention of prior 
reforms.
                      Agency-wide recommendations
      Jurisdiction to challenge retaliatory investigations as 
prohibited personnel practices when opened against the whistleblowers. 
Although made illegal in the Patient Protection Act, there is no 
enforcement mechanism.
      Jurisdictions to challenge Administrative Investigations 
Board proceedings as prohibited personnel practices, if initiated 
against an employee because of (or subsequent to) whistleblowing. AIBs 
should focus on halting abuses of power, not perpetuating them.
      Reform of the AIB structure and process so it stops being 
a ``Star Chamber.'' Board proceedings should conform to the due process 
requirements of the Administrative Procedures Act and the constitution, 
such as the right to call witnesses and confront accusers.
      Roll back gutted due process for internal agency 
personnel rights, which have been exploited against whistleblowers. For 
example, if a PPP is alleged, employees should have 30 days to respond 
to proposed personnel actions.
      Prohibit the delegation of authority to apply Section 714 
any lower than the director level, whether it be Network or Hospital. 
That is, any Section 714 disciplinary action would have to be proposed 
and decided by directors or higher.
      Extend to senior DVA executives the same protections in 5 
U.S.C. Sec.  714(e)(1)-(2) that apply to all other agency 
whistleblowers: after an alleged prohibited personnel practice, 
proposed termination, demotion or suspension cannot proceed without 
prior OSC approval. There should be analogous OAWP authority if an 
employee blows the whistle to that office.
      Provide temporary relief after an initial OSC, Inspector 
General or Merit Systems Protection Board Administrative Judge finding 
that there is a prima facie case under the Whistleblower Protection Act 
that an adverse action was taken because of whistleblowing. Few actions 
will be more effective to prevent retaliation than a realistic chance 
to freeze retaliatory faits accompli that exile whistleblowers for 
years while legal actions proceed at a molasses pace.
      If necessary as a pilot program, provide a jury trial 
``kick-out option'' for whistleblowers who do not receive a legal 
decision on appeals within 180 days. This would be similar to 
provisions under the Energy Reorganization Act (42 U.S.C. Sec.  5851) 
giving this option to Nuclear Regulatory Commission and Department of 
Energy employees.
      Identify as a prohibited personnel practice retaliatory 
referrals to licensing boards or the National Practitioner Data Bank. 
Employees should be able to challenge and have the agency vacate false 
or inaccurate reports, and must include in any report that the employee 
was a whistleblower. The DVA routinely uses these referrals to 
blacklist whistleblowers after firing them.
      Reinforce existing confidentiality protection with best 
practices. Employees should receive notice when their personnel or 
medical records have been accessed and by whom. Confidentiality rights, 
including those in OIG investigations, should extend beyond identities 
to shield all ``identifying information.'' Whistleblowers should 
receive immediate notice of legally-required, specific boundaries for 
confidentiality rights, such as court orders. Whistleblowers should 
receive advance notice when their identities must be exposed or 
compromised.
      Develop oversight measures to ensure all investigations, 
both disclosure and retaliation, referred to facility and program 
offices are consistent with policy and reviewed by an official 
independent of and at least one level above the individual involved in 
the allegation. To ensure independence, referred allegations of 
misconduct should be investigated by an entity outside the control of 
the facility or program office involved in the misconduct. This 
suggestions echoes (Recommendation 12 of the Government Accountability 
Office report GAO-18-137, July 2018).
                     OAWP specific recommendations
      The Secretary of Veterans Affairs should direct OAWP to 
develop a process to inform employees how reporting lines operate, how 
they are used, and how the information may be shared between the OSC, 
the OIG, OAWP, or VA facility and program offices when misconduct is 
reported (GAO Recommendation 16).
      OAWP should have, and only be responsible to report to 
its own General Counsel and directly to the Secretary.
      OAWP should have authority to enforce stays and other 
corrective action(s), including in response to actions proposed under 
authority other than Section 714.
      There should be mandatory annual OAWP staff training on 
whistleblower rights, identification of prohibited personnel practices, 
and the psychosocial elements of working with whistleblowers suffering 
from workplace traumatic stress. No OAWP employee should be permitted 
to participate in a whistleblower case without certification of 
completing this training course.
      OAWP should be required to provide mandatory No Fear Act 
training to all DVA employees on how to work most effectively with the 
Office both for whistleblowing disclosure and retaliation cases.
      The prior OAWP mentoring program should be restored as a 
mandatory channel for counseling and negotiation to find a fresh start 
for whistleblowers as an alternative to litigation, and should include 
solutions to reduce workplace traumatic stress.
      Regulations should be published that include dataset 
definitions (including veteran status), engagements procedures, and 
outcome options. Referral for adjudication of non-employee complaints 
should also be highlighted. The Secretary of Veterans Affairs should 
direct OAWP to develop a time frame for the completion of published 
guidance that would develop an internal process to monitor cases 
referred to facility and program offices (GAO Recommendation 14).
      There should be a Memorandum of Understanding Better 
between OAWP & OSC to reduce whistleblower confusion and prevent 
duplication by remedial agencies that already are overextended.

    Government Accountability Project has appreciated the thorough 
committee staff preparations for this hearing. The GAP team is 
available and would be honored to work with committee staff further on 
any of these recommendations. Both your committee and the whistleblower 
community are committed to making Whistleblower Protection Act rights a 
reality at the DVA. However, our work is far from finished.

                                 
    Prepared Statement of Jacqueline Garrick, LCSW-C, BCETS, SHRM-CP
    Chairman Pappas, Ranking Member Bergman, Distinguished Subcommittee 
Members:

    I am truly grateful to be here today because my journey could not 
have happened without the support that I have gotten from this 
Committee. By September 2017, it had been 3 years since I first 
disclosed my perceptions of a conflict of interest over the Defense 
suicide prevention funds and contracts at VA and reported waste, fraud, 
and abuse at the Departments of Veterans Affairs (VA) and Defense 
(DoD). Since then, I have experienced several forms of retaliation, 
including threats to stop speaking about my disclosure by a former 
government official. It was a very frightening, lonely, and ostracizing 
journey until I started to compare notes with other DoD and VA 
employees. These connections were so affirmational that it led to the 
creation of Whistleblowers of America (WoA), a nonprofit organization 
that, among other things, provides assistance to whistleblowers who 
have suffered retaliation. When we realized the potential level of 
conflicts and favoritism permeating government contracts, we jointly 
filed complaints with the DoD and VA Offices of Inspectors General 
(OIGs). That was Veteran's Day 2016. We wanted to send a strong message 
that the lives of veterans mattered. But other than getting a case 
number, there was no response from the VA OIG. The DoD OIG refused to 
even open a case. Almost a year later, the VA OIG finally came to my 
home - a day after this Committee became involved. I gave the OIG 
stacks of documents, shared emails, and named witnesses I thought would 
corroborate my story. Over the last year, the OIG interviewed witnesses 
in the search for a ``smoking gun'' - which was how they would later 
describe the level of evidence they were looking to find. However, it 
felt like the burden to develop that evidence was on me, not them. They 
were asking me to produce documents and witnesses, which I could only 
do through publicly available sources - such as USA Spending, Gov 
Tribe, or SAM.GOV. Evidence I got through FOIA was different than 
documents I could get during Discovery. As of today, I believe that the 
2016 investigation is still on-going, as well as inquiries by the FBI. 
However, waiting almost 3 years is a long time for justice, especially 
while VA underperforms in its High-Risk areas and has not met all of 
the GAO recommendations to be removed from that list. This, while 
veterans are dying by suicide and are being denied access to care; 
benefits take years to adjudicate, and staff shortages increase.
    I can personally attest that reporting waste, fraud, and abuse, 
inconsistencies in claims processing, substandard care, medical errors 
and wrongful deaths is asking to have your career killed by VA leaders 
who are more interested in covering up wrongdoing than in the lives of 
veterans. For example, in one case of retaliation, Medal of Honor 
recipient, David Bellavia can confirm that a blog he wrote included 
information from at least one source inside VA. The blog targeted a VA 
whistleblower who was working to correct a series of personnel and 
contracting issues she reported as fraudulent. The allegations made 
against the whistleblower in Bellavia's blog were proven to be false 
(after a 2-year, taxpayer-funded VA investigation), but VA never 
investigated the instigators of those false allegations nor did it take 
any steps to protect the whistleblower, who experienced violent threats 
(``slashing,'' ``clubbing,'' etc.) against herself and her family. 
Finally, the Department of Homeland Security got involved after a 
schizophrenic man approached the whistleblower at a conference and 
called her direct line with threats. Who was held responsible for 
inciting these acts of violence towards the whistleblower - acts that 
came just short of a physical altercation? No one. Sadly, VBA leaders 
stated that they had no recourse or reason to investigate. The 
whistleblower was left on her own, to try to find assistance from local 
law enforcement. No one has ever been held accountable for the false 
statements or cyber/verbal assaults against this VA employee. We can do 
better. We must do better.
    I founded WoA to build a peer support network, offer Whistleblower 
Protection Advocate certification, champion a Workplace Promise, and 
help employees rescale the harsh imbalances of justice that they 
endure. Since August 2017, WoA has heard from almost 200 VA employees 
who wanted to engage in ``rightdoing,'' but instead suffered 
retaliation, harassment and/or discrimination. WoA data is similar to 
the 33% VA workload reported by the Office of Special Counsel (OSC). 
\1\ By far, VA employees are reporting the most egregious risks to 
patient care, fiscal mismanagement, and abuse of authority.
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    \1\ OSC FY 2018 Congressional Budget Justification and Performance 
Budget Goals Report. https://osc.gov/Resources/CBJ-FY2018-Final.pdf
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    Furthermore, the Office of Accountability and Whistleblower 
Protection (OAWP) has not acted in the way we thought it would - to 
assist, support, and guide whistleblowers through a protected 
disclosure process, and provide a decision algorithm for whether to 
report to OSC, MSPB, EEOC, OSHA, FBI, or some other resource. There are 
many redundancies in these systems, along with gaps in services 
provided. OAWP should assist in navigating these systems and laws and 
ensure proper representation. Instead, VA employees--who are the eyes 
and ears of veteran care or benefits--are ignored, attacked, or 
relegated to obscurity when they try to engage in a continuous process 
improvement, seek ethical decisions, or solve patient care challenges.
    In my own interactions with OAWP, I was left leery. My first OAWP 
experience came after WoA issued a statement about a VBA hearing, along 
with feedback from employees. Unsolicited, I received an email from an 
OAWP case manager telling me that she was directed to reach out to me 
and requesting more information about a WoA allegation of impropriety. 
Primarily, she wanted whistleblowers' names, but I refused to give her 
that information and directed her back to VBA managers. My next 
interaction was after I met with the Veterans Service Organizations 
(VSOs) in an effort to engage them in a Veteran-Centric Accountability 
Council (VCAC). I had a vision for a VCAC that could address 
disclosures at a faster pace than a formal OIG and inform veterans 
about potential problems with their care. My main worry is that 
veterans do not know when they have been harmed by wrongdoing and that 
we need a stronger community voice to address these needs. The VSOs, 
such as the American Legion, conduct hospital site visits and could be 
``boots on the ground'' in reviewing any potential issues impacting 
patient care or benefits delivery. The American Legion hosted a meeting 
on October 2, 2018, which was attended by the ``Big Six.'' \2\ They 
suggested that our next step should be to meet with OAWP and get a 
policy briefing. The American Legion took the lead and tried to 
schedule the briefing. Suffice to say, it never took place and in fact 
Legion staff were purportedly accused by VA of trying to subvert the 
mission. Undeterred, I reached out to an OAWP employee who was a former 
whistleblower himself, thinking that he would have better guidance for 
how to proceed. When I got an insulting response, I shared it with 
another VA official who then got me in touch with Dr. Tamara Bonzanto 
and Mr. Todd Hunter, who did have a phone conversation with me on 
February 13, 2019. Dr. Bonzanto was newly appointed as the 3rd leader 
of OAWP and outlined her ``Engage then Change'' strategy for a way to 
reset the office. I have requested follow up meetings to discuss her 
assessment of the situation and hear her plans to develop policies and 
respond to the VCAC proposal, which could be FACA \3\ compliant, but 
was told that General Counsel needed to make the decision about working 
with WoA. To date, no word.
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    \2\ Along with the American Legion, also in attendance were the 
Disabled American Veterans (DAV), Veterans of Foreign Wars (VFW), 
Paralyzed Veterans of America (PVA), Vietnam Veterans of America (VVA), 
AMVETS, and the Military Officers Association of America (MOAA).
    \3\ FACA - Federal Advisory Committee Act of 1972
---------------------------------------------------------------------------
    In taking a closer look at hundreds of VA whistleblower 
conversations, several themes have emerged about VA accountability and 
the OAWP specifically.

Summary of OAWP Issues:

    Although whistleblowers bring forward a variety of issues related 
to wrongdoing, the retaliation they suffer usually occurs along similar 
lines. They experience reprisal in the form of physical or emotional 
violence, gaslighting, mobbing, shunning, marginalizing, devaluing, 
doublebinding, blackballing and counter accusing. \4\ These toxic 
tactics are features of Workplace Traumatic Stress and can lead to 
posttraumatic stress disorder (PTSD), depression, or suicide, and can 
have other psychosocial impacts. Employees go to OAWP to describe these 
toxic conditions as evidence of retaliation in hopes that OAWP would 
protect and assist them quickly. However, that has not typically been 
the case. Instead, the OAWP has caused most of them more harm because 
it is plagued with deficiencies related to timeliness, unfair 
processes, and inadequate staffing that do not allow for an unbiased 
and independent approach.
---------------------------------------------------------------------------
    \4\ Garrick Inventory: Whistleblower Retaliation Checklistc. I 
developed this checklist with indicators designed to assess severity of 
whistleblower retaliation and its psychosocial impacts on employees.
---------------------------------------------------------------------------
    Timeliness - OAWP does not provide timely responses. When a 
whistleblower contacts the OAWP, they are assigned a case manager who 
asks them to fill out the VA Form 10177. Whistleblowers wait several 
months and are then given ``boilerplate'' answers. They are told that 
they will hear back, but most never do. I've seen dozens of email 
exchanges between VA employees and OAWP case managers that demonstrates 
this lack of responsiveness.
    Process - Another consistent issue with OAWP is that it has no 
Standard Operating Procedures or a policy statement, so there is no way 
to manage expectations for engagement. Because of the language in the 
VA Form 10177, attorneys have advised clients not to sign it because it 
creates conflicts of interest and may be interpreted as waiving certain 
rights. However, once the Form has been signed and a case manager 
assigned, the process entails a report to the OAWP Director. But then 
the information goes back to the VISN and the hospital or RO Director, 
\5\ and then to the supervisor. This means that OAWP is asking the same 
chain of command to investigate the very wrongdoing it has been accused 
of perpetrating. Leadership will ask for a ``fact-finding'' or hold an 
Administrative Investigation Board (AIB) hearing. These boards are used 
as weapons for gathering information on the whistleblower and to learn 
more about their evidence for later legal admissions, interrogatories, 
and other discovery. Retaliation increases for the whistleblowers who 
are set up for counteraccusations and become victims of cyberbullying 
when VA officials plant misinformation in the public domain. 
Furthermore, AIBs are often conducted by untrained co-workers within 
the same chain of command. At times, the investigator and the proposing 
official have been the same person, or the deciding official was named 
in the original complaint.
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    \5\ There are 22 Veterans Integrated Service Networks (VISN) across 
the country that oversee all of the medical centers in the catchment 
area. The VISN Directors report to the Under Secretary for Health. 
There are also 58 Regional Offices within 4 districts (RO), and those 
Directors report to the Under Secretary for Benefits. WoA has not 
received complaints from National Cemetery Administration (NCA) 
employees and is less knowledgeable about that process.
---------------------------------------------------------------------------
    This process seems to also involve hospital chiefs of staff sending 
letters of investigation to licensing boards and professional 
associations, which can have career-ending implications. Doctors are 
reported to the National Practitioner Data Bank (NPDB) even when no 
charges have been substantiated. But once a physician is identified to 
the NPDB, his/her medical career is virtually over. There are at least 
15 VA physicians who can speak to this level of identity destruction 
and their lack of recourse. Living under this threat is causing some 
practitioners to leave VA out of fear. A Readjustment Counseling 
Services conference in June 2018 reportedly ended with Vet Center 
employees being reminded that President Trump has curtailed their due 
process rights and that they can be fired at any time.
    Meanwhile, OAWP engagement seems limited to ``trafficking'' 
paperwork and monitoring the whistleblowers, but not a lot of time is 
spent on advocacy or on a duty to assist in developing the case. OAWP 
does not appear to have the capability to independently investigate, 
mediate, or arbitrate an outcome. They should be required to provide 
case management updates and disclose outcomes to victims. Although 
privacy of all parties must be respected, whistleblowers should at 
least be able to receive notice on the section(s) of law reviewed and 
how the law was applied.
    Additionally, since veterans comprise 30% of the federal workforce, 
many VA whistleblowers are veterans. (There seems to be a propensity 
for whistleblowing among the veteran population, although this needs 
further study \6\). Veterans have raised numerous concerns over denials 
of reasonable accommodations for their service-connected disabilities, 
Family Medical Leave Act (FMLA) retaliation, privacy invasions of their 
medical records, restrictions from VA treatment facilities, and having 
their disability compensation ratings targeted. Last summer, the GAO 
found that VA employees were 10 times more likely to suffer retaliation 
with limited accountability for the perpetrators. \7\ Congress needs to 
follow up on this report and focus specifically on how veterans 
employed by VA are treated when they make disclosures, because their 
earned benefits could be at risk.
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    \6\ There are propensity studies in the literature on whistleblower 
demographics and personality types, but veteran status is still 
unknown.
    \7\ July 19, 2018 GAO Report on VA: Actions Needed to Address 
Employee Misconduct Process and Ensure Accountability: https://
www.gao.gov/products/GAO-18-137
---------------------------------------------------------------------------
    Finally, no settlement of whistleblower retaliation claims should 
be allowed to contain a nondisclosure agreement (NDA). The VA should be 
barred from asking, and whistleblower employees should be informed that 
they cannot negotiate an NDA. These transactions involving taxpayer 
money, government resources (including General Counsel time) and the 
welfare of veterans should remain in the public domain.
    Staffing - A job series issue seems to be impacting effectiveness. 
OAWP was created by overtaking a former Human Resources (HR) function--
and the staff still tends to have that background. Therefore, there is 
a shortage of the right staffing mix of HR specialists, investigators, 
mediators/arbitrators, and decision makers. The Office would benefit 
from being authorized to engage independent consultants to conduct 
these investigations and issue unbiased reports. It should also require 
that Union Representatives be consulted since not every employee knows 
that they are covered by a bargaining agreement. This would increase 
transparency, accountability, and confidence in the system.
    When employees leave VA (regardless of whether they are terminated, 
resign or retire), they should be required to participate in an exit 
interview that captures information related to their employment 
experience and reasons for leaving. This information should be reported 
to Congress annually, and the data should be compared to the National 
Federal Employee Viewpoints Survey.
    Performance - The OAWP reports accountability and disclosures on 
its website. \8\ The accountability report (adverse actions) details 
demotions, suspensions and terminations, while the disclosure report 
identifies the types of whistleblower reports made. However, almost 
half of those contacting the office were found not to be 
whistleblowers. This data point is concerning because it either means 
that employees are not being educated in accordance with the NO FEAR 
Act or whistleblowers are being unjustly denied. There is also a lack 
of data on how whistleblowers are being assisted. Is OAWP tracking 
``stays,'' reassignment, or other agreed upon solutions? The OAWP needs 
to open the aperture on how it is defining its whistleblower terms and 
capturing retaliation (in its many forms), and it must be able to 
account for the assistance provided. It should also denote how many of 
the adverse actions taken involved any whistleblowers and how many 
among them were veterans. If half of the employees described in the 
reports were not whistleblowers, then who were they?
---------------------------------------------------------------------------
    \8\ OAWP website: https://www.va.gov/accountability/
---------------------------------------------------------------------------
    The Chris Kirkpatrick Act mandated that agencies report employee 
suicides. \9\ However, according to OSC, there have been no Section 105 
compliance reports made. This is concerning since the Act was named for 
a VA psychologist who took his own life in the aftermath of 
whistleblower retaliation. If suicide prevention is the number one VA 
priority, then it should care about its own workforce who have died by 
suicide too.
---------------------------------------------------------------------------
    \9\ PL 115-73. https://www.congress.gov/115/plaws/publ73/PLAW-
115publ73.pdf
---------------------------------------------------------------------------
    There are three main options that Congress can take to improve VA 
Whistleblower Protections:

    1.Hold OAWP officials accountable for mission execution by 
requiring policy publication and a transparent key to its data with the 
above outlined recommendations; utilizing independent investigators and 
mediators; and sanctioning retaliators;
    2.Abolish OAWP and require VA to transfer funds to OSC. Although, 
transferring funds is a process, detailing OAWP employees is not as 
difficult and could be the next step along with the following option. 
If VA ever does produce policies and data that are acceptable then 
those resources could be shifted back to OAWP and/or;
    3.Allow VA employees to take their cause of action to civilian 
courts for a jury trial if there is no resolution within 180 days.

    WoA would like to believe that OAWP could provide the right 
resources for VA employees seeking justice, but the agency has so far 
failed to meet those expectations.

Summary of OIG Issues:

    VA employees are reliant on the VA OIG and OSC investigations to 
develop evidence. Unfortunately, both systems have generally failed 
them. First, there is very limited accountability for when the VA OIG 
makes recommendations related to disclosures. Those should be better 
tracked and reported. There are no mandates to implement an OIG 
recommendation, only suggestions to VA senior leaders, which can 
literally, ``sit on the shelf.'' Furthermore, managers who were guilty 
of retaliation or other wrongdoing are often not held accountable - 
rarely are they even identified by the OIG. Most of the time, the OIG 
recommendation is for ``further training.'' Such was the case when the 
OIG found that $11.7 million of VBA money inappropriately went to 
Calibre on a contract, \10\ but no action was taken to reclaim those 
funds or hold accountable the managers who oversaw the wasteful 
spending. Congress also should know what happened to the $6 million 
that went unspent for suicide prevention. WoA suggests that Senior 
Executives or managers with any pecuniary responsibility must be 
required to pass a background check and hold a security clearance. In 
the future, Congress should ask the OIG to oversee annual 
accountability on such funding executions, as with the $25 billion 
VECTOR IDIQ with 68 companies on the award performing management 
initiatives \11\ and other high impact spending authorities.
---------------------------------------------------------------------------
    \10\ https://www.va.gov/oig/pubs/VAOIG-16-04555-138.pdf
    \11\ https://www.va.gov/OSDBU/acquisition/vector-town-hall.asp
---------------------------------------------------------------------------
    WoA notes that there should be more serious penalties for 
retaliation (fines, demotions, loss of retired pay, contract bans, etc) 
to discourage these tactics. Congress should expand requirements to pay 
into the Judgment Fund to include those identified as engaging in 
whistleblower retaliation. Whistleblowers who must defend themselves 
against retaliation often must pay out-of-pocket - sometimes upward of 
$100,000 - while wrongdoers are defended by the Government, at the 
expense of taxpayer money reserved for veterans. This is antithetical 
to common sense, and the Judgment Fund could be used to assist 
whistleblowers and offset costs related to retaining private sector 
attorneys chosen by the whistleblowers and reduce the burden on the 
taxpayer when damages are awarded. There are now Legal Aid services in 
over 120 VA Medical Centers. This authority could be expanded to 
support VA employees in their retaliation, harassment, and 
discrimination cases. Without more serious steps towards accountability 
and justice, a corporate culture that allows retaliation to fester will 
continue.

Antagonistic Relationship between OAWP and OIG

    There has been a history of animosity between the VA OIG and its 
leadership. After being investigated for alleged misuses, former VA 
Secretary David Shulkin (through a private team of lawyers) criticizes 
his own OIG by saying, ``VA OIG reports `must be accurate,' `must be 
fair,' and `must be objective,''.''This report is none of those 
things.'' \12\ Later, Acting Secretary (and former OAWP Director) Peter 
O'Rourke was accused by this Committee of trying to intimidate IG 
Michael Missal in a letter during an OAWP investigation. \13\ This 
Committee sent a letter to the US Attorney General asking that O'Rourke 
be investigated for alleged perjury, misleading or withholding 
information from Congress, or making otherwise unlawful statements in 
testimony and communications during two oversight hearings on June 26, 
2018 and July 17, 2018, in response to questions regarding the 
withholding of access to information and a database from the OIG, and 
the status and disposition of a VA whistleblower complaint \14\ (Dr. 
Dale Klein, WoA Board Member). The GAO \15\ has also stepped in to 
investigate outside influence from the ``Mar-A Lago Crowd'' on VA 
leadership and personnel decisions following a ProPublica report. \16\ 
WoA is concerned that emails outside of official VA sources would not 
be accessible during investigations or discovery. WoA also is unaware 
of any resolution to these investigations, but we believe they 
highlight the antagonistic nature of whistleblowing at VA. Since 
Congress has demonstrated that it does not trust VA to properly handle 
personnel issues, why would you ask VA frontline employees to trust 
these internal organizations with their careers, personal well-being, 
financial security, and family stability?
---------------------------------------------------------------------------
    \12\ February 11, 2018 Response to Administrative Investigation 
Draft Report: VA Secretary and Delegation Travel to Europe and 
published in the OIG Report: https://www.va.gov/oig/pubs/VAOIG-17-
05909-106.pdf
    \13\ June 19, 2018 Press Release from House Veterans Affairs 
Committee Ranking Member Tim Walz: https://veterans.house.gov/news/
press-releases/rm-walz-responds-unprecedented-attack-acting-va-
secretary-o-rourke-va-inspector
    \14\ July 26, 2018 letter from members of the House Committee on 
Veterans Affairs to the US Attorney General: https://causeofaction.org/
wp-content/uploads/2018/08/2018.07.26-Letter-from-Rep.-Walz-to-AG-
Sessions-re-ORourke.pdf
    \15\ November 19, 2018 Letter to Senator Elizabeth Warren the GAO 
agrees to investigate ProPublica allegations: https://
www.warren.senate.gov/imo/media/doc/
GAO%20response%20accept%20EW%20request%20for%20investigation%20Mar-A-
Lago%20Cronies%20VA%2011.19.2018.pdf
    \16\ August 7, 2018 ProPublica Investigation: https://
www.propublica.org/article/ike-perlmutter-bruce-moskowitz-marc-sherman-
shadow-rulers-of-the-va

---------------------------------------------------------------------------
Conclusion

    The feedback VA whistleblowers can provide is informative, but fear 
of reprisal causes many to remain bystanders and not veteran advocates. 
Those who do disclose have seen the demise of their careers, moral 
injuries, and identity disruption. Employees risk their careers to 
protect veterans, while senior VA officials travel to Europe, attend 
NASCAR events, and curry favor with contractors at taxpayer expense. VA 
should not treat whistleblowers like adversaries but should treat these 
employees with the same public health approach it describes for 
communities, and it should incorporate that approach into comprehensive 
continuous process improvements while ensuring independent and unbiased 
investigations. To reduce stigma and retaliation, Congress should 
authorize VA to host an annual Whistleblowers' Award that highlights 
VA's ``rightdoing'' in overcoming agency wrongdoing. Furthermore, 
Congress should consider authorizing a National Whistleblower Memorial 
on the grounds of the Capitol that demonstrates the lamplit pathway 
many have taken in exercising their First Amendment Rights.