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[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]

 
                 VA WHISTLEBLOWERS: EXPOSING INADEQUATE

  SERVICE PROVIDED TO VETERANS AND ENSURING APPROPRIATE ACCOUNTABILITY

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

                                HEARING

                               before the

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

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                         TUESDAY, JULY 8, 2014

                               __________

                           Serial No. 113-78

                               __________

       Printed for the use of the Committee on Veterans' Affairs

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

                  U.S. GOVERNMENT PUBLISHING OFFICE
89-377                    WASHINGTON : 2015
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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              MARK TAKANO, California
BILL FLORES, Texas                   JULIA BROWNLEY, California
JEFF DENHAM, California              DINA TITUS, Nevada
JON RUNYAN, New Jersey               ANN KIRKPATRICK, Arizona
DAN BENISHEK, Michigan               RAUL RUIZ, California
TIM HUELSKAMP, Kansas                GLORIA NEGRETE McLEOD, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
DAVID JOLLY, Florida
                       Jon Towers, Staff Director
                 Nancy Dolan, Democratic Staff Director

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

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                                                                   Page

                         Tuesday, July 8, 2014

VA Whistleblowers: Exposing Inadequate Service Provided to 
  Veterans and Ensuring Appropriate Accountability...............     1

                           OPENING STATEMENTS

Hon. Jeff Miller, Chairman.......................................     1
    Prepared Statement...........................................    84

Hon. Mike Michaud, Ranking Minority Member.......................     3
    Prepared Statement...........................................    86

Hon. Corrine Brown...............................................
    Prepared Statement...........................................    87

Hon. Gloria Negrete McLeod.......................................
    Prepared Statement...........................................    88

                               WITNESSES

Jose Mathews, M.D., Former Chief of Psychiatry, St. Louis VA 
  Health Care System.............................................     5
    Prepared Statement...........................................    88

Christian Head, M.D., Associate Director Chief of Staff Legal and 
  Quality Assurance Greater Los Angeles VA Health Care System....     8
    Prepared Statement...........................................    97

Katherine Mitchell, M.D., Medical Director, Iraq and Afghanistan 
  Post-Deployment Center Phoenix VA Health Care System...........    10
    Prepared Statement...........................................   113

Mr. Scott Davis, Program Specialist, VA National Health 
  Eligibility Center.............................................    11
    Prepared Statement...........................................   140

The Hon. Carolyn Lerner, Special Counsel, Office of Special 
  Counsel........................................................    53
    Prepared Statement...........................................   142

    Accompanied by:

      Mr. Eric Bachman, Deputy Special Counsel for Litigation and 
          Legal Affairs, Office of Special Counsel

James Tuchschmidt, M.D., Acting Principal Deputy Under Secretary 
  for Health, Department of Veterans Affairs.....................    54
    Prepared Statement...........................................   149

    Accompanied by:

      Edward C. Huycke, M.D., Deputy Medical Inspector for 
          National Assessment, Office of the Medical Inspector, 
          Department of Veterans Affairs

                   MATERIALS SUBMITTED FOR THE RECORD

Letter to Hon. Miller From DVA...................................   152
Letter to AFGE From DVA Inspector General........................   154
Letter to President Obama From Hon. Carolyn Lerner...............   157

VA WHISTLEBLOWERS: EXPOSING INADEQUATE SERVICE PROVIDED TO VETERANS AND 
                  ENSURING APPROPRIATE ACCOUNTABILITY

                         Tuesday, July 8, 2014

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The committee met, pursuant to notice, at 7:33 p.m., in 
Room 334, Cannon House Office Building, Hon. Jeff Miller 
[chairman of the committee] presiding.
    Present: Representatives Miller, Lamborn, Bilirakis, Roe, 
Flores, Runyan, Benishek, Huelskamp, Coffman, Wenstrup, 
Walorski, Jolly, Michaud, Takano, Brownley, Titus, Kirkpatrick, 
Ruiz, Negrete McLeod, Kuster, and O'Rourke.

    Also present: Representative Price.

           OPENING STATEMENT OF CHAIRMAN JEFF MILLER

    The Chairman. Good evening, everybody. This hearing will 
come to order. I want to welcome everybody to tonight's hearing 
entitled ``VA Whistleblowers: Exposing Inadequate Service 
Provided to Veterans and Ensuring Appropriate Accountability.'' 
I would also like to ask unanimous consent that Representative 
Tom Price, from the great State of Georgia, be allowed to join 
us here on the dais and participate in tonight's hearing. 
Without objection, so ordered. Oop, I think I heard an 
objection.
    Tonight we'll hear from a representative sample of the 
hundreds of whistleblowers that have contacted our committee, 
seeking to change the VA to improve patient safety and better 
serve veterans who have served our great Nation. We'll also 
hear from the Office of Special Counsel regarding its work 
protecting VA whistleblowers and the vital information that 
they provide. Representatives of VA will also be here to answer 
for the Department's reprisals against whistleblowers and its 
continuing failure to abide by its legal obligation to protect 
employee rights to report waste, fraud, and abuse and 
mismanagement to the Inspector General, to the Counsel, to 
Congress, and to this committee.
    It's important to emphasize that the national scandal 
regarding data manipulation of appointment scheduling did not 
spring forward out of thin air at the Department of Veterans 
Affairs. Deceptive performance measures that serve as window 
dressing for automatic SES bonuses have been part of the 
organizational cesspool at the Department for many, many years. 
Instead of being a customer-driven Department dedicated to 
veterans, the focus instead has been on serving the interests 
of the senior managers in charge. The manipulation of data to 
gain performance goals is a widespread cancer within the VA. We 
have often heard that VA is a data-rich environment, but when 
data is exposed as vulnerable to manipulation it cannot be data 
that is trusted.
    Until recently, VA would continue to trot out the tired 
canard that patient satisfaction exceeds the private sector. 
That may be true at a few select VA centers. However, as our 
colleague Mr. O'Rourke demonstrated through local polling, such 
results have been over generalized. Moreover, during the course 
of the past year this committee has held a series of hearings 
showing a pattern at VA of preventable patient deaths across 
the country, from Pittsburgh to Augusta, to Columbia, to 
Phoenix. VA's satisfaction results are refuted by these tragic 
outcomes.
    In every one of these locations whistleblowers played a 
vital role in exposing these patient deaths at the Department. 
Whistleblowers serve the essential function of providing a 
reality check on what is actually going on at the Department. 
At great risk to themselves and their families, whistleblowers 
dare to speak truth to power and buck the system in VA designed 
to crush dissent and thereby alter the truth.
    Tonight we're fortunate to have three distinguished 
physicians testify with regard to their experiences in the VA. 
We'll also hear from a conscientious program manager in VA's 
National Health Eligibility Center who will show that the 
disease of data manipulation may have spread to the initial 
eligibility determinations for medical benefits. None of these 
whistleblowers lost sight of the essential mission of the VA--
that mission to serve veterans. They understand that people are 
not inputs and outputs on a central office spreadsheet. They 
understand that metrics and measurements mean nothing without 
personal responsibility. Unlike their supervisors, these 
whistleblowers have put the interests of veterans before their 
very own interests.
    Unfortunately, what all of these whistleblowers also have 
in common is the fear of reprisal by the Department. They will 
speak of the many different retaliatory tactics used by VA to 
keep employees in line. Rather than pushing whistleblowers out, 
it is time that VA embraces their integrity and recommits 
itself to accomplishing the promise of providing high quality 
health care to America's veterans.
    In order to make sure there is follow through at VA, I have 
asked my staff to develop legislation to improve whistleblower 
protections for VA employees, and I invite all the members of 
this committee to work with us towards the end.
    With that, I now yield to my good friend and ranking 
member, Mr. Michaud, for any opening remarks that he may have.

    [The prepared statement of Chairman Jeff Miller appears in 
the Appendix]

   OPENING STATEMENT OF MIKE MICHAUD, RANKING MINORITY MEMBER

    Mr. Michaud. Thank you very much, Mr. Chairman.
    This committee has held many hearings over the last years 
on problems with access to VA health care. At each of these 
hearings, problems were disclosed and the VA promised to 
improve, but little has changed. VA is widely known to have a 
culture of denying problems and not listening to feedback, be 
it from Congress, veterans, or its own employees.
    The Department of Veterans Administration has had a 
reputation as being intolerant of whistleblowers. So far in 
this fiscal year, nearly half of the matters transmitted to 
agency heads by the Office of Special Counsel, 7 out of 15 
involved the VA. According to the OSC, it currently has 67 
active investigations into retaliation complaints from VA 
employees and has received 25 new whistleblower retaliation 
cases from VA employees since June 1 of 2014.
    A recent New York Times article stated that within the VA 
there was a ``culture of silence and intimidation,'' end of 
quote. Acting Secretary Gibson recently stated that he was 
deeply disappointed, not only in the substantiation of 
allegations raised by the whistleblowers, but also in the 
failures within the Department to take whistleblowers' 
complaints seriously.
    Within VHA, the problem of intimidation and retaliation may 
be magnified by what some consider a protective culture of the 
medical profession. It is often thought to be against the code 
to point out colleagues' mistakes or where a nurse or attendant 
is told it is not appropriate to question a physician or 
surgeon. The natural tendency is to close ranks, to deny that 
problems exist or mistakes were made.
    So after we listen to the testimony before us this evening 
from the whistleblowers, the Office of Special Counsel, and the 
VA, will anything change after we hear what the whistleblowers 
have to say, and how do we fix this culture and encourage all 
VA employees to step forward to identify problems and work to 
address those problems?
    Changing a culture is not easy. It cannot be done 
legislatively and it cannot be done by throwing additional 
resources at it. Talk is cheap. Real solutions are hard to 
find. It is clear to me that the VA as it is structured today 
is fundamentally incapable of making real changes in the 
culture.
    I note that Acting Secretary Gibson announced today that he 
was taking steps to restructure the Office of Medical Inspector 
by creating a, quote, ``strong internal audit function which 
will ensure issues of the quality care and patient safety 
remains at the forefront,'' end of quote. This is an 
improvement, but it raises additional questions regarding how 
these restructures will better enable OMI to undertake 
investigations resulting from whistleblowers' complaints 
forwarded by the OSC, or how will it also have the authority to 
ensure that medical actions will be taken to the appropriate 
components of the VA?
    Time and time again, as the June letter from OSC 
demonstrates, the VA found fault, but determined that these 
grave errors did not affect the health and safety of veterans. 
Anyone reading the specifics of any of these cases will find 
that this harmless error conclusion, as stated by the OSC, to 
be a serious disservice to the veterans who received inadequate 
patient care for years. I agree that the OSC June 23 letter, 
and it quotes, ``This approach has prevented the VA from 
acknowledging the severity of the systematic problems and from 
taking the necessary steps to provide quality care to 
veterans,'' end of quote.
    We all seem to have some goals this evening. We all want 
the VA employees to feel comfortable raising problems and 
having them addressed without fear that raising their voices 
will mean the end of their careers. The VA has stated that it 
wants to make fundamental changes in its culture so that the 
workforce intimidation and retaliation is unacceptable. Talk is 
cheap. Real change is difficult.
    I would propose that the very first order of business at 
the VA is to take accountability seriously. If any VA employee 
is shown to have intimidated or retaliated against another VA 
employee, then that employee should be fired. The VA should 
have zero tolerance for policies that would harm whistleblowers 
and intimidate whistleblowers or retaliate against 
whistleblowers. As I see it, effective leadership and real 
accountability is the only way to begin the process of 
institutional changes, and I hope tonight is the beginning of 
that change.
    And with that, Mr. Chairman, I yield back the balance of my 
time.
    The Chairman. Thank you very much to the ranking member.

    [The prepared statement of Hon. Mike Michaud, appears in 
the Appendix]

    The Chairman. Thank you very much to the Ranking Member. I 
would ask that all members would waive their opening 
statements, as is the custom of this committee.
    Thanks to the witnesses that are here at the witness table 
tonight. Our first panel that we're going to hear from is Dr. 
Jose Mathews, former Chief of Psychiatry at the St. Louis VA 
Health Care System; Dr. Christian Head, Associate Director, 
Chief of Staff, Legal and Quality Assurance, at the Greater Los 
Angeles VA Health Care System; Dr. Katherine Mitchell, Medical 
Director for the Iraq and Afghanistan Post-Deployment Center at 
the Phoenix VA Health Care System.
    And at this time I'd like to introduce our colleague, Dr. 
Price, to briefly introduce his constituent, who will be the 
fourth witness on the panel this evening.
    Mr. Price. Thank you, Mr. Chairman. I want to thank you and 
the ranking member for allowing me to offer this introduction. 
This is a remarkably important topic, and I commend the 
committee for the work that you've done.
    As a physician, I worked at the VA hospital in Atlanta, as 
a matter of fact, for a number of years during my training, and 
I know how important it is to have honest and real information 
for our veterans to honor their service, which is why I am so 
very pleased to offer Scott Davis, Mr. Davis, who will be on 
the panel today. He is a resident of my district. He is a 
graduate of Morehouse College. His father served in Vietnam.
    Mr. Davis is a program specialist at the VA's National 
Health Eligibility Center in Atlanta. He's been in contact with 
my office for a number of months outlining his concerns. He's 
come forward with the allegations and concerns that he has in a 
very brave and courageous manner. He's put his career and 
reputation on the line, and I have no doubt that his testimony 
tonight will help shine a light on the situation at hand. We 
must know the facts on the ground in full before we can truly 
begin to fix the untenable situation at the VA.
    So I welcome Mr. Davis, and I thank you for allowing me to 
join you for this introduction.
    The Chairman. Thank you very much, Dr. Price. We appreciate 
you joining us here this evening.
    I appreciate the testimony of the witnesses today and look 
forward to working with all of you to find a solution for our 
veterans.
    I would ask the witnesses if you would please rise. Raise 
your right hand.
    [Witnesses sworn.]
    The Chairman. Thank you. Please be seated. All of your 
complete written statements will be entered into the record.
    And, Dr. Mathews, you are now recognized for 5 minutes.

                STATEMENT OF JOSE MATHEWS, M.D.

    Dr. Mathews. Honorable Chairman and distinguished members 
of the committee, I am honored to appear before you today to 
speak about my experiences while serving in the capacity as the 
Chief of Psychiatry with the Department of Veterans Affairs in 
St. Louis, Missouri, and in the capacity of the detail when I 
was removed from this position. I just want to very briefly 
outline the goals I had when I took this position as the Chief 
of Psychiatry, leaving my full-time faculty position at 
Washington University.
    I had very simply wanted to create the very best care 
possible with the resources I had. And very soon I realized 
that the metrics I had, that the VA was putting out, was not 
reflecting what I was actually seeing. I had made it a point 
that I'd review every veteran complaint, and the majority of 
the veteran complaints I had its had to do with their inability 
to obtain care at a reasonable time, the long wait times, 
having difficulty even contacting the clinic to schedule an 
appointment.
    So I started out with a very simple question as to how busy 
are we really at the outpatient clinic. And the answer I got 
was not very good. I got the answer that I verified that the 
psychiatrists were only spending approximately 3.5 hours in 
direct patient care. I could not account for the rest of their 
time. I verified this. I put this data transparently as 
prospective data where any psychiatrist could challenge me and 
ask me question whether that was accurate or not, and I did not 
get one valid question.
    So I knew that the data was accurate, I discussed this with 
the Chief of Staff, and I wanted to change this. There were two 
things that I wanted changed. One was that the veteran has easy 
access to care, timely access to care. And the second was that 
no veteran would be turned away if they come to the clinic. I 
had a very sad veteran complaint about a disabled veteran who 
had requested his friend to drive because he does not drive. He 
drove approximately an hour and a half to come to the clinic. 
He had two requests. He wanted to see his provider earlier 
because he was not doing well and he wanted his medications 
refilled.
    Unfortunately, that veteran had neither of these requests 
met. He was sent away with another appointment 48 days later, 
and his medications were not refilled. And just before this 
meeting I checked, and that veteran, unfortunately, is lost to 
follow-up, has not come back to the clinic since last May. And 
his description of that event includes how disappointed and how 
upset he is at the VA for not providing him care.
    So that was the context of how I started out. I discovered 
that the physician time was not being utilized properly. There 
was long wait times. And one of the metrics that's very 
important is, especially in mental health, is engagement and 
care or the dropout rate, and what I found was there were 60 
percent of the veterans were not coming back for their visits 
in the outpatient setting. So there was 60 percent attrition 
rate.
    So there were only four pieces of information that I needed 
to provide very good care. One was the wait time to care. The 
second was the utilization of expertise or what amount of time 
does a physician actually expend in direct patient care. The 
third was the retention in care, how many veterans actually 
follow up with care or dropping out of care. And the fourth 
metric, that was not existent, is the veteran's satisfaction 
with care.
    Like Chairman Miller talked about these surveys not being 
complete and may not be reflective of all places, I wanted the 
survey to be a complete set. So I talked to some donors who I 
knew from Washington University, and they pledged $60,000 over 
2 years to institute a real time veteran satisfaction survey. 
So I had the contract, the educational contract for iPads, I 
had logged in people to program valid questionnaires in it, and 
my intent was that while a veteran is waiting in the waiting 
area to be seen would be able to complete this questionnaire 
using touch screens, which would be automatically compiled, and 
I would have information on whether a particular clinic or a 
particular healthcare professional I need to focus on.
    So this last bit was very concerning to the staff, and 
shortly after I made these disclosures, including two avoidable 
deaths, that I wanted root cause analysis on and an inpatient 
suicide attempt while the joint commission was reviewing our 
hospital, which was completely covered up, and I did not go 
along with that. So very shortly I was put on detail. I was 
told that there would be an administrative investigation and 
that I was put to compensation and pension, doing compensation 
and pension evaluations.
    Now, I took this job, also it was dealing with veterans, 
I'd filed the complaint with OSC, and while they were 
processing my complaints I took this very seriously, to 
evaluate the veterans for whether they had compensate mental 
disorders related to their service. And what I found again here 
was that in many instances the veteran was not even heard 
properly. I had doubts whether the prior evaluation report was 
the same veteran or not, and this was a serious concern, so I 
actually started to look at their IDs again to make sure that 
this was not some other person.
    And the problem here was that the veterans did not have 
enough time to explain their situation. It was a hurried, 
conveyer belt-like system where I was specifically told that I 
was spending too much time with the veteran, that I should 
hurry up and see the veteran and just check a few boxes in my 
evaluation because it's meant for some rater somewhere to rate 
the disability. But that's not how I saw my job, and I think 
that's not the right way to do it. The three competency to be 
accomplished in these evaluations, because these are disability 
evaluations: You have to make sure that the veteran is heard 
properly, and the second thing is that I review the prior 
records properly to make sure that I capture a full history, 
and then the third is to make sure that my report reflects some 
of the inconsistencies in the record and I speak to it, so that 
the very next person, if it becames an appeal issue, can 
determine how I made my decision.
    Now, there were a few egregious errors that were there, and 
that really bothered me, and as I was detailed under primary 
care. So I wrote to the Chief of Primary Care recently about 
these examples, about why this was really unfair to the veteran 
and how it affected the life of the veteran. And just 2 weeks 
ago, on the 26th of June, I'm detailed now to another place.
    So from my perspective, I have always put the veterans' 
interests first, and I have disclosed, I have disclosed the 
wrongdoings that I found promptly to the Chief of Staff and to 
the Chief of Mental Health with the expectation that they would 
address it. And what I have found is that nothing has really 
changed. As late as June, just 2 weeks ago, the response to my 
finding about these evaluations that were not done properly was 
to just detail me elsewhere.
    So this seems to be an ongoing practice. When it's detailed 
I don't have any responsibility of the Chief of Psychiatry. 
That's the position I accepted. Two people who I really worked 
hard on recruiting, both excellent psychiatrists, one trained 
at Hopkins, the other at Harvard, they both declined to join 
the VA after I had to disclose that I'm no longer the chief, 
I've been removed.
    So there's a sense of mission that's lacking, and I'm 
really hoping that this committee with its powers will take 
aggressive actions to really make sure that this retaliation 
stops and that the people responsible are held accountable, 
because really, with the data being so cooked up and so 
unbelievable, it's extremely important that, while we work on 
data integrity, to make sure that the data reflects reality, 
it's extremely important that people step forward and are able 
to speak the truth and talk about what's really happening at 
the patient interaction level. I'm really hoping that this 
committee would do that, and I'm really honored that I have 
this opportunity to be able to answer questions and to be here.
    The Chairman. Thank you, Dr. Mathews. We'll have an 
opportunity, each of us, to ask questions and get into 
specifics a little bit later on.

    [The prepared statement of Dr. Jose Mathews, appears in the 
Appendix]

    Next I'd like to recognize Dr. Head for 5 minutes.

               STATEMENT OF CHRISTIAN HEAD, M.D.

    Dr. Head. Thank you for inviting me to testify today. I'm 
honored, Congressman. And I think it's a very important topic, 
our veterans, and we shouldn't lose focus of that. I'm 
Associate Director/Chief of Staff at the West Los Angeles VA 
Hospital. I'm very proud of my position, and I can't think of a 
better job than serving our veterans.
    But retaliation is alive and well across our country, 
especially within the VA Administration. My first encounter was 
a number of years ago. I was subpoenaed by the Inspector 
General to investigate time card fraud involving two surgeons 
in my area. I was among close to 30 individuals who gave 
testimony. I gave honest and true testimony. And during that 
testimony I said I feared retaliation, and I outlined how I 
felt they would retaliate against me.
    Every aspect I outlined came true. The person who did the 
deposition was Inspector Solomon from the Inspector General's 
Office, and she promised I would be protected both from the 
State and Federal Government. Three months after they came out 
with the final results, one of the individuals was paid back a 
year's salary to the Federal Government and resigned. Another 
individual who they recommended immediate termination was 
allowed to stay in her supervisory role.
    There was an end-of-the-year party because we're affiliated 
with a university that's nearby. At that party, this slide was 
shown.
    [Slide]
    Dr. Head. I know. That actually is me. I'm much younger 
back then, and I had hair. But you see I'm flipping the bird, 
and it says, ``If all else fails, call 1-800-488-VAIG.'' In 
front of close to 300 individuals, I was labeled a rat. I was 
labeled the person who ratted out this person.
    The slide that followed this is so heinous that I can't 
even show or discuss it today. I could discuss it under 
subpoena. That person, by the way, is still in the supervisory 
role at the VA. No apology, nothing.
    I somehow survived that. Retaliation has been relentless. 
The problem my retaliators have is that I think the VA and the 
veterans deserve far better. No matter what happens to me, I 
think the focus still should be on the veterans of this 
country.
    I somehow survived that process, and again I was retaliated 
again later when I gave my opinion on the investigation of a 
physician who was wrongly terminated. I was asked to change my 
testimony. I stopped getting paid for two weeks. And because of 
a number of other factors, my house went into foreclosure. I 
didn't lose my house, but the harm it causes the family members 
of Federal workers who are being retaliated against cannot be 
measured. I have two young girls who I would be proud if they 
decided to join the Armed Forces or even work for the VA.
    I think the VA has the potential to be one of the finest 
institutions in the world. We have seen certain aspects. The 
pharmacy cannot be matched. It's one of the best in the world. 
Very efficient. There are many different things that are 
efficient within our system, but what we should ask ourselves. 
When someone came up with the idea of seeing a veteran in 14 
days, that actually sounded like a good idea, that a veteran 
should be seen promptly. What we should be questioning is, if 
we made a mistake and somehow overloaded the system, how come 
people's names disappeared off lists? How come hundreds of 
thousands of veterans electronically no longer existed? That 
should be the question.
    Retaliation exists because there's a culture. This culture 
of retaliation, that's really the cancer to the Veterans 
Administration. Most physicians and nurses and people who work 
in the hospital are disgusted. Morale is extremely low. People 
come up to me all the time and say, did that happen here? 
People care. When I heard some of the testimony from the 
Phoenix VA, it was gut-wrenching, I couldn't sleep. And I 
believe there's a lot of people within the VA system that feel 
the same way.
    But there exists a cancer within leadership, a few 
individuals that perpetuate this idea that we should be silent, 
that we shouldn't stand up and do the right thing and be 
honest. Everyone makes mistakes. But when you make a mistake 
and you try to conceal it, that is really the question we 
should be asking. Who are these individuals who would alter 
data and hide the truth and prevent patient care?
    I've been receiving text messages all day from veterans 
saying, be careful, Dr. Head, we don't want to lose you as a 
surgeon. Be careful, something might happen to you. If you get 
labeled as a whistleblower, oh, my God, they'll take you out. 
I'm not afraid to be taken out. I do hope if I am taken out 
someone will take care of my family. But I think people need to 
speak up. And we shouldn't be isolated, ostracized.
    And the level of defamation, you notice that every time 
there's a whistleblower there's usually an email that follows: 
Well, this person is not getting a bonus and so they're upset. 
Or this person didn't get the raise they wanted, so they can be 
suspect. Or this person didn't do this. They always defame. 
They defame. They isolate. Usually they transfer you to another 
position. Why? Because they're slowly building a case, if they 
don't have one already, to say that you're crazy, that you're 
not being truthful.
    And I would hope--I apologize for running over--I would 
hope that--I've given you close to 176-276 pages, I think, of 
evidence and a number of other statements of other individuals 
that would be helpful in trying to improve the system--I would 
hope--and especially the press, I will challenge you also to be 
a real reporter and actually report the truth--but also--not to 
insult the reporters--and also the Congressmen and 
Congresswomen, this is very important, that we try to focus on 
what's really important here, and that's the veterans of this 
country.
    Thank you.
    The Chairman. Thank you very much for your courage, Dr. 
Head.

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

    The Chairman. Dr. Mitchell, you're recognized for 5 
minutes.

                STATEMENT OF KATHERINE MITCHELL

    Dr. Mitchell. Good evening. I am deeply honored by the 
committee's invitation to testify tonight.
    As a Phoenix VA employee, I have suffered retaliation for 
years for routinely reporting health and safety concerns. My 
written testimony details some of that retaliation and the 
devastating effects on patient care. In addition, section 4 and 
section 5 of my written testimony outline specific tactics that 
the VA uses to suppress whistleblowing and also to retaliate 
against anyone who speaks up within its ranks, even without 
whistleblowing. The VA, in my opinion, has routinely 
intimidated any employee who brings forth information that is 
contrary to the public image that the VA wishes to project.
    In 2013, I submitted a confidential OIG complaint regarding 
the life-threatening issues within the Phoenix VA system. 
Approximately 10 days after the national VA received my report 
I was placed on administrative leave for a month. I was 
subsequently investigated for misconduct because I had provided 
limited amounts of patient information through the confidential 
OIG channel in order to support my allegations of the suicide 
trends and the facility's inappropriate response to them. 
Eventually I would receive a written counseling stating that I 
violated a specific patient policy, but to this day my human 
resources department refuses to tell me the name of the policy 
I violated.
    This is relatively minor retaliation considering what 
happened during my last 3 years as Medical Director in the 
Emergency Department. During that time we were grossly 
understaffed in terms of physicians and nurses. In addition, 
there was insufficient ancillary staffing to do basic items 
such as wash beds, answer telephones, deliver patients, 
transport labs. As a result, doctors and nurses were routinely 
pulled away from direct patient care in order to perform these 
extra duties.
    When the number of patient visits increased greatly to our 
ER, the deficiencies became obvious. The actual number of 
mistakes, as well as near misses, in our nursing triage 
skyrocketed. Symptoms such as stroke, heart attack, pneumonia, 
blood infections, and other serious medical issues were 
routinely missed by inexperienced triage nurses or by seasoned 
triage nurses who were simply overwhelmed by the flood of 
patients that were hitting our ER.
    I started reporting the cases of actual mistakes or near 
misses to the facility chain of command. In the process of 
reporting hundreds of these, approximately 20 percent of the ER 
nurses would retaliate against me. They would stop doing my 
orders for patients. They would refuse to answer questions in 
the nurses station. They would not give me verbal reports on 
patients that were placed in rooms.
    Administration was made aware of this and yet declined to 
intervene to stop this behavior that was obviously interfering 
with my care for patients. In addition, they ignored my 
repeated requests for additional resources for our ER, and they 
would never institute the comprehensive standardized nurse 
triage training that we needed in order to prevent future 
mistakes in care being made in our ER.
    This is not to say they were idle however. They did ban me 
from reporting any cases to the Risk Management Department. My 
proficiencies dropped each year that I worked. I was forced to 
work 2 years of unlimited scheduled shifts to fill in holes in 
the physician staffing because HR was too slow at credentialing 
emergency room physicians to fill in.
    Eventually things reached a critical mass. When the new 
oncoming Medical Center Director Sharon Helman arrived, I told 
her that the ER was too dangerous on an hour-to-hour basis to 
remain open and we should be closed unless additional vitally 
needed support was given. Unfortunately, the administration's 
response was to haul me into a meeting within about a week and 
a half and tell me that the only problem in the ER was my lack 
of communication skills. The nursing backlash that was reported 
would never be investigated.
    Eventually I was involuntarily transferred based on 
critical need to an empty medical clinic. I assumed the medical 
director position of a clinic that only houses a social work 
program, and that's where I remain today. I do very useful 
work, but it's certainly not what I intended when I started 
reporting patient safety, health, and concerns.
    The veterans needing care that presented to the ER have 
survived campaigns like D-Day, Iwo Jima, Chosin Reservoir, Tet 
offensives and counteroffensives, Desert Storm, Kosovo, 
Croatia, the battle of Fallujah, and dismal years in Helmand 
Province. It is a bitter irony to me that I as a physician 
could not guarantee their health and safety within a VA 
facility in the middle of cosmopolitan Phoenix.
    The VA needs to embrace the core values that it advertises 
on its Web site. Administrators who place their own personal 
gain above the welfare of veterans need to face consequences 
for so doing. However, in the process it's very important that 
employees of any pay grade who truly care about veterans and 
their welfare, that they be protected. They were often placed 
in the unthinkable position of being forced to follow orders or 
else permanently lose their livelihoods and their ability to 
help any veteran in the future.
    Most importantly, the ability to positively influence the 
patient care and safety of any veteran should not be considered 
a Democratic or Republican stance, a pro-union or anti-union 
choice, or even a uniquely American problem. The ability to 
freely advocate for the health and safety of any patient is a 
human issue, and it has ethical implications for all of us.
    Thank you for your time.
    The Chairman. Thank you very much, Doctor.

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

    The Chairman. Thank you very much Mr. Davis. Mr. Davis, you 
are now recognized for 5 minutes.

                    STATEMENT OF SCOTT DAVIS

    Mr. Davis. Thank you, Mr. Chairman. I'd like to thank the 
committee for providing a platform so that the voices of VA 
whistleblowers can be heard. I urge the committee to take 
prompt action as time is running out. Every day a window of 
opportunity closes on a veteran to receive quality health care 
because of the inaction of senior VA officials. Some veterans 
even face the burden of being billed for care their service has 
earned them.
    As noted in the Office of Special Counsel report, VA 
leadership has repeatedly failed to respond to the concerns 
raised by whistleblowers about patient care at VA. Despite the 
best efforts of truly committed employees at the HEC and the 
Veterans Health Administration who have risked their careers to 
stand up for veterans, management at all levels have ignored 
them or retaliated against them for simply exposing the truth.
    Some of the critical issues reported to senior VA officials 
by whistleblowers at the HEC include mismanaging critical 
veteran health programs and wasting millions of dollars on an 
Affordable Care Act direct mail campaign; the possible purging 
and deletion of over 10,000 veteran health records at the 
Health Eligibility Center; a backlog of over 600,000 pending 
health applications; nearly 40,000 unprocessed applications 
discovered in January of 2013. These were primarily 
applications from returning servicemembers from Iraq and 
Afghanistan.
    The harassment I've experienced at the HEC from top levels 
of management include my whistleblower complaint to White House 
Deputy Chief of Staff Rob Nabors was leaked to my manager 
Sherry Williams, who stated in writing that she was contacting 
me on behalf of Acting Secretary Gibson and Mr. Rob Nabors. 
Neither Mr. Gibson nor Mr. Nabors have responded to this fact. 
My employment records were illegally altered by CBO Workforce 
Management Director Joyce Deters. I was illegally placed on a 
permanent work detail by Assistant Deputy Under Secretary 
Philip Matkovsky and Acting Chief Business Officer Stephanie 
Mardon. I was placed on involuntary administrative leave 
curiously at the same time the OIG investigation was taking 
place in Atlanta by Acting HEC Director Greg Becker.
    Unfortunately, my experience is not unique at VA. Daron and 
Eileen Owens, who work at the Atlanta VA Medical Center, have 
experienced the same retaliation for reporting medical errors 
and patient neglect, as well as misconduct by senior VA police 
officials. Our Local 518 union president, Daphne Ivery, is 
routinely harassed as a direct consequence of assisting me and 
other disabled Federal employees with retaliatory actions by 
members of management. Mr. Owens, Mrs. Owens, Ms. Ivery are all 
veterans. And in fact, over 50 percent of the staff that works 
at the HEC are disabled veterans.
    In 2010 allegations surfaced that applications for VA 
health care were being shredded at the HEC. Under the direction 
of the HEC Director and Deputy Director, Ms. Kimberly Hughes, 
former Associate Director for Informatics, and her team began 
to investigate this allegation. Her team discovered nearly 
2,000 applications that were reported as being processed that 
did not appear as new enrollments in the enrollment system. Ms. 
Hughes' investigation was abruptly closed by the HEC Director's 
office. She was also subjected to harassment and intimidation 
because she dared to advocate for veterans.
    The whistleblower statements I have provided to the 
committee were also provided to the OIG and are more relevant 
to the committee than many may realize. I urge additional 
review of those whistleblower statements. In addition to 
providing specific examples of whistleblower harassment to the 
committee, I hope my testimony provides some insight to three 
key issues VA management fails to address: Reckless waste of 
Federal funds and causing greater backlog of enrollment 
applications for the sole purpose of achieving performance 
goals; why there is resistance to implementing proper and 
effective processing and reporting systems, and the source of 
the resistance, as addressed previously by Dr. Draper during 
her testimony; and the need to remove ineffective managers, and 
the critical need for the VA Management Accountability Act to 
be fully implemented.
    Thank you for this opportunity. I look forward to your 
questions.
    The Chairman. Thank you very much, Mr. Davis.

    [The prepared statement of Mr. Scott Davis, appears in the 
Appendix]

    The Chairman. Thank you very much. And, Mr. Davis if you 
would, explain a little bit further the information you 
provided to Rob Nabors, who was detailed from the White House 
over to VA, that led to adverse employment actions being taken 
against you.
    Mr. Davis. Yes. I contacted Mr. Nabors about 4 weeks ago. 
As the point of contact for the White House, I wanted him to be 
aware of what was going on in our office. A lot of attention 
has been placed on scheduling, but it's important to understand 
if you're not enrolled, you're not going to be placed on a 
schedule. I wanted him to know about shortcomings with the 
enrollment system, a system that many of you have talked about, 
we have spent millions of dollars on, and yet we're still back 
at square one with these VA systems.
    I also reached out to him about a Medicare Part D marketing 
initiative by VA to encourage senior citizens who are veterans 
to drop their subsequent companion Medicare insurance and 
enroll in VA. That was problematic because, as you know, if you 
enroll in VA you can only use the pharmacy at VA. You have to 
use your VA doctor. Many of our most vulnerable veterans were 
not aware of that and could be confused and cancel their 
supplemental Medicare insurance and end up being stuck in the 
donut hole in the backlog.
    I also contacted Mr. Nabors about the continued 
mismanagement of VA health programs managed by the HEC and the 
Chief Business Office under the direction of Mr. Philip 
Matkovsky and Lynne Harbin.
    After sending that information to Mr. Nabors, I did not 
receive a response. I subsequently contacted the office of 
Deputy Chief of Staff Anita Breckenridge. I also did not 
receive a response until after receiving notification from Ms. 
Sherry Williams that she was contacting me on behalf of the 
Acting Secretary and Mr. Rob Nabors. It surprised me that Ms. 
Williams would do this because she is a former OIG official.
    To this date no action has been taken to reprimand Ms. 
Williams for her behavior. This goes to the very heart of the 
question whether or not VA should be allowed to police itself 
and whether or not an outside agency should be brought in to 
fully conduct an investigation into the actions taken at VA.
    The last thing I will say is I did receive an email from 
the White House Office of White House Counsel directing me to 
contact the Office of Special Counsel. If that was the official 
position from the White House, there would have been no need 
for anyone to contact Ms. Williams about my complaint.
    The Chairman. You also, in your testimony, you described 
the possible purging of over 10,000 veteran health records at 
the Health Eligibility Center, that there's a backlog of 
600,000 pending benefit applications and 40,000 unprocessed 
applications discovered that span 3 years?
    Mr. Davis. Absolutely. Currently we have over 600,000 
pending applications. These are applications that have been 
applied for by a veteran, turned in to VA, and for whatever 
reason we could not take that application to a final 
determination. This backlog has reached again the number of 
600,000. What we should have done, instead of hiring 40 people 
to address the Affordable Care Act in a belief that we're going 
to have this surge of people because of a buddy letter 
marketing campaign where the veteran was encouraged to pass on 
information about enrolling into VA health care to a fellow 
veteran, well, unfortunately, the information for the veteran 
to take the action was on the second page of the letter. 
Therefore we ended up getting 80,000 duplicate applications of 
which only about 1,650 were actually applications that we could 
actually do something with.
    In terms of the 40,000, this was discovered in January of 
2013, and this is important to the committee because I want to 
share something that was in a report that I forwarded to the 
committee from 2013. Increasing online application submissions 
versus paper and improving turnaround times for eligibility 
decisions has a positive direct impact on providing timely 
access to health care. Data reveals applications submitted in 
person are processed with higher urgency while online 
applications linger in a less visible queue.
    To answer your question how could this happen, because 
these applications linger in a less visible queue. Even though 
the IT Department had paid licensing fees for over $40,000 for 
us to have a new system for managing the queue, a system 
referred to as BizFlow, that system was only put into play for 
implementation until after the 40,000 applications that were 
lingering in the queue, in some cases for nearly 3 years, was 
discovered. That is something that is shameful.
    The Chairman. Thank you, Mr. Davis.
    Members, I have one more question I'd like to ask Dr. Head.
    Dr. Head, you talked about the retaliation against you, and 
I want to specifically talk about a Dr. Wang, who I read that 
the OIG concluded that Dr. Wang had, in fact, committed time 
card fraud. Is that correct?
    Dr. Head. Yes. The official report was not released to the 
layperson. The information I received was that they had 
recommended immediate termination of her and this other 
individual. Through other chief of staff and counsel, they had 
said that they had found significant fraud, time card fraud.
    The Chairman. And so she's been terminated?
    Dr. Head. She has not been terminated. She has been 
maintained in a supervisory role.
    The Chairman. Can you explain a little bit about how that 
has occurred?
    Dr. Head. I have no idea how she was able to maintain her 
position.
    The Chairman. But VA did not follow the Inspector General's 
recommendations?
    Dr. Head. They elected not to follow the Inspector 
General's recommendation. She has been left in her Division 
Chief position. She was my supervisor. I filed a complaint, 
numerous complaints. They moved me from that office under her 
chain of command to the Chief of Staff, which in my opinion was 
an excellent opportunity. I rose in the ranks, became head of 
Legal and Quality Assurance, and have become I think an expert 
in system analysis and quality assurance, which I think will 
help the veteran even more, ironically, now from being 
retaliated against. That's just how I was brought up: Find a 
way.
    The Chairman. Thank you, Doctor.
    Mr. Michaud. Thank you very much, Mr. Chairman.
    As you all know, whistleblowers, you often risk your career 
in order to bring problems to light. What would you recommend 
that we do as far as to change the rules or laws government-
wide to actually help protect the whistleblowers. And I'll 
start with Dr. Mathews and work down, if there's anything that 
we should do to strengthen the Whistleblower Protection Act.
    Dr. Head. Yes. That's an excellent question. And one of the 
things that I experienced was that I was immediately removed 
from my position. So under the guise of an administrative 
investigation with a specific directive to not contact any of 
the psychiatrists that I was managing, and they cut off my 
access to the databases, some of which I'd set up myself to get 
accurate data. So one of the things could be that if there is 
this sort of an investigation, that the person continues rather 
than be detailed. And if the person has to be detailed, perhaps 
there should be a review by peers to see whether that's even 
warranted or not.
    There seems to be no time limit to these kinds of detail. 
And this is the second time I've been detailed. Just recently 
I've been detailed again. So as Dr. Mitchell mentioned, these 
are not the jobs that we wanted to do, not that we would not do 
it. We would do it to the best of our abilities. So having that 
protection. Having the OSC have some sort of a time limit to 
review these complaints would be very beneficial. Having a 
process for, you know, like you rightly mentioned, if a 
supervisor is, indeed, found to have retailed, to have some 
very tangible consequences to that person would be very, very 
important.
    Right now I think, at least in the St. Louis VA, they do 
not think that this is a serious issue. Like I said, like 2 
weeks ago I was called into a meeting with the Chief of Staff 
where the chief of the outpatient psychiatry, the person I had 
worked with very closely to implement my changes was also 
called into that meeting. And in that meeting I was 
specifically told that the chain of command must be respected 
at all times, that if I had any issue or if Dr. Esses had any 
issue, that we should report it first to our supervisor and 
then move up to the next level and the next level. So I called 
the--
    Mr. Michaud. Could you finish up because I'm running out of 
time. We have got three others, so.
    Dr. Head. Yes. So I think your recommendation for having 
very quick and serious consequences to retaliation would be 
very important.
    Mr. Michaud. Thank you. Dr. Head.
    Dr. Head. Yes. I think there needs to be greater 
repercussions for retaliation. We have laws referred to shield 
laws and sword laws. Sword laws meaning that if I retaliate 
against someone, there are Federal laws that say, look, 
retaliation is against the law, and they can warn the person 
don't retaliate. But they can continue to retaliate against the 
person, which ultimately will have a direct or indirect effect 
on the care of the veteran, endangering the veteran only 
because their caregiver or doctor or nurse is being retaliated 
against.
    Shield law means that not only do you have a sword law, 
repercussions for retaliation, but you have a shield law where 
you can immediately take action and there can be immediate 
repercussions for any type of retaliation against the 
whistleblower. In other words, you tell the Chief of Staff, 
look, if this person gets retaliated against, pushed out of a 
job or anything, we're going to hold you accountable for this 
until we figure out what's going on here.
    And we have a shield law that was enacted in the State of 
California, but that's something that should be considered by 
Congress. Ultimately you will address it one way or another 
because retaliation in the health place is different than in a 
factory, because if you retaliate against a physician or 
surgeon or nurse practitioner or nurse, you're going to have 
direct repercussions one way or another to the health and well-
being of a veteran.
    Mr. Michaud. Thank you. Dr. Mitchell.
    Dr. Mitchell. I'm not sure all of it needs to be 
legislated, but certainly the OIG needs to put in writing that 
providing limited patient information to support allegations in 
a complaint is not a violation of HIPAA. It isn't, but 
certainly there are employees charged all over the Nation for 
it.
    In addition, sham peer reviews need to be part of the 
prohibited personnel actions. That's where they drum up a 
reason to examine a physician's cases. They have a 
predetermination that this physician is not properly 
functioning, even though there certainly is no problem with 
this level of functioning. And then they can permanently 
sabotage a physician's ability to get employed not only inside 
the VA, but in a private sector.
    Whenever you're subjected to a peer review you have to 
report being a subject of a peer review for the rest of your 
professional life, on every job application, on every license 
renewal. Sham peer reviews are done specifically to sabotage 
the credibility of a physician. Physicians truly face losing 
their livelihood, their ability to be employed again as a 
physician. You need whistleblowers that are physicians, people 
that are trained to identify the high risk problems.
    Mr. Michaud. Mr. Davis.
    Mr. Davis. Yes, thank you. I don't know if a new law would 
really change anything, honestly, at VA if you don't have 
accountability. I think there are some structural changes that 
need to take place, one being a centralized human resource 
office that actually has operational authority.
    Currently, when I went through my situation of retaliation, 
I spoke with a representative from the VA HR office. They told 
me they're only a policy body, that they could contact the HR 
office where I work and maybe make some recommendations and see 
what they could negotiate. That's problematic, because in VA, 
unlike a corporation or a normal healthcare system, every 
division or the hospital itself has its own HR department which 
becomes the secret police force for the managers who harass 
employees. And that's problematic, and that's what needs to 
change. So I think an operational change for a centralized 
human resource office would also help.
    But also I think you need to start making bad managers pay 
their own legal fees. Currently, managers who engage in 
harassment have no fear because the bill is going to be passed 
on to the taxpayer. And even if they lose the case or they're 
found guilty of wrongdoing, well, the bill just goes on to the 
taxpayer. Currently, we have managers in our office that have 
several different complaints for harassment. It's not a big 
deal to them. Regional counsel will take care of it. The Office 
of General Counsel will take care of it. So I think that's the 
issue that really would change people's behavior, if you hit 
them in their pocket.
    The Chairman. Mr. Lamborn, you're recognized for 5 minutes.
    Mr. Lamborn. Thank you, Mr. Chairman, for having this 
hearing.
    And I want to thank all of you for being here. You're 
showing a lot of bravery and courage. You're putting it all out 
on the line to do this, and I know that you're doing it for our 
veterans.
    Dr. Mitchell, I'd like to ask you, you've been at the 
Phoenix VA for 16 years. Do you believe that the lack of 
response to safety issues that you've brought up over the years 
have threatened the health and even the life of veterans in 
Phoenix.
    Dr. Mitchell. Yes. Anything that impairs the efficiency or 
the delivery of care threatens the lives of patients. Certainly 
in the ER I can recall at least three specific deaths and 
several more I believe actually occurred in the ER. As a 
resident I also trained through the Phoenix VA. There were at 
least two patients I know that died because they were delayed 
in getting their cardiac cath because the VA only did cardiac 
catheterizations Monday through Friday, not on weekends. These 
veterans had to wait because there wasn't time to get them done 
on Friday, so they died on Sunday.
    When I was a nurse there, there were tremendous problems 
with patient care, and there weren't sufficient nurses to turn 
patients the adequate number of times. We had patients 
developing huge bed sores. I can remember JCAHO certification 
inspections that to this day still haunt me because 
administration would authorize overtime for charting, because a 
JCAHO administrator would look at charting, but would not 
authorize overtime for nursing staff to turn patients because 
there wasn't enough staff to do it or to feed patients. We used 
to volunteer our time quite a bit because we couldn't leave the 
team short staffed.
    Mr. Lamborn. Doctor, did these problems catch the hospital 
and the administrators by surprise or had they been warned that 
there were pending problems if something didn't change?
    Dr. Mitchell. I am aware of problems throughout the 
facility without necessarily having access to upper 
administration. I know that people communicate these concerns 
as best they can. What happens is any concern you bring up you 
have to present to your supervisor in a politically correct 
manner, because if you don't you will be retaliated against, 
either you'll be harassed at the moment you're giving the 
information, your proficiencies will drop, something bad will 
occur. It's best that management not know your name, because if 
they do it makes you an automatic target. And I'm sorry, that's 
not to say that all supervisors are that way. There are some 
incredibly ethical supervisors at the facility where I work.
    Mr. Lamborn. Okay, good. That's good to hear. The interim 
OIG report which brought out some of the issues that we're 
seeing even better as a result you believe didn't go far 
enough, if I understand your testimony correctly. Do you think 
that there were flaws with the methodology and that it could 
have even been more revealing of problems out there?
    Dr. Mitchell. There's a saying that has to do with lies, 
damn lies, and statistics. And what they did was they took out 
a segment of patients and said, well, this is the average wait 
time. The NEAR list that they were looking at was divided by 
clinics. Some of the clinics had relatively short waiting time. 
The NEAR list ran from I believe January of 2013 to April 24 of 
2014.
    Some clinics had very short waiting times. The downtown 
Phoenix clinics were all aggregated or an aggregate of some, 
and the waiting time started at 477. They didn't hit down to 
the 110s, 120s until page 8 or page 9. Because some of the wait 
times were zero or 1 day or 2 days, because they extended up 
until April 24, I have no idea which patients they picked. It 
would have been certainly more accurate to say at the Phoenix 
VA clinics we had this many patients waiting zero to 30 days, 
this many from 31 to 45.
    Mr. Lamborn. So as a result, and we are getting the real 
detail here, you don't think that the report revealed nearly as 
much of the problems as it could have?
    Dr. Mitchell. No. I told them about the mental health 
waiting delays, the huge problems with that. Other people told 
them that, the issues. I told them about the patient safety 
issues. It certainly didn't go into that.
    Mr. Lamborn. Okay. Thank you.
    Once again I want to thank you all for your service to our 
veterans and for being here today.
    Mr. Chairman, I yield back.
    The Chairman. Thank you.
    Mr. Takano, you are recognized for 5 minutes.
    Mr. Takano. Thank you, Mr. Chairman.
    Dr. Mathews, are you familiar with the Federal 
classification of employees, whether it is SES or Title 38 
employees? Are you aware of that system?
    Dr. Head. Yes.
    Mr. Takano. In your capacity as chief of psychiatry, was 
that a Title 38 position; do you know?
    Dr. Head. Yes. Title 38 position.
    Mr. Takano. Okay. Dr. Head, in your position where you 
formally were, was that a Title 38 position or something below 
a Title 38?
    Dr. Head. Title 38. I am still employed by the----
    Mr. Takano. You are still employed, I understand.
    Dr. Head. Yes.
    Mr. Takano. Okay. And Dr. Mitchell?
    Dr. Mitchell. Yes, I am a Title 38 employee, and I have 
been employed as a physician throughout my VA career there.
    Mr. Takano. Okay.
    And Mr. Davis?
    Mr. Davis. No, I am just a General Service employee.
    Mr. Takano. General service employee.
    So one of the things I am grappling with is the proposal 
for us to make it easier to fire VA employees guilty of 
wrongdoing, so a more at-will sort of basis, and that would 
apply to the Senior Executive Service. And typically 
whistleblowers come from the lower ranks of employment, but 
there is a debate about whether or not we should extend this 
sort of standard to Title 38 employees. And so in my mind, I am 
going through this contradiction of, well, there is a sense 
among some Members that we want to make it easier to fire 
people at certain levels of service, but that might seem to run 
against the idea that we need to also protect people who speak 
up.
    Dr. Mathews, do you have any thoughts on this? We have a 
whistleblower protection, but, I mean, how do you feel about 
making it easier for us to fire Title 38 employees?
    Dr. Head. Well, I think, you know, when veterans' life and 
health is at issue here, I think that, you know, you should be 
able to be fired. Any person in direct patient care right now 
enjoys almost a lifetime tenure where they are completely 
protected from their actions, the consequences of their 
actions, and I think that is not good for providing a safe work 
environment for the veterans, or safe health environment for 
the veterans, or work environment for the physicians and other 
people who come forward.
    I do not think that the Chief of Staff or the Chief of 
Mental Health, who just threatened me 2 weeks ago, has any 
concern about their position being threatened in any manner. So 
I think that kind of protection should end.
    At the same time, I also would want us to consider that a 
workplace is only as good as the employees there, and I'm 
hoping that we take a look at what the salary structure is, 
especially for some hard-to-fill positions, so that, you know, 
we can have less protection with----
    Mr. Takano. Dr. Mathews, excuse me, but wouldn't that 
ability to have fired you so absolutely have eliminated your 
ability to even voice any dissent or act as a whistleblower?
    Dr. Head. Well, that already exists. I mean, they already 
professionally assassinated me in the sense that, you know, I'm 
no longer the Chief of Psychiatry. They've already spread this, 
you know, the fact that I am no longer the Chief of Psychiatry. 
In fact, the way I found out that there was this--you know, 
this administrative investigation stuff going on is when one of 
the psychiatrists I recruited called me concerned that, you 
know, are you fired? I mean, I hear that you're fired. So 
professionally--and it's a bad statement on the VA that, you 
know, me having trouble with the VA is----
    Mr. Takano. But would you have been worse off having your 
voice completely eliminated by you being summarily fired 
because they had the ability to do so? You at least are able to 
be here and voice your concerns. And actually, I mean, it's far 
from where we need to be in order to have feedback from people 
at the mid level and lower levels to be able to say what is 
wrong.
    That is our interest, right, I think, in our national 
interest, to be able to have lower-level employees be able to 
speak up without fear of being retaliated, but is whistleblower 
protection enough? Do we need to have some sense of due 
process, which some of the Members would like to see eliminated 
so it's easier to fire people? I see a tension here. I mean, I 
think you might even recognize. I, too, would like to be able 
to fire people, not have them have complete tenure and they 
feel insulated.
    Dr. Head. Right.
    Mr. Takano. But I don't know how we solve this.
    Dr. Head. Well, you know, I think one way that I can 
suggest is to put ourselves or our loved one in the veteran 
position. Would I want to obtain care, or would I want my son 
to obtain care, at a system where poorly performing nurses or 
physicians cannot be fired? And I would not want to go to that 
hospital. So I think, I mean, that would help perhaps resolve 
this tension about who are we protecting? Are we protecting the 
veterans, or are we protecting the VA employees?
    Mr. Takano. I understand.
    Mr. Chairman, I yield back.
    The Chairman. Thank you very much.
    And also, the legislation that we have passed in the House 
does not reach down to this level of a SES or Title 38 
employee, only senior level, the top 450.
    Mr. Bilirakis, you're recognized for 5 minutes.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it. 
Thanks for holding this hearing.
    And I want to thank you, the people that are testifying 
tonight, for putting the veteran first. Thank you so much for 
your courage. I really appreciate it.
    Dr. Head, I know I don't have a lot of time, you mentioned 
in your testimony that this potentially could be--the VA 
system, VHA, could be the best healthcare system in the world. 
How do we get there?
    Dr. Head. I believe with leadership. You know, there are 
certain people in leadership that have been there for 18, 20 
years, and if they're a great leader, it's fabulous; but if 
they're not, it's very disruptive to the system.
    We need to find ways to bring in leadership on a continuing 
basis. Maybe term--I don't know if this is the answer--maybe 
term limits. And if you're a good leader, you're identified as 
a good leader, and perhaps you could be part of the team that 
brings on new leadership and show them the right direction. And 
if you're not such a good leader, maybe you should be 
integrated in another part of the Federal Government or retire.
    But leadership is clearly the key. Our surgical team at the 
West L.A. VA could be matched against any surgical team in the 
country, possibly in the world. My wife, much smarter than I 
am, is an interventional electro physiologist, cardiologist at 
the VA. She could work anywhere in the country. Somehow she 
agreed to marry me and also dedicated her life to serving 
veterans. She loves her job. She obsesses over it. She's always 
worried about trying to save another veteran. I commend that. 
And there's lots of people like that within our system.
    We need leadership. The leadership will take the VA to that 
next level. I think it's not resources. We all care about the 
veterans. And you're very giving. And we'll do anything to 
serve our veterans. And it's not resources. We'll do anything 
it takes to make this situation right and to serve the 
veterans. And I have no doubt that if the right leadership is 
brought to bear on this problem, we can solve this problem.
    Mr. Bilirakis. Thank you.
    My next question, and this is for the entire panel: In the 
previous fiscal years, all Senior Executives Service employees, 
all received a fully successful performance. Last year, in 
particular, they received a fully successful performance, which 
totaled to $2.8 million in performance awards. Yes or no, and 
we'll start with Dr. Mathews--yes or no, do you believe that 
this is an accurate assessment and that all eligible senior 
employees performed at a fully successful capacity and higher?
    Dr. Head. No.
    Mr. Bilirakis. No. Okay.
    How about Dr. Head?
    Dr. Head. No.
    Mr. Bilirakis. Mr. Davis?
    Mr. Davis. Based on what we now know in the public record, 
absolutely not.
    Mr. Bilirakis. Dr. Mitchell?
    Dr. Mitchell. No.
    Mr. Bilirakis. Thank you.
    Next question is for Dr. Mathews: Through your own 
investigative work during your time at the St. Louis VA, you 
identified that on average--you spoke to this in your 
testimony--on average, psychiatrists were seeing six veterans 
per day, which accounted for 3.5 hours in an 8-hour workday. 
When you contacted other psychiatry chiefs regarding actual 
time spent in direct patient care by psychiatrists seeing 
veterans, do you know if they had been tracking this 
information prior to your inquiry?
    Dr. Head. No, I do not know if they were tracking it. I 
know that our VA does not track it, and I know that many other 
VAs do not track it, because a lot of the other chiefs wanted 
to know the answers as well. So I got a lot of emails from 
other chiefs saying, you know, why don't you forward the 
responses to me as well? And just recently there was another 
new Chief of Psychiatry who had the exact same question that 
was, you know, sent out to everybody saying, you know, what is 
a reasonable expectation? What number should be reasonable?
    Mr. Bilirakis. Thank you.
    Next question, again, for Dr. Mathews: Your findings also 
discovered that 60 percent of veterans were dropping out of 
mental health care after one or two visits. And I have town 
meetings, and I have veterans advisory councils, and they tell 
me the same thing. Do you believe it was directly connected to 
the experience they had while seeking treatment with the VA? Is 
it the type of treatment? Should there be alternatives to that 
treatment? If you could----
    Dr. Head. Sure. You know, my goal was to make the VA mental 
health clinic a very welcoming place with very easy access to 
care. The majority of the veteran complaints that I reviewed 
had to do with long wait times, not being able to come to seek 
their care, and, you know, that really demoralized them from 
obtaining care.
    Some of the young veterans that I saw in my new capacity--
well, the previous capacity as the compensation and pension 
evaluator, I came across some really horrendous barriers to 
care for veterans who had tremendous amount of combat exposure. 
They were in some of the specialized forces.
    And just one instance I will mention here----
    Mr. Bilirakis. Please do.
    Dr. Head [continuing]. This veteran was doing so poorly 
that his roommate, who was also a veteran, had both taken off a 
day of work so that he can take this veteran and get him care. 
So they come to the VA, and it takes 3 or 4 hours to find out 
whether this person is even eligible for care or not, and then 
they determine that, yes, this person is actually eligible for 
care.
    So this veteran then comes to the PTSD clinic and is not 
seen by a healthcare provider, is told that we will contact you 
next week after a meeting to determine what we can--what we are 
going to do for it. Now, I was doing a compensation and pension 
evaluation, so I had access to the records, and I was looking 
at whether there's a record of this veteran actually going to 
the clinic or not, and I did not find any record. But there is 
a subsequent notation saying--a form letter that was sent to 
this veteran that stated that we learned that you were 
interested in obtaining care at our facility; please call these 
numbers to schedule an appointment.
    So this is for a veteran who has served our country and 
sacrificed a lot, who even the military recognized had PTSD, 
had taken a day off of his low-paying job to obtain care, and 
then there was no record of this person being at the VA, and 
the contact was not made. So when I evaluated him, I asked this 
person that, you know, would you consider coming to the VA to 
obtain care, and this veteran was very clear in saying, no, I 
am not going to obtain care here. I was not treated with 
respect. And, you know, he didn't want to come to get care 
there.
    So that's one really bad example that I can say about how 
the access to care and the whole attitude of it not being a 
welcoming place, of erecting barriers, you know, that really 
prevents people from coming back. And there's a lot of such 
complaints that I heard in my capacity as the Chief.
    So yes, the answer is yes. You know, how we are interfacing 
with the veteran, what kind of access we are providing, and 
what kind of care and environment we are providing, I think, is 
critical in maintaining patients and care.
    Mr. Bilirakis. Thank you very much. I appreciate it.
    Thank you all for your testimony.
    The Chairman. Thank you.
    Ms. Brownley, you're recognized for 5 minutes.
    Ms. Brownley. Thank you, Mr. Chairman, and thank you for 
holding this hearing, and thank you to all of you for being 
here. Your testimony is extremely important, and we appreciate 
it very, very much, and I believe that all of you, by virtue of 
being here and having gone through what you have gone through, 
you have also, as our veterans, served our country honorably. 
So thank you for that service.
    I just wanted to ask Dr. Mitchell and Mr. Davis, because 
both of you went through a--well, Dr. Mitchell, you went 
through a formalized process, a confidential process with the 
OIG, and somehow that information leaked out, and it was not 
confidential. And, Mr. Davis, you reached out to the White 
House, and obviously there were--based on your testimony there 
were leaks as well. So I was wondering if the two of you could 
just comment on do you know how those leaks occurred? Were you 
promised confidentiality?
    Dr. Mitchell. Yes. The Senator McCain's office submitted 
the request--or my complaint with two requests, one, that there 
be an outside investigative team because the local OIG had a 
long history of not doing very good investigations, and the 
second one was that my name be kept confidential. I don't know 
who leaked my name; I just know that it was leaked. And I don't 
even know if there's any consequence to whomever leaked my 
name.
    The second thing is I don't even know if the OIG actually 
investigated. What happened was there's no official report, 
although certainly the Web site--the OIG has complete 
discretion as to which reports it puts on the Web site. 
Anecdotally I have been told that those that are unfavorable to 
SES service do not go on there. Someone has since forwarded me 
a complaint that is certainly unfavorable to SES service, and 
it can't be found on the Web site. I have no idea what 
occurred, and I can't even get a report of it.
    Ms. Brownley. Have you tried to find out, though?
    Dr. Mitchell. I had Senator McCain's office checking, and 
they're stonewalling them.
    Ms. Brownley. Thank you.
    And Mr. Davis.
    Mr. Davis. I can tell you that as late as about 4:30 p.m. 
this evening, I was informed by my union president that the 
Acting Chief Business Officer Stephanie Mardon sent a 
correspondence saying that Ms. Williams, the person who said 
she was responding on what behalf of Secretary Gibson and Mr. 
Nabors, was not officially authorized to speak on their behalf.
    What she didn't provide, which would probably be more 
important, is who told her in the first place. And I think that 
is the problem with VA: a complete lack of accountability. And 
when people know that they can engage in behavior without 
consequences, something has got to change.
    Ms. Brownley. Thank you.
    Dr. Head, I represent Ventura County in California, so my 
veterans use your facility in West Los Angeles. And so I am 
wondering, after being here this evening with us, what it's 
going to be like for you when you return back to West L.A.? 
What will the environment be?
    Dr. Head. I'm not sure. I do fear retaliation, but I also 
know this was the right thing to do. And more importantly, I 
think many veterans that I care for support me.
    Ms. Brownley. And do you believe by virtue of what you have 
been through and now being here, do you think that that has--
and everything that has happened, and what we have learned 
about what is going on in the VA across the country, I mean, do 
you feel a difference when you go back to West Los Angeles than 
you did a few months ago?
    Dr. Head. Well, I think more importantly I've enlightened, 
I believe, Congress, and they have an opportunity to look very 
factual. All I ask is that you look at the facts and unveil the 
facts, and I think that in itself will be helpful.
    And as far as going back to my job, I could afford not to 
work, but I want to work, and I want to serve the veterans. And 
when I first came, Dr. Mitchell and I were chatting, and we 
both want to retire within the VA Administration.
    Ms. Brownley. Yeah. I think I'm just trying to drill down a 
little bit to see if there's been any shift or change over the 
course of the last month or two in the culture, because you 
feel it every single day, and, you know, changing culture is 
really a hard thing to do. But I'm just curious to know if 
there's been--you know, do you feel a shift?
    Dr. Head. I think there's been awareness. They are very 
much aware that I was coming here tonight, and I think they're 
very much aware that I will stand up for myself and for the 
veterans, that I will not cower down.
    I'm human, I have my frailties, and this is wearing on me. 
I wish I could just go to work and dedicate all my energy to 
caring for veterans and to make processes that will improve the 
care of veterans, but instead, the reality is I do worry about 
retaliation on a daily basis. I'm always looking over my 
shoulder. I'm always wondering about, you know, peer reviews. 
Fortunately, I've been head of a certain area of peer review, 
so I've been immune to some of those retaliatory efforts.
    I am worried, and I'm tired. If you could do one thing for 
me tonight, you would relieve the obstructions of this 
retaliation and allow me to serve the veterans and be able to 
work without the fear of retaliation. That would be a great 
gift.
    Ms. Brownley. Thank you, Dr. Head.
    And again, thank you to all of you, and my time is up, and 
I yield back.
    The Chairman. Thank you.
    Dr. Roe, you are recognized for 5 minutes.
    Mr. Roe. I thank you, Mr. Chairman.
    Dr. Mathews, I was a young doctor once, and I remember 
returning from Southeast Asia, and I was full of vim and vigor, 
and I was stationed at Fort Eustis, Virginia, and there was 
2,000 women that needed Pap smears. I was going to solve that 
problem. When I left Fort Eustis, Virginia, there were 2,000 
women on the Pap smear list. I ran into inertia, which is what 
I think you ran into.
    And I admire what you did because you touched on two very 
important things. You all have hit the nail on the head. It's 
the backlog, which we can easily take care of. We can do that. 
Number two, changing the culture of the VA is going to be much 
more difficult, and that's much more critical downstream years 
from now.
    But what you did when you got to the VA in psychiatry was 
you recognized a problem. You saw long wait times for patients, 
and you wanted to make sure those patients in need got there. 
And I have seen those patients in my office.
    Two, you said how much work are we actually doing? And when 
you evaluated it, you found out that your colleagues were 
seeing basically six patients a day. There's no private 
practice in the world doing anything that can stay afloat 
seeing six patients a day.
    So you wanted to increase productivity, shorten the wait 
times. And what I found astonishing was that 60 percent of our 
veterans who sought out care--and these are folks have PTSD 
that desperately need this care, and we know there is a 
shortage of your kind of specialty in the VA and in the 
country, quite frankly--wouldn't come back. I found that 
absolutely amazing to me that they found the environment so 
inhospitable to them that they refused to come back.
    And then very simply, how we're all being evaluated with 
accountable care organizations and so forth is were you 
satisfied with your visit? A very fair question. And you hit 
the nail right on the head a minute ago when you said, what if 
you were the veteran? Would you want to be in a place where 
less-qualified people or people who didn't seem to have your 
best interests at heart, would you want to be them?
    I want to ask all of you, Dr. Head and Dr. Mitchell, too, 
just very briefly, how does retaliation within the VA affect 
patient care? And I think we all know that, because if you're 
retaliated against, you go back to the six patients a day, that 
means 60 percent of those veterans that need care are not 
getting it. Am I right?
    Dr. Head. That's unfortunately the case. And I can tell you 
that being in compensation and pension evaluation, I know of at 
least one veteran who committed suicide while waiting for, you 
know, the call-back to get care. So, you know, unfortunately it 
went back to where it was, and we really don't have a real-time 
veteran satisfaction with care metric.
    And I think that's very important, because we do not really 
know, other than these surveys which are incomplete and which 
are administered not correctly. You know, mostly the clinic 
itself hands out these surveys to the veterans to fill out, and 
then they collect it as well. So although you tell them it's 
confidential, I don't think anyone would really believe that.
    Mr. Roe. Yeah, I think you could take what you did and go 
across primary care, specialty care, anything, and find out is 
it a staffing need? Do we need more people to work, or do we 
need to be more efficient at work while we're there?
    I want to ask Mr. Davis a question, and it dawned on me 
just a minute ago, what happened to the 40,000 veterans that 
were queued up? What happened to them?
    Mr. Davis. Well, the 40,000 veterans that were discovered, 
40,000 applications, they were eventually processed. But I 
think here lies the problem of sort of the callous and 
carelessness in VA management, and that's why I go back to my 
point of make them pay for it.
    The problems with the queue, as it's referred to, could 
have been addressed. Again, VA was paying for licensing and 
maintenance fees for them to institute a new workflow 
management system that could have resolved that issue. It 
wasn't resolved or addressed until after the 40,000.
    Now, what's interesting is--and I'll give you an example of 
the sort of lackadaisical attitude by VA management. In the 
report that I read from earlier, in 2013, it talks about the 
backlog. It talks about the slow processing of online 
applications. You're a physician. Could anyone imagine an 
application for health care that you can write in your house, 
drive to a VA medical facility, wait in line, turn it in to 
someone at the counter, wait for them to process it is actually 
faster in 2014 than the online process? If this was a private 
corporation, we would be run out of town.
    Now, let's put that into context. I have submitted to the 
committee a document, a fact-finding report, which dealt with 
the marketing contract, that dealt with waste and 
mismanagement, and it addresses the issue at our office that 
the contract was so poorly mismanaged that the $5 million 
contract would not withstand scrutiny if it was subject to a 
third-party audit.
    I ask you to look at this in the context of the enrollment 
system, look at it in the context of the workflow management 
contract, about $2 million. It's the same sort of reckless 
attitude. They don't assume responsibility for their actions 
when it comes to retaliation, and they don't assume 
responsibility for their actions when it comes to wasting the 
resources given to them to provide services to veterans.
    Mr. Roe. Mr. Davis, just one other thing, and it's a 
statement, not an answer. But in our briefing today, it said--
and officially the St. Louis VA Medical Center is reporting to 
VA central office that its productivity was along the highest 
in the Nation. When that sort of thing happens, how in the 
world can we believe anything that's in front of this 
committee? I get asked at home, why do you know about this? And 
I say, well, we get this kind of information. How would we know 
about it when the people giving us information are not giving 
us factual information?
    Thank you, Mr. Chairman. I yield back.
    The Chairman. Thank you very much.
    Mrs. Kirkpatrick, you're recognized for 5 minutes.
    Mrs. Kirkpatrick. Thank you, Mr. Chairman.
    I'd like to start by thanking our whistleblowers for having 
the courage to come forward when you witnessed wrongdoing. I 
would particularly like to recognize Dr. Katherine Mitchell 
from the Phoenix VA. I asked you to come and testify before our 
committee. I know that you've risked your career to report 
wrongdoing and suffered repeated retaliation from 
administrators who refuse to do the right thing, so thank you.
    By bravely stepping forward, Dr. Mitchell and Dr. Foote 
made Congress, the IG and the VA aware of the problems in 
Phoenix which led to the discovery of systemic patient wait 
time data manipulation at VA facilities across the country. 
Unfortunately, without whistleblowers we were unable to 
identify many of the problems in the VA. Because of 
whistleblowers, we can now work to fix them.
    It is unacceptable and reprehensible that almost half of 
the Office of Special Counsel's whistleblower retaliation cases 
involve the VA. The bullying of patients and VA employees that 
report wrongdoing must stop now. I sent a letter to Acting 
Secretary Gibson last month asking him to remind all VA 
employees of their rights at whistleblowers; however, it is not 
enough that employees are informed of their rights. The VA must 
still develop a culture of zero tolerance for whistleblower 
retaliation at all levels of its organization.
    Employees should not be afraid of losing their jobs or 
ruining their careers for speaking up when something is wrong. 
Patients should not be afraid that they will be denied care 
because they think something is wrong. The VA must stop using 
the harmless error defense to downplay wrongdoing. This finding 
by the VA Office of the Medical Inspector in most cases was 
baseless and an excuse for administrators to do nothing while 
patients were put at risk.
    This is why I'm introducing a bill this week to give 
further protections to VA whistleblowers. Employees and 
patients should be able to report wrongdoing directly to the 
Office of the VA Secretary so they do not have to face 
retaliation from the same administrators that refuse to act. 
The office will investigate complaints of whistleblower 
retaliation and ensure that whistleblowers' rights are 
protected.
    While all VA employees should work to serve veterans, the 
sad reality is that the VA has a corrosive culture and a 
history of retaliating against those who speak to break the 
code of silence. Until the VA is able to instill transparency 
throughout its ranks and develop a culture focused on caring 
for veterans, I believe additional protections for VA 
whistleblowers are necessary.
    My question is for all of our witnesses: If you could name 
one thing that the VA could do immediately to change its 
culture of silencing whistleblowers, what would it be? And 
let's start with you, Dr. Mathews.
    Dr. Head. Well, if I had one wish, that would be that data 
integrity is there. And the VA has demonstrated over and over 
again that they will make up numbers, they will come up with 
blatant lies. Like Dr. Mitchell said, and I will paraphrase the 
great person from Missouri, Mark Twain, that there are lies, 
damned lies, and VA statistics that go beyond lies.
    So that would be my one wish would be to have meaningful 
metrics that are transparent and accurate and are vouched for 
by another organization, perhaps a major university that have a 
higher degree of integrity, and people who are found cooking 
these numbers are punished, because it has real-life 
consequences for veterans. These are not just, you know, some 
games that they are playing. People's lives are at risk here.
    Mrs. Kirkpatrick. Thank you, Doctor. Not to cut you off, 
but I want to hear from the others. I'm starting to run out of 
my time. I have about 45 seconds here.
    Dr. Head. I believe accountability. When people or 
supervisors have knowingly done something wrong, and they have 
been shown they have done something wrong, but they're allowed 
to maintain their position, sometimes even get raises and 
bonuses, that should be unacceptable. You're sending a signal 
throughout the entire VA that----
    Mrs. Kirkpatrick. Thank you. I'm sorry, I'm just going to 
go quickly to Dr. Mitchell and then Mr. Davis.
    Dr. Mitchell. I think that most whistleblowers want to make 
sure that--they are willing to put their careers on the line, 
but they want to make sure that if there is retaliation, it 
will be investigated immediately. Right now they sent out the 
memo that said all the places you could go if you felt you were 
being retaliated against. Those haven't worked in the 16 years 
I've been there. No one that I know of thinks that they'll 
work, and they're waiting to see what will happen.
    Mrs. Kirkpatrick. Thank you.
    Mr. Davis.
    Mr. Davis. I think the body that's going to be responsible 
for enforcing whistleblower protection at VA cannot be a part 
of VA. I can tell you that whistleblowers who shared 
information with me to take to the committee are scared to 
cooperate with the OIG.
    Mrs. Kirkpatrick. Thank you, all. I've run out of my time, 
but thank you all very much.
    And thank you, Mr. Chairman, for the extra time.
    The Chairman. Thank you, Mrs. Kirkpatrick.
    Mr. Flores, you're recognized for 5 minutes.
    Mr. Flores. Thank you, Mr. Chairman.
    I thank each of you for your service to our veterans, also 
for your courage in joining us here tonight to share your 
stories.
    Dr. Mitchell, as you know, the VA has had several internal 
investigations now. We've had reviews by the medical inspector. 
We've had OIG inspections or reviews. We've actually had a 
couple of high-profile resignations. And so in response to 
that, the VA has begun to make some changes and take some 
actions to try to deal with the news that's come out.
    My question is this: Based on what you've seen so far, will 
any of the changes in activities that the VA's been involved in 
the last 3 or 4 weeks really make a measurable difference in 
the care for our veterans?
    Dr. Mitchell. No. Right now what's happening is that 
although they've checked into--looked into the appointment 
scheduling, nothing has changed for me. The chain of command 
that refused to investigate nursing retaliation is still in 
place. The chain of command that authorized a written 
counseling for violating a policy and then said they don't have 
to tell me what policy I violated is still in place. The chain 
of command that interpreted the 24/7 Federal contract to mean 
that I could be forced to work unlimited scheduled shifts for 2 
years without any compensation is still intact.
    You've only addressed the scheduling issue. You certainly 
haven't addressed what's happening when you bring all those 
vets in, and you've already got your physicians overloaded.
    Mr. Flores. Okay. That's the answer I was afraid that I was 
going to get.
    Dr. Head, I think you passed over something pretty quickly 
in your testimony. You said that your pay was stopped for a 
while. Did you say that?
    Dr. Head. Yes.
    Mr. Flores. Were you ever told why it was stopped? Was it 
blamed on administrative error or what?
    Dr. Head. I was accused of time card fraud, and they said 
they weren't going to pay me. And when I obtained an attorney 
and showed proof of my presence, they paid me. But it took a 
number of months to do that, and, you know, I interpreted that 
as clear retaliation. It was a very painful time when that 
occurred, and they really gave me no clear explanation.
    Mr. Flores. That's truly amazing that the Federal 
Government would do something like that.
    Mr. Michaud asked a question regarding legislative fixes to 
some of the things we're talking about. Let me ask you this: I 
mean, is there any legislation that we could do to fix the 
culture at the VA? I mean, I think what each of you have said 
clearly in your testimony, we have a real cultural issue, a 
sick culture at the VA. What can we do legislatively to fix 
that, if anything?
    Dr. Head. I'll be very brief. You know, I think there has 
to be some fear of accountability. Currently evidently certain 
individuals feel they can act with impunity; that either the 
system is too slow to respond, or maybe it never responds. But 
they fear they can engage in these activities and know that 
they have government attorneys to represent them on the 
taxpayer's dollar to protect them in these legal fights. And 
sometimes they know they're absolutely wrong, and they have a 
protracted battle on purpose because they know most individuals 
can't withstand that type of punishment.
    Mr. Flores. I see.
    And, Mr. Davis, anything you could add to that?
    Mr. Davis. I would echo what I said earlier. You have to 
spread the accountability. It's one thing to have a VA manager 
go through initial lawsuit or some sort of just claim of 
retaliation and be represented by an attorney, but when you see 
a pattern behaving--just as when we look at people's time 
cards, if you see people constantly taking Friday off, you know 
something is probably wrong, if you see the same VA manager 
constantly being represented by the General Counsel's Office, 
then at some point you need to less that coverage.
    Think about it like car insurance. If I keep banging my car 
into other cars, I'm going to get dropped off the policy. So if 
the VA official continues to put the agency at risk of 
litigation and liability, then the coverage should lapse as 
well in that situation.
    Mr. Flores. Dr. Mitchell?
    Dr. Mitchell. I would agree with the others on the panel in 
the interest of time.
    Mr. Flores. And, Dr. Mathews, you can go until the light 
turns red.
    Dr. Head. Okay. I'll be more mindful.
    So if I had two wishes, the first would be that the data 
integrity should be there, because once the data is transparent 
and accurate, I think, you know, our lawmakers can act on it, 
the veterans service organizations can act on it, the 
newspapers can report on it. Now, if they just cook up data, 
there is no way to even find out that there is a problem, so 
that would be number one. And the second thing--and, at least 
for a short while, to take away that responsibility away from 
the VA, of managing their old data. And the second is, I agree 
with everybody else about accountability and not having 
lifetime tenured positions.
    Mr. Flores. Thank you, Dr. Mathews.
    I yield back, Mr. Chairman.
    The Chairman. Thank you.
    Dr. Ruiz, you are recognized for 5 minutes.
    Dr. Ruiz. Thank you, Mr. Chairman.
    Thank you all for being here.
    I'm an emergency medicine physician, and oftentimes we're 
put in a position where we are the last stop for our patients, 
the gatekeepers, and also in the front lines in taking care of 
our patients. And I understand that we have to sometimes fight 
the system very hard in order to do what's right for our 
patients, because if not us, then who?
    And I appreciate all of your efforts in advocating for your 
patients despite the consequences and the risks that you put on 
yourselves regardless of your specialty or of your 
responsibilities in the hospital, and that's admirable, and 
that's what I refer to as a high-quality, veteran-centered 
culture of responsibility and accountability in our VA system 
that we need to transform into. We're not there yet, and we 
need to make sure that we apply the mechanisms, the processes 
and the evaluations within the system that will lead to a 
veteran-centered institution.
    Now, having said that, in the private sector and in our 
training as physicians, there's a form of ceremony that we do 
that ensures that we address these atrocities, and that is the 
M&M rounds, morbidity and mortality rounds. Do you have those, 
Dr. Head and Dr. Mitchell?
    Dr. Mitchell. Not for the emergency room. I know that they 
exist in surgery service.
    Dr. Ruiz. Do you have one, Dr. Head?
    Dr. Head. Yes, we do. It's more traditionally in surgery, 
but we have equivalents for internal medicine, also for 
emergency.
    Dr. Ruiz. I think all specialties should have them. 
Emergency medicine practices throughout the country also have 
them where they review things that went wrong, mortalities, 
people that have died, and what were the causes of those. Do 
you have the COO of the hospital or Administrator sitting in to 
listen in to determine if there was any lapses of any 
systematic failures that led to those problems? Dr. Head?
    Dr. Head. Traditionally there's several layers. We have our 
risk management committee, then it's presented to risk 
management. I often will hear things either through the tort 
process or a week or two after it's been presented, and then 
egregious activities presented by our Chief of Staff directly 
to the COO.
    Dr. Ruiz. Well, there should definitely be metrics based on 
those morbidity and mortality results and classifications to 
determine if it was a staffing issue, a medical error, any lack 
of processes or following in integrity and practice, or lack of 
judgment, et cetera. And that will give information as to what 
needs to happen, and that information should be directly linked 
to the COO's and the Administrator's ability to make those 
changes that are necessary.
    The other way to ensure a systemic and a transparent, open 
way to evaluate certain practices so that we don't have to rely 
on whistleblowers are through chart reviews and spontaneous or 
random audits. Do any of that exist in your practices?
    Dr. Mitchell. I was the person that would look at the 
issues that would come up, because the physicians would give me 
all their cases. I asked them to do that so that I would be the 
only one that would be retaliated against by the nursing staff.
    I do know there is a process of looking at suicides in our 
facility, but the chain of command over that area refuses to 
release that information. That was not even available to the 
suicide prevention team members when I asked them.
    Dr. Head. And the M&M process is only as strong as the 
people who self-report those issues. If there is a 
complication, it's not reported, it can become invisible.
    And the other thing, too, is another strong part of our 
component, of our institution's root cause analysis, but that's 
only as strong as the ability to actually report an incident. 
If an incident is not reported, then it can go invisible. And 
usually I will catch it later, several years down the road when 
it's coming to the tail end of the tort process. It's too late 
at that point.
    Dr. Ruiz. Yeah. I agree, and I think that mortality is very 
evident. When somebody dies, that should be investigated and 
determined if there was any wrong during that care for that 
veteran. I believe that part of the solution, and I'm very 
encouraged on Ms. Kirkpatrick's efforts and advocacy with the 
Phoenix VA, and I appreciate her leadership, and I believe that 
the idea of taking the responsibility away from those that will 
have to do self-evaluations, from those supervisors, and 
placing it in another location that has more of the advocacy 
role is a very good idea.
    With that, I yield back my time.
    The Chairman. Thank you very much, Doctor.
    Mr. Runyan, you're recognized for 5 minutes.
    Mr. Runyan. Thank you, Chairman.
    And thank you, all, for, again, your courage to come out 
and stand up for our veterans.
    Mr. Davis, I want to just put this out there because I know 
Dr. Ruiz just talked about this, and Ms. Kirkpatrick had ran 
out of time, but, again, a statement you made earlier: Can the 
VA police itself, and if not, who?
    Mr. Davis. Thank you. I don't think VA can police itself. 
It's kind of like a scholarly journal; you don't peer-review 
yourself. I would look at maybe an organization like the 
Government Accountability Office maybe finally setting up some 
sort of oversight panel of healthcare professionals.
    One of the things I will tell you that VA employees talk 
about is during the financial crisis there was talk about 
bringing people like Elizabeth Warren. During the talk about 
national security issues, they talked about bringing back Dr. 
Gates. When we had the crisis in VA, we were sent the Deputy 
Chief of Staff, and that is no disrespect to Mr. Nabors, but 
where's the medical leader that's going to come rescue health 
issues at the Nation's largest health organization? And I think 
that's the issue. It goes to the issue of how people look at 
VA.
    One of the reasons why I reached out to the White House was 
because I was trying to find the person who could answer 
questions and resolve the issue. We have almost a czar for 
almost everything you could imagine in this town, but not one 
for veterans, and I think that's the issue. There has to be an 
outside source to say, Mr. Chairman, Members of Congress, Mr. 
Speaker, Mr. President, I have noticed this information; this 
information came to me; it's not going to work.
    In terms of the context of giving the Secretary the right 
to fire people, in November 2013, a memo was released by the 
Assistant Secretary for Human Resources stating that employees 
were not to go to the Secretary's office about complaints 
because it obstructs the final decision of disputes, but he 
still will accept confidential emails. Well, if that's the 
approach they take, even if we change the law, we still would 
not get the information to the right people to hold the 400-
and-something-odd people accountable. There has to be some 
change in the law to allow outside institutions to become the 
policing organization over VA. It's simply not going to come 
from within.
    Mr. Runyan. Which kind of leads to my next question, and 
I'll ask Mr. Davis first, and if there's any time left, I'll 
ask Dr. Mathews to follow up. Because Dr. Mathews said in one 
of his statements that he doesn't necessarily know that it gets 
above the St. Louis regional into maybe the central office. Can 
you shed some light on that?
    Mr. Davis. I can shed light on that. I will tell you the 
only reason why my case got to where it was, because I didn't 
go through the elongated grievance process, because that's a 
way of trapping the employee and constantly filing complaints, 
filing complaints, appeal process after appeal process.
    What I decided to do was to go to the person at the top, 
the principal executive in our organization, and I sent the 
information to him. When that didn't work, I sent it directly 
to the Secretary. When that didn't work, I went to my 
Congressman. So I think that we have to put something in place 
which would allow VA employees to fast-track the grievance 
process.
    And it depends on the variation. If it's something, me and 
supervisor doesn't get along, well, that can go through a 
normal process. If it's about patient care and the welfare of 
human beings or lost applications to people who have served in 
Iraq and Afghanistan, that needs to be fast-tracked and brought 
to the forefront.
    In Ms. Hughes' case, when she was conducting the 
investigation of the 2,000 missing applications, once the 
Director said stop, there was no recourse for her. And so I 
think we've got to find something to put in place to allow 
these complaints to kind of go to the forefront based upon the 
severity and the critical nature that they represent.
    Mr. Runyan. And with my remaining time, Dr. Mathews, I 
mean, you made the statement. Do you have a sense if central 
office sees this as an issue? Because it seems like there's a 
disconnect.
    Dr. Head. Well, there is a disconnect, and, you know, I 
really don't believe any of the data that the VA puts out, 
unfortunately. And, you know, we have to have data integrity, 
and how we, you know, are basically talking about ways to make 
that happen, and that at least at this time, maybe for a 
temporary period of time, we need to have an external agency 
that has higher integrity than the VA looking into the data, 
looking into these complaints and triaging as to what needs to 
happen first and what can wait.
    And unfortunately, the VA has demonstrated over and over 
again that they are not able to police themselves. They are not 
able to come up with honest, negative information. And it, 
again, is not an academic exercise; it really hurts the lives 
of our veterans.
    Mr. Runyan. Thank you.
    Mr. Chairman, I yield back.
    The Chairman. Thank you.
    Ms. Kuster, you are recognized for 5 minutes.
    Ms. Kuster. Thank you, Mr. Chair, and thank you to all of 
you for your courage in coming forward. We appreciate it, and 
we understand the risk that you are taking, and just know that 
we are your witness. If there is anything that happens to you, 
please be in touch with our offices.
    I would like to follow up on Dr. Ruiz's questions to Dr. 
Head and Dr. Mitchell. In the private sector, in the healthcare 
field, we have a process of quality assurance that sounds like 
maybe what you're doing in your root cause analysis, but to get 
at the issues that impact patient safety and the safety of 
veterans, but also some of the staffing issues, Dr. Mitchell, 
that you raised in your testimony.
    Is there any type of process within the VA for sharing best 
practices or for determining what are effective mechanisms? The 
types of problems that you are describing we perhaps are 
fortunate not to have. I have toured our VA facilities in 
Manchester, New Hampshire, and White River Junction, Vermont, 
and found very high levels of competence, and access and 
quality of care. So I'm wondering, what is the practice of 
sharing best practices, and how would you go about improving 
upon that?
    Dr. Head. Well, in 2012, November of 2012, I noticed a 
spike, increased number of veterans who were presenting with 
advanced cancer. And once I did a little research, I found they 
were in the system, but, for whatever reason, they weren't 
either receiving a screen, like a colonoscopy, or there wasn't 
really follow-up, and that troubled me.
    So I sent the email to the Director around 1:30 in the 
morning saying that we should follow the practices that are 
well established in the community and the standard of care 
within the National Institutes of Health. And it's around 50 
pages. There are flow diagrams, standard operating procedures 
to kind of make it basically idiot-proof that when you have 
certain patients that come in, that you should have guidelines 
of when the patient should be screened, when they should 
receive treatment; that if they have cancer, they need to be 
presented a multidisciplinary team so we can expedite therapy, 
because most therapy is a multimodality of either chemotherapy, 
radiation therapy, surgery, if possible.
    For whatever reason, this was not happening in the number 
of patients that I saw. And so I encourage us to adopt some of 
those things. And but----
    Ms. Kuster. Did you have any success with that?
    Dr. Head. Well, I had some success, but I think one veteran 
who's in the system who doesn't receive the screenings 
necessary is too many, in my opinion. And so I thought that we 
should have more--those type of ideas should always be flowing 
within the VA to have procedures so we don't miss the veterans. 
No veteran should be left behind, even if it's cancer.
    Ms. Kuster. And is there any process for quality 
improvement? Is there any--do you have any procedures or 
protocols within the VA system that you could bring forward 
these types of standards and procedures?
    Dr. Head. That's what I'd like to do. But, you know, I 
can't say I've been able to do it because of the other 
activities I've had to be involved in. But----
    Ms. Kuster. Dr. Mitchell, have you had any experience with 
that?
    Dr. Mitchell. Yeah. There is a whole quality assurance 
division in our VA. And certainly I was on an email group for 
ER physicians, the Directors, and we shared ideas. The problem 
is what we need is a best practice of how to overcome bad 
management, because we all knew we were all suffering from 
short staffing. We were all suffering from other issues, 
problems with nurse triage, other things. We just couldn't get 
anyone in our facility to listen to us that had the power to 
make the change. Again----
    Ms. Kuster. And with the short staffing, were you told that 
that was a fiscal issue, that you couldn't hire people, or is 
it an issue of timing in terms of getting professionals 
credentialed?
    Dr. Mitchell. The reason varies depending on the week. It 
can be because we're short, there's a hiring freeze. It can be 
there aren't enough good applicants, which is often the case. A 
lot of times there are fantastic applicants, but the process of 
credentialing them takes 8 or 9 months, in which case they've 
already found another job.
    Ms. Kuster. And just briefly, and I have very little time 
left, but I just want to say, Dr. Head, having reviewed your 
testimony in the various lawsuits, I'm extremely concerned 
about the issue of racial bias in your record, and I just want 
to commend you on your courage and your professionalism and 
admire the strength that it takes for you to just get up and go 
to work every single day. So thank you for coming here today. I 
appreciate it.
    Dr. Head. That is quite a compliment. Thank you very much.
    Ms. Kuster. Thank you, Mr. Chair.
    The Chairman. Thank you.
    Dr. Benishek, you're recognized for 5 minutes.
    Mr. Benishek. Thank you, Mr. Chairman. I.
    Want to thank you all for your very, very powerful 
testimony that you presented here today. You know, I was a VA 
doctor for a long time myself, and, you know, I really feel 
that there's a great deal of difficulty in communicating with 
leadership.
    And I think, Dr. Mitchell, you sort of mentioned it, too, 
is that when you find problems within the VA as a physician, 
you try to tell somebody up the ladder what the problem is in 
order to improve care, there is no one that seems to be able to 
get something done. I mean, you talk to your Chief of Surgery 
or the Chief of Psychiatry, the Chief of the ER and then you 
talk to the Chief of Staff.
    Is the Chief of Staff usually an advocate for the 
physician, or are they an advocate for the administration? Or 
who do you go to then? My concern is that physicians don't have 
enough access to management to make changes that they recognize 
need to be done. How can we do that better? Let me ask all of 
you how to do that.
    Dr. Mathews, why don't you start.
    Dr. Head. Yeah. Well, you know, in my particular case, you 
know, I was the Chief of Psychiatry, and I was going to the 
Chief of Staff, and it seems like, you know, these things don't 
register, like you said. It's not given the right urgency or 
the right priority.
    Mr. Benishek. Does the Chief of Staff have somebody that 
they can talk to up higher on the list? You know, I mean, that 
seems to be the place where it seems to stop, from my 
experience working there. Is that the problem, you think?
    Dr. Head. Well, you know, I really do not know what the 
Chief of Staff----
    Mr. Benishek. Dr. Head, what's your opinion about that?
    Dr. Head. Well, you know, one person's Chief of Staff came 
to my defense, and this person was severely punished and pushed 
out. So I do think there are a good people in Chief of Staff. 
In our hospital, we have one of the largest VAs in the country, 
there is close to 12 Chief of Staff members. You know, some of 
them know that retaliation is a problem, and then others are 
part of it, so----
    Mr. Benishek. Dr. Mitchell, what do you think about that?
    Dr. Mitchell. My experience with Chief of Staff, and we 
certainly run through several at the Phoenix VA, is that 
generally they advocate for themselves. We do have the option 
of going above to the VISN level, but often they just refer you 
back to the facility director.
    Every physician has the ability to go to the local union 
office and say they want to organize. There are certainly some 
physician groups that have done that that have gotten memos of 
understandings to stop the overload of physician panels and 
things like that.
    But the physicians have to organize themselves in whatever 
way they want to approach that, whether it's through the union 
or whether it's by themselves, and then going through 
management. The problem is everyone is too afraid to do 
anything because the risk of retaliation is so real, and that's 
the loss of your livelihood at best. At worst, it's the loss of 
your career and your ability to be employed anywhere within the 
vicinity of that VA.
    Mr. Benishek. Can you tell me more about this--I understand 
there is kind of a sham peer review thing. Can you explain that 
to me again?
    Dr. Mitchell. Normally a legitimate peer review is where 
someone has questioned the ability of a physician to meet----
    Mr. Benishek. Well, I'm familiar with M&M, morbid and 
mortality conference. That's where we typically would do that 
in my hospital setting.
    Dr. Mitchell. It's more than just an M&M, though. Everyone 
can make a mistake, and things can be overlooked. A peer review 
is where you are so afraid that this person is not practicing 
up to the standard of care that you pull a large section of 
cases and have his peers review them to see if there are truly 
significant deficits in the person's ability to practice 
medicine. That is only supposed to be done in extreme cases 
where there truly is legitimate concerns that this physician is 
not up to standard as far as practice.
    Sham peer review is where you have the ability to call a 
review, a major review, of a physician's cases. If you can't 
find anything that they have done wrong that's significant, 
then what you can do is put kind of subjective findings; well, 
this physician, you know, doesn't necessarily practice with the 
most professional ability to interact with people, or something 
very vague, very subjective.
    What happens is that in the medical community, peer reviews 
are only done if there are huge red flags. That's the reason 
why it's important that if you were ever the subject of a peer 
review, you have to report it on a license or a job 
application. Most people that don't work in the VA don't 
realize that peer reviews are done as punitive actions in the 
VA in order to sabotage a physician's credibility. It's also 
incredibly demeaning and debasing for a physician to go through 
a peer review practice because they are practicing 
professionally. Psychologically it's so stressful, most 
physicians would quit.
    Mr. Benishek. This is done by other physicians on the staff 
with you, though.
    Dr. Mitchell. Yeah. Usually it's the Administrator and then 
friends of the Administrator. They all get together and say, 
this guy, you know----
    Mr. Benishek. There is not a physician, then, you're 
saying? There is not really peer review.
    Dr. Mitchell. No, it's physicians. Just because someone has 
an M.D. doesn't mean they have ethics.
    Mr. Benishek. I guess I'm out of time.
    The Chairman. Thank you, Doctor.
    Mr. Walz, you're recognized for 5 minutes.
    Mr. Walz. Well, thank you, Mr. Chairman, and, again, I will 
associate myself with my colleagues. Thank you, all, for the 
work you are doing, because you understand the corrosive nature 
of this is not just the personal damage that is done to you, 
but, as each of you have so clearly stated, and eloquently and 
with passion stated, it hurts our veterans. That's what's at 
stake here, too, so I appreciate that.
    Mr. Davis, you summed up what I've been beating this drum 
for years: There is no national veterans strategy. When I asked 
them what their strategy was, they give me a goal that they're 
going to get to. There's no strategy how to get there. So it 
doesn't surprise me when you call the White House, they're not 
quite sure who to send, they're not quite sure who to go with, 
because it doesn't work that way.
    I've been asking for a quadrennial vets review just like we 
do in DOD so that we can have a strategy, we can resource it 
correctly, and we can have the things in place to make the 
corrections, but that is lacking.
    And I would go further on this, and I could tell each of 
you that we're coming to this how do we get this. I am with Dr. 
Mathews. I will tell you, Dr. Mathews, I am not putting my 
veterans' health care nor my reputation on the data I receive. 
So when people ask me how are the local facilities doing, I am 
worried to tell them. I said, well, the data they've given us 
is showing this. I'm out there every day. I'm someone who has 
been there.
    But here we sat, and my colleagues will tell you this, 
months ago we got flagged after the audit, and we had some of 
our facilities flagged. And they sat right there, and those of 
you sitting in the VA behind there, you can be sure that we 
want an answer, and we will ask you again tonight, whether it's 
your field or not, why don't we know what happened at 
Rochester? Why is it flagged? Why is it flagged? Can somebody 
speak to that? Can somebody say? And tonight we get general 
counsel. They all blamed you in all the other hearings, so now 
you get the answer tonight.
    But I would suggest this--and not to point at you, because 
I know the good work that is going on. I would submit to all of 
us here, the watchdog on this and the outside agency to look at 
this is here, is us. We are given the constitutional right to 
do it.
    When I go home, I'm asked about this, and I should be held 
accountable of where this is asking, but we don't know where to 
get it. And I would suggest that this committee is the most 
nonpartisan in many cases. The staff that sits up here, I can 
go to either one, the majority and minority, and get answers to 
fix problems for veterans because that's what they do, but it's 
been historically understaffed.
    I would like to send this staff out there to tell me what's 
happening in St. Louis, to what's happening in Los Angeles, 
come back to report so I get it from the horse's mouth, because 
right now I can't trust where that data's coming.
    So that's my soapbox to each of you. And we all feel very 
strongly, but we have to come up with a solution. We have to 
have an accountability. We have the constitutional power. We 
need to get some authority to be able to do this. We need to 
add to these good staffers who are up here so that they can get 
out there and ask the questions and start doing this.
    And I would suggest or put forward to each of you, maybe 
I'm a little Pollyannaish on this, but, I mean, it's just 
beyond the pale to me that there's people acting--I'm a high 
school teacher. This is bullying. I mean, this is what it 
amounts to. You talk about horizontal violence. There's been a 
lot of research done on this. Here's what happens when you have 
that: Increased turnover; lost productivity; employee loss of 
motivation, commitment, satisfaction; lots of lateral 
transfers, lawsuits; and adverse impact on patients' customer 
satisfaction. We know all that. That research is out there.
    The question I have is that we can say it's the VA, we can 
go down this it never happened in the private sector. It 
happens in the private sector, too. This is about people and 
accountability.
    What we need to figure out: National strategy, put in place 
the accountability pieces, have the elected people who get here 
by the public's will who want to get this right, and then have 
the resources and the power to make sure it happens. Because 
there's wonderful people--you work with them every day--
providing great care.
    Mr. Walz. One question to you, Dr. Mitchell. You said, over 
16 years, the care has improved at Phoenix, the care of 
veterans. How do you simultaneously improve care while this 
corrosive culture has existed? Is that just the quality of the 
people that are coming there to work?
    Dr. Mitchell. Yeah, what you have is you have an incredible 
force for change in your employees. The majority of employees 
are veterans themselves or family members of veterans. They 
give incredibly good care, whether it's direct patient care or 
whether it's indirect care.
    And so, despite the fact that there's a knot that their 
stomach when they try to get in their car to go to work, 
despite the fact that they know that their supervisors are 
going to harass them all during the day, they try to give the 
best care that----
    Mr. Walz. So that's really happening? So when someone says 
the care--when my veterans say the care at the VA, once you get 
in, if you can get past that--I would ask each of you, have you 
been in different VA hospitals? Does Minneapolis look like 
L.A.?
    Dr. Mitchell. I've only been in Phoenix, and we give tons 
of really good care. The problem is, with healthcare needs, 
when you ignore them, a veteran falls through the cracks, and 
that has devastating consequences to their health.
    So what we're focusing on is the hundreds of thousands of 
cases where there's been bad care given. We shouldn't lose 
sight of the fact that we give millions of instances of quality 
patient care. And that's the reason why the VA is worth saving, 
because our employees make it worth saving.
    Mr. Walz. Well, our young residents and our young graduates 
of our medical institutions, will they still choose to continue 
to go to the VA like you did and give careers? Because my fear 
is this: We drive them away, we make it so unattractive, we 
make it so poisoned that we can't--and I'd just----
    Dr. Mitchell. I wouldn't recommend, in the current state, 
that people get a job at the VA as a physician until there's 
some guarantee that whistleblower retaliation will be 
protected, that the pay will be the commensurate with what's in 
the community, that there's a professional work environment. 
Everyone just--I'm really proud to be a VA physician----
    Mr. Walz. That's a nightmare scenario for me, because we 
know what the numbers look like, we know the care that our 
veterans are going to need, and we've got to get this figured 
out.
    So I yield back. Thank you, Chairman.
    The Chairman. Thank you, Mr. Walz.
    Mr. Huelskamp, you're recognized for 5 minutes.
    Mr. Huelskamp. Thank you, Mr. Chairman.
    I appreciate the witnesses coming and visiting with us 
tonight and sharing your story.
    And I'm particularly troubled by the last comment, the 
suggestion, the recommendation that folks look for employment 
elsewhere until these problems are fixed, Dr. Mitchell.
    One thing I would ask for each you: Each named superiors or 
other senior staff who ignored your pleas, violated your 
confidentiality, knowingly injured veterans or placed them at 
risk. Do you know if any of these have been punished or 
censured by the VA?
    I'll start with you, Dr. Mathews.
    Dr. Head. No, I do not know. And, you know, with the 
whistleblower retaliation and cooking up numbers, it's 
basically sending all the wrong messages, that it doesn't 
matter, care is optional, we'll protect you, we'll come up with 
the numbers. You know, it's so corrosive.
    And, you know, going back to the point of Mr. Walz, I 
started the Washington University residents rotating through 
the VA. And I had one resident, who was very good, who wanted 
to join, who did not. And I had two other people I knew in the 
community who were excellent psychiatrists, trained at very 
good places. And they came and interviewed, but, you know, they 
couldn't, they didn't want to work in these situations where--
they were wanting to join because I wanted to build a good 
mental health clinic there. And then it was inconceivable that, 
you know, they just removed me from that position.
    So this is a very corrosive--it's very demoralizing to a 
lot of the ethical people who work there, as well, because they 
see either they have to leave or they have to just keep quiet 
and suffocate internally. I think that there are no other 
choices there.
    Mr. Huelskamp. So there's no doubt in your mind other 
employees see the mistreatment, the violations, and see your 
treatment and choose to remain silent in the face of that.
    Dr. Head. I absolutely know that for a fact, that that's 
the case.
    Mr. Huelskamp. What would you recommend--and all members of 
the committee have probably heard from constituents since this 
scandal really broke open, and the committee's been looking at 
this for a number of years. But what would you recommend to 
whistleblowers that have knowledge, have this concern, that 
share your doubts about how they'll be treated? What should 
they do? Who should they turn to?
    I've had three to four whistleblowers. I showed up 
unannounced for a surprise visit to a facility, somehow was 
able to get in and started to uncover things. But what do I 
tell whistleblowers when they say, Congressman, this is what 
we've seen happen, but we're not going to tell you our name 
because we're afraid we're going to lose our job? What should I 
tell them?
    Dr. Mitchell. Well, at this point, you could give them my 
name, and I'll report it. Since I've already got a target on my 
back, it doesn't matter.
    Actually, that's what's happening. I've had multiple phone 
calls from physicians from VAs across the country. There's a VA 
facility that's bedsore-free, not because they don't have 
bedsores, but because the physicians and the nurses were 
forbidden to document bedsores.
    There's several--and there are many, many, many issues. 
I've certainly contacted Jeff Miller's, or Representative 
Miller's office and gotten a phone number of someone who said 
that they would maintain the confidentiality and investigate. 
And, at this point, I would tell whistleblowers to go to the 
Congressman or see Mr. Miller. And that's a problem above my 
pay grade.
    Mr. Huelskamp. Yeah, and that's what's happened in our 
office.
    Mr. Davis?
    Mr. Davis. Yeah. I would say, I've had several 
whistleblowers come to me directly, and I've shared their 
testimony with the committee, and I've actually read some of 
their statements into the record. And I, too, would say those 
that I know are familiar with the administrative process side 
of the House, I'll be more than happy to take their 
whistleblower complaint to the public. I think that's our 
ability to do what we can. My background is communications, so 
I was able to navigate through the press process a little bit 
quicker than most whistleblowers.
    And I think that's the key thing. It doesn't take everyone 
to do the same thing. Some people may be comfortable at just 
going to the IG. Some may be comfortable going to their 
Representative or Senator. Some may be comfortable going to the 
press. But there's different levels of whistleblowing. You 
don't have to go as far as we did. I think we're something--a 
little bit, in some cases, the exception. But I think there are 
different ways you can get the information out.
    And there are different people who want to report it. 
There's interest groups, there are civil groups, there are 
veteran service organizations who would be more than happy to 
get the information. They have the right connection with many 
of the leaders in Congress. There are different ways you can 
get the information out. But I will tell you this: You feel 
much better when you say something versus holding it in.
    Mr. Huelskamp. And I have no doubt there are VA employees 
that are as concerned as you are listening tonight or seeing 
the comments. And, I might add, there are probably--there's 
folks out there probably tearing all four of you down for 
having the courage and bravery to show up.
    But recognize, if you're listening, step forward. And my 
office, other offices, we'll be there to carry that water for 
brave employees like yourself. So I appreciate your commitment.
    Mr. Chairman, I----
    Dr. Mitchell. Excuse me, I wanted to make a clarification. 
Even though I said I would not recommend getting a job at the 
VA, I actually am not looking for a job elsewhere. The VA is 
really important work. I would tell those people they're 
working--they'd be working with great people, but they have to 
have a true understanding of the administrative culture and 
where it stands today and then make the decision.
    Mr. Huelskamp. Yeah, Dr. Mitchell, there is no doubt in my 
mind your commitment to our veterans, so thank you.
    And, Mr. Chairman, I yield back.
    The Chairman. Thank you, Mr. Huelskamp.
    Mr. O'Rourke, you're recognized for 5 minutes.
    Mr. O'Rourke. Thank you, Mr. Chairman.
    To follow up on Mr. Huelskamp's statement, Dr. Mitchell, I 
couldn't help wondering during your testimony and in the answer 
to many of the questions that were asked of you, as you 
detailed the ostracism that you endured, the being shunted 
aside when you made problems for management, ending up in a 
position now where you say you're doing good but it wasn't the 
position that you signed up for, and then I know you just 
clarified it but earlier saying you would recommend to somebody 
who's thinking about working for the VA, not now, not until we 
get accountability and oversight and protection for 
whistleblowers, I couldn't help wondering why you stayed.
    Dr. Mitchell. I stay for a couple of reasons. One, the work 
is incredibly fulfilling and important. I went back to medical 
school specifically to be a VA physician because I saw there 
was a great need.
    Everyone who works at the VA knows there are limitations. 
That's--we're a Federal department; there are limitations. The 
veterans are so grateful for the quality of care. You'll see 
such a wide variety of people at the VA and, certainly, disease 
states. From a physician standpoint, it's interesting. My 
background is geriatrics. It was a playing field for geriatric. 
In fact, ER was geriatric urgent medicine at its best. It's 
very interesting, it's very fulfilling.
    I don't always feel so resilient, though, as a physician 
there. I'm definitely tenacious, I'll give myself that, but 
sometimes it's really hard. There is that knot in the center of 
your stomach driving in, where you just don't want to show up 
because, as much as you love the veterans, the administration 
wears you down, and you begin to doubt your own professional 
abilities.
    Mr. O'Rourke. Just from your answer to my question and what 
you said earlier--and, really, for everyone on the panel, I 
mean, we keep asking about culture, which is the most important 
issue but probably the most difficult task before us as a 
country in terms of turning around the VA, but you really 
represent the culture that I think we're looking for and that 
we want to see throughout the system, not just at the provider 
level, at management, at the Secretary level, on through this 
committee, and, again, as a country. So I want to thank you for 
that and thank you for the example that you provide.
    But I also want to follow up on another comment that you 
made. You mentioned surviving 16 years of this. And these 
problems didn't just occur, you know, under this administration 
or the administration prior to that, but they're longstanding.
    And I remember--I've been here for a year and a half, and 
one of the first hearings I attended was a joint hearing with 
the Senate VA Committee, where we heard from the veteran 
service organizations. And I remember a commander coming before 
us and saying, you know, this is my--I don't know what the 
exact number was--this is the 32nd time I've appeared here, 
I've been coming up for decades, and I've been saying the same 
things over and over again.
    So you said that this is a system worth saving, but my 
question to you is, is it salvageable?
    Dr. Mitchell. Oh, yes. You've got thousands and thousands 
of employees that are dedicated to the veterans and the welfare 
of the veterans. I am really discouraged when I hear people say 
the VA is too big to change. You have an entire group of people 
that are ready for a revolution, and they want this. They want 
a productive healthcare system delivering good care.
    The horizontal violence has to stop. That was one of the 
implications of whistleblower retaliations, that it affects 
care because you don't speak up to say what the problems are 
because you're afraid of the repercussions. The corollary to 
that is that you begin to--it's a pressure cooker--you begin to 
pick on each other. Gossiping, bullying, exclusive cliques at 
work. We kind of feed on each other because we're don't know 
what--we're under so much pressure. And that needs to stop, 
too.
    Mr. O'Rourke. Yeah.
    I wanted to--and each of you have given us some ideas and 
some direction on how we can make those changes, but I do 
wonder how we're going to be able to do it after so many years 
and so many fundamental systemic problems.
    Dr. Mathews brings up the issue of not being able to trust 
the integrity of the data, which has become obvious to all of 
us. And I commend your efforts to measure those things that are 
important to patient care and outcomes in the facility at which 
you worked. We've been trying to do that in El Paso. We've seen 
similar attrition rates of over 40 percent of veterans seeking 
mental health who can't get an appointment just give up and 
stop trying. And we can only, right now, because we don't have 
the full story, wonder at the outcomes.
    Mr. Flores and I and Mr. Jolly and others on the committee 
introduced the Ask Veterans Act, which would not rely on the VA 
to tell us how the VA is doing but ask veterans to do exactly 
what you are trying to measure in your facility.
    So, anyhow, let me just conclude by thanking you all for 
what you're doing. And I hope that the recommendations and 
direction that you gave us tonight lead to some of the cultural 
changes that we all know are essential to turning the VA 
around. So thank you.
    Mr. Chair, I yield back.
    The Chairman. Thank you, sir.
    Mr. Coffman, you're recognized for 5 minutes.
    Mr. Coffman. Thank you, Mr. Chairman.
    Thank you all for stepping forward as whistleblowers. I 
believe that the rank-and-file in the Veterans Administration 
are, in fact, employees that truly care about serving the needs 
of our Nation's veterans. And without the whistleblowers, such 
as yourself, who have had the courage to step forward, we would 
never know the problems that exist within the Veterans 
Administration, because none of the problems have ever been 
self-identified by the leadership within the Veterans 
Administration. We've always been aware of them simply by 
whistleblowers coming forward and sharing with us the reality 
of what is occurring on the ground within the Veterans 
Administration, particularly the Veterans Health 
Administration.
    Mr. Davis, one thing, I think, when we became aware of--
started to become aware of the magnitude of the crisis, it was 
concerning the patient wait times and the fraudulent changes in 
terms of those records, often fueled by a drive for bonuses.
    Mr. Davis. Uh-huh.
    Mr. Coffman. But what you're saying is, actually, the 
problem was much deeper than simply patient wait times, that 
they were also denying people inside the system. Is that 
correct?
    Mr. Davis. They were actually----
    Mr. Coffman. To get into the system.
    Mr. Davis [continuing]. Neglecting the applications. And I 
think this is where I think we have to look at--you can only 
get the appointment if you're enrolled.
    Mr. Coffman. Oh, okay.
    Mr. Davis. And so we have systemic problems in the 
enrollment system.
    And to give you some context--you may hear this from the 
next panel--the office where I work, the Health Eligibility 
Center, is about to start what they're calling a command 
center. This is something that they're going to probably send 
to VA leadership, perhaps even this committee.
    But I want you to understand that real change will only 
come from real solutions at VA. Currently, this is part of what 
I call the gimmicks that go on at VA. We announce something, 
give it a new name, and we send it out, making the public and 
the leadership on the Hill think there's a change.
    But I will tell you, when you look at this document, the 
communication training people perform communication training 
every day. That's not anything new. The enrollment people 
perform the enrollment task. The call center people perform the 
call center task. This is not going to change anything. The 
strategy is to take people from the fifth floor and put them in 
a room on the second floor. This is what constitutes responding 
to veteran concerns at VA.
    And so I think what has to happen, what I would encourage 
the committee to do is follow something that I do think does 
work in business, and that is make people sign off on the 
reports they turn into the Congress. I can tell you what's 
disappointing to me, as a citizen and a VA employee, is to 
watch leader after leader in the VA sit in these chairs and 
say, ``I don't know. I'll get back to you. So-and-so was 
supposed to do that. General Counsel won't let me.'' That, to 
me, is just inefficient. If you're going to be in a leadership 
position, you first need to lead. And so making people sign off 
on quarterly reports to say that I own the data that I turn in, 
I own the enrollment records that we turn in.
    I doubt very many people in this room knew there was a 
600,000 pending backlog at VA or that, last year, 40,000 
applications, 18,000 or more from Iraq and Afghanistan 
veterans. If people would've known that, something could've 
happened. If those reports had to be signed off on by people 
like Ms. Harbin, people like Mr. Matkovsky, people in positions 
that were held formerly by Dr. Jesse, Dr. Petzel----
    Mr. Coffman. Uh-huh.
    Mr. Davis [continuing]. This is where the change comes 
from.
    Mr. Coffman. Right.
    Mr. Davis. But you've got to document. One of the problems 
we have as whistleblowers, the first time you go to make 
something public, they tell you, ``Well, where's your proof? 
Where's the document?'' Well, most people are not going to sign 
a document, ``I'm deleting applications. I failed to process 
applications.'' But this is the type of conversation----
    Mr. Coffman. Sure.
    Mr. Davis [continuing]. You get when you go and talk to 
them.
    Mr. Coffman. Well, let me just put it this way. And if you 
all could comment on this. The Veterans Administration is so 
dysfunctional right now in terms of its leadership, in terms of 
the culture, as well, so, I mean, having a new Secretary come 
in, the culture is still there. I mean, I hope that the new 
Secretary can make the appropriate changes, but it's going to 
be difficult.
    Do you all believe that there should be an entity really 
outside of the Veterans Administration for which a 
whistleblower reports?
    To Mr. Davis, and then let me go down to the physicians 
here.
    Mr. Davis. I would absolutely say, yes, it's imperative. If 
you really want real change and a true whistleblower 
environment where people will come forward, you have to take 
the policing power outside of VA.
    Mr. Coffman. Dr. Mitchell?
    Dr. Mitchell. I would agree. No one trusts the VA to handle 
their own problems, nor report it to them.
    Mr. Coffman. Dr. Head?
    Dr. Head. I agree.
    Mr. Coffman. Dr. Mathews?
    Dr. Head. I completely agree. I mean, VA doesn't 
acknowledge a problem exists. So, you know, I mean, it's absurd 
to expect that they would want to fix it. Their position has 
been that there is no problem. And we have the numbers to prove 
it.
    Mr. Coffman. Okay.
    Mr. Chairman, thank you. I yield back.
    The Chairman. Thank you, Mr. Coffman.
    Ms. Titus, you're recognized for 5 minutes.
    Ms. Titus. Thank you, Mr. Chairman.
    Thank you for being here.
    I realize that there's a pattern that leads us to the 
conclusion we need to go outside the VA. But aren't we at a 
point where there's a real opportunity to make a change because 
about nine of the top positions, including the Secretary, are 
vacant right now?
    So if we can bring in a new leadership team and impress 
upon them the need for this accountability, which we have heard 
repeated in every hearing, whether it's on the backlog or the 
bonuses or whistleblowers, that this is the message, that maybe 
we're at a point where we can start to make that difference?
    I'm sorry that Mr. McDonald can't come in here and hear 
what we are hearing. I know that Sloan Gibson is scheduled to 
come, but, Mr. Chairman, we need to get the new Secretary in 
here as soon as we can, because he needs to hear the kind of 
things that we're hearing so that we can move this in a new 
direction.
    I would just ask y'all: You're located kind of near my 
district in Las Vegas. We have a new hospital. I met with some 
of the emergency room doctors there. It was at my invitation. 
They were scared to come. They aren't as brave as y'all are. 
They wanted to be sure that they knew I invited them, because 
they feared some retaliation.
    Have you heard--and you travel in small circles. Have you 
had any contact with people at the Las Vegas hospital or are 
familiar with any whistleblower problems there?
    Dr. Head or Dr. Mitchell?
    Dr. Mitchell. No. The individuals who've contacted me are 
from across the country but not from Las Vegas.
    Dr. Head. No, I haven't. And we've had a significant number 
of our staff actually relocate in Las Vegas when they were 
building their new hospital, but I haven't heard of any 
whistleblower problems.
    Ms. Titus. Well, I'm glad to hear that.
    One other thing I wanted to ask you, Dr. Head, you 
mentioned that the first response to a whistleblower is to try 
to impugn their integrity. And one of the examples you 
mentioned is that they often say is, well, you're just a 
disgruntled employee because you didn't get the bonus that you 
wanted.
    I just wonder, could you talk about maybe the possible 
nexus between bonuses and whistleblowing? Are people getting 
paid to be quiet?
    Dr. Head. I don't--well, I have no evidence of people 
getting paid to be quiet.
    But I do think, you know, there is a tendency to try to 
generate a motive for why someone is coming forward and telling 
the truth or reporting wrongdoing, and it's often associated 
with somehow a personal gain from a whistleblower. But I'll 
tell you, there is no personal gain from being a whistleblower. 
Even when you go through long litigation and you ultimately 
win, you know, there's no financial incentive whatsoever----
    Ms. Titus. Right.
    Dr. Head [continuing]. Believe me.
    Ms. Titus. Oh, I'm sure of that. I was thinking of just the 
opposite, that you keep people kind of tamped down and not 
speaking up if you give them regular bonuses. And----
    Dr. Head. I don't----
    Ms. Titus [continuing]. That maybe keeps that culture of 
silence that you mentioned.
    Dr. Head. I think you'll see that the bonuses are usually 
among the Chief of Staff or higher-ups who are receiving those 
bonuses. You're not necessarily receiving bonuses at the level 
of some of these whistleblowers.
    Ms. Titus. Dr. Mathews or Dr. Mitchell?
    Dr. Head. You know, in my experience at the St. Louis VA, I 
had productivity data or had data for every psychiatrist as to 
the number of patients being seen. And I know that there's only 
one psychiatrist, perhaps, who did not get the full performance 
pay, which is, you know, what could be considered a bonus, and 
that's me. I got 50 percent, and, actually, not for the wrong 
reason. They were correct, because I only could accomplish 
probably less than 50 percent of what I set out to do.
    But it sends a very wrong message, that, you know, the way 
to go about in the VA is to just keep quiet, just do what you 
want to do, and you will not get into trouble for not working. 
You know, the only reason, I think, one can get into trouble is 
by identifying problems and coming forward. So that has to 
change.
    And I think, you know, it's a complex issue if you call it 
``culture,'' but I think the fix to it can be very simple: 
demanding data integrity and holding people accountable. You 
know, that once that starts to happen and once some senior 
positions, not people who resigned who, you know, again, have 
high integrity that they resigned--I mean, the people resigned 
because, you know, they have integrity--but the people who 
don't care. And those people need to be fired so that it sends 
the message that this is not--this cannot be tolerated anymore.
    So, you know, I would say that you are right. You know, the 
people who get bonuses are the ones who just keep quiet and 
keep doing what they're doing.
    Ms. Titus. Dr. Mitchell?
    Dr. Mitchell. Well, there's a difference between a 
performance measure bonus and proficiency bonus. Performance 
measure bonus is what you get if your facility has met the 
performance measures to whatever degree. Most of us that are 
eligible for those are quite frustrated because the facility 
never has the resources to meet the performance measures. And 
so there is a bonus per se, but it is nowhere near--we want to 
be rewarded for the work we do on our proficiencies.
    Our proficiencies are actually how we perform through the 
year on our own personal merits, and those are subjective. Our 
administrators, if they like us, can rate us high; if they 
don't like us, can rate us low and don't necessarily have to 
give a reason why.
    Basically, most people stay quiet just for survival in the 
VA system, not because there's any benefit one way or the 
other, at least at my level. I don't know what's in the SES 
service.
    Ms. Titus. Thank you, Mr. Chairman.
    The Chairman. Dr. Wenstrup, you're recognized for 5 
minutes.
    Mr. Wenstrup. Thank you, Mr. Chairman.
    And I thank all of you for being here tonight.
    And as I sit here and listen to your testimony, one of the 
things that comes in my mind is, somewhere along the line, 
through your parents or somewhere, someone taught you about 
doing the right thing and about being able to look in the 
mirror at the end of the day and know that you're doing the 
right thing. And I applaud you for that. And know that you're 
respected by those that matter. And those that don't, they have 
their own issues. And I appreciate that.
    You know, I served in Iraq as a doctor, and we had 
something that you mentioned tonight, a sense of mission. We 
had a shared sense of mission, and everyone was on the same 
page. We're a Reserve unit. We all come from private practice. 
There's no room for slacking, and the patients were the first 
priority. And you work through the night if you have to, and 
you take shifts sleeping. And there's esprit de corps. And 
wouldn't you love to be able to practice in an environment like 
that every day?
    And the people that I'm talking about, these are our 
veterans, the ones that provided that type of service and they 
provided for the others that are our veterans today. And it's 
really sad for me to hear that there is a need for an agency 
with a higher integrity than the VA, which was said tonight, 
that the people in the VA would be willing to accept that they 
need someone to watch over them because of their lack of 
integrity.
    And Dr. Ruiz brought up mortality and morbidity, and we 
talked about peer review. What I'm used to with peer review in 
my hospital was you had people from the same specialty 
reviewing charts and people that are familiar with the 
procedures you're talking about, the problems that maybe exist. 
And you do that to try and make things better. And if someone 
is really failing, then they have to go, because the reputation 
is on the line. And it's not there to be punitive but to make 
everything better, as far as care.
    So my question is, besides whistleblowing, is there any 
chance for provider input, such as, ``We have too much 
administrative responsibility, we don't get to see patients''; 
such as, ``I need another clinical assistant in here, I need a 
PA or a medical assistant, then I can see five times more 
patients''? Or do you have the opportunity to say, ``So-and-so 
is really a poor performer in the clinic, and it's slowing my 
time down with my patients and I don't get to see as many''? Is 
that available to you?
    I'll start with you, Dr. Mitchell.
    Dr. Mitchell. In that particular form, that's not 
available.
    There are certainly--in section 4 and 5, I talk--especially 
4--I talk about the retaliation tactics against providers. And 
one of them is failing to fill the ancillary services so the 
provider's clinical time is stretched incredibly thin. There's 
another one where they overload the provider's patient panel so 
there's no way they can humanly get through them.
    You're not talking--we're not at the level to be able to 
communicate equally with our administration. We're far below. 
And anyone that speaks up is retaliated against. We don't have 
that freedom to speak freely and advocate for patients and 
ourselves.
    Mr. Wenstrup. And, as you said before, just because you 
have ``M.D.'' after your name doesn't mean you have ethics. So, 
in those situations, it may be another doctor, but they're 
saying, you don't need this, or, we're not listening to you. 
Would that be correct?
    Dr. Mitchell. Yes, that would be correct. And for a variety 
of reasons. Certainly, a legitimate reason like, you know, 
Congress hasn't passed funding, or something like that, we 
can't hire anyone, that's legitimate. But there are decisions 
that are made, at least as far as we can tell in the rank-and-
file, that are made for the benefit of the administrators, not 
for the benefit of the facility or the veteran.
    Mr. Wenstrup. Any other input?
    Dr. Head. You know, I think it's--I think it's mixed. I 
mean, I've seen extraordinary efforts to move mountains, to, 
for instance, build a new cath lab in our institution that was 
definitely needed. There was----
    Mr. Wenstrup. By providers?
    Dr. Head. Yeah, by providers. Basically, the provider said 
they would no longer practice their craft in an area they felt 
endangered veterans. And they were responsive to that. Now, it 
took a certain amount of receptive, particularly receptive 
leadership. And it also took very stern providers who, as a 
group, spoke up and said, this is not right.
    And so I did think the response was appropriate in that 
instance, but other times I think resources are placed in areas 
where there's too many resources and things. And so, again, you 
know, it involves leadership.
    Mr. Wenstrup. Real quick. I'm almost out of time.
    Dr. Head. To quickly add, you know, I was trying to 
institute a time map of the available time of a physician and 
what's being provided. That, along with veteran satisfaction, 
if we have those two accurate measures, we can know which 
facility is overloaded. You know, if a physician's time--if 
they're putting in more than, say, 50 hours or whatever and 
still if there's a wait time and the veteran satisfaction is 
not there, then the answer there is more resources.
    But in the St. Louis VA, in the mental health, the 
situation was that the physicians were--the psychiatrists that 
I was monitoring or I was responsible for were working less 
than 50 percent of their time. So, you know, the solution there 
is more accountability and more efficiency; it's not more 
resources. And we can only know that if we have real data that 
we can believe.
    Mr. Wenstrup. Correct. Well, thank you very much. I 
appreciate it.
    I yield back.
    The Chairman. Ms. Walorski, you're recognized for 5 
minutes.
    Mrs. Walorski. Thank you, Mr. Chairman.
    And I'm grateful, as well, that you're all four here.
    And it's interesting that you said something, Mr. Davis, 
that I find that I relate to, and I can see it even again 
tonight, and you hear it from members of the committee, as 
well. But I've been here 18 months, as well. And the typical 
pattern of how this issue, with the investigation of the VA and 
looking out for our veterans and making sure they get the 
health care that we promised them when they fought for our 
liberty and freedom. And, typically, a panel comes in--and you 
referenced this--and tells us unbelievably shocking stories--
and back to your comment, Dr. Head--that are so shocking and 
they're so disappointing, they're disappointing to me as an 
American, horribly disappointing to me as representing veterans 
in my district, 54,000 of them in Indiana, horribly 
disappointing, nothing celebratory about it, just shocking.
    And, I think, every time I come to these hearings, I want 
so much for a panel to say, okay, we've turned the corner, you 
know, we've drilled down, we've routed out the bad actors, 
we've turned the corner, and now we can hit the reset button, 
and we have a bright future, and we can promise our fellow 
Americans and our veterans we have a bright future.
    But, again, tonight, you know, we're going to sit here--and 
Representative Walz alluded to this, as well. You're going to 
walk out of here, and there's going to be another VA panel--
there's been dozens of VA panels--that are going to come in and 
give us two answers, either that you're not telling the truth 
or they simply don't have the answers to all the questions that 
we're going to ask based on your testimony. And that's going to 
happen again tonight. And if it doesn't happen tonight, I will 
be absolutely shocked.
    But, you know, there are dozens and dozens and dozens of 
high-ranking members of the VA that come in here and have 
really absolutely said nothing.
    And I guess my question to all of you, but specifically Dr. 
Mitchell, because the Phoenix facility has kind of been at the 
apex of this whole kickoff of this urgent reaction time. And 
one of the things that has floored me is the lack of urgency on 
the part of the VA, that there's a five-alarm fire and nobody 
is rushing to put it out.
    I'm thinking, if I was in the Phoenix VA and I was 
responsible for any of the stuff that's been going on in the 
Phoenix VA that the minute this hit the fan nationally, I would 
be looking and trying to figure this out double-time and make 
sure that my facility is the standard and that we've raised the 
standard and that we've reset the record and we are an example 
for the rest of the country.
    In the 3 months that this has been under the scrutiny of 
the American people--and the American people have stood up and 
said they will not tolerate this. This committee has said we're 
not going to tolerate this either. We're going to drill this 
down and rout out these back actors to where we can provide the 
best health care to our veterans.
    But have you seen anything, Dr. Mitchell, in the last 3 
months in Phoenix that says, wow, what a turnaround, they got 
the message, people have been fired, they've removed these 
people, there's a ton of accountability, and there's 
transparency because of the American people demanding 
accountability? Have you seen that in the last 3 months in 
Phoenix, any kind of turnaround?
    Dr. Mitchell. The turnaround I've seen has to do with 
scheduling. I've actually had consults. I've actually--because 
the backlogs have been reduced, I've actually put in a consult 
with the patient, and they've gotten a phone call from the VA 
during my appointment with the appointment time for the 
consult.
    They've certainly done tremendous work getting the veterans 
processed. The problem is they only fixed the problem that was 
in the media. They haven't fixed the patient care problems, the 
hidden mental health delays, although they're certainly working 
on that for the psychiatry department.
    But it boils down to there are still administrators there 
who refuse to address nursing retaliation that was directly 
impeding care for ill patients in the emergency room. There was 
actually a meeting where five or six of the full-time 
physicians told the chain of command this, and they said flat-
out, ``We will not investigate the backlash against Dr. 
Mitchell.''
    Mrs. Walorski. Well, and we had the Inspector General in 
here a couple weeks ago, who said that the issue of routing out 
corruption at the administrative level is not going to stop, 
it's still actively going on--and you're really corroborating 
that it's actively going on, against you--until somebody goes 
to prison and people are fired, that there's actually tangible 
action taken that, number one, the American people can see; 
number two, the veterans, to restore some kind of faith and 
integrity in that system where they're going for health care; 
and then, thirdly, so your colleagues that you work with, as 
well, feel like their backs are covered.
    How long do you see, if it took a national urgency to move 
the scheduling issue and it took a resilience on the part of 
the chairman and the ranking member to really go after this 
issue and try to reset it, how long do you see, even if we keep 
pressure up, even if a new VA Secretary comes in--if we don't 
rout out the corruption, a new VA Secretary won't be any more 
successful than Shinseki was.
    How long do you see it's going to take to turn this around 
if we keep up the same amount of pressure?
    Dr. Mitchell. I'm not sure I'm in the best position to 
judge that. What I do know is that the media paid attention to 
the scheduling issues, and, all of a sudden, I get consults 
completed within 10 minutes. The media needs to pay attention 
to the lack-of-ethics issue, and maybe we'll get that turned 
around.
    Mrs. Walorski. Absolutely.
    And, Mr. Davis, just quickly?
    Mr. Davis. Yes, I wanted to say that I think we've got to 
do two things.
    I think, first of all, we do need a separate group to look 
at VA, because, as you alluded to, when the new Secretary comes 
in----
    Mrs. Walorski. Yeah.
    Mr. Davis [continuing]. He or she, whoever finally gets 
approved by the Senate, will have to deal with the healthcare 
issue first. They're probably not going to have time to become 
the chief of police for VA and also make the healthcare 
reforms. So you're going to need some assistance, even if it's 
a sunshine law where this operating authority only acts for a 
period of years until you get VA under control.
    The next thing you have to look at, look at performance 
standards for leadership. Unlike those of my colleagues who 
work at medical facilities, they may have some legitimate 
reasons for their challenges in terms of dealing with their 
leadership group. At our organization, our primary function is 
to enroll veterans into health care. We stir that away to the 
ACA project.
    And this is not about the politics of the law. This is 
about VA having a public affairs division here in DC, a 
national veteran outreach office here in DC, a health system 
communication office here in DC. And that project was sent down 
to Atlanta for the sole purpose of a senior executive reaching 
a performance goal. It had nothing to do with our core 
business.
    I go back to a previous point I make, why you need an 
outside agency to look at this. We have, again, 600,000, and 
that rivals the number of people who actually enroll in VA in a 
given year. So imagine a year's worth of applications just 
sitting in a pending status. Put this in the context of if we 
were talking about a bank: 600,000 deposits go in on Monday, we 
never hear about them for another year or 2. Do you think the 
walls in that bank would still be standing here today?
    Yet the men and women who sacrificed for this country have 
to deal with this. And why? Not because we don't have the 
resources. Because we focused on ACA, we focused on the veteran 
dental insurance program. We create marketing materials for 
Delta Dental and MetLife. Yet we could put these same little 
fliers in a post office, in a grocery store, to let people 
know, hey, if you had a pending application in VA through the 
years 2000 and 2014, contact such-and-such a number.
    The same effort we put in getting senior leadership bonuses 
and the same interest we put in attaching ourselves to high-
profile projects is the same amount of attention that needs to 
go to veterans.
    So I encourage you guys, if nothing else, please make sure 
that we move to a system that has more data integrity. Require 
the people who come here and sit on these panels to sign off on 
the information they turn in to Congress. This way, when they 
come back, they can't say, ``That report was done by somebody 
else.'' That's the only way. Hold them accountable, and do it 
in public, and do it while the cameras are on.
    Mrs. Walorski. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Mr. Jolly, you're recognized for 5 minutes.
    Mr. Jolly. Thank you, Mr. Chairman.
    Dr. Head, what is the relationship between UCLA and the 
L.A. VA hospital?
    Dr. Head. Like many of our VA institutions, we have an 
affiliation agreement. It's a, you know, public institution. 
And a number of the physicians, surgeons have joint 
appointments with both their chair counterparts within the 
university and also with the VA.
    Mr. Jolly. So I ask because you're a very egregious case. 
And I share my colleagues' comments admiring your courage. But 
it was a case, ultimately, against UCLA and the Board of 
Regents of California; is that right?
    Dr. Head. That's correct.
    Mr. Jolly. And so the settlement, the $4.5 million 
settlement, was with the Board of Regents of California, not 
with the VA; is that right?
    Dr. Head. Well, it's a complicated case. I would say, with 
my case with the regents, we both satisfactorily agreed to part 
ways. But, as you have noticed, there's tremendous overlap, and 
there is a Federal component to that.
    Mr. Jolly. Right. I guess my--so here's my question. And 
I'm trying to distinguish between the fact pattern and the law 
on this.
    So the incident that you refer to was a June 2006 party, 
one of the more egregious cases, which was referred to as a 
UCLA party. Was it strictly a UCLA party, or was it also--was 
the VA institutionally involved in that?
    Dr. Head. At that particular party, there were a number of 
members who were employed as physicians at the VA.
    Mr. Jolly. Right.
    Dr. Head. And, as you have seen, a component of that was 
directly related to an investigation that occurred at the VA.
    Mr. Jolly. Right. The facts of the case that led to a 
settlement with the Board of Regents of California, did the 
facts also support a claim against the VA and the law simply 
prohibited you from filing some type of legal action against 
the VA? Or was the fact pattern specific to UCLA and not to the 
VA?
    Dr. Head. I won't comment on the--on the State component of 
it, but there----
    Mr. Jolly. Well, I guess, I mean, here's my question.
    Dr. Head. Yes.
    Mr. Jolly. Because it is a very significant case.
    Dr. Head. Yes.
    Mr. Jolly. Do the facts solely lead you to litigation 
against UCLA, or does the law prohibit somebody in your 
position from seeking redress from the VA?
    Dr. Head. The law allows me to seek redress from the VA. 
And there is a State component, and there's a Federal 
component, and----
    Mr. Jolly. But your settlement was strictly on the State 
side.
    Dr. Head. That is correct.
    Mr. Jolly. Okay.
    Now, for the entire panel, a question for you: Are you 
familiar with the VA's ``Stop the Line'' program, the video? 
It's something that I've seen at my--and that's interesting 
that you're not, because it's something that has been 
highlighted by my local VA hospital as a program that every 
employee sees.
    It says, for anybody from custodial staff to a doctor, if 
they see something that interferes with the delivery of patient 
care at any level, it says, ``Stop the line.'' You know, it's 
an imagery, if you will, that any employee has the ability to 
stop operations immediately out of concern for something that 
they might see.
    I know it's been adopted at a number of different 
facilities, but none of you are aware of this?
    Dr. Head. I certainly am not.
    Mr. Jolly. Okay.
    Dr. Head. More like, ``Stop the train wreck.''
    Mr. Jolly. Right.
    Well, listen, I will be honest with you. It was promoted to 
me as an effort by the VA to encourage every employee to be 
able to step up and say there's a problem. But each of you have 
already stepped forward in a whistleblower capacity and yet 
have no knowledge of the program, which says to me perhaps it 
is not as promoted internally as some would suggest it has 
been.
    Dr. Head. I would say, I felt alone during this long 
process that continues. And I find that very disturbing.
    Mr. Jolly. Okay. Very good.
    Thank you, Mr. Chairman. I yield back.
    The Chairman. Thank you very much.
    Members, I'd like to go ahead to the next panel unless 
somebody has a burning question that they want to ask.
    Thank you very much to the witnesses. We do all appreciate 
the courage that it took to come here tonight. And we will be 
watching, and rest assured, if any of you contacts us, we'll 
all jump to protect you from any further retaliation at the 
Department. Thank you for being here tonight.
    And, Members, we're not going to take a break. We're going 
to continue on with the next panel.
    Okay. Members, we're going to go ahead and call our second 
panel to the witness table.
    Our second panel, we're going to hear from the Honorable 
Carolyn Lerner, Special Counsel, who is accompanied by Mr. Eric 
Bachman, Deputy Special Counsel for Litigation and Legal 
Affairs. From the VA, We will hear from Dr. James Tuchschmidt, 
Acting Principal Deputy Under Secretary for Health. He is 
accompanied by Edward C. Huycke, Deputy Medical Inspector for 
National Assessment at the VA's Office of the Medical 
Inspector.
    If you would please rise again before you get too 
comfortable. Raise your right hand.
    [Witnesses sworn.]
    The Chairman. Thank you very much. If you would take your 
seats.
    As with the first panel, your complete written statements 
will be made a part of the hearing record.
    Ms. Lerner, you are now recognized for 5 minutes.

                  STATEMENT OF CAROLYN LERNER

    Ms. Lerner. Thank you.
    Chairman Miller, Ranking Member Michaud, and members of the 
committee, thank you for the opportunity to testify today about 
the U.S. Office of Special Counsel and our ongoing work with 
whistleblowers at the Department of Veterans Affairs.
    I am joined today by Deputy Special Counsel Eric Bachman, 
who is supervising OSC's efforts to protect VA employees from 
retaliation.
    I also want to acknowledge the many employees at the Office 
of Special Counsel who have been working tirelessly on all of 
our VA cases. There are too many of them to identify by name, 
but several of them are here with us this evening.
    My statement tonight will focus on three areas: First, the 
role of the Office of Special Counsel in whistleblower 
retaliation and whistleblower disclosure cases; second, an 
overview of OSC's current VA caseload; and, third, some 
encouraging signs of progress.
    OSC is an independent investigative and prosecutorial 
agency with jurisdiction for over 2 million Federal employees. 
We have a staff of about 120 and the lowest budget of any 
Federal law enforcement agency.
    We provide a safe channel for employees to disclose 
government wrongdoing, and we evaluate disclosures using a very 
high standard of review. If the standard is met, I send the 
matter to the head of the appropriate agency, who, in turn, is 
required to investigate and send a report back to me. It was 
within this statutory framework that we received and are still 
receiving dozens of disclosures from VA employees from across 
the country.
    The Office of Special Counsel also protects Federal workers 
from prohibited personnel practices, especially retaliation. In 
these cases, OSC conducts the investigation and determines if 
retaliation occurred.
    Turning first to VA whistleblower disclosures, we have 
found that, rather than using the valuable information provided 
by whistleblowers as an early warning system, the VA often 
ignores or minimizes problems. This approach has allowed 
serious issues to fester and grow.
    In the numerous cases before our agency, we see a pattern 
where the VA, in particular the VA's Office of Medical 
Inspector, admits to serious deficiencies in patient care, yet 
implausibly denies any impact on veterans' health. The impact 
of this denial has been to hide many of the issues which have 
only recently come to light.
    My written testimony provides several examples of this 
approach, but I want to highlight one egregious example about 
patient neglect in a long-term VA mental healthcare facility in 
Brockton, Massachusetts. Specifically, the OMI report 
substantiated allegations that two veterans with severe 
psychiatric conditions waited 7 and 8 years, respectively, to 
get mental health treatment. Despite these findings, OMI denied 
that this neglect had any negative impact on patient care. This 
unsupportable conclusion is indicative of many other cases we 
have reviewed and reported on.
    Turning now to retaliation cases, OSC has received scores 
of complaints from VA employees alleging retaliation. We 
currently have 67 active investigations into retaliation 
complaints from employees who reported health and safety 
concerns. These complaints come from 28 States and 45 separate 
facilities, and the number increases daily. Since June 1st, we 
have received 25 new retaliation complaints.
    In addition to these ongoing investigations, we are taking 
several steps to resolve these complaints. For example, we've 
reallocated staff and resources to investigate reprisal cases, 
and we now have a priority intake process for VA cases. And in 
an effort to find ways to work constructively with the VA, both 
my staff and I have met with many VA officials, including 
Acting Secretary Gibson.
    I do think it's very important to note the encouraging 
recent signs that we have seen from the VA leadership. There 
appears to be a new willingness to listen to concerns raised by 
whistleblowers, act on them appropriately, and ensure that 
employees are protected for speaking out.
    When I met recently with Acting Secretary Gibson, he 
committed to resolving meritorious whistleblower complaints on 
an expedited basis. If this happens, it will avoid the need for 
lengthy investigations and help whistleblowers who have 
suffered retaliation get back on their feet quickly. It will 
also send a very powerful message to other VA employees that if 
they have the courage to report wrongdoing the VA will take 
prompt action to protect them from retaliation.
    In conclusion, I want to applaud the courageous VA 
employees who are speaking out. These problems would not have 
come to light but for the information they have provided. We 
look forward to working with the whistleblowers, with this 
committee, and with the VA to find solutions to these ongoing 
problems. And we look forward to answering any questions that 
the committee may have.
    Thank you.
    Office of Special Counsel
    The Chairman. Thank you, Ms. Lerner.

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

    Dr. Tuchschmidt, you are now recognized for 5 minutes.

              STATEMENT OF JAMES TUCHSCHMIDT, M.D.

    Dr. Tuchschmidt. Thank you. Good evening, Chairman Miller, 
Ranking Member Michaud, and to the committee.
    I know I come here tonight with my credibility in question. 
There is no doubt about that. I have some prepared remarks, but 
I'd rather just speak my mind.
    We failed in the trust that America has placed in us to 
fulfill our mission. Patients have clearly waited too long for 
care that they have earned. And I would agree with 
Congresswoman Kirkpatrick that it seems that it took a 
whistleblower and a crisis to expose the events and get us 
focused on those--correcting those deficiencies.
    As I sat and listened to the first panel, I, quite frankly, 
was very disheartened that staff feel that they cannot fix 
problems in the organization that affect safety, quality, and 
our business integrity. I think this is unacceptable. The 
Acting Secretary has made it clear that this is unacceptable. 
He sent a memo to all employees on June the 13th indicating 
that that kind of behavior was unacceptable and that we would 
not tolerate retaliation.
    The stories I heard tonight clearly depict, in my mind, a 
broken system. I have to believe, have to hope, that these 
things are exceptions and not the rule. I know that there are 
many, many good employees in this organization who work 
tirelessly on the behalf of veterans, and there are many 
managers and executives within the organization that do the 
same.
    The sad part of it is that, for every whistleblower who 
comes forward and says something, there is someone out there 
who is quiet, who tries, can't make any effort, and just goes 
away. And those, unfortunately, leave risks in our system and 
deficiencies that are not fixed.
    I apologize to every one of our employees who feels that 
their voice has been silenced, that their passion has been 
stifled, because that's just not acceptable, and it's certainly 
not what I stand for.
    Quite frankly, I'm past being upset and mad and angry about 
this. I'm very disillusioned and sickened by all of this. I 
think that--I can't believe that I'm at a point in the 
organization where we are, of a place that I was so proud of 
and have worked so hard to make it a great place.
    I left private medicine to come to work for the VA. I did 
that because I thought there was no nobler mission, no more 
greater devotion than what I'm doing. I did not come to work 
for a mediocre healthcare system. I came to work for one of the 
best healthcare systems in the country. And I believe the 
system can be the best healthcare system in the country once 
again.
    The problems we have can be fixed. We went through probably 
one of the greatest transformations in the healthcare industry 
in the mid-1990s to become what I think was a great, great 
system, and I have hope and confidence that we can do that 
again.
    So, Mr. Chairman, that really concludes my remarks, and I 
promise you we will do our best to answer your questions.

    [The prepared statement of James Tuchschmidt, appears in 
the Appendix]

    The Chairman. Thank you for your comments. Still, there are 
a lot of things that we need to cover.
    And I was looking over the testimony of the OSC, where they 
described an issue at the Montgomery VA, where, in fact, a VA 
physician, instead of writing accurate notes for a given 
patient, was confirmed to have copied and pasted pulmonologist 
notes to 1,241 separate records, yet, astonishingly, he still 
works for VA.
    Explain to this committee how that can be.
    Dr. Tuchschmidt. So, I don't want to go into a lot of 
detail in these cases tonight for a number of reasons. There 
are ongoing investigations in a number of areas around the 
country by the OMI, by other entities, law enforcement 
entities. There are potential issues around privacy and the 
rights of both employees and patients here. And most of these 
issues are very complicated issues, and I think we would be 
better discussing those in a brief with you, and I'm happy to 
do that.
    The Chairman. Well, it may be better for you, but it's not 
better for this committee.
    Dr. Tuchschmidt. I understand.
    The Chairman. I haven't identified anybody by name; we 
haven't divulged any patient names. Do you accept the fact that 
OSC says that, in fact, they found where a pulmonologist did, 
in fact, do this?
    Dr. Tuchschmidt. Absolutely. I don't dispute that. So----
    The Chairman. Okay. So the question is, how in the world 
can this person still be employed at the VA?
    Dr. Tuchschmidt. So, as I said, I don't feel like I can 
really go into the details, but I would say this to you, and 
that is that I think that we very much are interested in the 
quality of care within VA. That documentation is an important 
part of that.
    It is a common practice to take historical information from 
prior notes and use that information; that doesn't change. But 
we don't copy and paste material from other--from old records 
into new records as evidence of the current encounter with a 
patient. We would not tolerate that, we would not support that 
in the organization. That would clearly represent inferior 
patient care.
    The Chairman. Ms. Lerner, could you comment on what's going 
on? You may not share the same fear that Dr. Tuchschmidt shares 
tonight of discussing something that may, in fact, be a source 
of the VA investigation.
    Ms. Lerner. The theme that we see is that there is an 
investigation by the Office of Medical Inspector; the OMI 
confirms the whistleblower's allegations but then says it's not 
a problem.
    So here in Montgomery, Alabama, the whistleblower said this 
is happening with a doctor who--a surgeon who discovered that 
another physician was cutting and pasting patient records. And 
these are things like vital signs, treatment plans--really 
important information for the surgeon to have before he 
operates on someone. He discovered that this physician was 
cutting and pasting. An OMI investigation substantiated it and, 
in fact, substantiated that it was over 1,200 patient records 
that were involved.
    The problem is they put that physician on sort of a review 
plan. There's a specific name for it, FPPE, and I'm forgetting 
what all that stands for. But they did a review. While he was 
on that review, he still was cutting and pasting. And instead 
of them taking disciplinary action against the physician, they 
ended the FPPE--I think that's right, FPPE--and, as far as we 
know, no serious disciplinary action was taken.
    So this fits the pattern that we're concerned about, where 
allegations are confirmed, no harm is found to patient health, 
and no corrective action is taken against wrongdoers. And 
that's really what I think needs to be fixed.
    The Chairman. Who's luckier, the doctor that cut-and-pasted 
or the veterans that didn't get harmed by the egregious 
incident that the doctor, in fact, perpetrated on the patients?
    Dr. Tuchschmidt. Well, so, I think--I can't answer that 
question, but what I can say to you is that I think that, 
again, the cutting and pasting of information, if that 
particularly misrepresents things, would not be acceptable. 
It's not acceptable to us. And I'm happy to come and discuss 
those details.
    There is this issue of harm. And when the OMI does their 
briefing and puts out their reports and says that they found no 
harm, I think that--I mean, I've looked at some of these cases, 
clearly. And I think that, while there might not have been 
evidence that someone actually was harmed by the process, I 
don't think that means that we, as an agency, would say that 
what happened was appropriate. I think those are different 
things, in terms of the OMI's work that they did of saying our 
review could not disclose that someone was actually harmed by 
that. But I want to reiterate that I do not believe that that--
I don't personally interpret that, and I don't think our agency 
does, as necessarily condoning appropriate behavior.
    The Chairman. But I would submit to you, before I yield to 
Mr. Michaud, that, in fact, by this person still being employed 
at the Department of Veterans Affairs, it does give the signal 
that it is an appropriate thing to do.
    Dr. Tuchschmidt. I understand.
    The Chairman. Mr. Michaud.
    Mr. Michaud. Thank you very much, Mr. Chairman.
    Doctor, according to the VA's press release that today 
Acting Secretary Gibson has announced a restructuring of the 
Office of Medical Inspector in order to create a strong 
internal audit function which will ensure that issues of care, 
quality and patient safety remains in the forefront. What do 
you believe is the primary mission of OMI, what it should be?
    Dr. Tuchschmidt. Well, the OMI was set up really as a 
quality-improvement process within the organization. I think 
that it is clear, particularly with respect to the OSC cases, 
they were done prior to this in a different way. When the OMI 
took over them, the quality of those reviews improved 
tremendously. I think everybody agreed to that. The OMI did it 
at the request of OSC.
    Today I think we realize that we need a different function 
within the organization, and that is really this kind of 
internal quality-control audit function that has been proposed. 
Today I can tell you that the OMI calls are going to the OIG. 
The OMI is not taking new cases in this interim period. And all 
of the issues, whether they come from OSC, or the OIG, or law 
enforcement or wherever they might come from, whistleblowers, 
are now being handled by a team of people at the Department 
level that report directly to the Secretary.
    So I think that the organization is trying desperately to 
address the issues that are there with respect to doing these 
investigations, and the Secretary has made it very clear that 
not only will we expedite those investigations, but that, where 
appropriate, we will expeditiously take disciplinary action and 
hold people accountable.
    Mr. Michaud. How many more employees does the Department 
plan to add to create this strong internal audit function?
    Dr. Tuchschmidt. I do not believe at this time that the 
plans for that--I know; it's not that I don't believe--I know 
the plans for that have actually not been entirely formulated, 
so I don't really have an answer to that question.
    Mr. Michaud. Thank you.
    Ms. Lerner, in your opinion, does the press release by the 
Department today vowing to restructure the Office of Medical 
Inspector address the issues that you have raised time and 
again regarding VA responses to complaints that your office has 
forwarded?
    Ms. Lerner. That's a tough question to answer because we 
don't really know what the restructuring is going to look like. 
I am encouraged by the VA's sort of new response to this issue. 
I'm encouraged by statements that have been made to me 
personally by the Acting Secretary and by other leaders at the 
VA. You know, I'm an optimist. I think that it is very possible 
to make improvements and solve this problem. So I don't know 
the answer to your question. I think time will tell.
    Mr. Michaud. This is for the VA: How would the VA ensure 
the recommendations and results of investigations undertaken by 
OMI are acted upon?
    Dr. Tuchschmidt. So we have for a long time taken the 
recommendations, the findings of the OMI. We ask facilities to 
develop plans of corrective action, and they have those plans, 
and those plans are tracked.
    I think that one of the things that we need to do going 
forward in this new process is clearly to tighten up those 
various steps of the process from discovery, investigation, to 
action planning and accountability in a much tighter way. Those 
have been, up to now, really distributed over different silos 
within the organization. And, you know, in any system like 
that, that's prone for things to fall through the cracks, et 
cetera. So I think part of this process is really beginning to 
tighten those things up and draw a clear line through them.
    Mr. Michaud. And following up on Chairman Miller's point, 
how will OMI achieve real accountability?
    Dr. Tuchschmidt. So I think the OMI itself--I don't know 
that the OMI will ultimately be doing this work, but the OMI 
itself probably will not be responsible for the accountability 
part, right? So that's a management function that requires its 
own set of activities to be able to do the fact finding, to 
look at the evidence and say, this is an appropriate 
disciplinary process. That needs to happen swiftly and 
systemically, but also with fairness.
    Mr. Michaud. Thank you.
    The Chairman. Mr. Lamborn, you're recognized for 5 minutes.
    Mr. Lamborn. Thank you, Mr. Chairman.
    Ms. Lerner, you heard my questions to Dr. Mitchell and her 
responses. Veterans' health and safety, at least in Phoenix, 
was compromised because her warnings as a whistleblower were 
not heeded even to the point of patients dying, according to 
what she said. And as thanks for her efforts, she was 
retaliated against, to make it even worse.
    How can we strengthen the whistleblower statutes that are 
already on the books to better protect whistleblowers like Dr. 
Mitchell in the future?
    Ms. Lerner. You know, the Whistleblower Protection 
Enhancement Act, I think, has all the elements that are 
necessary to protect whistleblowers. It has to be enforced. 
People need to feel comfortable coming forward. The employer 
needs to create a welcoming environment for whistleblowers, and 
then welcome change that whistleblowers recommend and not 
ignore it, not minimize it.
    Our agency, you know, enforces the Whistleblower Protection 
Act. And I think it's a good act. I think the structure is in 
place now for whistleblowers to be protected. I think robust 
enforcement is really important. I'm not positive what changes 
I would recommend making to the act to provide more protection.
    Mr. Lamborn. Well, then, if it's not working as well as it 
was intended to work, and you just said it needs to be better 
enforced, what has to change in the culture of the VA to 
prevent these problems from happening in the future?
    Ms. Lerner. One step that can happen is the VA can become 
certified under the Section 2302(c) certification program. It's 
a pretty simple program that our agency helps to implement. I 
have gotten a commitment from Acting Secretary Gibson to have 
the VA become certified under that program. It's things that 
require more training for new employees, training for existing 
employees, having posters put up in the facilities, having a 
link to my agency's Web site on their Web site. Pretty simple 
steps, but it's a good first step for the VA to take.
    I think another really important step is for the VA to 
actually take some expedited actions once retaliation cases are 
before us, and if we are working with them, to try and resolve 
them. Not having to go through a prolonged investigation and 
getting relief quickly to whistleblowers will send a very 
positive message. It would put some meat on the bones of the 
promise not to tolerate retaliation. So I'm very hopeful that 
will happen, and if it does, I think that will be a positive 
step.
    There are other things that agencies do when they have a 
problem with culture of retaliation. We have worked with many 
agencies since I became Special Counsel 3 years ago. One that 
comes to mind very easily is the Air Force, where we got very 
serious complaints about retaliation at the mortuary when there 
were allegations about lost body parts and misconduct happening 
up in Dover, and we heard repeatedly from whistleblowers that 
the culture there was very, very bad. And once the Air Force 
decided to take steps to improve things and change the 
leadership and sent a strong message to its employees, we got 
reports back that things were much, much better.
    So I don't think that this is an insurmountable problem, 
but because the VA is so big, it's going to really require a 
lot of effort to train supervisors at the regional level in how 
important it is not to retaliate when people come forward, and 
how to value the information that we're getting from 
whistleblowers.
    Mr. Lamborn. Well, if you want to weigh into this, there's 
legislation at least that the House has passed making it easier 
to fire certain people, the top 400 or so people in the VA. To 
me, that would send a very powerful signal, even if it's just 
the threat of that being available.
    Ms. Lerner. That's possible. I haven't reviewed that 
legislation. I don't really feel comfortable commenting on it. 
But I will tell you, I think that it doesn't require firing. 
What we're seeing is not even sort of minimal disciplinary 
action. I'd like to see, you know----
    Mr. Lamborn. Anything. Anything at all.
    Ms. Lerner.--at least some disciplinary action. I am not 
sure it requires termination, although in some cases it 
probably does. But I think, again, there's probably a structure 
in place that would provide for that type of disciplinary 
action; we just haven't been seeing a lot of it. I'm not sure 
if new legislation is really necessary rather than just 
enforcement of the law as it exists today.
    Mr. Lamborn. Okay. Thank you very much.
    Mr. Chairman, I yield back.
    Mr. Bilirakis [presiding]. Thank you.
    Mr. Takano, you're recognized for 5 minutes.
    Mr. Takano. Thank you, Mr. Chairman.
    Ms. Lerner, so are you saying that the current civil 
service protections are not so onerous for managers to be able 
to impose progressive discipline, discipline dismissals in this 
case that we have cited today about the doctor copying and 
pasting medical records?
    Ms. Lerner. You can be terminated for misconduct under the 
Federal civil service laws for sure.
    Mr. Takano. And there's a current----
    Ms. Lerner. There's a current framework for doing that.
    Mr. Takano. You are saying, for whatever reason, it's just 
not happening at the VA. Do you have any--can you speculate as 
to why it's not? Is it because managers aren't adequately 
trained? I mean, it's quite extraordinary for a colleague to 
turn on another colleague, so it points to a management 
abandonment here in this instance.
    Ms. Lerner. We do have at least one case I know of where 
the VA has taken disciplinary action in a retaliation case. 
It's not impossible to do it at all; there just has to be a 
willingness to do it. What we have seen for the most part in 
our cases is that people are not really disciplined, or if they 
are, it's a very mild discipline. What is going on at the VA in 
terms of why they are not doing that, I really can't say, but 
it is certainly possible, and we have seen it done.
    Mr. Takano. I'm just curious, Dr. Tuchschmidt, this case of 
this particular physician copying and pasting, I've generally 
heard positive reviews of VistA by VA doctors. Some people 
outside the VA tell me that the--it's not--it's incredibly user 
friendly; that there can be pages and pages, and finding 
relevant data is difficult.
    One doctor I spoke to recently, who is retired from private 
practice, now evaluates records for the courts for the purposes 
of determining whether people are eligible for SSI disability. 
He reviews lots of veterans records, and he says he'll get a 
record from the VA that will be like a phone book, whereas 
other record systems in the private sector, much, much thinner, 
and he has to go through pages and pages and pages to be able 
to get the relevant information.
    Is there some truth to this? And is part of the reason why 
this doctor was able to maybe think that he could get away with 
this is some vulnerability in the VistA system?
    Dr. Tuchschmidt. Well, so when you print out charts, they 
may be very thick. Our patients tend to have multiple complex 
diseases, have a lot of visits in the organization. They're 
sicker than the average private patient.
    I think that the computerized patient records system--so 
without going into the specifics of this case, I can talk a 
little bit about what is common practice. So that if I am 
seeing a patient, and I need to put into that record the 
patient's problem list, the things that are wrong with them, a 
list of things that are wrong with them, their past medical 
history about when they had surgery or when they were 
hospitalized in the past, those facts don't change.
    So it is common practice on paper to go look at the chart 
and rewrite those things on a new note, or, in an electronic 
record system, to copy that section and paste it. If someone is 
not careful, they may capture more than they intend to and 
inadvertently place it in a new note. I'm not saying that's 
what happened here. I'm actually not defending what happened in 
this situation; I'm just trying to explain a common practice in 
what could happen.
    You know, I want to say a couple things, and that is that I 
think that we have many elements of the whistleblower 
certification program in place. We have training. We've had 
training for a long time. I think the Secretary has made a 
commitment to have that. We've had some discussions about that, 
and, you know, we want to do that.
    I think that accountability, we heard a lot tonight about 
culture. You know, you can change structure and processes and 
people. In the end it's about leadership, and it's about 
accountability in the organization, and I think that's the 
commitment that Secretary Gibson has made. It's a commitment 
I'm making tonight.
    And I would say I think one of the biggest issues that I 
heard tonight was people who felt like they suffered while the 
process was being resolved. And I would make a commitment 
tonight: I'll give you my cell phone number, and you can call 
me, and I will do whatever I can to intervene the moment you 
know so that those employees do not suffer adverse consequences 
while you do your investigations.
    Ms. Lerner. Thank you. You're the second person who's given 
me their cell phone number for that very reason. So, you know, 
I am getting that message. I am encouraged.
    Mr. Takano. Mr. Chairman, my time has expired.
    The Chairman [presiding]. He didn't say he would answer his 
cell phone.
    Dr. Roe, you're recognized for 5 minutes--excuse me, Mr. 
Vice Chairman, Mr. Bilirakis, you're recognized for 5 minutes.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it.
    Dr. Tuchschmidt, how many employees have been placed on 
administrative leave, reprimanded or terminated thus far in 
connection to falsifying or negligence which negatively affects 
a veteran and the health care they receive through the VA?
    Dr. Tuchschmidt. I can't give you a number tonight, sir. I 
can tell you that we have in some of these--specifically some 
of the cases cited looked at those action plans, and where 
there was administrative action recommended, we have taken 
administrative action in those cases. I am not prepared tonight 
to actually----
    Mr. Bilirakis. You can't give me a rough estimate over the 
past year?
    Dr. Tuchschmidt. I can't. I don't have that.
    Mr. Bilirakis. Can you get that information to me as soon 
as possible?
    Dr. Tuchschmidt. I can take it for the record, and we can 
get that to you.
    Mr. Bilirakis. All right. Thank you.
    Mr. Bilirakis. How many employees have been placed on 
administrative leave, reprimanded or terminated for actively 
retaliating against whistleblowers?
    Dr. Tuchschmidt. Again, I would have to take that for the 
record.
    Mr. Bilirakis. I would like to get that information as soon 
as possible.
    Dr. Tuchschmidt. Sure. Absolutely.
    Mr. Bilirakis. Thank you.
    Mr. Bilirakis. Ms. Lerner, how many whistleblowers have 
been placed on administrative leave, reprimanded or terminated 
for attempting to expose misconduct within the department? Can 
you give me a rough estimate if you don't have that information 
at this time?
    Ms. Lerner. I don't actually have that information. I can 
tell you that we have complaints from 67 whistleblowers right 
now that are active in our agency. I'm going to turn to my 
deputy Mr. Bachman and see if he can add to that.
    Mr. Bilirakis. Okay.
    Mr. Bachman. Thank you.
    Yes. I don't know that we have a specific number. We do, 
however, have at least three whistleblowers from the VA who 
have come forward recently that OSC has been able to get stays 
of pending disciplinary action against them. For example, they 
come forward and are almost immediately hit with the 14-day 
suspension, a 7-day suspension. We have contacted the VA and 
persuaded them to stay those actions while OSC conducts its 
investigation. So that's one role that OSC is able to play in 
all this.
    I would be happy, though, to go back and check our records 
and see if we can find exact numbers for you in terms of 
administrative leave or even other disciplinary actions.
    Mr. Bilirakis. Yeah. Would you say that there are more 
whistleblowers who are being reprimanded per se as opposed to 
those who have misconduct and negligence in treating our 
veterans?
    Mr. Bachman. If what you are asking is do the 
whistleblowers who come to us suffer adverse consequences and--
--
    Mr. Bilirakis. Adverse consequences more so than maybe 
someone who has committed negligence or malpractice on a 
veteran?
    Mr. Bachman. Unfortunately, I just don't know the goings on 
of those negligence or malpractice cases.
    Mr. Bilirakis. Anyone on the panel know the answer to that 
question?
    Dr. Tuchschmidt. No, I don't think I could answer that 
question.
    Mr. Bilirakis. Okay. I'd like to get that information as 
soon as possible, please.
    When cases are referred to the OSC, and claims of 
misconduct have been substantiated, what disciplinary action is 
taken? Anyone? Ms. Lerner.
    Ms. Lerner. Sure. One of the things that we look for when 
we get the agency's report of investigation is what 
disciplinary action, if any, has been taken. And I would say in 
most of the cases that we have reviewed, there has not been 
disciplinary action taken. I can't give you exact numbers, but 
I can tell you that it is the exception and not the rule.
    Mr. Bilirakis. Okay. One last question. Dr. Tuchschmidt: 
What consequences will those who provide false information to 
the OIG face?
    Dr. Tuchschmidt. Well, I don't know that I can answer that 
question specifically, but I can tell you that when we do 
believe that disciplinary action needs to be taken, there is a 
set of criteria that depend on the egregiousness of the, you 
know----
    Mr. Bilirakis. Give me a hypothetical case.
    Dr. Tuchschmidt. Well, so I'm not sure I'm going to be able 
to make up a hypothetical case. So there is a table of 
penalties that exists, and that is both judged by what has 
happened before, because the intention of disciplinary action 
is not to, you know, be punitive, it is intended to try and 
change the behavior of the employee. Where we feel that we 
can't change that behavior, it's a hopeless situation, 
obviously separation is what has to happen. But usually that's 
the end result of a series of processes to try and remediate 
the situation.
    Mr. Bilirakis. So if they give false information to the 
OIG----
    Dr. Tuchschmidt. That would be criminal, I would think.
    Mr. Bilirakis. Okay. All right. Thank you very much.
    I yield back, Mr. Chairman. And I would like to have that 
information as soon as possible, the answers to those 
questions. Please. Thank you.
    Dr. Tuchschmidt. Yes, we'll get you what we can.
    The Chairman. Ms. Brownley, you're recognized for 5 
minutes.
    Ms. Brownley. Thank you, Mr. Chair.
    Ms. Lerner, you spoke about the whistleblower program and 
certification as being a good first step. So can you tell me 
why the certification program is an optional one, and why it's 
not mandatory?
    Ms. Lerner. Now it is mandatory. Recently the President and 
Office of Management and Budget issued an order requiring 
agencies to go through that certification process, and their 
plans for doing so were supposed to have been posted by June of 
this year. I don't know why it was initially made a voluntary 
program. We started this certification program, I believe, in 
the early 90s, and unfortunately not a lot of agencies have 
been certified.
    Ms. Brownley. So did the VA comply with that by the 
deadline of June, or are they saying now they are going to go 
through the steps for certification?
    Ms. Lerner. I don't know if their plan has been posted. I 
don't think it has, but I was told last week by the Acting 
Secretary that they would be doing so very soon. So I'm going 
to try and follow up.
    Ms. Brownley. Trust and verify.
    Ms. Lerner. We'll verify for sure, and our agency will help 
them become certified. In fact, I sign a little certificate for 
every agency that becomes certified, so I will know the minute 
that they reach that milestone.
    Ms. Brownley. Very good.
    And we heard from our panelists earlier today whose 
identities were compromised in the process of working with the 
IG and one panelist with the White House. You heard the 
testimony. So can you give me an idea of what your office does, 
what the IG's office, what steps are taken to ensure protection 
of a whistleblower?
    Ms. Lerner. Sure. If someone comes to us with a disclosure, 
they have the option of remaining anonymous. If they choose not 
to remain anonymous, when we refer it to the agency for 
investigation--and let me just make it clear, we don't do 
independent investigations for disclosures. Once we make a 
finding of a substantial likelihood, it's a high burden, we 
then send it to the agency for investigation. We then review 
the agency's investigation for reasonableness and then report 
to the President and the oversight committees in Congress.
    So the first step on keeping information confidential is 
asking the whistleblower if they want to remain anonymous. The 
second is that when we refer a matter for investigation to an 
agency, we remind them of the need to protect the 
whistleblower. If they are choosing not to remain anonymous, we 
remind them that they have to protect that person from 
retaliation.
    In order to do a full investigation, though, sometimes you 
have to actually speak to the whistleblower. One problem that 
we have found is that often in the investigations, the IG or 
OMI doesn't actually talk very thoroughly to the whistleblower, 
and sometimes they don't even interview them. And that's a 
problem in and of itself because the whistleblower is really a 
subject matter expert, and they have to speak to the 
whistleblower to really get the full picture. So it's very hard 
to, you know, do an investigation without disclosing identity.
    Ms. Brownley. Will part of the certification program, 
though, help with enforcement in terms of the protection piece?
    Ms. Lerner. The certification program in itself doesn't 
directly involve enforcement, but by making sure that 
supervisors are trained and informed and knowledgeable about 
their responsibilities when someone does come forward, and 
reminding them that retaliation in all forms is unlawful, I do 
think that it would have the derivative effect of serving that 
purpose.
    Ms. Brownley. Thank you.
    And, Dr. Tuchschmidt, so I understand you're relatively new 
to this position?
    Dr. Tuchschmidt. Yes, I am.
    Ms. Brownley. And you were formally with the VHA and their 
transformation efforts?
    Dr. Tuchschmidt. Yes.
    Ms. Brownley. So I presume that means the VA's 
transformation. And so I'm just curious to know from in your 
old position, you know, how you thought you were doing vis-a-
vis the transformation of VHA, and did you know of any of the 
things that have been discovered over the last few months in 
this committee? Were you aware of any of those things?
    Dr. Tuchschmidt. No, I don't think--I was not aware. I 
think most people in the organization at senior levels were 
unaware, which I think is actually part of the problem. I think 
that--you know, I mean, my job as transformation lead for the 
organization, we implemented our PACT program, we expanded our 
telehealth program. Those are the things that I was working on. 
I can tell you before that I was a medical center director for 
12 years, so I have, you know, a lot of operational experience.
    I think, just to add on to her point, you know, I think 
that training and education is really important, right? People 
have to know what the right standard of conduct is. And then 
second point I would make is that once they know, it makes it a 
lot easier for us to hold people accountable. I mean, you can't 
say, I didn't know, you know, those rules anymore. So I think 
that program actually has the potential to have a pretty 
positive impact.
    Ms. Brownley. Thank you. I yield back.
    The Chairman. Dr. Roe, you're recognized for 5 minutes.
    Mr. Roe. I thank the chairman.
    Dr. Tuchschmidt, we do a lot of things to patients, as you 
know----
    Dr. Tuchschmidt. Yes, we do.
    Mr. Roe [continuing]. That require one thing that is very 
important, and that is called trust. And, you know, you've said 
the VA was great, and I want it to be that. I have a VA a mile 
from my home, and a lot of good people tomorrow are going to 
get up and go to work at the VA and try to take the very best 
care of patients they can. But through all of this 
investigation, we've lost trust in the VA. How can we trust 
anything the VA says when we have panel after panel that come 
explain, tell us these egregious things that have occurred?
    And let me just give you an example. It's almost impossible 
to make a politician speechless, but the VA has done that. And 
Brockton, Massachusetts, when you have two severely mentally 
ill veterans in the hospital, and, listen to this, a second 
veteran was admitted to the facility in 2003 with significant 
and chronic mental health issues, yet his first comprehensive 
psychiatric evaluation did not occur until 2011, how in the 
world in a healthcare system in America could that happen 
anywhere?
    And let me go on. No medication assessments or 
modifications occurred until 2011 when another doctor came 
along and reevaluated this veteran. Despite these findings, the 
OMI would not acknowledge that the confirmed neglect of 
residents at the facility had any impact on patient care. The 
VA's typical answer is a harmless error approached concluding 
the OMI feels that in some areas the veterans could have been 
better taken care of--yeah, not like ignored for 8 years--but 
the OMI does not feel their patients' rights were violated. How 
in the world with a straight face can you do that?
    And then back to the chairman just a moment ago with this 
person pasting and cutting and all that, that is someone who is 
dishonest. And me, when I have a consultant, and I've been to 
the operating room thousands of times, I have got to know what 
they're telling me is truthful. And I can promise you this: If 
that had occurred in my practice, they would have been fired on 
the spot. If we found that out in our hospital where I 
practiced for over 30 years, they would have been fired on the 
spot.
    And what we are hearing is is that the people, the 
whistleblowers who bring this up, as Mr. Bilirakis just said, 
suffer more consequences than the people who actually did the 
egregious act. I don't understand that at all. Can you 
enlighten me a little bit?
    Dr. Tuchschmidt. Well, quite frankly, I'm speechless. I 
mean, I'm appalled. I mean, I don't know what else to say. I 
think that--and Dr. Huycke may have some comments about the OMI 
process that he'd like to make, but I can tell you that I don't 
think any of us think that that's acceptable for a patient to 
be in one of our facilities for 8 years and not have a major 
psychiatric exam except once. I can't defend that.
    Mr. Roe. It is beyond comprehension to me that not one but 
two veterans were at that facility. And I know you said this a 
moment ago, but we have--the OIG brings information up here. If 
someone knowingly lies to the OIG, you shouldn't have to go any 
further. You're dealing with a liar. You shouldn't have to go 
any further other than you're out of here today. Don't go by 
the cash register and pick up your check. You're fired.
    Dr. Tuchschmidt. Yep.
    Mr. Roe. And right now it doesn't appear the VA is doing 
that. We tap dance around all these things.
    Let me just ask one other question very quickly. My time is 
about up, also. Basically how can you--and I know you're new in 
this position--undo the damage you've done to physicians and 
others whose careers have been damaged by this? What do you do 
to repair their reputations?
    Dr. Tuchschmidt. I don't know the answer to that. You know, 
in some cases the damage clearly has been done. I don't know. 
But, you know, I think that we clearly owe some people an 
apology. I think that we need to figure out how, where we can, 
make people whole. I think we try to do that. But, you know, I 
think the most important thing is that we have to go forward. I 
can't undo the past, but I can do something to change the 
future.
    Mr. Roe. I appreciate that, and, as I said, I feel very 
badly for the people who are going to go to work tomorrow for 
the VA who are doing a good job. They're working hard. And let 
me tell you who needs an apology: the two veterans who are 
mentally ill and their families who they were completely 
ignored, and the 1,241 people that had something done to them 
at the VA. You have a reasonable expectation when you're in a 
hospital that people are being honest.
    I mean, I handed off cases at night when we would turn over 
the duty, and you'd take the beeper--now it's a cell phone--
take the beeper. You expected your partner to tell you the 
truth because people's lives depended on it. This is not some 
game we're playing.
    Dr. Tuchschmidt. Absolutely.
    Mr. Roe. These people's lives are at stake.
    Mr. Chairman, I yield back.
    The Chairman. Thank you.
    Mrs. Kirkpatrick, you're recognized for 5 minutes.
    Mrs. Kirkpatrick. I appreciate what Acting Secretary Sloan 
Gibson is doing with restructuring the OMI and coming up with a 
strong internal audit system; however, I must express that I am 
skeptical about how that's going to work. Ms. Lerner testified 
that we have the Whistleblower Protection Act, but it's not 
enforced. And so my concern, first of all, is that we've heard 
so much testimony in this committee about a culture of secrecy, 
about a culture of retaliation, and retaliation is a huge 
deterrent to hearing complaints.
    So my first question, Ms. Lerner, is to you. We've heard 
that there's been retaliation against employees. I'm concerned 
that there is retaliation against patients who might feel that 
they have a complaint against a facility. Are you aware of any 
retaliation against patients, against veterans?
    Ms. Lerner. I think that's a really important question, and 
I don't know the answer to it. I'm not aware of any 
retaliation, in part because my agency's jurisdiction is just 
for employees to come forward with retaliation complaints or 
disclosures of waste, fraud or abuse, or health or safety 
problems. Someone could come to us with a disclosure if they 
thought that a patient, you know, was being retaliated against. 
I don't believe we've gotten any of those cases.
    People do come to my agency with disclosures about poor 
patient care, where they complain about patients not getting 
appropriate treatment and then are retaliated against 
themselves for having made those complaints. But in terms of 
patients, we probably wouldn't get those.
    Mrs. Kirkpatrick. Is there some kind of national hotline 
that VA patients can call if they have a complaint about a 
facility?
    Ms. Lerner. I don't know the answer to that.
    Mrs. Kirkpatrick. Doctor, do you know?
    Dr. Tuchschmidt. So there are a number of mechanisms that 
patients now have to give us feedback about their system. They 
complain, quite frankly, do complain directly to our patient 
advocate system. That is a real human being sitting at each 
facility that they can go to.
    Mrs. Kirkpatrick. That's my concern: at each facility. So 
you see, what we're seeing here is this pattern that, yeah, the 
complaint stays within the facility. It never goes outside of 
that.
    Dr. Tuchschmidt. Yes.
    Mrs. Kirkpatrick. And let me just throw out an idea. You 
know, I'm a former prosecutor, and we used to have a really 
difficult time getting people to report child abuse and 
neglect, elder abuse until we established a hotline where the 
reports could be anonymous, but there would be an 
investigation, and then we started to be able to get these 
reports. There was absolutely no possibility of retaliation any 
way, anywhere because of those reports, even if they turned out 
to be false.
    And I just don't see how we're going to be able to get to 
the root of this without something like that in place where 
there's a hotline that veterans can call if they feel like that 
they didn't get the care they wanted, and that employees can 
call and make reports so that there's absolutely no possibility 
of retaliation. Would you consider something like that?
    Dr. Tuchschmidt. Yeah. So in addition to the local options 
that veterans have, veterans can--patients can call the OIG hot 
line today, and we are----
    Mrs. Kirkpatrick. But who knows that? Who knows that? Who 
knows how to do that? Do you get my point? I mean, we're really 
going to have to look at this very hard, you know, and really 
put our veterans first.
    Dr. Tuchschmidt. Absolutely.
    Mrs. Kirkpatrick. The employees are taking care of them 
first. I'm sorry to interrupt you, but I feel very passionate 
about this.
    Dr. Tuchschmidt. I do, and I respect that tremendously. You 
know, so I think that one of the things that we are looking at 
today, so the Department of Defense has a program that they 
call ICE. It is an interactive thing on their Web site. 
Actually any patient, any employee can go right on that Web 
site and provide feedback, file a complaint, say you did a 
great job, and it goes right up to the top of the command 
chain. We are looking at that. It'd be free to us to bring it 
over into the VA, to be able to put it on our Web site.
    Right now we are in discussions about what's the mechanism, 
you know, what's the business processes behind that. And, quite 
frankly, I will take your point that you're making tonight back 
home and say it needs to be high in the organization.
    Mrs. Kirkpatrick. Thank you. Thank you very much.
    I yield back the balance of my time, Mr. Chairman.
    The Chairman. Mr. Flores, you're recognized for 5 minutes.
    Mr. Flores. Thank you, Mr. Chairman.
    Ms. Lerner, it's our understanding the OCS is spending a 
substantial amount of its time on these whistleblower--on the 
caseload from the whistleblowers. Can you tell us what Congress 
can do to help alleviate the amount of time that you're having 
to spend on that activity so that you can continue to take care 
of the needs of the VA whistleblowers?
    Ms. Lerner. Well, I want to maybe start by answering the 
question by noting that this committee has been particularly 
supportive of our work. I want to recognize the staff of the 
Oversight and Investigation Subcommittee for their work on this 
issue and their work with our agency. We consider it to be a 
real partnership, and we are very grateful for this committee's 
support. We've also received a number of referrals from this 
committee, and we appreciate your confidence in our ability to 
work with the employees that your office refers. So that's one 
thing that's already happening.
    We are doing everything that we possibly can to address VA 
cases quickly and thoroughly. We've set up a priority intake 
system for VA cases. We've reallocated staff to handle VA 
employee claims. But as the numbers increase, it's very hard to 
keep up. We were at capacity before the VA cases kind of 
overtook us, and the total number of cases between disclosures 
and retaliation cases now exceeds 130, and the number, as I 
mentioned, continues to increase pretty much daily.
    Mr. Flores. Wow.
    Ms. Lerner. We're a tiny agency. We have 120 employees, 
more or less. We have jurisdiction for four statutes: the Hatch 
Act, the Uniformed Services Employment and Reemployment Rights 
Act, and we are working now on the demonstration project that 
this committee provided to us. We also handle disclosures, over 
1,200 a year, and this year will be a record with the VA 
disclosures. And we also handle prohibited personnel practices. 
So we're stretched pretty thin right now.
    Mr. Flores. Well, please continue to let us know what we 
could do to be helpful so that we can sort through your current 
workload as well as the new VA workload that you're having to 
deal with now.
    Ms. Lerner. Thank you.
    Mr. Flores. Dr. Tuchschmidt, one of the things we've talked 
about is that some whistleblowers have provided some limited 
patient information which is allowed through special channels 
to deal with what they perceive as problems at the VA. When 
they do this, it is not a violation of HIPAA, but yet these 
employees are being charged with privacy violations. What can 
we do about this? How do we get the VA to stop the charges of 
privacy violations when the whistleblowers go through the 
proper steps to do this?
    Dr. Tuchschmidt. So I am aware of one instance where that 
happened, and an employee, in my opinion inappropriately, was 
put on administrative leave while that investigation was being 
done over concerns that the person took patient information and 
did violate HIPAA. I can tell you that the leadership at that 
facility now knows that people, whistleblowers have a right to 
have information, can share that information with the OSC, the 
OIG, with Congress, and it is not a HIPAA violation.
    We need to do a better job of making sure people across our 
organization understand this issue clearly. And, you know, I 
wish I could say it will never happen again. I think that would 
certainly be our intention to make sure that people are more 
aware and more cautious about what they do.
    Mr. Flores. Okay. We will continue to try to put that 
message out.
    I yield back.
    The Chairman. Ms. Kuster, 5 minutes.
    Ms. Kuster. Thank you very much, Mr. Chairman, and thank 
you to all of you for coming this evening.
    I wanted to ask Dr. Tuchschmidt, in the private sector in 
hospitals, they have a process of quality assurance, typically 
a quality assurance committee where information that is shared 
in reviewing cases with that committee is typically by statute 
protected from discovery in a medical malpractice lawsuit.
    And as an attorney, I want to get to the bottom of whether 
part of the behavior that we're hearing about tonight and 
throughout the testimony from the whistleblowers has to do with 
people within the VA trying to protect the agency from medical 
malpractice lawsuits; and, if that's the case, is there 
something that we could do statutorily?
    This is something that I'd worked on at the State level 
many, many years ago is a statute that protected quality 
assurance so that you can have a quality-improvement process 
going forward without all this behavior of covering their backs 
and, you know, blaming people that are bringing these issues 
forward. Could you comment on that?
    Dr. Tuchschmidt. So I think we have, quite frankly, 
adequate protections in place for quality assurance documents 
that are covered statutorily, right? I can't say--I mean, we're 
an organization of 300,000 people, right? I don't know what 
everybody thinks when they go out and do something, but I can 
tell you that I don't--I'd be surprised if a concern about the 
release of quality information is part of what might be 
motivating some of the concerns and particularly the 
retaliatory behavior about whistleblowers.
    You know, I think clearly managing those situations is 
difficult for local management. I think we need clearly to do a 
better job of informing and educating. I mean, again, I don't 
know how to say it any better. I mean, I was appalled by the 
stories I heard tonight. I don't think we as an organization 
should tolerate that. I don't think you should let us tolerate 
that.
    Ms. Kuster. Trust me, we're shocked.
    Dr. Tuchschmidt. I'm shocked. I'm shocked.
    Ms. Kuster. Well, I just wanted to get to that issue.
    On another issue entirely, another level of shock for me 
was the information in the record that we have about Dr. Head 
and the very clear pattern, disturbing pattern, of racial 
prejudice. Can you tell me, within the organization, first off, 
how does that exist in this day and age? But second off, is 
there some way to cope with that and make sure that that's 
not--you know, in this day and age, honestly, with the progress 
that we've made in our country in all aspects of diversity, 
gender, race, religion, ethic background, I can't imagine with 
this many employees that it could even begin to be tolerated, 
the type of behavior that is documented here in this lawsuit. 
It's extraordinary.
    Dr. Tuchschmidt. Well, I mean, I was absolutely floored. I 
was floored when he held up his picture tonight, and I know 
what was in his other slide, and it's even more abhorrent. And 
it's astounding that it happened at the UCLA medical school 
amongst highly educated professionals. I don't get it. I mean, 
I just don't get it. You know, again, in an organization with 
300,000 people, people do stupid things, right, and we can't 
always control that.
    Ms. Kuster. But would there be a procedure, would there be 
any kind of protocol or process if that was reported up the 
chain?
    Dr. Tuchschmidt. Absolutely. And, you know, in my 20-
something years, I can tell you, I think that this organization 
has been for a long time one of the most inclusive and 
supportive of diversity organization I have seen. I mean, we 
train people. We train people on EEO and workplace harassment 
issues. We have programs to support cultural diversity and 
cultural competency within the organization. You know, I'm 
astounded, quite frankly, by Dr. Head's story. Quite frankly, I 
learned about three of these four whistleblowers the first time 
by reading about it in the paper.
    So I think that, you know, we clearly need to do a better 
job of making sure that people can communicate their concerns. 
There are a lot of avenues, right? I mean, they have the OSC 
process. They have the OIG. They can come to you all. But my 
dismay is that they don't feel like they can come to us within 
the organization, because that's where it has to start.
    If we really want an organization that is dedicated to 
safety, to quality, to integrity, it has to start with our 
employees on being engaged on the frontline, and taking a 
meaningful role, and feeling like they can fix those things 
that are within their sphere of influence and go to people that 
can when they can't. And if we can't do that, we will fail.
    Ms. Kuster. My time is up, but we all concur that that's 
what we need to do. And as far as I'm concerned, there are 
people that need to lose their positions over this.
    So thank you, and I apologize, Mr. Chairman.
    Dr. Tuchschmidt. Thank you for letting me go over.
    The Chairman. Dr. Benishek, you're recognized for 5 
minutes.
    Mr. Benishek. Thank you, Mr. Chairman.
    Ms. Lerner, Dr. Mitchell in the previous panel talked about 
what she thought was--explained was a sham peer review process. 
Have you seen anything like that in your investigations?
    Ms. Lerner. I'm going to ask Mr. Bachman.
    Mr. Bachman. We have seen that in some of our 
investigations and are taking a very close look at those when 
we see them. These types of investigations can be difficult to 
prove as pretext for retaliation sometimes, but we are seeing 
that as an emerging trend, and it's something that we are 
focusing on and making sure that we're gathering all the 
evidence we can to see exactly why was this peer review 
undertaken.
    Mr. Benishek. All right. Thank you.
    Dr. Tuchschmidt, are you aware of this VA program that was 
started on April 2013 called the ``Stop the Line'' patient 
safety initiative that Mr. Jolly talked about? Are you aware of 
that program?
    Dr. Tuchschmidt. Yes. So I'm not sure exactly I know which 
program you're talking about, because there are--you know, so 
Stop the Line is part of a lean technology, right, process. 
There are many----
    Mr. Benishek. Well, as I understand, it's a way for current 
VA employees to step forward when they see something going on 
that they would expect a change in quality.
    Dr. Tuchschmidt. Absolutely. So many of our facilities have 
implemented lean on their own, but as part of our national 
patient safety program, we have a Stop the Line timeout 
process. So any employee--and this is particularly true in our 
procedure-based areas--any employee who feels like something is 
not right before something is about to happen to the patient 
can call a timeout, stop the line and say, I disagree with 
that. That could be the doctor; it could be the nurse; it could 
be the housekeeper in the operating room that stops the line 
because they feel that something isn't right, and the line 
stops until it's resolved. So that's part of our national 
patient safety.
    Mr. Benishek. Does the VA keep track of how many times this 
initiative is invoked?
    Dr. Tuchschmidt. No, not to my knowledge.
    Mr. Benishek. Are reports collected?
    Dr. Tuchschmidt. Not to my knowledge. It's part of the 
business process. It's not something----
    Mr. Benishek. You know, I was just aware of this incident 
here where I've got a report of 60 Chiefs of Anesthesia within 
the VA around the country invoked a formal communication to the 
VA with this Stop the Line initiative regarding a policy that 
would change how surgical care was delivered. And the Chiefs' 
communication was sent to the VA Secretary, the Under Secretary 
for Health and the Principal Deputy Under Secretary for Health 
on October 1, 2013.
    Dr. Tuchschmidt. That would be the former Principal Deputy.
    Mr. Benishek. Yeah, yeah, yeah, you're the acting, I 
understand. But despite being told otherwise by VA officials on 
as recently as June 17, the Chiefs of Anesthesia have informed 
me that they haven't received a response at the VA.
    Dr. Tuchschmidt. I'm unaware, I can't comment, but I'm 
happy to take that back and find out----
    Mr. Benishek. We were briefed that they did get a response, 
and then subsequent to that we were told by them that they 
didn't. So I'd like to know what the response is, and if you 
didn't respond, could you please get that to me?
    Dr. Tuchschmidt. I have no idea, but I will get a response 
for you and for them if they didn't get one.
    Mr. Benishek. Do you know how often the VA gets a letter 
from more than 60 Department heads about a problem?
    Dr. Tuchschmidt. I don't.
    Mr. Benishek. It would seem like that would be worth a 
response to me.
    Dr. Tuchschmidt. It would seem atypical, yes.
    Mr. Benishek. Well, there's so many atypical things, 
Doctor, that you're having to explain. And, actually, I really 
appreciate your apology to the veterans of this country. I felt 
your emotion when you first gave your statement.
    Dr. Tuchschmidt. Thank you.
    Mr. Benishek. But you see what a huge problem we're trying 
to deal with here.
    Dr. Tuchschmidt. We have----
    Mr. Benishek. I mean, you know, you yourself are 
expressing, you know, severe emotion, and it's hard for us to 
even sit here without going, what is going on, and how do we 
fix this. And you're in the same boat. And, you know, we need 
some real dramatic change here. And we're hoping--we're all 
hoping that this new Secretary and the legislation that we will 
work on will make a dramatic change within the VA, because, you 
know, I worked at the VA for 20 years, and I felt that. And 
with the comment you made earlier about these things being 
isolated incidents that these guys talked about, it's not. It's 
not isolated incidents. I mean, I went to the meeting of the VA 
physicians in Dennis, and there's like a whole mess of them are 
telling me this. So, you know, it is a systemic problem, and we 
need to deal with it.
    Dr. Tuchschmidt. I appreciate your sentiments.
    Mr. Benishek. Anyway, I am out of time. Thanks.
    The Chairman. Mr. Walz, you're recognized for 5 minutes.
    Mr. Walz. Thank you, Chairman.
    I thank you all for being here.
    And, Dr. Tuchschmidt, I agree. And as so often is the case, 
I concur with Dr. Roe. I think what's at heart here and maybe 
something it doesn't appear like to me people have come to 
grips with. Your feeling of being sick and disillusioned, 
that's how I feel. That's how my veterans feel. A generation of 
good work has been erased. I think you understand that.
    Dr. Tuchschmidt. Absolutely.
    Mr. Walz. Very, very difficult because this is about care. 
It's about getting the trust in them. It's about getting them 
into the system. It's about working on things like seamless 
transition. It's about making sure programs for blinded 
veterans are there, all the things we've worked on. And I sat 
sitting here for 8 years and 24 years prior in uniform trying 
to prove to be a good actor on this or whatever. But the 
question I have is, again, what's going to change? What's your 
definition of ``unacceptable''?
    Dr. Tuchschmidt. Well, I think, quite frankly, that the 
bottom line for me from the time I went to medical school until 
today has been has the patient gotten what he or she believes 
they needed? And it has to be quality; it has to be safe and 
effective. I mean, to me, that's the bottom line.
    Mr. Walz. The thing is we try and work around this and find 
what the fix is, because at the end of the day, we're going to 
sit here--and I agree, we have to diagnosis first before we can 
prescribe the treatment on this. We're going to have to commit, 
but we have to move forward on how to get it fixed.
    So today the letter comes out on the restructuring of the 
Office of Medical Inspector. And it is very clear that the 
Acting Secretary made it clear, as I told our workforce, 
intimidation or retaliation against whistleblowers or against 
any employee who makes a suggestion or reports what may be a 
violation of law is absolutely unacceptable.
    Was it not unacceptable to Secretary Shinseki? Was there 
any way in that man that you got the impression or your 
employees got the impression that it was acceptable then; it's 
not now?
    Dr. Tuchschmidt. That was never apparent to me.
    Mr. Walz. What changed? What changed today?
    Dr. Tuchschmidt. I think what has changed today is that we 
do have new leadership, right? I mean, so Acting Secretary 
Gibson has stepped up. He is out in the field going to medical 
centers. He has, in fact, pulled this process of whistleblower 
and investigations up to the Department level where he can 
personally supervise it. His engagement and commitment in this 
is phenomenal.
    Mr. Walz. One of the complaints about how the VA works and 
the insular nature of it is that there's a belief that they can 
just outlive people. They are going to outlive Mr. Gibson. And 
they might be thinking, we'll outlive this guy. November is 
coming around; he'll be gone. Secretaries will be gone, 
Presidents will be gone or whatever.
    I have to tell you, and this pains me more than anything, 
this breach of faith--and I have sat up here for 8 years, and 
I'm your strongest supporter, but I'll be your harshest critic. 
I listened to this today, and it floors me that I don't believe 
with one fiber in my being that you're going to get this right, 
and that is disturbing, which makes me then come back and say, 
and if I were you sitting there asking what are you going to do 
about it, that's what I'm asking for. I want us to take back 
more of this, I want us to pull this back in, and I want to do 
the data and know that the data is true.
    And so I ask you, Ms. Lerner, is there a way to do this? Is 
there a way to have the third-party validation, to have that 
accountability? I would argue we can be the most accountable 
people because we have to stand in front of voters that are the 
constituents and the veterans every 2 years. Those SES folks 
are never going to see my veterans, ever. So I ask you, how do 
we restructure this? Are we trying to fix a broken system that 
is beyond repair on trying to get this accountability?
    Ms. Lerner. Well, I said before, I'm an optimist.
    Mr. Walz. I am, too. I supervised a high school lunchroom 
for 20 years.
    Ms. Lerner. And you're very brave as well.
    Mr. Walz. So I am the ultimate optimist, and I have been 
shaken by this. So that's why I ask you, what proof is there? 
Words or something. What proof is there to you? Your reputation 
is on the line now, too, if you say it's going to be fixed by 
this.
    Ms. Lerner. Well, I don't know. I mean, my job is to shed 
light, because that's the best disinfectant on, you know, a 
broken system. And the whistleblowers are shedding light on 
where the problems are. The next step is to actually see some 
action.
    Mr. Walz. Correct.
    Ms. Lerner. And what we've heard in the last several weeks 
from the new leadership I believe is encouraging, but it is 
going to have to be----
    Mr. Walz. Eight weeks ago I asked what is the problem with 
the Rochester VA, and higher people than you sat there and told 
me, you are right, Congressman, you deserve an answer right 
away. So here I said I'm off the reservation on this one. Why 
has there not been an answer on that? So how should I believe 
that? A Member of Congress was told they would get them an 
answer about what's wrong with their local VA, a place where I 
sat much time with my veterans, and I have not got an answer.
    Ms. Lerner. I'm not here to defend the VA. I mean, I've had 
a pretty ringing indictment of what's been going on. But I 
think that there are steps that can be taken.
    Expediting review of whistleblower complaints when people 
believe that they're being retaliated against, if we get can 
get that expedited review in place and whistleblowers can see 
quick action, that sends a very powerful message, not just to 
the individuals who are involved but to the facility. If 
there's disciplinary action when someone retaliates against 
someone, we need to have actions that back up the positive 
words.
    Mr. Walz. Yes.
    Ms. Lerner. And we haven't----
    Mr. Walz. And you think we can get them, doing this new 
structure?
    Ms. Lerner. I'm going to do my best to follow up on the 
promises that have been made to me. I expect this committee 
will join me in continuing to do oversight. That's our job. I 
am happy to come back here in 6 months and report back to you 
on what actions we've actually seen taken.
    But one of the problems, I think, has been that we've 
gotten the warnings from the whistleblowers about where the 
problems are, but they have been sort of hidden from, I think, 
probably VA leadership because the OMI has been saying, no 
harm, no foul, you know, there's no violation here, there's no 
regulation that's been violated.
    In Brockton, what we heard from the OMI----
    Mr. Walz. Why did you not suggest total elimination of the 
OMI?
    Ms. Lerner. Well, whatever replaces the OMI is going to 
have the same issues. I think there are certain steps that can 
be taken, whether it's the OMI, whether it's the IG.
    Whatever the entity is that is investigating, there needs 
to, number one, have a review triggered whenever there is a 
finding of a problem. It has to go higher than whatever the 
investigating entity is.
    I think the second thing is there has to be a look to see 
whether actual harm has occurred. Because what we've been 
seeing is that the OMI says, yes, the allegations are true but 
there's no harm here, but they don't really look to see whether 
patients have been harmed or not.
    In the Brockton case, the OMI only looked at the three 
patients that the psychiatrist reported on. The psychiatrist 
said, ``I think this is probably a widespread problem 
throughout the facility,'' but the OMI only looked at those 
three patients, didn't look to see if it was a more widespread 
problem. And that's----
    Mr. Walz. I appreciate that. I'm beyond my time, Ms. 
Lerner. I'm sorry.
    Thank you, Mr. Chairman. I apologize.
    The Chairman. Yes, sir, Mr. Walz.
    Mr. Huelskamp, you're recognized for 5 minutes.
    Mr. Huelskamp. Thank you, Mr. Chairman.
    I'd like to go back to some of the testimony we heard on 
the prior panel. And the first question would be for Dr. 
Tuchschmidt.
    In his testimony, Dr. Mathews stated that when he 
repeatedly brought up problems with doctors only doing 3-1/2 
hours of work during any given 8-hour workday, the consistent 
explanation he received was that this is the VA.
    Considering that response, is it common practice throughout 
the VA for doctors to work only a proportion of the time 
they're being paid for?
    Dr. Tuchschmidt. No, that's not a common practice. That's 
not actually an expectation. You know, so I think that----
    Mr. Huelskamp. Doctor, can you tell me how you know whether 
that's true or not?
    Dr. Tuchschmidt. Well, so I think there was a briefing on 
capacity in the organization that----
    Mr. Huelskamp. Yeah, and I'll tell you, the VA briefing 
said their data was no good. And I've had whistleblowers to 
that effect.
    The second question is with reference to Mr. Davis, if Ms. 
Lerner could shed some light on this. But you indicated that 
folks from your association had met with White House Deputy 
Chief of Staff Rob Nabors and Secretary Gibson about these 
issues. Were you in on those meetings?
    Ms. Lerner. I was. And Mr. Bachman was, as well.
    Mr. Huelskamp. Okay. And I'd like to ask you, because Mr. 
Davis does note that he believes that the Deputy Chief of Staff 
of the White House, Rob Nabors, leaked his whistleblower 
complaint, did you visit with Mr. Nabors about this possibility 
and what the problems and penalties might be for doing such an 
action?
    Ms. Lerner. My meeting with Mr. Nabors was--did not focus 
on this matter. I don't know anything about it, quite frankly. 
My guess----
    Mr. Huelskamp. Okay.
    Ms. Lerner. [continuing].--Is that, and I'm just guessing 
here, is that Mr. Nabors was trying to probably intervene to 
help and not to leak someone's name in a vindictive kind of 
way.
    Mr. Huelskamp. Well, this goes to the highest levels. You 
said that you thought they understood very well, but the 
allegation tonight was that the very folks at the very highest 
level that we're relying on actually were violating their own 
whistleblower laws that are very clear.
    And I want to ask Dr. Tuchschmidt, how do you inform the 
employees about the rights in a whistleblower protection? How 
often do you do that?
    Dr. Tuchschmidt. So we have training that employees take in 
our electronic education system. So there's online training 
that is available to all employees and supervisory training, as 
well.
    Mr. Huelskamp. Is it mandatory?
    Dr. Tuchschmidt. Yes, it is mandatory.
    Mr. Huelskamp. How often do they take this training?
    Dr. Tuchschmidt. I believe it's annually.
    Mr. Huelskamp. And you will certify everyone takes this 
training?
    Dr. Tuchschmidt. We do track it in the--the TMS system 
tracks----
    Mr. Huelskamp. Well, your data is sometimes questionable. 
If you could provide evidence of that, as well.
    Following up on a few more things, Dr. Tuchschmidt, in 
fiscal 2013, Donna Beiter, the director of the VA Greater L.A. 
Healthcare System, received an $8,985 bonus. Based on the 
testimony from Dr. Head tonight, including the continued 
retaliation and discrimination, will there be any effort to 
pull back or rescind her bonus?
    Dr. Tuchschmidt. I really--I can't comment. I don't know. 
You know, we----
    Mr. Huelskamp. Okay. Let me ask you about another one then.
    Similarly, in the VISN 18, the director of that VISN, which 
includes Phoenix VA Healthcare System, the director, Susan 
Bowers, received an $8,985 bonus in fiscal year 2013, as well. 
Based on what we heard tonight about retaliation, 
discrimination, will there be any efforts to rescind that 
bonus?
    Dr. Tuchschmidt. So, typically, we--performance awards are 
tied to a performance evaluation, that a performance evaluation 
was done based upon the knowledge at the time that was 
completed. And we don't really believe that we have the 
authority to go back, once those are done, and change prior 
performance evaluations.
    Mr. Huelskamp. And, thirdly, Dr. Tuchschmidt, Mr. Davis's 
testimony, folks above him, the Deputy CBO, received an $8,252 
bonus, and the CBO for Member Service received a bonus of over 
$7,600. Will there be an effort, or are you going to ignore 
these--allow these bonuses to remain, as well?
    Dr. Tuchschmidt. I think that, again, my answer would be 
that we don't normally go back and change performance 
evaluations once they're completed.
    Mr. Huelskamp. I want to zero in on the 1,241 patient 
records that were falsified. How many records do you have to 
falsify in order to be fired as an employee?
    Dr. Tuchschmidt. I would hope you don't have to falsify 
any.
    Mr. Huelskamp. 1,241 apparently was not enough.
    Dr. Tuchschmidt. One would be unacceptable.
    Mr. Huelskamp. 1,241?
    Dr. Tuchschmidt. I can't comment on the specifics of that 
case.
    Mr. Huelskamp. Well, I know you're not commenting on a 
specific case, but you said it's one. But we've verified--the 
lady next to you has verified 1,241 times. And they're still 
working serving veterans, when they've falsified data in clear 
violation of the law and harming potentially veterans. And your 
response is, well, they still get to keep their job.
    Dr. Tuchschmidt. I'd be happy to arrange a time to come and 
share the details of that with you.
    Mr. Huelskamp. I would be happy to hear that. But what I 
think the American public needs to know is, are you really 
serious about that? Still giving out bonuses, still hearing 
these reports, and 130 complaints still continue to be 
investigated.
    I yield back, Mr. Chairman.
    Dr. Tuchschmidt. I hear you, sir.
    The Chairman. Dr. Tuchschmidt, the VA has come and briefed 
our staff and said that the VA believes that they have up to 1 
year to be able to claw a bonus back. And is it your testimony 
that, even though fraud was committed, that a bonus is still 
something that an individual should receive based on the 
information that was known at the time?
    Dr. Tuchschmidt. So I think you're getting out of my swim 
lane. I don't know the technical answer to that question, but 
I'm--I am happy to go back and get that answer for you.
    The Chairman. It's called fraud, and that's illegal.
    Dr. Tuchschmidt. I understand.
    The Chairman. Mr. O'Rourke, you're recognized for 5 
minutes.
    Mr. O'Rourke. Thank you.
    I want to continue Mr. Huelskamp's line of questioning 
about Montgomery and just highlight some of what Ms. Lerner 
included in her testimony: that, in 2012, a whistleblower who 
was a surgeon was first alerted to this misconduct by an 
anesthesiologist during a veteran's preoperative evaluation 
prior to an operation. So I think that establishes the danger 
and the threat and the potentially bad outcome for the veteran 
when we don't have the right information for the 
anesthesiologist, in this case.
    Whistleblower reports these concerns to the Alabama VA 
management in 2012. They put him on this--him or her--this FPPE 
evaluation. And during that evaluation, he does this again; he 
cuts and pastes information onto veterans' medical records.
    And then you get OMI involved. And then, far worse than 
previously believed, the review determines that the 
pulmonologist engaged in copying and pasting, as Mr. Huelskamp 
and others have said, in 1,241 separate patient records.
    So, a couple things. You keep saying you can't comment on 
this. I mean, it just defies commonsense and what all of us 
would expect from anyone, that you would just say that this 
person will be fired. I don't know why Ms. Lerner can tell us 
all these details--and this is now public record--and you can't 
tell us, and you can't tell the people in Alabama, more 
importantly, the veterans there, what's happening.
    And, also, if we're talking about creating a culture of 
accountability, what does it say to the surgeon who is the 
whistleblower? What does it say to the anesthesiologist that 
this pulmonologist is still working? What does it say to the 
people who testified in the panel before yours about what 
happens when you have the courage and take the risk to stand up 
and alert your superiors to malpractice or malfeasance within a 
VA?
    I think the signal you sent to everybody tonight is, 
``Don't take that risk. We're not going to do anything.'' I 
mean, the sin could not be more glaring than that documented by 
Ms. Lerner here.
    Is there anything that you can say? What would it cost you 
or the VA or the Federal Government to go out on a limb and 
say, ``We're going to fire that person; he or she should not be 
working for us''?
    Dr. Tuchschmidt. Right. So, as I said earlier, I mean, 
there are reasons why I feel I cannot go into details here. 
Right? So there are still active investigations going on into a 
lot of these issues by the OIG. There are--if I put enough 
details out there, somebody can make connections, right, back 
to individuals. And, again, these are complicated issues that--
--
    Mr. O'Rourke. It's--I don't know how it's complicated.
    Let me ask this follow-up question for Ms. Lerner.
    In your testimony related to this case, you say, ``OSC 
requested and has not yet received information from the VA to 
determine if the 1,241 instances of copying and pasting 
resulted in any adverse patient outcomes.''
    When did OSC request that?
    Ms. Lerner. I'm sorry, I don't know the exact date. We 
have----
    Mr. O'Rourke. More than a week?
    Ms. Lerner. Yeah.
    Mr. O'Rourke. More than a month?
    Ms. Lerner. I'm quite sure.
    Mr. O'Rourke. Okay.
    Ms. Lerner. And we'll do a final----
    Mr. O'Rourke. And, Dr. Tuchschmidt, what's the response 
on--I mean, I still don't understand why you can't answer our 
previous questions about why this pulmonologist is still 
working, but certainly you could answer this question, about 
responding to the request to understand how this has affected 
patient outcomes.
    Dr. Tuchschmidt. Yeah, so--I don't know where that response 
is. I did not know that they had not received something. But I 
can go back and take care of that and find out where that is 
and why a response hasn't been received.
    I mean, I can say to you that I think that, you know, it is 
our intention--I'm committed in the job that I am now acting in 
to try and address these issues----
    Mr. O'Rourke. I'm not convinced--and I apologize for 
interrupting. I'm just not convinced that you're going to do 
it. And I don't know you, so you can't take this personally, 
but it's been reflected in testimony we've heard from almost 
every representative of the VA for almost as long as I've been 
here, which has not been a long time but long enough to know 
that we have a major problem with accountability and 
performance. And I'm not convinced that we're going to be able 
to turn it around, from what I've heard.
    I mean, everything was lined up beautifully by the previous 
panel about the kind of problems and for how long they've 
existed and what's needed to change this. And then we hear from 
the VA essentially a non answer that basically sends the 
message to us and to every employee of the VA that you don't 
take this seriously.
    I mean, you can say you're appalled, you can say you're 
outraged, you can said you're deeply disappointed, but that's 
all been said before. What we need now is: This is what we have 
done, this is what we are currently doing, this is what we will 
do. And I haven't heard any of that tonight.
    And just really quickly, Mr. Chairman, Dr. Jesse, the 
previous head of the VHA, when we alerted him to these 
outrageous problems in El Paso, with 36 percent of veterans 
seeking mental health appointments not being able to obtain 
one, huge, gross discrepancies between what El Paso VHA was 
reporting and what we finally learned through the VHA audit was 
the truth, Dr. Jesse's response was, ``Let's not get into 
assigning blame.'' In other words, let's not hold anybody 
accountable, let there not be consequences, let's not change 
anything we're doing.
    I just have to register that very deep, profound 
disappointment that I have and you've heard from so many others 
today. And I, through you, ask the Acting Secretary to change 
the culture now and change the responses that we're getting at 
these hearings.
    Dr. Tuchschmidt. Message heard.
    Mr. O'Rourke. Thank you.
    The Chairman. Mr. Coffman, you're recognized for 5 minutes.
    Mr. Coffman. Thank you, Mr. Chairman.
    Dr. Tuchschmidt, based on the testimony provided by the 
four whistleblowers here tonight, it appears that the same 
unethical tactics are occurring at numerous VA medical centers 
across the country. This would seem to indicate that there is a 
universal policy in place against whistleblowers that is well-
known among all the VA SES-level supervisors throughout the 
country.
    Do you have an explanation for this?
    Dr. Tuchschmidt. Well, I don't believe there is any policy 
or a collusion to suppress whistleblowers amongst the top 
leadership at the organization. In fact, I think the 
organization has said today, particularly Secretary Gibson, 
that we intend to do something about that. The message has 
clearly gone out to everybody in that June 13th letter that 
there are consequences for retaliation.
    We have to go through a process when those complaints come 
in, I think, of investigating those so that we treat people 
fairly and we know both sides of the story and we have the 
facts before we take action. But I think the organization--the 
Secretary speaks for the organization. And I think that 
commitment is there, and I have to take him at his word.
    It is clear to me tonight from all of the comments here and 
from the comments from all of you, I mean, we have an enormous 
problem. And we are a huge organization; it isn't going to 
change overnight. I would--I know we're all impatient, but it's 
going to take some time, I think, to fix some of these 
fundamental issues.
    It's going to start with, really, leadership. And we have a 
new Acting Under Secretary, we have a nominee. We will have a 
new Under Secretary for Health at some point and, I hope, a new 
Principal Deputy Under Secretary. And I think that the 
organization--that's the kind of change we need in the 
organization to get back on the right track. And it's going to 
take----
    Mr. Coffman. But how long have you been a part of--you've 
been a part of leadership in the VA for quite some time. How 
long have you been a part of the leadership of the----
    Dr. Tuchschmidt. For over 20 years, I've been in----
    Mr. Coffman. Over 20 years. And you testified tonight that 
this is really the first time that you've become aware of the 
problems that were brought forward by the whistleblowers 
tonight. Isn't that correct? That was your previous testimony.
    Dr. Tuchschmidt. I learned about these whistleblowers 
mostly by reading them in the paper, yes. So----
    Mr. Coffman. And so, you've been in 20 years. Here's the 
problem: That you've been in leadership within the VA----
    Dr. Tuchschmidt. Yes.
    Mr. Coffman [continuing]. And you've been in leadership for 
20 years, and you're just totally oblivious to what is 
occurring around you, in terms of all the problems, and it 
really wasn't until it's become a national story that now 
you're suddenly aware of them.
    And I think that that's--I think that really speaks to the 
culture of the VA and the problem, and that, if not for the 
whistleblowers who have come forward, we would never be aware 
of the magnitude of the problems that exist today, because the 
leadership, or the lack thereof, never brought these issues 
forward.
    And I've got to tell you--let me ask you, are you a veteran 
yourself?
    Dr. Tuchschmidt. No, I'm not.
    Mr. Coffman. Well, I've got to tell you, you know, if you--
the military axiom for this is, I don't think you could lead 
starving troops to a chow hall. And I've got to tell you, that 
if the new Secretary, when he comes aboard, after being 
confirmed by the United States Senate, which I believe he will, 
has folks like you in senior leadership, he is sending a 
message to us, the American people, and the veterans of this 
country that he's not serious about change.
    With that, Mr. Chairman, I yield back.
    The Chairman. Ms. Titus, you're recognized for 5 minutes.
    Ms. Titus. Thank you, Mr. Chairman.
    I'd like to go back to what I mentioned earlier, and that 
is my concern about the emergency room doctors at the new Las 
Vegas hospital. They came and spoke with me, at my invitation, 
and they talked about the problems there, the lack of 
leadership, the manipulation of schedules, those who work for 
the VA directly versus those who are contracted from the 
private sector who get special treatment.
    And I just don't want them to get in trouble because of my 
initiating an invitation to learn more about what was going on 
out there. So I would ask you if--maybe you can't provide it 
here, but if you can let me know if they are among those cases 
that you have that have been filed, if anything has come out of 
Las Vegas.
    Mr. Bachman. I can't speak to any of the specifics. I can 
tell you we have not received any complaints from the Las Vegas 
facility.
    Ms. Titus. Okay. Well, I'm glad to hear that.
    I would also like to ask you--we heard, I think Mr. Davis 
was saying there are different--different things are 
comfortable for different people. Some whistleblowers go to the 
press, some hire lawyers, some go to veterans advocacy groups, 
and some go to their Members of Congress. Well, I think a lot 
of them come to me. This is our biggest constituent kind of 
service that we do in the district, was with veterans.
    So if someone who works at the hospital, some doctor or 
somebody who works out there, feels like they want to be a 
whistleblower and they come to me, tell me what practical 
advice I give them: Here's what you should do, here's how 
you're protected, here's who you call, here's the form you fill 
out. What advice do I give them?
    Mr. Bachman. The first advice I would give is to please 
refer them to us. This is the number-one priority in our office 
right now. We are throwing everything we have at it. We've 
dedicated over half of our program staff to dealing with these 
whistleblower retaliation complaints. And so that would be the 
first step.
    And once we get in contact with them, we can find out what 
their issues are. If for some reason we're unable to help, we 
can point them in the right direction.
    Ms. Titus. And that would be--they would come to you here 
in Washington, not in Nevada?
    Mr. Bachman. Correct, in Washington.
    Ms. Titus. Okay.
    All right, thank you, Mr. Chairman. I yield back.
    The Chairman. Mr. Jolly, you're recognized for 5 minutes.
    Mr. Jolly. Thank you, Mr. Chairman. I'll be brief.
    I would just like to know, Dr. Tuchschmidt, for the record, 
this ``Stop the Line'' conversation that we had, because I do 
think it's important. You recognize the program; you mentioned 
the program. It was presented to me at my local hospital as 
something that was the end-all, be-all for accountability and 
the ability of employees to step up and make a comment. And yet 
we had four whistleblowers, clearly with the conviction and 
courage to come forward, who hadn't heard of the program.
    And there's not really a question other than just, I 
recognize the importance of the program, but clearly it hasn't 
penetrated to the level that at least was presented to me 
during my meeting.
    And I would just finish tonight, actually, with a bit of a 
softball question, I'll admit it, but----
    Dr. Tuchschmidt. I appreciate it.
    Mr. Jolly [continuing]. It's an important question. And I'm 
going to give you the rest of the time to answer it.
    You've apologized tonight. You've spoken of accountability. 
You've mentioned being appalled, speechless. You've passed your 
cell phone number. Mr. Matkovsky impressed me several weeks ago 
by apologizing and referring to what he called a ``crisis of 
integrity.''
    I notice, as a new Member of Congress, we have heard a 
change in tone under the Acting Secretary, and I will say but 
for the witness who, 2 weeks ago, said the system was 
dishonest, which, frankly, I think was a deferral of 
responsibility. But, by and large, I think we've seen a change 
in tone.
    You've been with the VA more than 20 years; is that----
    Dr. Tuchschmidt. Yes.
    Mr. Jolly. Here's the softball for you, but also 
exceedingly important: Have you noticed a change in the last 6 
or 8 weeks as a result of the attention? How we got here is 
another question. Do you believe, with 20-years-plus experience 
at the VA, that we are entering a new era of leadership within 
the VA, regardless of who steps into the position?
    And the time is yours on that one.
    Dr. Tuchschmidt. I do.
    So I think that there are many places around this system 
that are phenomenal, where we have outstanding care, better 
care than exists in private sector. We have places that have 
outstanding access.
    Our problem, I think--one, I agree with you absolutely, we 
have a crisis of integrity. How we restore that is going to be 
a slow and painful process.
    The clinical issues, I think our biggest issue is that we 
do not have a uniform, systematic approach to these things, and 
so we have pockets of excellence and places that are not 
performing so well.
    The amount of activity in the 4 weeks that I've been in 
this job and have had the opportunity to be aware of these 
problems has been outstanding. I mean, the Secretary's out 
there. We are sending hot teams into the facilities--I think 
we've sent teams into Phoenix now three or four times--to help 
them, to ask them what do they need. And we--I spend my days 
trying to get them what they need.
    I can tell you that 12 of those 20-something years I was a 
facility director. I practiced as a clinician in the intensive 
care unit. I'm a critical care physician. I practiced there. I 
knew what was going on in my facility. I walked the halls. My 
values I wore on my shirtsleeve. And people knew where I stood 
on issues around integrity, around bringing problems forward, 
about people coming together and solving those problems.
    There was no doubt in my mind about what it took to make 
sure the patient was the end-all and be-all of what we took 
care of. That's why we were there, every one of us. And if you 
weren't there for that purpose, then you better take a hike. 
That was clear, I think, to everybody.
    And I don't know that I'm the perfect shining example 
because, quite frankly, I spend many nights sitting in bed 
wondering what I could have done differently, what I personally 
could have done differently. When could I have raised my hand? 
Could I have pushed back harder? What did I not know that I 
should have known? Many sleepless nights.
    I don't know that I am the epitome of what it's going to 
take. But I think it's going to take leadership who really--not 
just at the Secretary level, not just at the Under Secretary 
level, but all the way down to the service chief--who owns the 
problem and says, we can fix it.
    And I think we have a lot of great people in this 
organization that will step up to the plate. And I am confident 
that we're going to bring new people into the organization 
today to help solve those problems.
    Mr. Jolly. Okay. Thank you very much.
    Mr. Chairman, I yield back.
    The Chairman. Thank you, Mr. Jolly.
    Thanks to the panel.
    Based on our hearing today, we would expect the Secretary 
of Veterans Affairs to establish a long-term plan of intended 
actions, with target dates, that would determine what actions 
to take against VA managers when reprisals have been found to 
have taken place, notifying on a periodic basis all employees 
of their whistleblower rights, and measuring the effectiveness 
of such actions, such as a periodic survey of employees, and 
designing and implementing a system for tracking overall 
whistleblower complaints--complaints for which reprisal was 
determined or the complaint was settled.
    In addition, we recommend that VA analyze this data 
periodically to ascertain whether additional steps are needed 
to ensure that reprisal is not tolerated.
    With that, I ask unanimous consent that all Members would 
have 5 legislative days to revise and extend their remarks and 
include any extraneous materials. Without objection, so 
ordered.
    The Chairman. I want to thank both panels of witnesses and 
the audience members for joining us at tonight's critical 
hearing on the importance of whistleblowers and effective 
oversight investigations.
    And, Dr. Tuchschmidt, one last question: Is Ms. Helman 
still on the payroll?
    Dr. Tuchschmidt. I don't honestly know the answer to that 
question.
    The Chairman. Does she work under your purview?
    Dr. Tuchschmidt. Many layers down.
    The Chairman. But you don't know if she still is on the 
payroll?
    Dr. Tuchschmidt. I would have to get an answer and take 
that for the record.
    The Chairman. Okay.
    With that, this hearing's adjourned.
    [Whereupon, at 12:01 a.m., Wednesday, July 9, 2014, the 
committee was adjourned.]
                                APPENDIX

              Prepared Statement of Jeff Miller, Chairman

    Good Evening.
    This hearing will come to order.
    I want to welcome everyone to tonight's hearing titled, 
``VA whistleblowers: Exposing inadequate service provided to 
veterans and ensuring appropriate accountability.''
    I would also like to ask unanimous consent that 
representative Tom Price from the state of Georgia be allowed 
to join us here on the dais and participate in tonight's 
hearing.
    Hearing no objection, so ordered.
    Tonight, we will hear from a representative sample of the 
hundreds of whistleblowers who have contacted this committee 
seeking to change the VA to improve patient safety and better 
serve veterans who have served this country.
    We will also hear from the office of special counsel 
regarding its work protecting VA whistleblowers and the vital 
information they provide.
    Representatives of VA will also be here to answer for the 
department's reprisals against whistleblowers and its 
continuing failure to abide by its legal obligation to protect 
employee rights to report waste, fraud, abuse, and 
mismanagement to the inspector general, to the special counsel, 
to congress, and to this committee.
    It is important to emphasize that the national scandal 
regarding data manipulation of appointment scheduling did not 
spring forward out of thin air at VA. Deceptive performance 
measures that serve as window dressing for automatic SES 
bonuses have been part of the organizational cesspool at VA for 
many years.
    Instead of being a customer driven department dedicated to 
veterans, the focus instead has been on serving the interests 
of the senior managers in charge.
    The manipulation of data to game performance goals is a 
widespread cancer within the VA.
    We have often heard that VA is a data rich environment, but 
when data is exposed as vulnerable to manipulation, it cannot 
be trusted.
    Until recently, VA would continue to trot out the tired 
canard that patient satisfaction exceeds the private sector.
    That may be true at a few select VA centers.
    However, as our colleague, Mr. O'Rourke, demonstrated 
through local polling, such results have been over generalized.
    Moreover, during the course of the past year, this 
committee has held a series of hearings showing a pattern at VA 
of preventable patient deaths across the country, from 
Pittsburgh to Augusta to Columbia and to Phoenix.
    VA's satisfaction results are refuted by these tragic 
outcomes.
    In every one of these locations, whistleblowers played a 
vital role in exposing these patient deaths at VA.
    Whistleblowers serve the essential function of providing a 
reality check to what is actually going on within the 
department.
    At great risks to themselves and their families, 
whistleblowers dare to speak truth to power and buck the system 
in VA designed to crush dissent and thereby alter the truth.
    Tonight, we are very fortunate to have three distinguished 
physicians testify with regard to their experiences in the VA.
    We will also hear from a conscientious program manager in 
VA's national health eligibility center who will show that the 
disease of data manipulation may have spread to the initial 
eligibility determinations for medical benefits.
    None of these whistleblowers lost sight of the essential 
mission of VA to serve veterans.
    They understand that people are not inputs and outputs on a 
central office spreadsheet.
    They understand that metrics and measurements mean nothing 
without personal responsibility.
    Unlike their supervisors, these whistleblowers have put the 
interests of veterans before their own.
    Unfortunately, what all of these whistleblowers also have 
in common is the fear of reprisal by the department.
    They will speak of the many different retaliatory tactics 
used by VA to keep employees in line.
    Rather than pushing whistleblowers out, it is time that VA 
embraces their integrity and recommits itself to accomplishing 
the promise of providing high quality health care to veterans.
    In order to make sure there is follow through at VA, I have 
asked my staff to develop legislation to improve whistleblower 
protections for VA employees and I invite all members of the 
committee to work with us towards this end.
    With that, I now yield to ranking member Michaud [MEE-SHOW] 
for any opening remarks he may have.
    Thank you, ranking member Michaud.
    I ask that all members waive their opening remarks as per 
this committee's custom.
    Based on our hearing today, we would expect the secretary 
of veterans affairs to establish a long-term plan of intended 
actions with target dates for:
    (1) Determining what actions to take against VA managers 
when reprisal was found to have occurred;
    (2) Notifying on a periodic basis all employees of their 
whistleblower rights and measuring the effectiveness of such 
actions, such as with a periodic survey of employees; and
    (3) Designing and implementing a system for tracking 
overall whistleblower complaints, complaints for which reprisal 
was determined, or the complaint was settled.
    In addition, we recommend that VA analyze these data 
periodically to ascertain whether additional steps are needed 
to ensure that reprisal is not tolerated.
    I ask unanimous consent that all members have five 
legislative days to revise and extend their remarks and include 
extraneous material.
    Without objection, so ordered.
    I would like to once again thank all of our witnesses and 
audience members for joining us for tonight's critical hearing 
on the importance of whistleblowers to effective oversight 
investigations.
    With that, this hearing is adjourned.

                Prepared Statement of Hon. Mike Michaud

    Thank you Mr. Chairman.
    This Committee has held many hearings over the years on 
problems with access to VA health care. At each of these 
hearings, problems were disclosed and the VA promised to 
improve. But little has changed.
    VA is widely known to have a culture of denying problems 
and not listening to feedback--be it from Congress, veterans or 
its own employees.
    VA has had a reputation as being intolerant of 
whistleblowers. So far in this fiscal year, nearly half of the 
matters transmitted to agency heads by the Office of Special 
Counsel, seven out of 15, involve the VA.
    According to the OSC, it currently has 67 active 
investigations into retaliation complaints from VA employees, 
and has received 25 new whistleblower retaliation cases from VA 
employees since June 1, 2014.
    A recent New York Times article stated that within the VA 
there was a ``culture of silence and intimidation.''
    Acting VA Secretary Gibson recently stated that he was 
``deeply disappointed not only in the substantiation of 
allegations raised by whistleblowers, but also in the failures 
within VA to take whistleblower complaints seriously.''
    Within VHA, the problem of intimidation and retaliation may 
be magnified by what some considered the ``protective'' culture 
of the medical profession.
    It is often thought to be against the ``code'' to point out 
a colleague's mistakes. Or, where a nurse or attendant is told 
it is not ``appropriate'' to question a physician or surgeon.
    The natural tendency is to close ranks to deny that 
problems exist, or mistakes were made.
    So, after we listen to the testimony before us this 
evening--from whistleblowers, the Office of Special Counsel, 
and the VA, will anything change? How do we fix this culture 
and encourage all VA employees to step forward to identify 
problems and work to address them? Changing a culture is not 
easy. It cannot be done legislatively, and it cannot be done by 
throwing additional resources at it. Talk is cheap and real 
solutions are hard to find.
    It is clear to me that the VA, as it is structured today, 
is fundamentally incapable of making a real change in its 
culture. I note that Acting Secretary Gibson announced today 
that he was taking steps to restructure the Office of Medical 
Inspector by creating a ``strong internal audit function which 
will ensure issues of care quality and patient safety remain at 
the forefront.''
    This is an improvement, but it raises additional questions 
regarding how this restructuring will better enable OMI to 
undertake investigations resulting from whistleblower 
complaints forwarded by the OSC, or how it will have the 
authority to ensure that remedial actions are taken by the 
appropriate components of the VA.
    Time and again, as the June letter from OSC demonstrates, 
the VA found fault, but determined that these grave errors did 
not affect the health and safety of veterans. Anyone reading 
the specifics of any of these cases will find this ``harmless 
error'' conclusion, as stated by the OSC to be a ``serious 
disservice to the veterans who received inadequate patient care 
for years[.]''
    I agree with the OSC's June 23rd letter--``This approach 
has prevented the VA from acknowledging the severity of 
systemic problems and from taking the necessary steps to 
provide quality care to veterans.''
    We all seem to have the same goals this evening--we want 
all VA employees to feel comfortable raising problems and 
having them addressed without fear that raising their voices 
will mean the end of their careers.
    The VA has stated that it wants to make fundamental changes 
in its culture so that workforce intimidation or retaliation is 
unacceptable. Talk is cheap. Real change is difficult.
    I would propose that the very first order of business at 
the VA is to take accountability seriously. If any VA employee 
is shown to have intimidated or retaliated against another VA 
employee then that employee should be fired.
    The VA should have a zero tolerance policy for 
whistleblower intimidation or retaliation. As I see it, 
effective leadership and real accountability is the only way to 
begin the process of institutional change. I hope tonight is 
the beginning of that change.
    Thank you Mr. Chairman, and I yield back the balance of my 
time.
                                 

                Prepared Statement of Hon. Corrine Brown

    Thank you, Mr. Chairman and Mr. Ranking Member, for calling 
this hearing today.
    As we have learned over the past few months there are 
serious problems at the VA. We now need to focus on what can be 
accomplished by these hearings.
    How do we address the change of culture at the VA? 
Currently, there is no leadership at the VA. All the top 
positions are ``acting.'' We can hold hearings from now until 
the cows come home and if we don't work with a permanent 
leadership at the Department, nothing will be accomplished for 
all these hearings.
    During the Cold War, in order to feel comfortable with the 
Soviet Union, we had what were termed Confidence Building 
Measures.
    Continuing to lob bombs from this dais will not help the 
veterans needing health care.
    The VA operates 1,700 sites of care, and conducts 
approximately 85 million appointments each year, which comes to 
236,000 health care appointments each day.
    The latest American Customer Satisfaction Index, an 
independent customer service survey, ranks VA customer 
satisfaction among Veteran patients among the best in the 
nation and equal to or better than ratings for private sector 
hospitals.
    I am confident in the health care our veterans in Florida 
are receiving. With eight VA Medical Centers in Florida, 
Georgia and Puerto Rico and over 55 clinics serving over 1.6 
million veterans, veterans are getting the best in the world. 
Over 2,312 physicians and 5,310 nurses are serving the 546,874 
veterans who made nearly 8 million visits to the facilities in 
our region. Of the total 25,133 VA employees, one-third are 
veterans.

                                 

               Prepared Statement of Hon. Negrete McLeod

    Thank you, Mr. Chairmen for having this hearing. VA's 
history of ignoring reported problems in the delivery of health 
care and not protecting whistleblowers is unacceptable and must 
change. I appreciate Acting Secretary Gibson announcing that 
the Office of Medical Inspections will be reformed. These 
reforms must be sincere and meaningful. VA must have an open 
and honest conversation about its practices and what steps must 
be taken to improve care for veterans. Thank you and I yield 
back.

                                 

                 Prepared Statement of Dr. Jose Mathews

    Executive Summary

    Since the tragic events of September 11, 2001 and our 
country's involvement in Afghanistan and Iraq, millions of 
troops have deployed overseas in the interest of protecting our 
nation and advancing others. Although the VA was charged with 
the responsibility of providing services to generations of 
veterans, it has only been in the most recent years that mental 
health care treatments for conditions like PTSD have been 
better understood with modalities of treatment reaching 
heightened rates of efficacy. We know now that with proper 
treatment of mental health concerns, joblessness, homelessness, 
and suicide risk can be mitigated and in some instances 
eliminated. And it is from this perspective that the VA's role 
in treating veterans should be evaluated.
    It is the responsibility and duty of the federal government 
to provide these esteemed service members with the best health 
care possible.
    I can only speak from my personal experiences and 
observations as the Chief of Psychiatry at the St. Louis VA. 
There, the healthcare system as currently exists, has proven 
only to be a maze of bureaucracy and red tape for veterans to 
weave through upon their return home. Instead of being provided 
with the immediate medical treatment and VA related benefits 
they are entitled to, the St. Louis, VA has failed the same 
vulnerable population it was designed to serve.
    The men and women who have so bravely served our country 
deserve a system that will be responsive and efficient; and 
more importantly, will not fail them. The only way to ensure 
effective and timely access to health care is to provide 
transparency and to create objective metrics that evaluate the 
care that is provided on a regular basis. Perhaps more 
poignantly, the existing resources to provide this care is 
simply not being managed effectively.
    There are several initiatives I would like to propose that 
will improve access and quality of health care afforded to 
veterans. These initiatives include: (i) objective metrics to 
increase transparency; and, (ii) ensuring accountability by 
amending the Whistleblower Protection Enhancement Act, which 
has proven inadequate for whistleblowers who make allegations 
regarding risks to veteran health and safety.
    These recommendations will provide a paradigm to ensure 
that the quality of care is not only maintained but exceeded. 
The Department of Veterans Affairs should be a world leader in 
the treatment of combat related medical conditions; not an 
institution where mismanagement and indifference breaches a 
community's prevailing standard of care.
    Mr. Chairman and distinguished members of the committee: I 
am honored to appear before you today to speak about my 
experiences while serving in the capacity as the Chief of 
Psychiatry with Department of Veterans Affairs in St. Louis, 
Missouri.
    In order for you to better understand my connection and 
interest in veteran related health care matters; I would like 
to provide you with some brief information about myself. I am a 
first generation immigrant from India and my father is a combat 
veteran of the Indian Army. I am well acquainted with the 
aftermath of a war and the toll it takes on the warrior and 
their family. I have had a longstanding interest in 
understanding mental illness, particularly mood disorders and 
trauma related illnesses. I was fortunate to have had the 
opportunity to study psychiatry and complete my residency 
training at Washington University in St. Louis, a top-notch 
psychiatry program in the country. I subsequently completed my 
fellowship training in forensic psychiatry at Yale University.
    I accepted the position of the Chief of Psychiatry at the 
St. Louis VA in November 2012. I considered my job as a mission 
to improve the mental health care of our veterans. I worked 
hard to understand the VA system of care and I diligently 
followed-up on veteran complaints about their mental health 
care. I was very concerned about some of the complaints I 
reviewed that were about poor access to care. I studied the 
official VA productivity data and this data showed that the 
psychiatrists at the St. Louis VA were amongst the most 
productive in the nation. Based on this, I concluded that I 
needed more psychiatrists to provide good, timely and safe 
mental health care to our veterans. During the course of my 
employment, and as I identified deficiencies I took actions to 
correct these deficiencies. Notwithstanding, the management 
structure of the VA not only precluded me from correcting the 
deficiencies, but treated me adversely as a result of my 
initiatives to make changes. This represented a dramatic 
departure from my experience working in private and academic 
settings.

A. Defining the Problem

    I requested an extra full time psychiatrist position and 
this was approved by the VA administration. However, some of 
the veteran complaints still persisted. Including the complaint 
of a veteran who came to the clinic with a deterioration of his 
illness and who instead of being evaluated by a provider, was 
turned away with an appointment scheduled for months later. 
Another case that I found alarming involved a disabled veteran 
without independent transportation, who was experiencing 
worsening of his serious mental illness and who had traveled a 
long distance to the VA clinic to get help. Again, he was not 
seen by his provider or any other provider, or any provider for 
that matter. His medications were not refilled; instead, he was 
sent away with an appointment that was no fewer than 48 days 
later. I found it difficult to believe that no one could spare 
15 minutes to address this veteran's urgent medical needs. I 
wanted to find the answer to a simple question: ``How busy are 
the providers at the outpatient clinic?''
    The St. Louis VA, to my surprise, could not identify the 
average number of veterans seen by a provider/day or the time a 
provider spends on direct patient care/day. I asked other 
psychiatry Chiefs to estimate similar data at their facilities 
by contacting them through a national e-mail group that 
encompassed other VA facilities and I received answers that 
ranged from 8 to 16 veterans/day/psychiatrist. I also worked 
with a VA database administrator and my outpatient psychiatry 
director to find out how many veterans were actually being 
seen/day/psychiatrist at the St. Louis VA. I was interested in 
estimating time spent on direct patient care. I wanted to know 
the amount of available physician time for direct patient care 
and the amount of actual time spent in direct patient care in 
order to estimate utilization of expertise (available time/
actual time).
    I was shocked to find that outpatient psychiatrists at the 
St. Louis VA were only seeing on average, 6 veterans/8 hours 
for 30-minute appointments with rare 60-minute appointments (3/
week). I could only account for 3.5 hours of work during an 8-
hour workday. In essence, we were utilizing less than 50% of 
the available physician time for direct veteran care. I checked 
my data multiple times and once I was confident that my data 
was accurate, I investigated why there was such low utilization 
of psychiatrist time, what the wait time for care was for the 
veterans and whether we were able to engage and retain our 
patients in ongoing mental health care and what the veteran 
experience of care was at the VA. The answers I got were 
alarming:
    1. Low utilization of expertise:
    a. I discovered that veterans were not being scheduled in 
all the available appointment slots. Three slots out of the 
possible 12 (1.5 hours) were inexplicably blocked from 
scheduling each day.
    b. There was a very high no-show rate (35%).
    2. Wait times:
    a. I found that the wait time for a new appointment was 25 
days and for a follow-up appointment was 30 days after the 
desired follow-up date.
    3. Retention in care:
    a. I was most troubled by my finding that 60% of the 
veterans were dropping out of mental health care after one or 
two visits with their psychiatrist.
    4. Veteran Experience:
    a. There was a lack of meaningful veteran satisfaction 
measure. The surveys administered by the VA that I saw were not 
done with safeguards to preserve anonymity and confidentiality 
e.g., the treating provider would hand out the surveys to the 
veterans and would also collect the completed surveys: From the 
veteran's perspective, it would be extremely difficult to make 
any negative assessment/comments under these circumstances as 
one cannot feel confident about confidentiality and will have 
concerns about their opinion impacting the care they receive.

B. Disclosing the Inadequate Care to Veterans

    I discussed my data with the Chief of Staff, Chief of 
Mental Health and my staff. The staff psychiatrists contested 
my data and offered various unconvincing reasons for not seeing 
more veterans/day (usually this involved pointing fingers at 
the scheduler/person tasked with reminder calls/other 
specialties). To address this, I collected prospective data 
(going forward) for 1 month for all the specialties 
(Psychiatry, Psychology, Social Work, Nurse Practitioners) and 
22 weeks (5 months) of data for the psychiatrists (other 
specialties opted out).
    I could only account for less than 4 hours of work during 
an 8-hour workday for any of the staff in Mental Health 
(psychiatry, psychology etc . . . ) It was as if there was an 
agreement amongst all the clinic employees to only work for 
less than half the time they are paid to work. An agreement 
amongst administration and staff that on paper everyone would 
be ``productive'' and that everyone would qualify for 
``performance'' bonuses.
    I argued that this situation was unethical and unsafe for 
our veterans and that this needed to change urgently. I ran my 
intervention strategies by the Chief of Staff and I instituted 
three changes:
    1. I increased the scheduling grid to accommodate 19 
veterans/day in the hopes of seeing, on average, 12 veterans/
day/psychiatrist and when this milestone was accomplished, to 
reduce the scheduling grid to 16 veterans/day to maintain 
access to care.
    2. Instituted a strict policy of not turning away a veteran 
who had presented for care. I instructed the clinic to arrange 
for the veteran to be evaluated by other providers if a 
provider calls in sick. I put myself in this pool and I saw 
veterans on three occasions to underscore my commitment to this 
policy.
    3. I instructed outpatient psychiatrists to stratify their 
patients into two groups: high intensity care and usual 
intensity care. I wanted more intense monitoring and follow-up 
for those in high intensity care group.
    I was also able to secure philanthropic support for a pilot 
program to collect real time, meaningful veteran satisfaction 
survey with questions such as: Did your provider address your 
concerns today? Do you know when your next appointment is? 
Using ipads and real time data integration.
    There was a significant amount of resistance from many 
psychiatrists and other specialties. I was yelled at on many 
occasions, I was told repeatedly, ``this is the VA'' to explain 
away the poor access to care. I persevered and I had partial 
success in increasing the number of veterans seen/day/
psychiatrist; in reducing the wait times and in implementing a 
real-time veteran satisfaction survey.
    I wanted to focus on four core meaningful metrics:
    1. Time to care.
    2. Utilization of resource (available/actual)
    3. Veteran retention in care.
    4. Veteran satisfaction with care.
    I had argued that if the above metrics were headed in the 
right direction, we would be advancing towards our goal of 
creating a care environment where we could honestly refer a 
loved one, and if these metrics were not improving, other 
metrics (e.g., productivity measures) were meaningless.
    I observed several unethical practices at the VA and I 
would bring this to the attention of the administration or 
address these if they were my staff.
    1. Some of the psychiatrists were not respecting their tour 
of duty time commitments. I called them on it that resulted in 
improved behavior.
    2. I was part of a search committee for a senior position 
at the VA and I was concerned about a particular candidate not 
being accorded proper consideration. I wrote a frank e-mail to 
all the members including the Chief of Staff where I argued 
that this was both unethical and possibly illegal.
    3. I had a transgender veteran complaint about the quality 
of psychological evaluation report that had resulted in the 
denial of hormonal treatment. I found this psychological report 
grossly inadequate and I strongly argued for a second opinion 
for this veteran. This resulted in the then Chief of Psychology 
falsely vouching for the ``expertise'' of the evaluating 
psychologist. Subsequently I found out that the evaluating 
psychologist was placed on probation, that her clinical 
privileges were restricted, that she had many veteran 
complaints and that she was hired despite concerns about her 
competence, I requested a meeting with the Chief of Staff and 
the Chief of Psychology where I voiced my concern about this 
incident and I suggested that this psychologist's work be 
reviewed by a psychologist from outside the St. Louis VA. The 
Chief of Staff did not seem concerned and the next veteran 
complaint against this psychologist for a similar issue was 
deliberately hidden from me.
    4. I had concerns about two avoidable deaths:
    a. One involved a young OIF/OEF veteran who was not 
assessed properly at the VA, whose medication management was 
sub-standard and who was discharged the very next day after his 
inpatient admission. My request for a Root Cause Analysis was 
not honored.
    b. An elderly veteran was not assessed properly in the ER 
and he died shortly after he was admitted to the psychiatry 
inpatient unit.
    5. A suicide attempt by a veteran in the inpatient unit 
while the Joint Commission was reviewing the VA was covered up 
and this incident was not reported to the Joint Commission. A 
safety barrier was breached during this attempt and this 
vulnerability was not addressed promptly as this event was not 
reported to the Joint Commission, hence, corrective actions 
were deliberately delayed at real risk of harm to the veteran.
    6. The Acting Chief of Mental Health had opened up a back 
channel communication with the psychiatrists who were opposed 
to my increasing access to care and with my demanding 
accountability from all. I had met with the Chief of Staff and 
the Acting Chief of Mental Health regarding this. The Acting 
Chief of Mental Health had apologized to me for his behavior, I 
accepted his apology and his assurances that he would fully 
support my efforts to improve access to care.
    7. However, shortly thereafter, while I was on paternity 
leave, the Acting Chief of Mental Health was the person who 
determined that an Administrative Investigation was warranted 
based on the complaints he got from the very disgruntled 
psychiatrists who were opposed to my initiatives.

C. Retaliation for Whistleblower Disclosure and Subsequent 
Disclosures

    On the heels of disclosing the deficiencies and barriers to 
care, the Chief of Staff called me into a meeting on August 26, 
2013 to inform me that there was a ``mutiny'' and that to 
``protect'' me ``and the VA'' he was authorizing an 
Administrative Investigation to investigate the allegation that 
I had created a hostile work environment for the staff 
psychiatrists. I reminded him that the staff psychiatrists had 
nominated me for an award before I had discovered the extremely 
poor work ethic and I had started to demand accountability. He 
told me that this would give people time to ``cool off.'' He 
assured me that I did not need an attorney and that he did not 
anticipate this process to take more than a few months and that 
I would be immediately detailed to Compensation and Pension and 
was not to access any of my patient files or information 
pertaining to the provider/patient care ratio.
    Although provided with very little information about the 
exact nature of the investigation against me, my understanding 
is that the Chief of Staff and the Chief of Mental Health met 
with all the staff psychiatrists after my meeting with the 
Chief of Staff. The three of the psychiatry directors were 
excluded from this meeting. This meeting was described to me by 
some of the psychiatrists I had recruited as ``embarrassing, 
bad-mouthing'' and I got a phone call from a concerned 
psychiatrist who wanted to know if I was fired.
    I continued doing Compensation and Pension evaluations 
throughout the pendency of the ``investigation.'' I 
independently filed a complaint with the Office of Special 
Counsel and although I disclosed all of this information, 
because of the way I phrased the information, the Office of 
Special Counsel declined to find that I had establish that I 
was subject to a prohibited personnel practice. I was forced to 
retain counsel and only with the assistance of an attorney was 
able to craft a complaint that has engendered the interest of 
the Office of Special Counsel; which only recently notified me 
last week that they were referring my complaint for 
investigation.
    In broad brush stroke terms, since the time of my 
disclosures last year, the VA has retaliated against me in the 
following manner:
    1. I was completely removed from my position as Chief of 
Psychiatry;
    2. I was forbidden from contacting other psychiatrists and 
my access to the database I set up to monitor the number of 
veterans seen by provider each day was terminated;
    3. The independent funding for the veteran satisfaction 
survey project I secured was put on hold because of my removal 
from the Chief position;
    4. Two excellent psychiatrists I had worked hard to 
recruit, who had interviewed at the VA, were from excellent 
training programs (Hopkins and Harvard) decided not to join the 
VA;
    5. A hostile work environment was created in so much as, 
some of the staff psychiatrists outwardly mocked me;
    6. I had an earlier performance review completed by Dr. 
Steve Gaioni who was the ACOS for Mental Health until July 2013 
that was a reasonable assessment however I did not agree with 
his assessment of my management as Dr. Gaioni would counsel me 
to ``go slow'' where I saw an urgent need to improve access to 
care. I was re-evaluated by Dr. Metzger and he used a 
``performance'' metric that I could not understand but it 
covered 5 weeks of my work from October 1 2013 until November 4 
2013 and he determined that I had only met 50% of the goals he 
had set for me that was unbeknownst to me and was set after I 
was put on the administrative investigation. I refused to sign 
this document, however Dr. Welling, the Chief of Staff 
determined that this was an accurate representation of my work 
for the entire fiscal year and as represented by their 
approval. This is why almost every psychiatrist got the full 
performance pay they were eligible for based on bogus 
``productivity'' data.
    7. I was overlooked for promotion opportunities. More 
specifically, The Chief of Staff, on at least two occasions, 
pre-selected individuals for the Associate Chief of Staff 
position (a position for which he was aware I intended to 
apply), before the position was even advertised. Although, as 
the Agency was also aware, the fact that I was under 
investigation, impacted my ability to compete for positions.
    8. Approximately one year after my initial disclosures, and 
although, no one at the VA had ever disagreed with my 
calculations concerning the number of veterans seen on a daily 
basis, the St. Louis, VA defamed my professional reputation and 
issued a press release suggesting that the VA's own careful 
investigation showed that the actual number was more than 
double of what I had found (14). This was blatantly false.
    9. After my disclosures to the Offices of Senators Blunt 
and McCaskill I was contacted by the VA Privacy officer, who 
suggested he was investigating violations of PHI; which I did 
not. They filed complaints with the Federal Prosecutors office 
and the OIG. I had to have my attorney intervene again on my 
behalf.
    10. Shortly after Senators Blunt and McCaskill made an 
inquiry into the caliber of patient care at the St. Louis, VA, 
the Chief of Staff called me into his office and demanded to 
know what my ``end game was? Where is all this going?'' I told 
him that I did not know and that I had no control over how 
everything was going to play out. This meeting ended abruptly.
    11. I discovered that false data was entered into the 
medical records of veterans in June of 2014. After disclosing 
this to Acting Secretary Gibson, I was immediately reprimanded. 
More specifically, both myself and a colleague were 
subsequently instructed to report to a meeting with the Chief 
of Staff, who stated in pertinent part that it was Acting 
Secretary Gibson's expectation that the ``chain of command is 
followed.'' The Chief of Staff went on to state that ``I am 
telling you what the chain of command is, this is what it is, 
you work for me.'' I was offended by this and I told him that I 
thought I was working for the US government and not for him. He 
reiterated that it was Secretary Gibson's expectation that we 
first discuss any issues first with Dr. Metzger, if there is no 
resolution, to ``go up the chain of command.'' I clearly felt 
that I was being reprimanded for writing to Secretary Gibson 
and that I should resolve the issue ``locally first.'' He 
commented that this was the best way to manage any organization 
and that this was the ``safe'' thing to do. The way he said 
safe and the manner he lingered on it made it clear to me that 
he was conveying a gag order and a threat. I called him on it 
and I asked him if this was a gag order. He said no but that 
this was the expectation of Secretary Gibson.
    He also stated that he wanted to tell us that even 
discussing de-identified information with outside agencies and 
looking for information in patient chart may constitute privacy 
violation and he wanted us to be aware of this. I asked for 
clarification if he was telling me that I could not contact 
OIG, OSC or Senators, he said that this is not what he meant 
but for us to be mindful of the fact that the VA takes veteran 
privacy very seriously. The spirit and tenor of this meeting 
was in direct contradiction to the memo Secretary Gibson had 
sent that called for Whistleblower protection.
    12. Shortly after I disclosed the false data entry in June 
of 2014, my official protected time for research was revoked.

D. Crafting an Effective Solution

    Any effective mechanism for improving Veteran care will 
necessarily incorporate transparency and accountability; 
neither of which is mutually exclusive of the other.
    I have had the opportunity to think deeply about some 
tangible and concrete measures that the Congress and White 
House could take immediately to restore trust and faith in the 
St. Louis, VA by focusing on two elements. The First component 
of which applies to patient care and transparency:

    Safe Guarding Patient Care

    1. Data Integrity: VA data must be managed by an 
independent entity. Transparently tracking just four simple 
metrics can yield huge benefits:
    a. Wait times for each specialty/procedure: This could be 
available on a real-time basis.
    b. Reasonable time veteran satisfaction measure: We have 
the technology to implement a concise, well validated measure 
of veteran satisfaction on a reasonable time basis (compiled 
weekly), at the point of contact to get a more complete set of 
veteran experiences.
    c. Utilization of expertise: Available time/actual time 
spent by providers.
    d. Retention in care or the attrition rate of the veterans.
    2. Employee Discipline: Those individuals in direct patient 
care role must not have life-time tenured positions. I think 
that this ``job security'' is a big factor in veteran interest 
not being central which then ironically threatens the very 
existence of VA as a health care system.

    Protecting and Fostering Transparency: As currently 
drafted, the Whistleblower Protection Enhancement Act (WPEA) as 
enacted, has done little to shield the professional rebuke that 
has occurred following my disclosures. Moreover, some of the 
events that have happened, although impacting my professional 
career, fall beyond the ambit of the definition of Prohibited 
Personnel Practice (PPP). For this reason alone, the WPEA 
should be amended to require the VA to maintain the status quo 
for all whistleblowers who allege breaches to the standard of 
patient care. This will ensure timely investigation and 
resolution of the allegations and will preclude the VA from 
conducting ``administrative investigations'' that, while 
harmful and professionally detrimental, may not fall neatly 
with the confines of the PPP.
    Perhaps more importantly however, is the personal and 
financial sacrifice associated with the disclosures. Although I 
have a medical degree and am a Yale trained psychiatrist, I 
could not navigate the OSC process without the benefit of 
counsel. Not every whistleblower will be able to afford to 
retain an attorney to provide the legal advice that is 
absolutely necessary when an Agency begins making professional 
and potentially criminal allegations; all of which are grossly 
unfounded. Even now that OSC is involved, an investigation has 
not been completed and I am required to commence an action 
before the Merit Systems Protection Board if the OSC declines 
to prosecute or if the OSC is not successful in negotiating an 
agreeable resolution to my complaint. To that end, the WPEA 
should be amended to make optional the need to exhaust 
administrative remedies by first filing whistleblower appeals 
with the OSC and to provide for the mandatory payment of treble 
attorney fees for prevailing parties in order to provide VA 
employees with greater access to private legal representation 
at all stages of the whistleblowing process.
    I would, and will continue to, blow the whistle a thousand 
times over again to protect the patients I treat; but some of 
the barriers I have identified may for example prove too 
onerous a burden for others to sustain. For this reason alone, 
the laws must change to afford actual and timely protection for 
whistleblowers.
    The recommended solutions identified will result in the 
following:

    Veterans: With readily available wait times and 
satisfaction measure, a veteran will have the choice to obtain 
care at a facility that optimizes acceptable wait time with 
satisfactory care. This will lead to a more even utilization of 
specialty care that in-turn will improve efficiency by 
distributing care. The cost savings from early intervention and 
reductions in secondary complications could justify travel 
assistance or other incentives to distribute care.

    Policy Makers: A more accurate and meaningful measure of 
resource utilization and hospitals/ specialties needing closer 
scrutiny will be available to guide sounder policy. VA will not 
be saddled with poorly performing employees who may be toxic to 
veterans health.

    Veteran Service Organizations: More effective monitoring of 
the VA with transparent reasonable time data.

    Taxpayers: Determine if we are getting value.

    Whistleblowers: Will be encouraged. This will create 
transparency in their individual VA institutions without the 
fear of professional rebuke and potentially, financial 
devastation.

    I would like to deeply thank the Committee for the 
privilege of appearing before you today on, what I view, to be 
a defining moment in how our Government responds to the mental 
health needs of veterans. Thank you.
    The Chairman. Thank you Dr. Mathews. We'll have an 
opportunity, each of us, to ask questions and get into 
specifics a little bit later on.
                                 

                Prepared Statement of Dr. Christian Head

Introduction

    Dr. Christian Head \1\ comes before Congress to testify, 
not motivated by any political agenda, but based purely on a 
genuine interest in seeking solutions to address employee 
mistreatment, but most importantly, to improve the healthcare 
provided to our Country's heroes. Dr. Head submits this 
testimony in response to Congress's request to appear and 
testify on this issue.
---------------------------------------------------------------------------
    \1\ To avoid confusion, I will refer to myself in the third person 
throughout this testimony.
---------------------------------------------------------------------------
    Dr. Head is uniquely qualified to testify regarding issues 
within the VA system. Dr. Head is a world-renown, board 
certified Head and Neck Surgeon. Between 2002 through 2013, Dr. 
Head held dual appointments at the UCLA David Geffen School of 
Medicine becoming a tenured Associate Professor in Residence of 
Head and Neck Surgery, as well as an attending surgeon at the 
West Los Angeles Campus of the VA Greater Los Angeles 
Healthcare System (``GLAHS''). In 2007, Dr. Head was promoted 
to Associate Director, Chief of Staff, Legal and Quality 
Assurance within GLAHS.
    Dr. Head's clinical and academic successes over the years 
have been numerous. However, despite Dr. Head's many 
accomplishments and contributions to the medical profession, 
Dr. Head has endured and witnessed, firsthand, illegal and 
inappropriate discrimination and retaliation of physicians, 
nurses, and staff members within GLAHS. Throughout this 
testimony, Dr. Head will speak on the growing number of 
complaints coming from VA employees, complaints ranging from 
racial, gender, and age discrimination and harassment to 
complaints regarding substandard patient care and treatment.
    Additionally, Dr. Head will address the inappropriate and 
often illegal response, or at times lack of response, by VA 
administration in regards to complaints by hospital employees. 
For example, this testimony will focus on how administrators 
and supervisors within GLAHS have created a climate of fear and 
intimidation, where the system not only fails to protect 
whistleblowers, but actively seeks to retaliate against them.
    Further, Dr. Head's testimony here will discuss the general 
lack of accountability of VA administrators and supervisors who 
actively retaliate against and ostracize hospital employees who 
attempt to speak out against illegal behavior. Dr. Head will 
testify, firsthand, about the climate within the GLAHS which 
perpetuates this illegal behavior, due in large part to the 
system's failure to take any action against certain 
individuals. Specifically, how wrongdoers are left in positions 
of high leadership to continue their illegal behavior without 
recourse.
    Dr. Head's testimony will further discuss how the current 
morale of employees within GLAHS is dangerously low. Dr. Head's 
testimony will discuss how the system's failure to properly 
respond to complaints leaves employees within GLAHS with a 
sense of helplessness, creating undue stress and anxiety 
amongst those attempting to provide quality healthcare to our 
Country's veterans.
    Finally, but most importantly, Dr. Head's testimony here 
will explain how this dangerous climate of intimidation and 
retaliation against whistleblowers negatively affects patient 
care. Dr. Head will discuss how he has witnessed, firsthand, 
veterans receiving below-standard healthcare, or no healthcare 
at all, because of the retaliatory behavior and lack of 
accountability within the system.

Background

    Dr. Christian Head is a prominent Head and Neck Surgeon, 
known worldwide. As some would say, ``one of our finest 
surgeons in Southern California. . . . [Who is] generous with 
his time and talent, helping Veterans and giving back to our 
community both locally and nationally. . . . [W]ho will make a 
difference in our world with his skills as a surgeon, his 
scientific research and laboratory.'' Unfortunately, Dr. Head 
has been the victim of outrageous racial harassment, 
discrimination, and retaliation occurring within GLAHS.
    Dr. Head obtained his Doctor of Medicine degree from Ohio 
State University, College of Medicine in 1993. Between 1992 and 
1993, Dr. Head completed an Internship in Surgery at the 
University of Maryland at Baltimore. Between 1994 and 1996, Dr. 
Head commenced his employment with a Fellowship in Neuro-
Otology Research at UCLA School of Medicine. Between 1996 and 
1997, Dr. Head completed a Surgical Internship at UCLA School 
of Medicine. Between 1997 and 2002, Dr. Head worked as a 
Resident in the UCLA School of Medicine Head and Neck Surgery 
Department. In 2002, Dr. Head joined the faculty as a Visiting 
Professor in Head and Neck Surgery at UCLA. In 2002, Dr. Head 
also joined GLAHS. During his time with GLAHS, Dr. Head worked 
as a Head and Neck Surgeon, and in 2007, was promoted to 
Associate Director, Chief of Staff, Legal and Quality Assurance 
within GLAHA. In August 2003, Dr. Head joined the faculty of 
the UCLA Geffen School of Medicine as a full time Head and Neck 
Surgeon. Dr. Head left UCLA in 2013. Dr. Head has been board 
certified in Head and Neck Surgery since June 2003.
    Over the years, Dr. Head's work has included clinical 
practice, surgery, academia, and research. Dr. Head has 
received accolades for his work, including the National 
Institute for Health National Cancer Institute Faculty 
Development Award. In or around 2001 to 2002, Dr. Head was 
nominated for the UCLA Medical Center Physician of the Year 
award. In or around November 2003, Dr. Head launched the UCLA 
Jonsson Cancer Center Tumor Lab, which has been tremendously 
successful, yielding valuable research and benefitting many 
physicians and patients at UCLA and worldwide. In 2003, Dr. 
Head was one of a few surgeons nationwide to receive the 
Faculty Development Award from the National Institute of Health 
Comprehensive Minority Biomedical Branch, intended to increase 
the number of minority physicians in cancer research at major 
academic institutions.
    An important point relevant to this testimony includes the 
relationship between GLAHS and the University of California, 
Los Angeles (``UCLA''). UCLA has several affiliated hospitals, 
one of which includes GLAHS. As part of this affiliation, UCLA 
provides physicians and surgeons to staff GLAHS. Until his 
departure from UCLA in July 2013, Dr. Head worked at both 
entities under this UCLA/GLAHS affiliation. \2\ 
---------------------------------------------------------------------------
    \2\ While there may be additional information relevant to Dr. 
Head's testimony, because of certain conditions, Dr. Head will focus 
his testimony here solely on incidents related to his employment at 
GLAHS.
---------------------------------------------------------------------------
    Dr. Head's supervisors include Marilene Wang, M.D. (``Dr. 
Wang''), UCLA/GLAHS Head and Neck Surgeon and Dr. Head's 
immediate clinical supervisor at GLAHS; Dean Norman, M.D. 
(``Dr. Norman''), GLAHS Chief of Staff; Matthias Stelzner, M.D. 
(``Dr. Stelzner''), GLAHS Chief of Surgical Services; and Donna 
Beiter, RN, MSN (``Ms. Beiter''), GLAHS Director. Dr. Head's 
immediate supervisor at UCLA was Gerald Berke, M.D. (``Dr. 
Berke''), Chairman of the UCLA Department of Head and Neck 
Surgery, who has tremendous power and influence at GLAHS.

Discrimination and Retaliation Against Dr. Head

    Despite Dr. Head's many accomplishments and contributions 
to the medical profession, Dr. Berke and Dr. Wang have made 
several inappropriate racial comments about black people, 
including Dr. Head. In or around 2003, Dr. Wang made comments 
that Dr. Head was hired as a Visiting Professor because he was 
an ``affirmative action hire'' and ``affirmative action 
project.'' In or around 2003, Dr. Wang also publicly stated 
that Dr. Head is inferior because he is black, that he would 
not pass the boards, and that he was unqualified. In or around 
2003, Dr. Wang stated that ``cream rises to the top,'' that Dr. 
Head ``would not make it in academic medicine,'' and that Dr. 
Head and ``doctors like him'' who are black, were the reason 
for failed hospitals like King Drew. In or around mid-2003, Dr. 
Berke stated that ``we're about to have some color'' in the 
department. Dr. Berke also stated, ``I guess we'll have our 
first Nigger'' now.
    From 2003 to present, Dr. Head has lived with Dr. Wang's 
threats and affirmative actions to destroy Dr. Head's career, 
reputation, and ability to earn a living. In that regard, in 
2003, Dr. Wang, who has supervisory authority over Dr. Head at 
GLAHS and prepared evaluations of his performance, clearly 
indicated it was her intention to prevent Dr. Head from 
receiving promotions, full time equivalents, tenure, and 
advancement. Dr. Wang's discriminatory conduct has been 
continuous and consistent throughout Dr. Head's employment.
    Starting in or around 2003, Dr. Wang began stating to other 
surgeons that she fully intended to interfere with Dr. Head's 
professional advancement, in part by giving Dr. Head subpar 
evaluations and falsely attacking Dr. Head's credentials and 
performance at GLAHS.
    In March 2004, Dr. Head submitted an EEO complaint 
outlining the discriminatory and hostile behavior against him 
by Dr. Wang. (A true and correct copy of this EEO complaint is 
attached hereto as Exhibit 1.)
    In or around June 2004, Dr. Wang was ordered by UCLA 
officials to stop submitting negative evaluations about Dr. 
Head after Dr. Wang was reported by Dr. Head as having called 
Dr. Head an ``affirmative action hire,'' amongst other racist 
comments. At that time, Dr. Wang promised not to interfere with 
Dr. Head's career advancement. However, in direct violation of 
this order, Dr. Wang continued to submit negative supervisor 
evaluations at GLAHS regarding Dr. Head's performance, which 
evidenced her obvious racial bias against Dr. Head. Dr. Wang's 
ongoing harassment and retaliation against Dr. Head in this way 
continued to negatively impact Dr. Head's career advancements.
    In or around November 2005, Dr. Wang gave Dr. Head a 
retaliatory and harassing evaluation of his teaching and 
performance at GLAHS in an attempt to interfere with his 
advancement at UCLA. Dr. Wang rated Dr. Head a 1 out of a 
possible 4 points in his review. Dr. Wang further wrote that 
Dr. Head ``doesn't teach, yells at junior residents,'' ``poor 
availability, doesn't respond to messages,'' and ``poor example 
& role model for residents.'' Dr. Wang's performance review was 
in sharp contrast to reviews and comments made by other 
colleagues.
    On or about February 2, 2006, Dr. Head sent a letter to Dr. 
Rosina Becerra (``Dr. Becerra''), then-Vice Provost for Faculty 
Diversity and Development at UCLA, regarding this harassment, 
discrimination, and related problems at UCLA and requested 
financial and other support to stop the harassment, 
retaliation, and interference with his career advancement. Dr. 
Head also requested that he be assigned more time working at 
UCLA in order to be removed from Dr. Wang's supervision at 
GLAHS. In response, Dr. Becerra told Dr. Head that she could 
not help him, and warned Dr. Head it was not a good idea to 
participate in an investigation against Dr. Wang.
    In or around April 2006, Dr. Head was contacted for the 
first time by Investigator Nancy Solomon (``Investigator 
Solomon'') of the Office of Inspector General (``OIG'') 
regarding an investigation of Dr. Wang for time card fraud 
concerning work Dr. Wang performed at GLAHS. Dr. Head learned 
from Investigator Solomon that Dr. Wang was under investigation 
by the federal government for submitting and/or approving false 
time cards pertaining to services provided at GLAHS. Dr. Head 
was asked by Investigator Solomon to testify about Dr. Wang's 
involvement in time card fraud. Dr. Head requested protection 
from Investigator Solomon, stating that he feared retaliation 
for his participation in the investigation. With a promise by 
Investigator Solomon regarding protection from retaliation for 
his cooperation, Dr. Head testified in an OIG deposition 
regarding Dr. Wang's time card issues.
    The OIG investigation concluded that Dr. Wang had in fact 
committed time card fraud. There was a recommendation by the 
OIG that Dr. Wang be removed from her leadership position and 
terminated from GLAHS; however, Dr. Wang's immediate 
supervisor, Dr. Berke, took steps to save Dr. Wang's job and 
leadership position--UCLA transferred vacation hours to Dr. 
Wang's account and research funds were transferred from Dr. 
Berke. Additionally, Dr. Berke approached Dean Norman, M.D. 
(``Dr. Norman''), GLAHS Chief of Staff, to request that Dr. 
Wang not be terminated. Due to Dr. Berke's intervention and 
powerful influence, Dr. Norman did not terminate Dr. Wang, did 
not dock her pay, and did not remove her from her leadership 
position as Chief of Head and Neck Surgery at GLAHS, despite 
the recommendation for termination by the OIG. In fact, the 
only action taken was a written warning issued to Dr. Wang and 
termination of a subordinate.
    Prior to Dr. Head's participation in the time card fraud 
investigation of Dr. Wang, Dr. Head had been nominated for Head 
and Neck Department teacher of the year. However, following Dr. 
Head's participation and truthful testimony in connection with 
Dr. Wang's time card fraud investigation in April 2006, Dr. 
Berke and Dr. Wang escalated their campaign of intimidation, 
harassment, discrimination, and retaliation against Dr. Head.
    In or around April/May 2006, Dr. Head met with Dr. Berke to 
discuss Dr. Head's total compensation package for the academic 
year 2006-2007. Dr. Berke threatened Dr. Head stating, ``If you 
complain about Dr. Wang,'' and about not getting the 
compensation enhancement (a Full-Time Equivalent (``FTE'') that 
was available, which Dr. Wang denied Dr. Head and gave to 
another surgeon from outside the hospital), ``you won't get 
anything, you'll be removed.''
    In or around April/May 2006, shortly after Dr. Head 
provided deposition testimony to the OIG, Dr. Wang discussed 
with the residents of the UCLA Head and Neck Department, whom 
she supervised and worked with, about Dr. Head's participation 
in the time card fraud investigation. In addition, Dr. Wang 
spoke with many of the residents who worked under her 
supervision as they each testified in the time card fraud 
investigation. As a result, these residents, began to 
participate in the intimidation, harassment, discrimination, 
and retaliation of Dr. Head. Dr. Head began to experience 
horribly offensive discriminatory comments, graphic racial 
photos, and retaliatory actions and statements.
    In or around May 2006, Dr. Head reported to Dr. Dennis 
Slamon (``Dr. Slamon'') that he was being harassed and 
retaliated against by Dr. Berke and Dr. Wang and was worried 
about his future. Dr. Slamon responded, ``They [Dr. Berke, Dr. 
Wang, and Dr. Abemayor] think you ratted out Wang in the IG 
investigation. You need to keep your head down and stay out of 
this. Don't complain.''
    In or around May 2006, Dr. Head requested a full-time 
appointment at GLAHS, but did not receive the appointment 
despite being more qualified than other choices.
    In or around June 2006, at the year-end closing ceremony 
and party for the UCLA Head and Neck Department--attended by 
approximately 200 people including UCLA and VA faculty, staff, 
chairs, residents, and spouses--the resident class presented a 
slide show. The slide show, presented by the Residents had an 
entire section about Dr. Head. These slides, directed toward 
Dr. Head, were exceptionally vulgar, disturbing, defamatory, 
discriminatory, retaliatory, humiliating, degrading, 
disgusting, demoralizing, and racist. One slide, referencing 
the OIG time card fraud investigation of Dr. Wang, showed Dr. 
Head on the telephone and read: ``If all else fails call 1-800-
488-VAIG.'' (See Exhibit 2.) The other slides throughout the 
presentation were similar to Dr. Wang's comments in her 
performance ``evaluations'' of Dr. Head: That he is a bad 
doctor, bad researcher, and bad teacher.
    In or around June 2006, Dr. Head's surgical practice was 
restricted, and more complex surgical operating room time was 
being given to vastly under qualified surgeons.
    In or around December 2006, Dr. Wang continued to submit 
false critical evaluations of Dr. Head, assigning him the 
lowest marks possible. Caused by her malice, personal vendetta, 
and discriminatory bias towards Dr. Head, Dr. Wang's false 
evaluations were defaming to Dr. Head's professional 
reputation, criticizing his competence generally and as a 
teacher, researcher, and mentor.
    In or around early 2007, Dr. Head learned that Dr. Berke 
and Dr. Wang were planning on terminating Dr. Head's employment 
if given the opportunity. Consistent with the repeatedly 
expressed intention to remove Dr. Head, Dr. Berke and Dr. Wang 
micromanaged Dr. Head's performance, concerning trivial matters 
or matters that were entirely manufactured. Although Dr. Head 
actively and successfully thwarted Dr. Berke's and Dr. Wang's 
efforts to vex, annoy, and harass him into voluntarily 
resigning his position, Dr. Wang continued to provide negative 
evaluations of Dr. Head between 2007 and 2008.
    In or around December 2007, Dr. Wang submitted another 
critical evaluation of Dr. Head giving him all 1's out of 5's. 
Dr. Wang made false statements such as: ``Difficult to reach on 
pager.'' ``No tangible research activity.'' ``Poor role 
model.''
    On or about May 5, 2008, Dr. Wang again submitted a 
Teaching Evaluation--knowing it was to be submitted into Dr. 
Head's Promotions Packet for tenure decisions--marking all 1's 
(Unsatisfactory), stating ``poor clinical judgment, poor 
availability, poor role model.'' (See Exhibit 3.) Dr. Wang 
continued to provide negative false information and evaluations 
about Dr. Head, despite orders to stop.
    In or around July 2008, in a further attempt to harass and 
retaliated against Dr. Head, he was wrongfully accused of ten 
counts of time card fraud and lying to his supervisor.
    In July 2008, Dr. Head was forced to file another EEO 
complaint regarding the threatening and retaliatory treatment 
against him by VA administrators and supervisors. (A true and 
correct copy of this EEO complaint is attached hereto as 
Exhibit 4.)
    In or around August 2008, in order to further retaliate 
against Dr. Head, his salary was reduced. At this time, in 
order to undermine Dr. Head's teaching, a fee-based physician 
was hired in the clinic to see Dr. Head's patients at an 
increased cost to GLAHS.
    In or around August 2008, Dr. Head was transferred to the 
Quality Assurance program to minimize the retaliation by 
management resulting from his 2004 EEO complaint.
    On or about September 10, 2008, Dr. Michael Mahler (``Dr. 
Mahler''), Chief of Organizational Improvement at GLAHS wrote a 
detailed account of the harassment, discrimination, and 
retaliation against Dr. Head. In this letter, Dr. Head was 
exonerated of time card fraud. Furthermore, it was found that 
``Dr. Stelzner and Dr. Wang improperly treated Dr. Head 
differently than other members of the section.'' (See Exhibit 
5.)
    In early 2009, Dr. Head again consulted with Dr. Becerra 
regarding Dr. Wang's unfair and improper evaluations of Dr. 
Head and her treatment of Dr. Head in assignments and research 
opportunities. Dr. Becerra responded, ``Oh my God, here we go 
again. I am going to legal with this.'' Dr. Becerra replied, 
``Come back to see me if you don't get tenure, otherwise you're 
not damaged.''
    In or around January 2009, in an attempt to further 
sabotage Dr. Head's tenure and career advancement, Dr. Wang 
again submitted false evaluations of Dr. Head.
    On several occasions, regarding Dr. Wang's unfair treatment 
and improper evaluations of Dr. Head's performance, Dr. Head 
individually met with Dr. Gold, Dr. Rosenthal, Dr. Mechoso, and 
Dr. Becerra, all of whom communicated a similar message that if 
Dr. Head wanted tenure, he better not take any action against 
Dr. Wang.
    In or around January 2009, Dr. Head presented to Dr. 
Richard H. Gold (``Dr. Gold''), Assistant Dean of Academic 
Affairs, a report conducted at GLAHS showing findings that Dr. 
Wang was biased against Dr. Head in her evaluations of his 
performance, assignments, and research. When Dr. Head first 
received this report, Dr. Head informed Dr. Berke that he had 
this report and could prove that Dr. Wang was treating him 
differently and unfairly in assignments and research 
opportunities. Dr. Berke offered to pay Dr. Head for the report 
saying, ``How much do you want for the report? You can't 
release that report.'' Dr. Head replied he did not want money, 
he wanted to be treated fairly and to receive the tenure he 
deserved and had earned.
    In or around October 2009, another GLAHS employee reported 
being transferred to another department and refused promotion 
for not submitting false reports against Dr. Head concerning 
his attendance at GLAHS.
    Also around this time, prior to Dr. Norman's vacation to 
Fiji, Dr. Head and Dr. Norman met to discuss Dr. Head's fear of 
more intense retaliation and loss of income at GLAHS. Dr. 
Norman stated that Dr. Head would be protected with a 
significant salary increase; however, that increase never 
occurred, instead, Dr. Head endured further retaliation. On 
information and belief, Dr. Norman later told a faculty member 
on his trip to Fiji that ``he really liked Dr. Marilene Wang 
and that they had a good relationship.''
    In or around September through November 2010, Dr. Head 
participated as a witness, and later in March through October 
2011, and even through today, Dr. Head has testified on behalf 
of Dr. Jasmine Bowers in a racial discrimination case against 
GLAHS. Dr. Wang is on the peer-review panel at GLAHS and 
considered a witness in the Bowers Case. Immediately after Dr. 
Head participated in the Bowers Case, Dr. Berke, Dr. Wang, and 
Dr. Norman escalated the retaliation and harassment against Dr. 
Head.
    In or around June 2011, in an effort to further discredit 
Dr. Head, Dr. Wang began making accusations of wrongdoing 
against Dr. Head. Dr. Wang stated to a group of surgeons that 
Dr. Wang was sure Dr. Head would not last long and that he 
would be investigated at GLAHS where Dr. Wang is Chief of Head 
and Neck Surgery.
    In or around September 2011, Dr. Norman confronted Dr. 
Head, stating ``you're a bad doctor'' and wrongfully accusing 
Dr. Head, claiming ``you're never here'' and asking Dr. Head 
about his work hours. Dr. Norman threatened Dr. Head stating 
``I'm very worried about you.''
    In or around October 2011, James Itamura, EEO Investigator, 
wrote a detailed account of the harassment, discrimination, and 
retaliation occurring against Dr. Head at GLAHS, which was 
provided to the Office of Special Counsel. (See Exhibit 6.)
    On or about October 25, 2011, Dr. Head was on an emergency 
call at UCLA when he contacted Vishad Nabili, M.D. (``Dr. 
Nabili'') to cover for him on an elective surgery at GLAHS. A 
few days later, Dr. Head learned that he was accused of not 
showing up for a surgical procedure, which was reported to 
Human Resources. Despite his promise to correct Dr. Head's time 
cards to correctly reflect Dr. Head's work, Dr. Norman charged 
Dr. Head with being Absent Without Leave (``AWOL'') and reduced 
Dr. Head's pay approximately $7,000.
    Around this time, Dr. Head was being told by co-workers 
that Dr. Norman was trying to push Dr. Head out of GLAHS. In or 
around November 2011, Dr. Joel Sercarz (``Dr. Sercarz''), 
fellow Head and Neck Surgeon at UCLA, informed Dr. Head that 
Dr. Wang told Dr. Sercarz that GLAHS was planning to ``get [Dr. 
Head] on time card fraud.'' Dr. Head reported these allegations 
to Dr. Norman and others. In retaliation, Dr. Norman tried to 
restrict Dr. Head's tour of duty.
    On or about November 20, 2011 Dr. Norman ordered his 
assistant to mark Dr. Head AWOL for 90% of the pay period. This 
action resulted in severe financial distress for Dr. Head, 
causing his house to go into foreclosure. Despite Dr. Head 
providing evidence showing he in fact did work his tour of 
duty, Dr. Norman did not turn in Dr. Head's time cards for 
several weeks. It was not until after Congresswoman Karen Bass 
and others inquired into Dr. Head's pay, that Dr. Head finally 
received a check.
    On November 23, 2011, Dr. Head filed a formal EEO 
complaint.
    On or about April 17, 2012, Dr. Head filed a lawsuit 
against the Regents of the University of California and certain 
individuals. The case, Christian Head, M.D. v. Regents of the 
University of California, et al., Case No. BC 482981, was filed 
in Los Angeles Superior Court. In or around July 2013, the case 
was settled and ``The matter has been resolved to everyone's 
satisfaction.''
    On or about July 18, 2013, UCLA release a statement which 
read:
    The Regents of the University of California and Dr. 
Christian Head today reached a settlement in a civil case he 
brought against the University last year. The case presented 
difficult issues of alleged discrimination and retaliation that 
were strongly contested.
    The University acknowledges that in June 2006 during an 
end-of-year event, an inappropriate slide was shown. The 
University regrets that this occurred. The University does not 
admit liability, and the parties have decided that the case 
should be resolved with a mutual release of all legal claims. 
The matter was settled to the mutual satisfaction of the 
parties. A true and correct copy of this press release is 
attached hereto as Exhibit 7.)
    Unfortunately, the retaliation against Dr. Head did not 
stop with Dr. Head himself, but spread to anyone that even 
attempted to support Dr. Head or provide truthful testimony on 
Dr. Head's behalf. In or around June/July 2012, Dr. Jeff Suh 
(``Dr. Suh''), fellow Head and Neck Surgeon at UCLA, told a 
representative of a sinus surgery supply company not to assist 
Dr. Head with necessary surgical supplies or with his lawsuit 
or the representative would lose all business at UCLA. Around 
this same time, Dr. Suh also threatened Dr. Sercarz not to 
assist Dr. Head with his lawsuit or his complex surgical cases 
or he would not receive help or referred cases. Dr. Suh claimed 
he was speaking on behalf of Dr. Wang in regards to these 
threats. Because of this retaliation, Dr. Sercarz was forced to 
bring his own civil action to protect his name and reputation. 
(A true and correct copy of this civil complaint is attached 
hereto as Exhibit 8.)
    On or about August 2, 2012, in further harassment and 
retaliation against Dr. Head, Dr. Wang refused to treat one of 
Dr. Head's patients, leaving the patient in the emergency room 
for days, using the patient's care and safety as a weapon 
against Dr. Head, creating a hostile environment and 
jeopardizing patient safety.
    Dr. Head was one of the first to draw attention to the 
delay in care and the backlog of patients within the VA system. 
On November 16, 2012, Dr. Head sent Dr. Norman an email 
discussing the issue of delayed patient care at the VA. 
Specifically, Dr. Head informed Dr. Norman that the delayed 
diagnosis of cancer was a major issue facing the VA. (A true 
and correct copy of this email and accompanying attachments is 
attached hereto as Exhibit 9.)
    In or around May 2014, Dr. Head learned that VA 
administrators had improperly taken approximately 60-100 days 
of sick leave time and approximately 80-90 days of vacation 
time from Dr. Head in retaliation for Dr. Head's protected 
whistleblower activity, specifically, Dr. Head's truthful 
testimony regarding Dr. Wang's illegal time card fraud, 
testimony in support of Dr. Bowers's racial discrimination 
case, and reports of delayed care and backlog of veterans 
within the VA system. Less than two months ago, administrators 
within GLAHS retroactively took these accrued time-off days, 
falsely claiming that Dr. Head had previously failed to enter 
his time.

Retaliation against other whistleblowers, because of Dr. Head's 
leadership position within glahs and his willingness to stand 
up against wrongdoers within the system, dr. head has become 
aware of many other VA employees who are enduring their own 
retaliation.

Incident 1:

    One instance involved a 53-year-old African American woman, 
Dr. Jasmine Bowers (``Dr. Bowers''), who is a board-certified 
anesthesiologist and has practiced in anesthesia and pain 
management for over 24 years.
    In May 2010, Dr. Bowers was offered a per-diem, fee-basis 
position, which was an hourly position with capped weekly 
hours, and no benefits. Because of the dire need for 
anesthesiologists at the VA, Dr. Michelle Braunfeld (``Dr. 
Braunfeld''), chief of anesthesiology, assured Dr. Bowers that 
the appointment would likely last longer than a year. When Dr. 
Bowers inquired about full-time positions, Dr. Braunfeld stated 
that the only available position was for an acute pain 
specialist. Having her fellowship in pain management, and more 
than twenty years of experience in the field, Dr. Bowers 
expressed interest in the position. Dr. Braunfeld was 
dismissive, and stated Dr. Bowers would likely have to have 
board certification in pain management to be hired for the 
position. Unbeknownst to Dr. Bowers, Dr. Braunfeld had 
advertised for a ``general anesthesiologist'' position in May 
2010. In addition, at or around the same time Dr. Bowers was 
hired (in June 2010), Dr. Braunfeld offered a full-time, FTE 
anesthesiologist position to Dr. Corey Downs (``Dr. Downs''), 
who began working at the VA in approximately July 2010. Dr. 
Downs was fresh out of his residency at UCLA, and was not board 
certified in anesthesia. Dr. Bowers began her fee-basis 
appointment on or about July 6, 2010, but continued to make 
inquiries regarding a full-time FTE position. At one point in 
her employment, Dr. Bowers overheard Dr. Braunfeld stating to 
someone else, ``We can't hire certain people for full time jobs 
because it's too hard to get rid of them.''
    After beginning her fee-basis position, Dr. Bowers began to 
experience demeaning and disrespectful conduct from the 
certified nurse anesthetists (``CRNAs'') at the VA. The 
harassment began with relatively minor incidents, including 
several CRNAs referring to her by her first name, and one 
particular CRNA, Krista Douglas (``Douglas'') making a rude 
comment in the CRNA lounge. Douglas and other CRNAs reprimanded 
Dr. Bowers in front of others, including patients, and were 
consistently treating her with disdain and disrespect. In over 
24 years of practice working with nurses and CRNAs without such 
issues, Dr. Bowers decided to speak to the lead CRNA, Dana 
Grogan (``Grogan'') and Dr. Braunfeld about her concerns. After 
she complained, the harassment escalated. Douglas refrained 
from speaking to her altogether, and refused to relieve her 
during surgeries, in spite of her duty to do so. On one 
occasion, Dr. Bowers had a conversation with a man working at 
an administrative desk in the surgery department, Terry Woods 
(``Woods''), and mentioned her issues with Douglas. Woods told 
her that Douglas had treated another African American 
anesthesiologist in a similar manner, and told Dr. Bowers to 
``watch her back.''
    Following a surgery on September 14, 2010 in which Dr. 
Bowers administered anesthesia, Grogan went to Dr. Braunfeld 
with printouts from the blood pressure monitor (``strips'') 
from the surgery, and the intra-operative anesthesia one-page 
report, but not the patient's chart. Grogan claimed that she 
went to Dr. Braunfeld to report her concerns about the 
patient's low blood pressure and what she found to be 
discrepancies between the handwritten chart and the blood 
pressure monitor strips. Dr. Braunfeld then went to Dr. 
Stelzner with her concerns, and then went to the Chief of 
Staff, Dr. Norman. Dr. Braunfeld later stated that she 
discussed her concerns with Dr. Norman and that they agreed to 
remove Dr. Bowers from the September schedule, and investigate 
the matter. Dr. Norman told Dr. Braunfeld to obtain a written 
response from Dr. Bowers. At the end of that day, and after Dr. 
Bowers was allowed to administer anesthesia all day, Dr. 
Braunfeld brought Dr. Bowers into her office and accused her of 
falsifying medical records and allowing a patient to remain 
hypotensive for 45 minutes during the surgery, essentially 
endangering the patient. Dr. Braunfeld told her she would not 
be allowed to return to work, pending an investigation, and did 
not ask Dr. Bowers to provide any written response. Dr. Bowers 
asked to be allowed to provide a written response, which she 
did on September 20, 2010. In her response, Dr. Bowers 
requested an independent, administrative review of the case, 
and expressed that she was shocked and upset at being accused 
of misconduct, especially in light of the fact that the surgery 
had no complications and was successful.
    The VA obtained a report from Dr. Nitin Shah (``Dr. Shah'') 
who is an expert, author, professor, and anesthesiologist at 
the Long Beach VA. On November 2, 2010, Dr. Shah spoke with Dr. 
Mahler, deputy Chief of Staff and head of Risk Management about 
his findings. Dr. Shah stated that while there were some 
discrepancies between the hand-written chart and the monitor 
strips, he did not believe there was any misconduct in 
charting. He also found no negligence, nor patient 
endangerment, by Dr. Bowers, in light of the patient's history 
of low blood pressure, and successful outcome of the surgery 
with no complications. Dr. Shah expressed that he was troubled 
by Grogan's failure to mention her purported ``concerns'' 
during the surgery to her supervising anesthesiologist or to 
the surgeon. Although instructed by the VA not to comment on 
the standard of care, Dr. Shah submitted a report on November 
4, 2010, with his findings. He stated that out of 16 blood 
pressure chart entries, 7 attributed to Dr. Bowers were 
inconsistent with the monitor readings. He stated that this may 
be the result of ``sloppiness,'' but not misconduct. He also 
stated that discrepancies in charting do occasionally happen 
when the anesthesiologist is managing other aspects of the 
patient's care. He reiterated his determination that there was 
no patient endangerment in the management of the patient's 
blood pressure by Dr. Bowers during the surgery.
    Dr. Head, in his role as head of Quality Assurance, 
reviewed the patient's charts and records. He spoke with the 
surgeon, the resident who participated in the surgery, the 
supervising anesthesiologist, and the CRNA and Dr. Raj who 
started the case. After determining there was no issue with the 
patient's low blood pressure, he told Dr. Norman and Dr. Mahler 
that he was troubled with the manner in which Dr. Bowers was 
being treated. Dr. Head also heard other medical staff 
discussing the case, and people stating that Dr. Bowers had 
``almost killed a patient.'' This was determined to have 
started with Grogan, and Dr. Head heard the same comment from 
Sandra Riley-Graves, an administrative assistant in Dr. 
Norman's office. Shortly after discussing his findings with Dr. 
Norman, Dr. Head overheard Riley-Graves state, ``It's a black 
thing'' to Dr. Mahler, implying that Dr. Head was supporting 
Dr. Bowers because he was also African American. After he heard 
Dr. Mahler yelling at Riley-Graves behind the closed office 
door, Dr. Mahler came out of the office and told Dr. Head to 
``stand down'' on the investigation and leave it alone.
    Dr. Braunfeld never contacted Dr. Bowers again, and never 
provided Dr. Shah's report to Dr. Bowers. In spite of Dr. 
Shah's favorable review, that there was no negligence, 
misconduct, or patient endangerment, Dr. Bowers was never 
reinstated or placed back on the schedule.
    Shortly after Dr. Bowers initiated the EEO process, 
Congresswoman Diane Watson wrote to Donna Beiter (``Beiter''), 
Director and CEO of the VA, with her concerns and questions 
about ongoing discrimination at the VA. The VA's response to 
Congresswoman Watson contains inconsistencies. For example, 
Beiter stated that Dr. Bowers never provided a response to the 
allegations, which was false.
    Dr. Bowers initially contacted the EEO office on September 
30, 2010. The EEO Office issued a Notice of Acceptance. After 
conducting its investigation, the EEO's assigned investigator, 
James Itamura, concluded that a culture of racial and age 
discrimination exists in the anesthesiology department at the 
VA, wherefrom Dr. Bowers and other older and non-white 
anesthesiologists were removed in order to make room for 
younger replacements from UCLA.

Incident 2:

    Dr. Saroja Rajashekara (commonly referred to as ``Dr. 
Raj'') was a cardiac anesthesiologist at the VA from 2002 to 
2011. Dr. Raj reported to the EEO Investigator she observed and 
experienced age discrimination at the VA. While she was 
initially hired by then-Chief of Anesthesia, Richard Chen, Dr. 
Raj worked under Dr. Braunfeld after she became Chief of 
Anesthesia in January 2010. After her mother became ill in 
early 2010, Dr. Raj took leave (which was approved) to visit 
her mother in India. While she initially expected to return in 
early May, she sent correspondence to Dr. Braunfeld stating 
that she needed to extend her leave. Dr. Braunfeld contacted 
the HR Department at the VA asking how to deem Dr. Raj AWOL. In 
Dr. Braunfeld's correspondence with HR, she lied about her 
prior contact and correspondence with Dr. Raj. As a result, Dr. 
Raj was considered ``AWOL'' and was removed from the cardiac 
schedule. She ultimately provided evidence of her contact with 
Dr. Braunfeld, and the AWOL status was removed from her 
personnel file; however, Dr. Braunfeld did not reinstate her on 
the cardiac schedule. Instead, Dr. Braunfeld had her replaced 
with younger UCLA graduates, who were far less qualified, with 
the knowledge and approval of Chief of Staff, Dr. Norman.
    Dr. Raj reported to the EEO Investigator her concerns 
regarding Dr. Bowers's treatment by the VA. (See Exhibit 10.) 
She was aware that there was a need for anesthesiologists at 
the time of Dr. Bowers's hire at the VA, but Dr. Braunfeld was 
``holding'' jobs for younger, less-qualified residents from 
UCLA. Dr. Raj also remarked about the unusual manner in which 
Dr. Bowers was immediately removed from the schedule following 
the September 14, 2010 surgery. Specifically, she stated it was 
not the typical protocol for a case such as Dr. Bowers's to 
bypass the Quality Assurance process, and that Dr. Bowers was 
``fired'' in spite of the patient having no complications.

Incident 3:

    Dr. Carol Bennett, an African American woman, has worked at 
the VA for over 15 years and is currently the Chief of Urology. 
Dr. Bennett filed an EEO complaint against Dr. Stelzner and Dr. 
Norman in 2005 based on race discrimination. Dr. Bennett was 
discovered to have been allowing her nurse to use her CPRS code 
to sign off on prescriptions on the electronic chart, albeit 
with her full knowledge and consent. On August 24, 2005, she 
received a letter from Dr. Stelzner advising her that she was 
placed on administrative leave. Dr. Bennett was immediately 
taken off duty without an investigation. She admitted to Dr. 
Stelzner her mistake, but that it was common practice among 
surgeons in order to move on to the next patient. All of the 
entries were with the surgeons' knowledge, and they would 
review and sign the chart later. In her EEO complaint, Dr. 
Bennett addressed the fact that another non-African American 
physician was found to have a similar infraction, but was only 
given warnings. She also complained that she was being ``super-
audited'' by Dr. Stelzner, as compared to other non-African 
American medical staff in the Department of Surgery. After 
mediation, Dr. Bennett was fully reinstated as Chief of 
Urology.

Incident 4:

    In another instance, an employee working as an EEO 
Counselor in the Office of Resolution Management was retaliated 
and terminated for making a protected whistleblower complaint. 
This employee, considered to be one of the top EEO counselors 
in the nation, filed a report to internal investigators 
regarding missing EEO files which contained private personnel 
information of specific VA employees. Because this employee's 
report reflected negatively on his supervisor, Ms. Tracy Strub, 
Ms. Strub retaliated against the employee, initiating an 
unjustified Performance Improvement Plan.
    In or around July 2013, shortly after Dr. Head settled his 
lawsuit with UCLA, VA administrators questioned this employee 
about whether or not this employee had helped Dr. Head with his 
lawsuit. This employee denied that he had helped Dr. Head, but 
because of this employees close relationship with Dr. Head, VA 
administrators did not believe him. Within hours of this 
meeting, the employee was terminated.

Incident 5:

    In another instance, Dr. Wang discriminated against a Nurse 
Practitioner working in the Head and Neck Department at the VA 
based on her national origin and Muslim faith. After seeing 
this employee working with Dr. Head, Dr. Wang also told this 
employee not to work with Dr. Head or provide him any 
assistance with patient care. Because of Dr. Wang's 
discriminatory animus towards this employee, as well as 
continued retaliation against Dr. Head, Dr. Wang had the 
employee terminated the day before her probationary period 
ended.

Incident 6:

    In a recent incident, an OR tech complained to VA 
management about dangerous conditions in the operating rooms, 
specifically, surgeons using dirty instruments while operating 
on patients. Following this report, this employee was given 
both verbal and written reprimands. Recently, the employee was 
suspended for 14 days for making these complaints.

Climate of fear and retaliation within the GLAHS: As outlined 
above in detail, administration within GLAHS has created a 
climate of fear and intimidation, where the system not only 
fails to protect whistleblowers, but actively seeks to 
retaliate against them. This retaliation by VA supervisors and 
administrators often takes shape through a similar process.
    Whistleblowers are first threatened and isolated, often 
being warned early that speaking out would not be beneficial to 
their career. Whistleblowers are made aware, in no uncertain 
terms, that if you tell the truth, you will be punished.
    If the whistleblower chooses to speak out despite the 
threats, they are quickly defamed and humiliated. Supervisors 
and administrators will begin spreading false information about 
the whistleblower, suggesting to co-workers that the person is 
incompetent, lazy, and untrustworthy.
    Finally, supervisors place the whistleblower under intense 
scrutiny, looking for any reason to find fault in the person's 
work. Whistleblowers, who otherwise have had long, outstanding 
careers within the federal system, all of a sudden are subpar 
workers who begin receiving failing evaluations, verbal and 
written reprimands, salary cuts, transfers, demotions, and 
sometimes even being forced to retire, or worse, terminated. 
Even those in high administration within GLAHS that attempt to 
do the right thing are not safe. For example, Dr. Mahler, 
former deputy Chief of Staff and head of Risk Management, who 
provided a written statement in support of Dr. Head, was 
eventually forced out.
    Administrators and supervisors with GLAHS have created a 
toxic environment with a clear message, if you do not follow 
the agenda and behave as a ``team player,'' you will suffer the 
consequences.

Lack of accountability: The current system within the VA is one 
of a general lack of accountability of administrators and 
supervisors who actively retaliate against and ostracize 
hospital employees who attempt to speak out against illegal 
behavior. This climate only perpetuates this illegal behavior, 
due in large part to the system's failure to take any action 
against certain individuals. Specifically, wrongdoers are left 
in positions of high leadership to continue their illegal 
behavior without recourse. In some circumstances, wrongdoers 
may even be promoted rather than disciplined.
    For example, the investigation regarding Dr. Wang led to a 
finding that Dr. Wang had committed time card fraud during a 
certain period of time in her leadership position at GLAHS. 
However, rather than being disciplined, Dr. Wang was instead 
promoted. Even worse, Dr. Head then was retaliated for 
providing truthful testimony in Dr. Wang's time card fraud 
investigation.
    Leaders within GLAHS, such as Ms. Beiter and Dr. Norman, 
not only have played an active role in retaliating against 
whistleblowers, but in other cases have chosen to ignore 
certain occasions of retaliation by GLAHS supervisors. Ms. 
Beiter and Dr. Norman have had many opportunities to take 
action against wrongdoers, but have chosen instead to look the 
other way.

Low morale amongst healthcare providers: Unfortunately, the 
current climate of fear and retaliation, coupled with the 
system's failure to properly respond and hold wrongdoers 
accountable, has caused morale to be dangerously low, leaving 
employees within GLAHS with a sense of helplessness, creating 
undue stress and anxiety amongst those attempting to provide 
quality healthcare to our Country's veterans.
    Dr. Head has witnessed a general sense of fear amongst VA 
employees. Workers within GLAHS have stated that they are 
scared to speak out for fear of being blamed and punished. Good 
people who are used to doing the right thing and standing up 
for others want to speak out about issues throughout the 
system, but fail to do so for fear of jeopardizing their 
careers.

Negative affect on patient care: The issue facing the VA system 
involves a growing epidemic in hospitals throughout our 
Country--hospital bullying. This issue spans race, gender, 
religion, and politics because of the life and death danger it 
poses to patients. This problem, while certainly applicable to 
the VA system, is an issue that plagues every hospital 
nationwide and must eventually be addressed by Congress.
    In her MSNBC article, Hospital Bullies Take a Toll on 
Patient Safety, JoNel Aleccia outlines how hospital bullying 
``threatens patient safety and has become so ingrained in 
health care that it's rarely talked about.'' (Exhibit 11.) 
Additionally, in Dr. Kevin Pho's article for FoxNews entitled 
Bullies in Hospitals?, he concluded that ``targeting the toxic 
culture that perpetuates the problem [of hospital bullying] 
requires everyone to share responsibility. Not just doctors, 
but nurses, hospital administration, and medical educators as 
well. Only when every stakeholder is part of the solution do we 
stand a better chance of eliminating bullying behavior in 
hospitals altogether.'' (Exhibit 12.) Dr. Pho's article was a 
response to a highly-touted New York Times article by Theresa 
Brown entitled Physician, Heel Thyself, in which she detailed 
bullying behavior she experienced as a nurse and explained how 
hospital bullying poses a critical problem for patient safety 
which, not surprisingly, leads to a rise in medical errors. 
(Exhibit 13.)
    Of course, all of these articles came after The Joint 
Commission published Sentinel Event Alert, Issue 40, on July 9, 
2008 which described how:
    Intimidating and disruptive behaviors can foster medical 
errors, . . . contribute to poor patient satisfaction and to 
preventable adverse outcomes, . . . increase the cost of care, 
. . . and cause qualified clinicians, administrators and 
managers to seek new positions in more professional 
environments. . . . Safety and quality of patient care is 
dependent on teamwork, communication, and a collaborative work 
environment. To assure quality and to promote a culture of 
safety, health care organizations must address the problem of 
behaviors that threaten the performance of the health care 
team. (Exhibit 14.)
    Unfortunately, health care organizations have not addressed 
the problem, and doctors, nurses, and hospital administrators 
are left to bully and belittle others; and sadly, anyone who 
dares speak out about this behavior threatens not only their 
job, but their entire career in the healthcare profession.

Possible solutions: While this testimony has focused on current 
problems within the VA system, all hope is not lost. The 
mission of the VA system is good and noble and should be 
maintained. The VA system has some of the best healthcare 
providers in the world; however, certain changes must be 
considered. There are a number of possible solutions that can 
be implemented to affect change and improve the system.
    The first, and obvious, solution is one of leadership. 
Administrators and supervisors within the VA system that are 
contributing to the current culture must be held accountable. 
New leadership must be established--leaders who will encourage 
and welcome open discussion and dialogue, leaders who will root 
out divisive and intimidating behavior, and leaders who will 
create a safe and enjoyable atmosphere that focuses on top-
quality patient care for our veterans.
    Another important improvement to the system would involve a 
change in the appointment scheduling of veterans. Rather than 
the current process of adding patients to a long list based on 
when the person calls for an appointment, patients need to be 
assigned appointments based on conditions. There is a Standard 
Operating Procedure (``SOP'') in place that could be updated 
and implemented which would greatly improve patient scheduling. 
Based on SOP flowcharts, schedulers would be able to schedule 
more critically ill patients sooner, ensuring every veteran 
receives the proper healthcare he/she deserves.
    Additionally, there needs to be some type of computer 
accountability process implemented. Currently, the computer 
records can be too easily manipulated to hide scheduling and 
patient backlog issues. Hospital administrators should not be 
able to clear patient information unchecked. Perhaps some type 
of centralized data collection can be created to ensure 
individual hospitals are not fraudulently changing records.
    Finally, the current proposal of simply assigning more 
patients to already overwhelmed physicians is not the answer. 
The system desperately needs to add additional primary care 
physicians. Then, veterans should be matched up to one specific 
primary care physician. This would allow the physician to 
establish a relationship with the patient and would create a 
vested interest with that physician who would then be more 
inclined to ensure his/her patient received proper medical 
care. That way, if the physician's patient is not receiving the 
needed care, that primary care physician would do what private 
practice physicians do and call his/her colleagues and follow 
up. For example, Dr. Head's wife, who is an interventional 
radiologist within the VA system, is deeply vesting in each of 
her patient's healthcare and does what is needed to ensure her 
patients are receiving the proper health services.
    Dr. Head provides this testimony with the hopes of finding 
solutions to address employee mistreatment and improve the 
quality of healthcare provided to our Country's veterans. As a 
long time employee within the VA healthcare system, Dr. Head is 
optimistic that appropriate changes can be implemented, and he 
looks forward to being an integral part of that change and the 
bright future that is ahead.
    Dated: October 31, 2014
    CHRISTIAN HEAD, M.D.
    For additional information, you may contact Dr. Christian 
Head through his attorneys:
    Lawrance A. Bohm, Esq., Bradley J. Mancuso, Esq. OR BOHM 
LAW GROUP, 14600 Northgate Blvd., Suite 210, Sacramento, CA 
95834, Phone (916) 927-5574 and Fax (916) 927-2046

                                 

                   Prepared Statement of Dr. Mitchell

                               Dedication

    This written testimony is respectfully submitted in memory 
of my uncles:
    Capt. Jay Anderson Mitchell, a good-natured, red-haired, 
blue-eyed, freckle-faced young Marine, husband, and father who 
lost his life & crew in 1967 when his helicopter shook apart 
over the South China Sea because the U.S. government failed to 
timely investigate the safety deficiencies of that aircraft 
type, and Phillip V. Mitchell, a former Institute of Defense 
Analyses employee and Army Veteran who moved heaven & earth 
within the Pentagon to ground and repair the remaining faulty 
helicopters in the days that followed Uncle Jay's death so 
other young Marines would have a chance of returning home alive 
to their families.

                            CONTENT SUMMARY

 I. Introduction & Background
 II. Executive Summary
III. Phoenix VA Administrative Retaliation: Personal 
Experiences and Clinical Implications
IV. VA Horizontal Violence: Specific Retaliation Tactics 
Against Title 38 Health Care Providers (Physicians, Surgeons, 
Dentists)
     1. Overview Summary
         A. Types of Retaliation
         B. Clinical Implications (in numerical order based on 
        retaliation type)
         C. Professional Implications (aggregate)
         D. Outcomes (aggregate)
     2. Detailed Explanation of Retaliation Tactics Against 
Title 38 Employees
V. VA Horizontal Violence: General Retaliation Tactics Against 
All Employees
     1. Overview Summary
         A. Types of Retaliation
         B. Clinical Implications (in numerical order based on 
        retaliation type)
         C. Staff Implications (aggregate)
         D. Outcomes (aggregate)
     2. Detailed Explanation of Retaliation Tactics Against All 
VA Employees

                 SECTION I:  Introduction & Background

    My name is Dr. Katherine Mitchell. I am an internist who is 
fellowship trained in geriatrics. My various positions caring 
for the Phoenix VA Veteran population have given me a great 
sense of personal pride during my 5 years as a registered nurse 
on the hospital wards, my 9.5 years as a physician within the 
Emergency Department, and my 1.5 years as medical director of 
the Post Deployment Clinic.
    I greatly admire my fellow VA employees, past and present, 
who have spent years trying to meet the VA mission despite 
facility politics, low pay, lack of resources, and the barrage 
of negative publicity that often overshadows the vast amounts 
of amazing care we have provided to countless Veterans through 
millions of high quality patient encounters.
    Like other Phoenix VA employees, I have diligently worked 
within the system to identify and resolve numerous care issues 
and system deficiencies slowing the provision of care to 
Veterans. I have rewritten policies, served on committees, 
developed action plans, participated in Lean Teams, and 
composed endless emails in the pursuit of better care. Along 
with a huge number of other VA personnel, I have spent untold 
hours each pay period trying to meet work responsibilities 
which cannot be humanly completed within the space of the 
designated 40 hour workweek.
    It is a great honor and pleasure to work with the many 
experienced VA employees who, though they could find private 
sector jobs with better working conditions, remain dedicated to 
providing and enhancing the quality of Veteran health care. 
Their combined expertise is vital to advancing the future of 
the Department of Veterans Affairs.
    It is imperative for us to join together and address the 
long-standing series of crises within our VA that are currently 
threatening the viability of our institution and undermining 
its ability to meet and exceed our obligations to the nation's 
current and future Veterans.

                     SECTION II:  Executive Summary

    In the last 75 years, the VA institutional culture has 
descended into a breeding ground for horizontal violence within 
the workplace. While overt acts of physical aggression are 
extreme examples, VA horizontal workplace violence includes, 
but is not limited to, open ridicule, shouting, failure to 
promote for merit, inappropriate down-grading of proficiencies, 
unfair distribution of workload, political back-biting, and 
formation of, as well as exclusion from, influential workplace 
cliques.
    Such horizontal violence has propagated in response to high 
stress levels, unequal distribution of power, disparate 
advancement opportunities, and unreasonable performance 
expectations. The destructive phenomenon of this internal 
violence has greatly eroded the quality of patient care 
throughout the VA system to the point that the VA has been 
unable to fulfill its mission to ``care for him who has borne 
the battle . . . '' for hundreds of thousands of Veterans.
    In unscrupulous VA health care administrators' hands, 
horizontal violence has been wielded as a specific tool to 
advance the administrators' personal and financial goals to the 
detriment of quality Veteran care and system efficiency. By 
directly propagating horizontal violence or by ignoring the 
presence of it among employee ranks, VA administration has 
betrayed the VA core values of integrity, commitment, advocacy, 
respect, and excellence.
    As a 16 year Phoenix VA employee who has routinely 
advocated for patient care improvements, I have been the 
recipient of horizontal violence at my facility for years. I 
have personally witnessed the devastating consequences such 
horizontal violence has wreaked on the quality of patient care 
within the Emergency Department.
    The purpose of this written testimony is to clearly 
describe the details of those experiences and provide a 
description of administrators' tactics of retaliation against 
others within the Phoenix VA Medical Center and elsewhere at 
sister facilities.
    Although improvements in overall care have propelled the 
Phoenix VA to a level of care significantly greater than what I 
observed in 1989 when I first jointed the facility, regretfully 
there has been no significant change in the dysfunctional 
institutional culture of the Phoenix VA Medical Center. 
Employees today still risk backlash for bringing up patient 
care problems, identifying misuse of facility resources, and 
questioning the presence of prohibited personnel practices.
    Quite simply, a problem isn't allowed to exist within the 
Phoenix VA care system unless senior administrators officially 
allow it to be recognized. No matter how critical the issue is 
to patient care or safety, senior officials will deliberately 
avoid the problem by covering up any evidence of deficiency. 
This routinely is accomplished by ignoring legitimate requests 
for resources, manipulating statistics, hiding objective 
reports critical of the local VA's operations, and providing 
misleading information to outside official inquiries. Most 
pointedly, certain employees systematically intimidate any 
fellow employee who dares advocate for Veterans in a manner 
inconsistent with the Phoenix VA administration's party line.
    Ethics have never been made an official VA performance 
measure, and thus do not appear to be a clear administrative 
goal. There seems to be no perceived financial advantage to 
pursuing ethical conduct. Administrative repercussions are 
lacking for unethical behaviors that are so routinely practiced 
among senior executive service employees. Unfortunately, 
Phoenix administration has had a financial incentive to 
artificially maintain a positive public image using retaliation 
tactics even if such a facade comes at the expense of quality 
patient care provision and the inability to attract and/or 
retain quality employees.
    The most serious retaliation against me occurred during my 
last 3 years as the sole ER medical co-director. During that 
time, our ER remained greatly understaffed in terms of nurses, 
physicians, and ancillary employees. New graduate nurses were 
filling in for seasoned triage nurses. There were insufficient 
personnel to wash beds, answer phones, transport patients or 
labs, and perform other tasks. The ER physicians and nursing 
staff continually were pulled away from direct patient care to 
absorb those extra duties in order to keep the ER flowing.
    As the number of patient ER visits greatly increased 
beginning in 2010, deficiencies in our ability to meet high 
standards of health care became readily apparent. In our tiny 
8-room ER, even the most experienced triage nurses could not 
have kept up with the dangerous flood of patients diluting 
triage time. The number of actual or potential misses in 
nursing triage sky-rocketed. Internal head bleeding, strokes, 
heart attacks, pneumonias, and dehydration were examples of 
cases missed by either inexperienced triage nurses or seasoned 
nurses overwhelmed by the glut of patients engulfing the ER.
    Without targeting any nurse, I began reporting actual or 
potential misses to the nursing chain of command. As backlash 
from a few nurses became evident, I had to ask all physicians 
to give me their cases to report. I knew I had to be the only 
backlash target. Any large scale adversarial relationship 
between physicians and nurses would grind patient care to a 
halt during a time when we were already gasping from 
insufficient resources.
    After reporting hundreds of cases, eventually about 20% of 
the ER nurses actively began to impede care of my own ER 
patients. Those nurses stopped initiating protocol orders for 
me, providing me with verbal patient reports, handing me EKGs, 
and answering basic questions I asked.
    Although my immediate supervisor provided support to the 
degree the VA culture allowed, senior executives chose not to 
intervene to stop or investigate the horizontal violence 
against me. I was accused of poor communication skills. I was 
banned from submitting cases to the risk manager. I worked 2 
years of unlimited scheduled shifts without compensation in 
order to keep my position as medical co-director and provide 
even bare bones physician staffing. My yearly proficiencies 
dropped. I was subjected to verbal abuse from senior 
executives. Human Resources failed to expedite requests for 
physician hiring. Eventually I would be involuntarily 
transferred to a medical director position in a defunct medical 
clinic without receiving a valid reason for such a transfer.
    Staffing was increased after I was removed from the ER. 
Additional resources were provided including additional patient 
rooms. Triage was expanded. However, the intense, recurring 
nurse triage training for which I advocated would never be 
instituted.
    With few avenues for change left open to me, in 2013 I 
submitted a 30+ page confidential OIG report through my 
senator's office outlining a variety of patient safety concerns 
& facility deficiencies. I was subsequently placed on 
administrative leave for a month, investigated for improper 
conduct, and eventually received a written counseling for 
violating a patient privacy policy which the Phoenix HR 
department still declines to name.
    I remain very concerned for the future of our Veterans and 
the Phoenix VAMC.
    The Veterans who present in Arizona for VA care have 
survived campaigns like D-Day, Iwo Jima, Heartbreak Ridge, Pork 
Chop Hill, Chosin Reservoir, Inchon Landing, multiple Tet 
Offensives and Counter-Offensives, Desert Storm, Kosovo, 
Croatia, Ethiopia, the Battle of Fallujah, and dismal years in 
Helmand Province. It is a bitter irony that our VA cannot 
guarantee their high quality health care and safety inside our 
medical facility in the middle of cosmopolitan Phoenix. This 
tragedy is no doubt mirrored in other VA facilities across the 
country.
    This country's founding fathers organized government into 3 
branches so that no one department would possess the majority 
of power. Eventually cabinets and departments would be created 
to help fulfill the obligations of the federal government to 
its citizens. President Lincoln conceived the VA mission 
eloquently as ``to care for him who have born the battle and 
his widow and his orphan''. Sometime in the last 75 years, the 
Department of the VA has evolved into a powerful, narcissistic, 
unethical bureaucracy which at times openly defies the laws of 
the land including federal employment law, flouts congressional 
authority by ignoring requests for information, and jeopardizes 
the health of Veterans by statistical indiscretions.
    There must be swift congressional bipartisan effort to 
address the gross misconduct within the VA. Congress must 
ensure those unscrupulous administrators who ignored ethical 
standards and sacrificed patient well-being for financial gain 
or personal prestige face consequences for unethical and/or 
illegal behaviors. In addition, steps must be taken to protect 
those employees truly devoted to patient care who found 
themselves in the untenable position of following orders or 
risk losing their livelihoods and their ability to provide any 
services to Veterans within the system.
    With proper reforms, the horizontal violence within the VA 
can be stopped. VA employees will then be free to voice 
concerns without fear of retaliation. It is only with the 
combined efforts and voices of our current dedicated VA 
employees that the Department of Veterans Affairs will be able 
to evolve from a bureaucratic institution today into a dynamic 
health care model for tomorrow.
    Most importantly, in this process, the ability to 
positively influence patient care and safety should not be 
misconstrued as being a specific Democratic or Republican 
platform, a pro-union or anti-union choice, or even a uniquely 
American problem. The ability to freely advocate for the health 
and safety of any patient is a human issue with ethical 
implications for all societies

     SECTION III  Phoenix VA Administrative Retaliation: Personal 
                 Experiences and Clinical Implications

    Note: Because whistle-blowing retaliation in my facility is 
currently being investigated, I cannot include of the names of 
the employees or the specific documents to which I refer. These 
omissions are necessary to maintain the integrity of the 
whistle-blower investigation and also prevent potential 
retaliation against my co-workers.
    In the last 75 years, the VA institutional culture has 
descended into a breeding ground for horizontal violence within 
the workplace. While overt acts of physical aggression are 
extreme examples, VA horizontal workplace violence includes, 
but is not limited to, open ridicule, failure to promote for 
merit, inappropriate down-grading of proficiencies, unfair 
distribution of workload, dangerous work hour requirements, 
political back-biting, and formation of, as well as exclusion 
from, influential workplace cliques. Such horizontal violence 
has propagated in response to high stress levels, unequal 
distribution of power, disparate advancement opportunities, and 
unreasonable performance expectations.
    In unscrupulous VA health care administrators' hands, 
horizontal violence has been wielded as a specific tool to 
advance the administrators' personal and financial goals to the 
detriment of quality Veteran care and VA efficiency. Horizontal 
violence is commonly used by many supervisors to ensure 
compliance with their personal agendas which are disconnected 
from the mission and stated values of the Department of 
Veterans Affairs. Administrators' retaliatory tactics 
essentially debase employees and suppress any identification of 
system deficiencies that would make the administration look 
unfavorable if the deficiency was openly identified.
    As a 16 year Phoenix VA employee, I have seen what happens 
to personnel who advocate for patient safety and welfare in a 
manner that challenges the administrative status quo. The 
devastation of the individual's career is usually the end 
result and likely is the only transparent process that exists 
within the Phoenix VA Medical Center today.
    During the last 3 years that I served as the sole medical 
co-director of the Phoenix VA Emergency Department, I routinely 
suffered negative workplace consequences for persistently 
reporting issues related to drastically inadequate staffing, 
lack of sufficient training, and lack of ancillary resources. 
After I was involuntarily transferred to the Post-Deployment 
medical director position in December 2012, the 
administration's retaliation tactics against me persisted into 
2014.
    Because I am a practicing physician, such retaliation 
greatly impeded my ability to provide high quality care for 
patients presenting to the ER and crippled my ability to serve 
as an advocate for patient health and safety throughout the VA 
system. The following details some instances of administrative 
retaliation toward me during the timeframe from 2009-2014 and 
the consequences to patient care.

    1. Phoenix VA ER background.

    I was a Phoenix VA emergency department staff physician 
from 2003 to approximately 2006 and then promoted to medical 
co-director of the ER from 2006-2009. After administration 
failed to fill the co-director position when my fellow co-
director resigned to attend fellowship training, I remained as 
the sole co-director from 2009-12-10-12. Because the co-
director position was never filled, I was referred to as the ER 
medical director by default even though the position was 
technically designated for two medical co-directors.

    2. Despite spending 3 years repeatedly alerting senior 
administration to the dangerous clinical situations in the 
Phoenix VA Emergency Department, my concerns were ignored 
repeatedly by Phoenix senior administration.

    Since 2009, I had been very vocal about the escalating 
danger to patient care in the ER because of physician 
shortages, nurse short-staffing, and lack of formal training 
for triage nurses. As a matter of habit, I notified the nursing 
chain of command with concerns as well as communicated the 
issues to staff in the physician chain of command.
    When reporting morbidity (illness) and mortality (death) 
related to lack of quality triage, I never targeted a specific 
nurse. Instead, cases were used to emphasize the need for 
formal, ongoing nursing triage training as well as additional 
nursing staff.
    From 2010 to 2011, I was involved in two ``lean teams'' 
(system redesign teams) to exam ER process issues affecting the 
quality and efficiency of the Emergency Department. Both teams 
concluded that the influx of new resources including additional 
manpower and formal nurse triage training were necessary to 
help resolve care issues and correct serious flow 
inefficiencies.
    Unfortunately, although the Phoenix VA administration did 
make some changes in availability of ancillary/non-medical 
staff, senior administration did not directly address those 
poor quality triage issues nor quickly resolve the ER nursing/
physician shortage. Although a few nurses were sent for formal 
triage training in early 2012, there was never any 
comprehensive nurse triage training implemented despite 
repeated episodes of the same nursing triage patient care 
mistakes being made.
    While on paper there were some gains in ER nursing 
staffing, those gains were offset by the loss of extremely 
experienced nurses who chose to leave the ER because of the 
unsafe working conditions. An increase in full-time physician 
manpower (above 6 full time physician positions) was extremely 
slow in coming. The significant understaffing of physicians in 
the Phoenix ER was not corrected until early 2013
    Although senior officials may contend the Emergency 
Severity Index (ESI) was the ``standard training'' required for 
nursing triage training, ESI is only a classification system 
based on ER resources used. It is not a nursing-based 
assessment of potential complaints presenting to the Emergency 
Department. It does not teach nurses how to stratify potential 
symptoms to determine the patient's proper level of acuity 
(severity of health impairment).
    Senior Phoenix VA administration has claimed the quality of 
nursing triage has significantly improved since 2012 after 
hiring of experienced triage nurses from the community. 
However, VA staff members continue to tell me anecdotally the 
triage process is still extremely variable. This variability 
increases the risk of mistakes and near-misses in ER triage.
    During the years I was in the ER, there were countless 
instances when the lives of Veterans were needlessly placed in 
jeopardy because of Phoenix VA administration's lack of 
response to clearly identified deficiencies within the ER 
including lack of sufficient triage training and resources. The 
following cases are a few examples when appropriate care was 
not expedited for Veterans:
    (a) A patient with homicidal thoughts and potential 
gastrointestinal bleeding was put in a room for 49 minutes with 
no report given to a physician. A patient like this is at risk 
for extreme violence as well as severe blood loss.
    (b) Two patients were discovered to have bleeding inside 
their heads after sitting in the lobby for several hours. They 
had to be transferred out immediately for stat neurosurgery.
    (c) An elderly patient with an elevated pulse rate of 119, 
nausea/vomiting, and abdominal pain was deemed stable for the 
lobby even though his presentation indicated severe illness.
    (d) A patient on a blood thinner who reported dark red 
blood in stool was deemed stable for the lobby. This patient 
was potentially at risk for severe blood loss.
    (e) An obviously ill, immunosuppressed patient was 
neglected for 5 hours before report was given to a physician.
    (f) A patient with possible heart attack had no mandatory 
protocol orders initiated by nursing staff.
    (g) No protocol lab orders initiated for an 
immunosuppressed patient on a blood thinner who had fallen and 
reported feeling lightheaded and weak.
    (h) A diabetic patient with a fast heart rate of 110 who 
was breathing rapidly was placed in the lobby instead of being 
brought to the attention of the physician on duty.
    (i) A patient with low blood pressure and a heart rate of 
130 at rest was left to wait in the lobby for 10 hours before a 
physician was notified. This patient was very ill.

    3. I was verbally banned from submitting cases to the Risk 
Manager/Patient Safety Office by a former Senior Executive 
Service administrator and well as by others who remain at the 
Phoenix VAMC.

    Frustrated by the nursing service's inability to stem the 
issues related to nursing triage and understaffing, I submitted 
several concerning cases to the Risk Management department in 
2011. When I checked on the status of those cases, I was 
informed that the cases would not be investigated. I learned 
the department had been told by Phoenix senior executives not 
to investigate my cases nor accept any future cases from me. 
This is contrary to both local and national VA policies which 
were designed to identify and address potential health and 
safety issues through the use of risk management reviews.

    4. In 2011 & 2012 I was forced to work unlimited scheduled 
shifts to prevent job loss and to provide at least minimal 
physician staffing coverage in the ER.

    When jobs were offered to ER physician candidates, Human 
Resources was so slow at credentialing them that those ER 
physicians eventually obtained employment elsewhere. Phoenix VA 
administrators then developed a plan to compensate for the VA's 
unsuccessful attempts at ER physician recruiting efforts. This 
plan involved having salaried ER physicians work without 
compensation to fill any open, scheduled shifts.
    To remain a salaried medical co-director, I was informed I 
would have to work all scheduled, unfilled shifts myself or 
convince my colleagues to work the shifts without compensation. 
I believed forcing ER physicians to work additional scheduled 
shifts was not safe or ethical unless there was a facility-wide 
emergency declared. I stated I legally couldn't schedule any 
physicians for more than 80 hours per 2 week pay period. In 
response, I was informed that the Human Resources department 
had investigated and determined current physician contracts 
allowed the unlimited scheduling of any physician.
    I had no choice but to work open unlimited shifts in order 
to keep my position and provide at least minimum physician 
staffing coverage in the ER. I knew if I refused to work those 
open shifts, my work environment would become more hostile from 
senior management. I hoped HR would expedite ER physician 
hiring as I was promised it would during that meeting.
    Unfortunately, HR never expedited the recruitment or hiring 
of additional ER physicians until late 2012/early 2013. Because 
I worked so many open shifts, the amount spent on fee basis 
(hourly) ER physicians in 2011 and 2012 significantly dropped 
prior to hiring any full-time physicians. At one point, I was 
physically present working various hours in the ER for 18+ days 
in a row to cover open shifts/short staffing. The physical and 
emotional strain on me was tremendous. Although administration 
seemed indifferent to the consequences of forced excessive work 
hours, I knew being forced to work abnormally long workweeks 
greatly increased the risk of patient care mistakes.

    5. I was ordered to cut fee basis (hourly) physicians even 
though insufficient ER physician staffing still existed and 
open shifts were covered only when I worked excessive hours.

    I was informed a senior administrator refused to approve 
any additional fee basis physicians until I cut the number of 
fee basis physicians. I was forced to fire several fee-basis 
(hourly wage) physicians who couldn't commit to the number of 
monthly shifts the senior administration was requiring. After 
cutting those fee basis physicians, additional approvals/hires 
for more fee basis physicians did not come/were not processed 
in a timely manner by HR. Thus I was forced to work even more 
hours above my scheduled workweek.
    In my opinion, I believe this was a deliberate attempt by 
senior executive service members to make my working conditions 
so intolerable that I would choose to resign.

    6. Because senior administrators ignored the growing 
problem in the Phoenix ER, short staffing and inadequate 
quality triage became routine within the ER in 2011 and 2012.

    The quality of triage in general was extremely inconsistent 
depending up on the skill set of the triage nurse assigned and 
the number of patients presenting for triage.
    At one point, I identified 3 full-time nurses who were 
considered extremely unreliable triage nurses by all full-time 
staff because of the inappropriate triaging of seriously ill 
patients and the frequency of mistakes made by those nurses on 
all shifts. However, I was told nursing staffing in the ER was 
too short-staffed to prevent the inexperienced and/or 
inadequately trained nurses from being placed in triage.
    One of these nurses actually sent a seriously ill patient 
to the Eligibility Clinic instead of performing triage because 
the patient had never been registered at the Phoenix VA before.
    Triaging of the patient's problem should always be done 
before any patient is diverted away from the ER.
    New grads were allowed to do triage only after a very short 
period of triage training. Some of them were even trained by 
nursing staff who previously had demonstrated inadequate triage 
nursing skills.
    The Phoenix ER patient flow rapidly increased and the 
inexperienced nurses could not keep up nor were they given 
sufficient time to be mentored in triage. By late 2011 and 
early 2012 the triage mistakes or near misses were so prevalent 
it was impossible for the physicians to monitor all the misses/
mistakes on an hourly basis.
    Although senior administrators may state that the ER 
usually met the minimum requirements for nursing staffing, in 
truth many times the ``ER nurses'' were float nurses from other 
parts of the hospital with no ER experience or specialty 
training. In addition, the minimum nursing staffing was 
inadequate because it didn't allow an increase based on the 
sheer number of patients presenting for triage nor make 
adjustments for the high acuity of patients presenting.
    Phoenix senior administration declined to institute formal 
nursing triage training on a recurrent basis even when the lack 
of nursing knowledge contributed to significant morbidity and 
some instances of mortality.

    7. Despite my well-articulated concerns regarding the 
number of nursing triage mistakes and the difficulty physicians 
would have addressing those mistakes quickly without paper 
print-outs of triage notes, Phoenix senior officials ordered 
the cessation of all paper-based triage note print-outs.

    The VA goal nationally was to move away from paper-based 
processing of triage notes. However, I felt this move could not 
be done safely at the Phoenix VA in 2011. I repeatedly 
explained in meetings that the majority of triage nursing notes 
as of 6/2011 were still inadequate with significant concerns 
regarding the quality of triage. Paper based print-outs allowed 
the physicians on duty to rapidly determine if there were 
serious symptoms/vital signs documented within the note that 
the triage nurse did not realize indicated seriously ill/
potentially unstable patients. I opposed the loss of backup 
printed triage nurse notes because it meant the physician on 
duty could not quickly monitor the triage notes/vital signs/
patient complaints to reassign the patient's acuity level to 
the proper category.
    The need for close physician monitoring was quite evident 
based on the admission data present during that timeframe. 
There continued to be a high number of patients who were 
inappropriately designated as low-acuity (indicating non-urgent 
condition) in triage. These Veterans were actually high-acuity 
and were subsequently admitted to the hospital.
    Multiple ER physicians reported to me that nursing triage 
quality was extremely unreliable. I repeatedly communicated 
those concerns to both the nursing chain of command and my 
physician chain of command. Senior executives still did not 
respond.

    8. I was exposed to ongoing extremely hostile working 
conditions in the ER from a small percentage of nursing staff 
whom senior administration refused to investigate.

    Beginning in approximately 2010, I became more vocal 
regarding the need for nurse triage training and the 
understaffing of triage. Shortly thereafter, a few nurses began 
intermittently ignoring my orders, not answering my questions 
in the nurses' station, not giving me verbal reports on 
patients, and not expediting the discharge of my patients. As a 
result, I asked that all ED physicians direct any concerns 
regarding nursing triage outcomes to me for submission in order 
to avoid having other physicians be the recipient of nursing 
backlash which could grind patient care to a halt in the ER.
    By late 2011, approximately 20% of nurses were consistently 
ignoring my orders, failing to give me verbal report on 
patients, declining to notify me of ekgs, and refusing to 
initiate protocol orders for serious complaints like as chest 
pain in my patients. Patient assignments would be changed to my 
name in the computer without telling me. Those nurses were 
intermittently verbally aggressive toward me when I was in the 
ER nurses' station.
    From 2011-2012, the aggressiveness towards me from those 
few nurses was so open that it was frequently observed by fee 
basis ER physicians, full-time ER physicians, other nursing 
staff, front desk staff, Phoenix VA police officers, and even 
housekeepers.
    Although I communicated my concerns through the nursing 
chain of command, there was no significant change in the level 
of hostile work environment for me. I was told by the nursing 
chain of command that the nursing department could not stop 
such behavior.
    When I spoke to my physician chain of command, senior 
administration refused to intervene on my behalf. I was told 
not create any problems for nursing staff which I believed 
included not completing formal write-ups.

    9. By late February 2012, ER conditions were so dangerous 
that I told the on-coming medical center director, Ms. Helman, 
the ER should be shut down completely unless additional 
staffing, resources, and triage nurse training were provided.

    I mentioned the multiple actual negative outcomes and 
potential near-misses that had been ignored by prior 
administrators for several years. I cited both acute and long-
term short staffing shortages in the ER. I told her the last 3 
days had been so dangerous for patient care that I believed the 
ER should be completely shut down unless there was an immediate 
influx of resources.
    I reported conditions had been dangerous during the prior 3 
days for a variety of reasons including nurses unable to write 
orders during shift because the current nursing protocols could 
not be found within the facility, extremely high flow of 
patient walk-ins, inadequate availability of nursing staffing, 
multiple instances of poor quality of nursing triage, 
inadequate physician staffing, and lack of ancillary services. 
I stated current policy for nursing order protocols was not 
available despite 2 months of me asking for the protocols to be 
located.

    10. After reporting to Ms. Helman the dangerous conditions 
in the ED at the end of February 2012, I was subsequently told 
by senior administrators that the only problem in the ER was my 
lack of communication skills.

    Within 1.5 weeks of telling Ms. Helman that the ER was 
grossly unsafe, I was called into a meeting with senior 
executives and told the only problem in the ER was my lack of 
communication skills.
    After emphatically stating the issue was not my 
communication skills, I gave the group a stack of 20+ cases of 
actual patients with negative outcomes related to triage. I 
also provided additional cases for the senior executives to 
review after the meeting.

    11. After I reported the dangerous conditions in the ER and 
discussing staffing shortages, no action was taken by senior 
executives for another 5-6+ weeks.

    Despite my statements describing life-threatening 
situations within the ER to S. Helman at the end of February 
2012 as well as my description of dangerous ER conditions at 
the early March 2012 meeting where I was accused of poor 
communication skills, no formal action or investigation was 
taken by the senior executives at the Phoenix VA to investigate 
or address the grave concerns I had verbalized.
    I sent additional emails to administration emphasizing the 
dire conditions within the ER. In my April 2012 email to my 
physician chain of command I wrote `` . . . I continue to be 
extremely concerned about the safety of our veterans who are 
presenting to the ED (Emergency Department) for care when the 
ED is saturated. Based on the events of [omitted] & [omitted] 
as well as numerous events over the last 24 months that have 
been reported on ongoing basis, I believe the potential for 
patient mortality in our ED is incredibly high during periods 
of ED saturation . . . The number of near-misses is so high 
during peak flow/high acuity days that multiple occurrences of 
significant nosocomial morbidity & mortality are inevitable . . 
. I have tried multiple avenues to alert this facility to the 
issues vital to our ED & improve provision of care in the ED 
despite being faced with incredibly toxic circumstances & 
political backbiting. This facility must not delay focusing 
immediate resources to reduce the risk of needless suffering 
and loss of life in our ED . . . ''
    Unfortunately, even that email would not generate any 
significant response for 3+ weeks from management.
    Finally, in late April 2012, my chain of command agreed to 
meet with ER physicians to corroborate my statements. During 
that meeting all the ER physicians confirmed the significant 
care issues, staffing shortages, and nursing backlash against 
me.
    A formal action plan was written by senior executives to 
address many of the issues outlined in the meeting. However, I 
was informed the nursing backlash against me would not be 
investigated. I was also told not to cause any problems for 
nursing staff. I was devastated to learn senior executives were 
ignoring nurses who had jeopardized ER patient care. I was very 
fearful for my patients in the ER because I knew it would be a 
continual struggle for me to provide quality care for ER 
patients in the face of continual backlash from a small group 
of nurses.
    There should have been an immediate internal response/
action plan developed after I informed former Director Helman 
of the severe internal crisis state existing in the ER. 
Inquiring into the issues including interviewing the other ER 
physicians should not have been delayed for almost 2 months.

    12. My care for patients remained impeded by a small group 
of ER nursing staff throughout 2012.

    The following are a few of the many episodes when my 
ability to care for ER patient was impeded by a small group of 
nurses in 2012 while I was on duty. (None of the delays were 
related to short-staffing issues.)
    (a) Patient with an elevated heart rate of 112 was placed 
alone in an exam room for 2 hours and 40 minutes before I was 
notified. (Such a resting heart rate can indicate significant 
illness requiring the patient to be seen much sooner.)
    (b) Nursing staff refused to draw blood on a patient 
because I had put a patient in a room they didn't like. (It was 
the only available bed and the care needed to be expedited for 
the patient.)
    (c) A nurse did not give me report or the ekg on a patient 
with recent chest pain who had a history of prior heart attack.
    (d) A hypertensive patient with a bad headache was put in a 
room for 20 minutes without ever telling me. This delayed care 
for a patient with a potential hypertensive emergency.
    (e) On one shift, four patients were placed in rooms 
without giving me any type of report.
    (f) An obviously ill patient with fast heartbeat was placed 
in a room without giving me any type of report on the patient.
    (g) A nurse refused my request to respond to telemetry 
alarm monitors on my patient even though the nurse was assigned 
to the room and was not otherwise occupied.
    (h) Labs I had ordered on an ill patient were still not 
drawn 3 hours after I ordered them.
    (i) My chest x-ray order for a patient with shortness of 
breath was ignored for 3 hours despite my asking the nurse 
twice to have it completed.
    (j) A stat ekg I ordered on a patient was not done for 2.5+ 
hours and my other orders were delayed including orthostatic 
vital signs.
    (k) IV fluid administration was significantly delayed 
because a nurse didn't want to restart a heplock on my patient.
    (l) Care was delayed when the pregnancy test and other 
tests I ordered were not done.
    I continued to communicate my concerns to the physician and 
nursing chains of command without any success.

     13. In December 2012, I was notified unexpectedly that I 
was being laterally transferred out of the ER to the Post-
Deployment Clinic because of a ``critical need'' which 
management would not specify.

    I was told this administratively-driven lateral transfer 
was necessary to meet a critical need in the Post-Deployment 
Clinic. However, that clinic had been a defunct medical clinic 
for 1.5 years prior to my transfer. It only contained a social 
work program working with returning combat Vets and a part-time 
polytrauma case manager. There was one physician assistant who 
performed basic registry exams for traumatic brain injury. 
These types of exams do not require a physician to complete.
    My chain of command declined to specify the critical need 
in the Post-Deployment clinic that I was supposed to address. 
It took over a month for senior administrators to grant me 
clinical privileges to see any Veterans.
    My transfer to the Post-Deployment Clinic left the ER 
critically short-staffed. At management's request, I returned 
for a few shifts over the Christmas holiday to provide 
emergency coverage for open shifts.
    Despite the circumstances of the transfer to the Post-
Deployment Clinic, I eventually discovered a way to make my 
position an important adjunct to the OEF/OIF/OND Transition 
Services social work team.

    14. I chose to submit a confidential OIG report to address 
multiple health and safety concerns within the Phoenix VA that 
were being ignored by administration.

    In 2013, I was working on a project to reduce the risk of 
suicides among Veterans. Despite phenomenal attempts by the 
Suicide Prevention Team to work within the confines of grossly 
inadequate resources, the rates of suicide at the Phoenix VA 
increased over a very short time span. I inadvertently became 
aware of long-standing Phoenix VA system inadequacies that were 
placing our Veterans at higher risk of successful suicide 
completion. Senior administration's lack of response heightened 
my concerns.
    I decided to initiate an OIG complaint and submit it 
through my senator's office. Our nation, has lost too many 
Veterans from all eras to suicide. While no one factor will 
prevent a suicide, as health care providers we are obligated to 
make the safety net as tight as possible in our attempt to do 
outreach to those who are considering taking their own lives.
    When I chose to initiate the OIG complaint, I was aware of 
previous inadequate OIG investigations at the Phoenix VAMC and 
failures to maintain confidentiality of those making the 
complaint. I could not submit the complaint anonymously because 
that would have severely limited the scope of the pending OIG 
investigation.
    I organized my complaint so it would address as many 
patient care and safety issues as possible. I hoped this would 
increase the likelihood that my OIG complaint would result in 
significant positive changes within the Phoenix VA.
    I went to my fellow Phoenix VA employees with whom I had 
developed a trusted relationship and asked them to provide me 
with information regarding the most serious issues within the 
VA facility. The problems must be easily proven and be urgent 
enough that the issues could not wait for resolution by the 
normally ponderous VA process of change. It was equally 
important the information could not be traced back by 
management to my ``sources''. I wanted only me to be the only 
target if my name was not kept confidential by the OIG. The 
Phoenix VA couldn't afford to lose any more good employees if 
management chose to retaliate against anyone else whose name 
might be associated with the report.
    As the result of the information collected as well as my 
first-hand knowledge of facility issues and overt backlash, I 
wrote a lengthy complaint detailing the various problems. When 
I presented my written OIG complaint to staff at Senator 
McCain's office, the seriousness of the VA situation was 
evident to even those staff who had no health care background. 
I was informed the most serious safety issues listed in my 
complaint would be forwarded with a request for an expedited 
investigation performed by an outside OIG team to address the 
issues and maintain the confidentiality of my name.
    Some of the issues in my complaint included disturbing 
system issues involving suicides, statistical manipulation of 
the wait list, failure to prioritize appointments according to 
national VA policy, and improper distribution of complex 
patients.

    15. My confidential 2013 OIG complaint regarding multiple 
safety concerns within the facility resulted in overt 
retaliation against me.

    My plan to address system deficiencies failed almost 
completely. My name was not kept confidential by the OIG. 
Shortly after the national VA acknowledged receipt of my 
complaint, I was placed on administrative leave for about a 
month and investigated for alleged wrong-doing for including 
truncated patient information in the confidential OIG complaint 
submitted through approved channels.
    I was told I acted outside the scope of my duties as Post-
Deployment medical director and ``may have'' violated privacy 
policy by including patient information to support my 
allegations regarding the disturbing suicide trends at the 
facility.
    I eventually would receive a written counseling in January 
2014 for violating privacy policy and for working outside the 
scope of my duties as purportedly evidenced by the content of 
the OIG complaint submitted for me by Senator McCain's office. 
There was no information in the written counseling specifying 
exactly what policy I had violated or how it was concluded I 
was working outside the scope of my duties. I was not given 
access to the investigative file. Instead, I was told the 
investigative file had been ``shredded for my protection''.
    I sent a formal request outlining my concerns and 
requesting to have the investigative file re-created. I also 
asked to be informed of which patient privacy policy I 
violated. I subsequently was told that HR determined it did not 
need to respond because written counseling did not rise to the 
level of disciplinary action that Title 38 employees were 
allowed to challenge.
    My senior physician chain of command did not intervene on 
my behalf, and thus clearly supported HR's decision. The 
written counseling was never rescinded even though HR declined 
to tell me the name of the policy I supposedly violated.
    16. The 2013 OIG report of my complaint was never 
officially provided to me and can't be found on the OIG web 
site. I was forwarded a brief email received by the senator's 
office indicating the investigative findings were benign. Of 
note, the investigation found no significant problems with 
scheduling issues.

    I have never seen the official OIG report on my 2013 
complaint and do not know if one exists. Senator McCain's 
office made attempts to locate the report for me without 
success. There is no indication of the investigation on an OIG 
Web site search.
    I subsequently learned the OIG has complete discretion as 
to which reports it puts on its Web site. I was told 
anecdotally the VA OIG often doesn't list any reports which are 
critical to senior administrators. Recently I was sent an OIG 
report critical to senior administrators at another VA. That 
report issued in 2014 and was assigned an OIG case number. 
However, this report cannot be located on the OIG Web site and 
was obtained only by FOIA request.

                              SECTION IV:

 VA Horizontal Violence: Specific Retaliation Tactics Against Title 38 
         Health Care Providers (Physicians, Surgeons, Dentists)

    Note: Variations of some tactics are commonly used against 
wage grade employees & Title 38-hybrid employees. The 
implications may differ (depending on the skill set) but the 
outcomes are similar.

                            Overview Summary

    A. Types of Retaliation:
1. Sham peer review.
2. Malicious down-grading of proficiencies.
3. Deliberate understaffing of Title 38 provider positions.
4. Deliberate understaffing of necessary ancillary personnel.
5. Inequitable distribution of extremely challenging patients 
to overburden provider.
6. Faulty clinical profile to overwhelm provider.
7. Unjustified written counseling.
8. Lateral transfer for factitious reasons.
9. Exploitation of ``24/7'' work contract.
10. False accusations of patient privacy violations in 
retaliation for whistle-blowing.
11. Unreasonable timeframe assigned for completion of 
nonessential training requirements or extraneous tasks.
12. Removal of teaching privileges to ostracize provider.

    B. Clinical Implications (in numerical order based on 
retaliation type):

1. Veterans are denied the skills of talented, qualified 
providers who are fired due to unjustified accusations of poor 
medical skills.
2. Qualified candidates for direct patient care positions or 
supervising administrative positions are not promoted to 
positions where they can use their skills sets to fulfill the 
VA's mission for quality health care.
3. Provision of direct patient care services is greatly slowed.
4. Direct patient care time is diminished due to additional, 
excessive daily tasks.
5. Punitive and dangerous system is used for managing care of 
complex Veterans.
6. Delays occur in necessary follow-up required for labs, 
studies, and consults.
7. Ineffective disciplinary system doesn't support high quality 
care for Veterans.
8. Potentially dangerous health and safety problems perpetuate 
when advocates for quality care are removed from clinical 
settings.
9. The risk of patient care mistakes increases when providers 
are physically/mentally exhausted.
10. Malicious administrative conduct stifles the reporting of 
future legitimate patient care concerns and perpetuates unsafe 
situations.
11. Delays occur in completion of important administrative 
tasks related to patient care.
12. Increased potential for patient health care mistakes occur 
when there is loss of talented attending physicians who 
normally would guide students/new doctors to consistently 
deliver high quality medical care.

    C. Professional Implications (aggregate):

    In an unethical and unprofessional institutional culture, 
providers quickly develop high stress, low morale, and 
physical/mental exhaustion. Providers who advocate for patient 
care and safety against the local administration's status quo 
are isolated in their work environments, demoralized, and 
professionally impeded in their careers. In some cases, 
providers are exposed to extreme retaliation that can 
effectively ruin their medical careers in both the VA system 
and the private sector.

    D. Outcomes (aggregate):

1. Administrators have extremely effective methods to ensure 
compliance with their personal agendas which are disconnected 
from the mission and stated values of the Department of 
Veterans Affairs.
2. The VA system is unable to effectively retain and/or recruit 
well-qualified providers who have been/would be effective 
advocates for patient health and safety.
3. Veterans are denied the highest quality, efficient medical 
services within the VA despite VA administration having access 
to a talented pool of dedicated patient care providers already 
employed within the system.
4. The U.S. government loses money compensating for high staff 
turn-over and defending administrators' inappropriate personnel 
decisions.
5. The horizontal violence within the VA institutional culture 
propagates.
6. Outcomes 1 through 5 above threaten the viability of the VA 
and undermine its ability to meet and exceed our obligations to 
the nation's current and future Veterans.

 Detailed Explanation of Retaliation Tactics Against Title 38 Employees

    1. Sham peer review.

    Note: In contrast to a sham peer review, a professional 
peer review is a formal, lengthy review done of a physician's 
cases by his/her peers and is initiated only when there is 
legitimate concern the physician may not be following medical 
standards of care. The outcomes are based on objective 
findings, not subjective opinion.

    Tactic: A well-orchestrated attempt to sabotage a 
physician's credibility/professional reputation via organizing 
a sham review of cases by the administrator's associates/
cronies. Even though there is no objective evidence of improper 
care, the predetermined written ``findings'' imply the 
physician has, at a minimum, subjective deficiencies in 
professional or personnel qualities. (The practice of sham peer 
review is not considered a prohibited personnel practice. The 
Office of Special Counsel doesn't accept sham peer review 
cases.)

    Clinical implications: Veterans are denied the skills of 
talented, well-qualified physicians when those providers are 
relieved of patient care duties or fired due to unjustified 
accusations of poor medical skills.

    Professional implications: Professionally and personally 
devastating to the provider. The physician has to fight the 
sham findings at great financial expense in civil court or via 
the Merit Protections Board. For the rest of his/her 
professional career, the physician has to report on job 
applications and license renewals that he or she was the 
subject of a peer review.
    Outcome:

    a. Management can effectively and permanently sabotage a 
physician's ability to be gainfully employed anywhere as a 
physician inside or outside of the VA system.
    b. Threat of a sham peer review can effectively stifle 
physicians who want to voice serious concerns about patient 
safety.
    c. Fighting a sham peer review can financially devastate a 
physician who is pitted against the unlimited legal resources 
of the U.S. Department of Veterans Affairs.
    d. Patient care is delayed as yet another VA physician 
chooses to resign or retire instead of facing a sham peer 
review.

    2. Maliciously down-grading proficiencies.

    Tactic: Deliberately reducing the accuracy of a provider's 
yearly written performance evaluation on the whim of the 
administrator instead of completing the evaluation based on 
objective criteria normally used to judge accomplishments of 
providers.

    Clinical implications: Qualified candidates for direct 
patient care positions or supervising administrative positions 
are not promoted to positions where they can use their skills 
sets to fulfill the VA's mission for quality health care.

    Professional implications: Physicians and other providers 
are not allowed to expand their professional careers. If the 
provider decides to obtain a position at another VA or in an 
outside institution, the unfairly downgraded proficiencies make 
the provider less apt to be selected for the new position.

    Outcomes:

    a. Patients are denied the benefits of having the most 
qualified personnel in supervisory/other positions who would 
normally work toward efficient/high quality care.
    b. Management has a direct/efficient method of sabotaging 
the professional reputation of a provider who verbalizes 
concerns about patient safety, fiscal irresponsibility, or 
prohibited personnel practices.
    c. Management saves money on bonuses associated with 
providers who earn ``outstanding'' ratings on yearly 
proficiencies.
    d. Management wields significant power to create compliance 
with administrative edicts by granting monetary awards to 
providers based on whim instead of merit.
    e. Rank and file staff member burn-out.
    f. Impedance of a provider's ability to be employed in the 
private sector or at another VA.

    3. Deliberate understaffing of provider/Title 38 provider 
positions.

    Tactic: Vacancies or identified needs for staffing 
increases are ignored by administrators so that remaining Title 
38 employees have to manage ever-increasing patient loads.

    Clinical Implications: Provision of direct patient care 
services is greatly slowed. Providers are routinely managing 
complex patient loads that are 10%-50% above the VA's 
predetermined safe levels for provider patient panels. The risk 
of overlooking key patient needs is very high. There is often 
slowed clinical response to mountains of patient requests 
flooding provider's clinic.

    Professional Implications: Providers frequently worry about 
meeting the complex needs of huge patient panels that outstrip 
the available resources. Providers are also penalized on their 
yearly performance appraisals because they can't keep up with 
the unwieldy patient flow.

    Note: Unlike wage-grade, non-supervisory positions, Title 
38 employees can be penalized on performance appraisals even if 
deficiencies in care are directly related to chronic 
understaffing/excessive patient workloads.

    Outcomes:

    a. Patient appointments/consults are difficult to schedule 
because the provider is booked so far into the future.
    b. Delays in patient care and interpretation/communication 
of testing results/future needs.
    c. Senior administrators save money/reap potential bonuses 
for avoiding salary expenditures.
    d. Rank and file staff members burn-out as workweeks extend 
far beyond 50-60 hours and their yearly proficiencies drop 
despite every attempt by the provider to meet the needs of the 
vast patient load.

    4. Deliberate understaffing/failing to post positions for 
necessary ancillary personnel.

    Tactic: Vacancies or identified staffing needs are 
unanswered by managers so that basic clerical/ancillary 
functions of clinic are not addressed.

    Clinical implications: Direct patient care time is 
diminished due to additional, excessive daily tasks. Providers 
have to absorb those tasks in order to keep the clinic running. 
This pulls providers away from direct patient care time.

    Professional implications: Providers have their 
administrative & clinical time stretched so incredibly thin 
that they are often unable to fully meet the needs of their 
patients during any given day. Providers have to use off-duty 
time to meet their ethical and medical obligations to patients. 
They are also faulted for failing to meet clinical requirements 
or performance measurements in a timely fashion.

    Outcomes:

    a. Provision of direct patient care is slowed.
    b. Patient frustration because they don't understand why 
phones aren't answered, lab results aren't timely communicated, 
and messages aren't returned promptly.
    c. Management can reap bonuses for keeping labor costs low 
by avoiding the salary expenditures for hiring/replacing basic 
staff members.
    d. Management is able to wring more time out of salaried 
rank and file employees.
    e. Rank and file staff member burn-out as workweeks extend 
far beyond 50 hours and impossible standards of achievement are 
mandated.

    5. Inequitable distribution of extremely complex patients 
to overburden provider.

    Tactic: Extremely complex patients are ``dumped'' onto a 
provider's panel en masse without allowing the provider 
additional clinical time to address the patient needs at each 
visit. These patients are time-consuming in terms of physical/
clinical interactions needed to address multiple physical 
problems and approach the psychological issues inherent to the 
patient's ability to engage in the health care process.

    Clinical implications: Punitive and dangerous system used 
for managing care of complex Veterans. The provider is 
chronically ``running behind'' in clinic trying to meet the 
pertinent needs of each Veteran within an appointment timeframe 
that is too short for such a complex patient.

    Professional implications: Although the provider tries to 
give quality patient care to each Veteran, the provider is 
penalized on proficiencies and in meetings for ``taking too 
long'' with his/her patients despite the complexity of the 
patients. The provider is rated negatively by administrators 
because the provider cannot process the complex panel of 
patients as fast as fellow providers who have lighter/less 
complex patient panels.

    Outcomes:

    a. Management easily creates burdensome working conditions 
to harass staff member.
    b. Managers who have patient panels quickly can reduce 
their own work load/improve their own efficiency ratings by 
dumping complex patients onto other provider panels.
    c. Patient frustration because his/her assigned provider is 
chronically late starting appointments or only has time to deal 
with 1-2 active problems during the appointment.
    d. A greater number of patients can be neglected when 
provider time is routinely monopolized by fewer but much more 
complex patients.
    e. Rank and file staff member burn-out.
    6. Faulty clinical profile to overwhelm provider.

    Tactic: Providers are given inadequate administrative time 
to follow-up on electronic alerts and other administrative 
tasks. The clinic appointment time is reduced to a bare minimum 
in order to give the appearance of adequate provider staffing 
in the entire clinic.

    Note: Electronic alerts are computer notifications of 
various information of which the provider must be aware. 
Examples of electronic alerts include requests to co-sign chart 
notes or the receipt of results from labs, radiology studies, 
consults, or pharmacy actions. Although some alerts can be 
cleared in seconds, other alerts can take from 5-15 minutes 
each because follow-up action is required. At the Phoenix VA, 
primary care providers average 85 electronic alerts per day.

    Clinical implications: Delays occur in necessary follow-up 
required for labs, studies, and consults because providers are 
inundated with administrative tasks.

    Professional implications: Providers feel chronically 
overwhelmed and stressed. His or her yearly proficiency is 
downgraded because the provider is unfairly labeled as being 
``inefficient'' even though the provider has been assigned 
tasks that no human being reasonably could meet within a 40-50 
hour workweek.

    Outcomes:

    a. Management is able to wring more time out of salaried 
employees.
    b. Management can save money on proficiency bonuses for 
staff by reducing the number of providers labeled as 
``outstanding'' on yearly proficiencies.
    c. Rank and file staff members burn-out as workweeks extend 
far beyond 50-60 hours.

    7. Unjustified written counseling.

    Tactic: Written counseling is used only as a punitive 
stepping stone for unjustified disciplinary actions and as 
false justification for penalizing employee proficiencies.

    Clinical implications: Ineffective disciplinary system is 
created which doesn't ensure high quality care for Veterans. 
Providers who perform appropriately are penalized unjustly. 
Providers who demonstrate inappropriate behaviors are not 
issued written counseling as long as those providers are 
pleasing the administrative chain of command.

    Professional implications: Providers are helpless to defend 
themselves because written counseling doesn't rise to the level 
of disciplinary action that Title 38 employees are allowed to 
challenge.

    Outcomes:

    a. Administrators have an easy tool to discipline providers 
without being challenged.
    b. Written counseling is never used to correct 
inappropriate behaviors of providers who are favored by 
administrators.
    c. Rank and file staff member burn-out.

    8. Lateral transfer for factitious reasons.

    Note: Lateral transfers are allowed in only 3 situations: 
an employee requests the change and a vacancy is open in the 
new workstation; an employee faces a disciplinary action and 
management believes a new workstation would be a better fit for 
the employee's skill set; or there is a true ``critical need'' 
in another area which management must meet by transferring the 
employee to the new location even if the employee doesn't 
desire the transfer. Declining a ``critical need'' lateral 
transfer can result in disciplinary action against the 
employee.

    Tactic: An employee is laterally transferred to a less 
favorable work site based on a factitious ``critical need'' in 
the new area. Often the employee will then be penalized on his/
her proficiencies for not performing well in the new area.

    Clinical implications: Potentially dangerous health and 
safety problems perpetuate when advocates for quality care are 
removed from clinical settings.

    Professional implications: Providers become hesitant to 
verbalize concerns for patient health and safety in any work 
station.

    Outcomes:

    a. Management has a powerful tool to punish employees who 
persistently advocate for patient care/other issues against 
administration's party line.
    b. Effective, dedicated professionals are essentially 
``moth-balled'' to areas where they have less of an ability to 
effect positive change within the work-environment.

    9. Exploitation of ``24/7'' work contract.

    Note: A full-time federal Title 38 employee at one agency 
cannot work for another federal agency simultaneously even if 
the second agency's work hours fall within the federal 
employee's off-duty work hours from the first agency. In my 
limited understanding, I believe that the salaried Title 38 
employee contract has been interpreted in recent years to mean 
the employee can only be scheduled for 80 hours per 2 week pay 
period even if the actual work day extends far longer. When a 
Title 38 employee's workday inadvertently lasts more than the 
usual timeframe, the employee does not get paid overtime or 
comp time. A VA Title 38 employee may be scheduled to work more 
than 80 hours per 2 week pay period if the VA facility director 
declares an emergency at the VA facility. The true 
interpretation/implication of the 24/7 work contract needs to 
be officially clarified in writing by senior VA officials.

    Tactic: Clinics are set up with faulty administrative time/
odd hours that routinely extend the usual 8 hour/day (40 hours/
workweek) to 10-12 hours per day (50-70 hours/workweek).

    Clinical implications: The risk of patient care mistakes 
increases when providers are physically/mentally exhausted 
during any given workweek.

    Professional implications: Even if actual mistakes are not 
made, providers are physically/mentally exhausted and greatly 
fear making a critical mistake or overlooking important health 
care needs of their patients.

    Outcomes:

    a. Management is able to wring more time out of salaried 
employees.
    b. Providers are quickly burn-out as their personal/family 
time is steadily eroded.

    10. False accusations of patient privacy violations in 
retaliation for whistle-blowing.

    Tactic: Even though the employee uses the approved 
administrative channels of VA oversight, any provider who 
includes the necessary patient care information to support the 
allegations of wrong-doing is subsequently disciplined for 
violating patient privacy. In extreme cases of administrator 
wrath, the practitioner will be reported to his/her 
credentialing board for privacy violations.

    Note: Disclosure of pertinent patient care information in 
support of whistle-bower activity through approved channels of 
VA oversight is not a patient privacy violation. Unfortunately, 
the Office of Inspector General has declined thus far to put 
that opinion in writing. With lengthy legal efforts, these 
inaccurate disciplinary actions can be overturned, but the 
process may take years.

Clinical implications: Malicious administrative conduct stifles 
the reporting of future legitimate patient care concerns and 
perpetuates unsafe clinical situations. Patient care cannot 
rise to the high level of quality care needed by our Veterans 
until health and safety issues are reported and corrected.

    Professional implications: Fear of retaliation can silence 
providers or reduce their ability to effectively advocate for 
patients.

    Outcomes:

    a. Administrators have a powerful tool to suppress any 
information that may be contrary to a positive public image of 
the VA facility.
    b. The quality of patient care in the VA can never reach 
its full potential.
    c. The U.S. taxpayers foot the bill for legal wrangling 
between the VA who supports the disciplinary action and the 
Office of Special Counsel which is trying to overturn the 
disciplinary action.

    11. Assigning unreasonable timeframes for completion of 
excessive training requirements/tasks to penalize the provider.

    Tactic: Mandatory training requirements/task assignments, 
often assigned at the last minute, are required to be done 
within a short timeframe without allowing any flexibility in 
administrative time. If requirements/tasks are not completed, 
the provider is penalized on proficiencies or in write-ups.

    Clinical implications: Delays occur in the completion of 
important administrative tasks related to patient care. 
Administrative time for most providers is filled with daily 
tasks including reviewing mandatory electronic alerts. Being 
given additional tasks without additional time allowance means 
the providers may have to ignore administrative tasks related 
to patient care during allotted timeframes to complete the 
extraneous or nonessential tasks. This tactic erodes the Title 
38 employee's ability to complete other/more pressing 
administrative tasks within the course of daily duties.

    Professional implications: Staff frustration/burn-out 
because unreasonable time demands force the employees to use 
lunch breaks, weekends, or other off-duty hours to either 
complete training criteria/extra duties or follow-up on patient 
care administrative duties.

    Outcomes:

    a. Management is able to wring more time out of salaried 
employees.
    b. Rank and file staff member burn-out as workweeks extend 
far beyond 50-60 hours.

    12. Removal of teaching privileges to ostracize provider.

    Tactic: An administrator will exclude the physician from 
teaching privileges, an inherently renewing professional 
activity.

    Clinical implications: Increased potential for patient 
health care mistakes occur when there is loss of talented 
attending physicians who normally would guide students/new 
doctors to consistently deliver high quality medical care.

    Professional implications: Involuntary removal of teaching 
privileges isolates/ostracizes the professional provider within 
the workplace.

    Outcomes:

    a. Management is able to effectively isolate ``trouble-
makers'' within the work environment who threaten 
administrator's status quo.
    b. Quality of training in the facility is reduced by the 
loss of an effective educator.

SECTION V   VA Horizontal Violence: General Retaliation Tactics Against 
                            all VA Employees

                            Overview Summary

    A. Types of Retaliation:

    1. Open ridicule in meetings.
2. Anonymous ``report of contact'' writing campaigns to 
sabotage employee's credibility and justify malicious 
disciplinary actions.
3. Deliberate exclusion of employee from participation in 
projects necessary for promotion/career advancement.
4. Failure to promote on merit by willfully denying promotions 
to the best qualified candidate.
5. Reassignment/relocation in the workplace in order to debase 
an employee.
6. Abrupt firing of probationary employees who report patient 
care concerns, identify misuse of facility resources, and/or 
question violations of human resource policy.

    B. Clinical Implications (in numerical order based on 
retaliation type):

1. Legitimate hazards to patient care and safety remain 
unaddressed due to perpetuation of hostile work environment.
2. The firing, resignation, or failure to promote competent and 
dedicated employees impairs the quality of direct and/or 
indirect Veteran services.
3. The available staffing expertise is not utilized for the 
maximum benefit of the patients.
4. Because less qualified employees do not possess the 
mandatory traits/skills required for their new positions, the 
quality of all direct and/or indirect care is compromised.
5. An employee who feels debased often cannot perform new 
duties to meet the standards and requirements of the VA system.
6. Potential health and safety concerns are not addressed 
appropriately.

    C. Staff Implications (aggregate):

    In a system where there is disparate advancement 
opportunities, unequal balance of power, and emphasis on 
retaliation, qualified employees dedicated to the care of 
Veterans and the VA mission are subjected to horizontal 
violence that prevents them from achieving their full career 
potential and encourages them to seek career opportunities 
elsewhere. Less qualified employees are allowed to fill direct 
and indirect care positions which results in a lower standard 
of care throughout the VA system.

    D. Outcomes (aggregate):

    1. Administrators can employ a variety of retaliatory 
methods to debase employees and to suppress identification of 
system deficiencies that may make the administration look 
unfavorable.
    2. The system is unable to effectively retain and/or 
recruit employees who have been/would be effective advocates of 
health and safety in all aspects of the VA health care system.
    3. Veterans are denied high quality, efficient medical 
services within the VA despite administration having access to 
a talented pool of dedicated employees already working within 
the system.
    4. The U.S. Government spends inordinate amounts of money 
trying to legally defend administrators' retaliation against 
employees and also compensate for high staff turn-over.
    5. The horizontal violence within the VA institutional 
culture propagates.
    6. Outcomes 1 through 5 above threaten the viability of the 
VA and undermine its ability to meet and exceed our obligations 
to the nation's current and future Veterans.

  Detailed Explanation of Retaliation Tactics Against all VA Employees

1. Open ridicule in meetings.

    Tactic: In meetings and other personal interactions that 
don't leave a paper trail, administrators use verbal behavior 
such as raising voice, profanity, sarcasm, and interruption in 
response to an employee verbalizing concerns about safety or 
care. Nonverbal behaviors such as crossing arms, rolling eyes, 
and scowling are done while the employee is speaking about his/
her concerns.

    Clinical implications: Legitimate hazards to patient care 
and safety remain unaddressed due to perpetuation of hostile 
work environment.

    Staff implications: The employee immediately becomes aware 
he/she is displeasing administrators and is often humiliated in 
front of co-workers. Thereafter, employees remain silent to 
avoid becoming targets for administrative abuse.

    Outcomes:

    a. Management has a method of discouraging employees from 
voicing concerns about safety.
    b. Management can later claim ``no knowledge'' of the 
problem if the deficiency/issue later comes to the surface in 
another manner.
    c. Lines of facility communication are impaired because 
rank-and-file staff avoid meetings.

    2. Anonymous ``report of contact'' writing campaigns to 
sabotage employee's credibility and justify malicious 
disciplinary actions.

    Tactic: Administrators orchestrate a ``write-up'' campaign 
against an employee wherein the employee is the subject of 
falsified or exaggerated reports of contact from employee's co-
workers. The employee is never told who composed each ``report 
of contact'' write-up. The employee is then penalized/
disciplined within the workplace based on these write-ups 
against which the employee cannot easily mount a defense.

    In a variation of this tactic, an administrator will 
pressure co-workers into writing up reports of contact on 
incidents, even if those incidents are outdated and/or 
insignificant. The co-workers are forced to write up the 
employee or face retaliation themselves from the administrator. 
Co-workers who refuse are viewed as ``not being team players'' 
or are told they are ``unprofessional''. These derogatory 
labels will negatively affect future proficiencies for the co-
workers.

    Clinical implications: The firing, resignation, or failure 
to promote competent and dedicated employees impairs the 
quality of direct and/or indirect Veteran services.

    Staff implications: An employee feels attacked by unseen 
enemies or by his/her own co-workers.

    Outcomes:

    a. Administrators have a tool to easily justify 
disciplining employees on trumped-up charges or minor 
infractions.
    b. Administrators have a divisive tool to isolate an 
employee or break up a cohesive team of employees.
    c. Employees have significant distrust of each other.

    3. Deliberate exclusion of employee from participation in 
projects necessary for promotion/career advancement.

    Tactic: Administrators avoid assigning an otherwise 
qualified employee to participate in projects that are needed 
to advance the employee's VA career. This is done because the 
administrators view the employee as a threat to the current 
status quo.

    Clinical implications: The VA doesn't utilize its staffing 
expertise to the maximum benefit of its operational goals.

    Staff implications: An employee's potential remains 
undeveloped even though the employee otherwise is truly capable 
of expanding his/her role within the VA.

    Outcomes:

    a. Administrators have an easy way to prevent employees who 
are vocal on patient care issues from ever being given 
opportunities to achieve career fulfillment or advance into 
supervisory roles.
    b. Inappropriate utilization of staffing resources.
    c. Overall staff productivity is decreased.

    4. Failure to promote on merit by willfully denying 
promotions to the best qualified candidate.

    Tactic: Administrators deliberately overlook qualified 
candidates in favor of the administrators' friends/co-workers 
who conform to the unethical administrative power structure.

    Clinical implications: Because less qualified employees do 
not possess the mandatory traits/skills required for their new 
positions, the quality of all direct and/or indirect care is 
compromised.

    Staff implications: Employees with desired expertise are 
extremely frustrated because they are unable to apply those 
skills to the maximum extent possible within their own 
department. Positions are filled with candidates who do not 
possess the preferred expertise and qualifications for the job.

    Outcomes:

    a. An administrator has now filled positions of 
responsibility with unqualified individuals who continue to 
promote an unethical and unsafe work environment.
    b. Government monies are wasted on avoidable legal 
proceedings between the VA that supports the administrator and 
the Office of Special Counsel/EEOC which is trying to overturn 
the prohibited personnel action.

    5. Reassignment/relocation in the workplace in order to 
debase employee.

    Tactic: An experienced employee is transferred to an entry 
level position/other position that doesn't effectively use 
employee's skill set while the employee is being 
``investigated'' for an alleged infraction.

    Clinical implications: An employee who feels debased often 
cannot perform new duties to the standards and requirements of 
the VA system.

    Staff implications: An employee's dignity is reduced when 
removed from a role that he/she had great personal pride in 
fulfilling.

    Outcomes:

    a. Administrators have an effective tool to isolate an 
employee or break-up a cohesive group of workers who verbalize 
health/safety concerns.
    b. Inappropriate use of experienced staff member.
    c. Loss of productivity.

    6. Abrupt firing of probationary employees who report 
patient care concerns, identify misuse of facility resources, 
and/or question violations of human resource policy.

    Note: Administrators have the ability to fire any 
probationary employee without cause during a period of 
probation that can last up to 2 years. This ability is supposed 
to be judiciously applied only in situations where the employee 
is not a good fit for the VA.

    Tactic: As a way of filtering out new employees who express 
health/safety concerns or violations of other policies/
procedures, an administrator unjustly/abruptly terminates these 
probationary employees simply because they are viewed as a 
threat to the administrator's power base.

    Clinical implications: Potential health and safety concerns 
are not addressed appropriately within the work environment.

    Staff implications: Probationary employees are afraid to 
vocalize health and safety concerns because they fear 
unjustified job loss.
    Outcomes:
    a. Administrators have an effective leverage over 
probationary employees to suppress any identification of system 
deficiencies that may make the administration look unfavorable.
    b. In order to meet administrators' personal goals, there 
can be coercion of probationary employees to do activities that 
are not in keeping with VA official standards of conduct.

                                 

                    Prepared Statement of Mr. Davis

    Good evening, I'm Scott Davis, a Program Specialist at the 
Health Eligibility Center in Atlanta, Georgia. I filed for 
whistleblower protection in January 2014.
    I'd like to thank Chairman Miller, Ranking Member Michaud 
and the committee for their leadership and for providing a 
platform, so the voices of VA Whistleblowers can be heard.
    I urge the committee to take prompt action as time is 
running out. Every day a window of opportunity is closing on a 
Veteran to receive care before irreparable harm is done to 
their health or mental well-being. Because of the inaction of 
senior VA officials, some Veterans even face the burden of 
being billed for care their service has earned.
    As noted in the Office of Special Counsel's June 23rd 
report, VA leadership has repeatedly failed to respond to 
concerns raised by whistleblowers about patient care at VA. 
Despite the best efforts of truly committed employees at HEC 
and the Veteran Health Administration, who have risked their 
careers to stand up for Veterans, management at all levels 
ignored or retaliated against them for exposing the truth.

 CRITICAL ISSUES REPORTED TO SENIOR VA OFFICIALS BY WHISTLEBLOWERS AT 
                            THE HEC INCLUDE:

    1. Mismanaging critical Veteran health programs and wasting 
millions of dollars on an Affordable Care Act direct mail 
marketing campaign.
    2. The possible purging & deletion of over 10,000 Veteran 
health records at the Health Eligibility Center.
    3. A backlog of 600,000 pending benefit enrollment 
applications.
    4. Nearly 40,000 unprocessed applications discovered in 
January 2013. These were primarily applications from returning 
service members from Iraq and Afghanistan.

    THE HARASSMENT I EXPERIENCED AT THE HEC WAS FROM TOP LEVELS OF 
                              MANAGEMENT:

    1. My whistleblower complaint to White House Deputy Chief 
of Staff Rob Nabors was leaked to my manager Sherry Williams, 
who stated in writing, that she was contacting me on behalf of 
Acting Secretary Gibson and Mr. Rob Nabors. Neither Mr. Gibson, 
nor Mr. Nabors have responded to that fact.
    2. My employment records were illegally altered by CBO WFM, 
Director Joyce Deters.
    3. I was illegally placed on a permanent work detail by 
Assistant Deputy Under Secretary, Philip Matkovsky and Acting 
Chief Business Officer, Stephanie Mardon.
    4. I was placed on involuntary administrative leave, 
curiously at the same time the OIG's investigation was 
occurring in Atlanta by Acting HEC Director Greg Becker.

               UNFORTUNATELY MY EXPERIENCE IS NOT UNIQUE.

    Daron and Eileen Owens, who work at the VA Hospital in 
Atlanta, GA, have experienced the same retaliation for 
reporting medical errors and patient neglect as well as 
misconduct by senior VA police officials.
    Our Local 518 Union President, Daphne Ivery is routinely 
harassed as a direct consequence of assisting me and other 
disabled employees with addressing retaliatory actions by 
members of management. Mr. and Mrs. Owens as well as Ms. Ivery 
are Veterans. In fact over 50% of the 300 employees at our 
office are disabled Veterans.
    In 2010 allegations surfaced that applications for VA 
health care were being shredded at the HEC. Under the direction 
of the HEC Director and Deputy Director, Ms. Kimberly Hughes, 
Former Associate Director for Informatics and her team began to 
investigate this allegation. Her team discovered nearly 2,000 
applications that were reported as being processed in WRAP that 
did not appear as new enrollees in the Enrollment System.
    Ms. Hughes, investigation was abruptly closed by the HEC 
Director's Office. Although she completed a report of her 
findings it is unclear whether that report was given to the OIG 
or whether the nearly 2,000 Veterans who sought medical care 
from VA ever received the health care they earned. She was also 
subjected to harassment and intimidation, because she dared to 
advocate for Veterans!

           RELEVANCE TO THE COMMITTEE JUSTIFIES CLOSER REVIEW

    The whistleblower statements I have provided to the 
committee were also provided to the OIG and are more relevant 
to this committee than many may realize. I urge additional 
review of those whistleblower statements.
    In addition to providing specific examples of whistleblower 
harassment to the committee, I hope my testimony provides some 
insight on three key issues VA management fails to address:
    1. Reckless waste of federal funds and causing greater 
backlog of enrollment applications for the sole purpose of 
achieving performance goals.
    2. Why there is resistance to implementing proper and 
effective processing and reporting systems and the source of 
that resistance, as addressed by Dr. Draper during her 
testimony.
    3. The need to remove ineffective managers and the urgent 
need for the VA Management Accountability Act to be fully 
implemented, as stated by Mr. Griffin.

                 WHY IT IS SO CRITICAL TO ACT QUICKLY:

    More records and documents could be deleted or manipulated 
to mask backlog and mismanagement, due to system integrity 
issues.
    VHA is losing talented, committed individuals who continue 
to transfer to other agencies or are harassed to the point of 
resignation. The volume of EEO complaints should be examined.
    TV commercials are currently airing across the country 
about VA career opportunities. VA will not attract much needed 
health care professional to improve the quality of care, if it 
is known and even stated by current employees that ``VA is not 
a place you want to work!''
    Most importantly: transitioning management, clearing 
backlog, restructuring care, implementing new access programs 
and building a quality organization will require the 
intervention and strong oversight by Congress.
    Thank you again for this opportunity. I welcome your 
questions on the issues I've noted or any items I've submitted 
to the committee.

                                 

         Prepared Statement of Carolyn Lerner and Eric Bachman

    ``VA Whistleblowers: Exposing Inadequate Service Provided 
to Veterans and Ensuring Appropriate Accountability''
    July 8, 2014, 7:30 P.M.
    Chairman Miller, Ranking Member Michaud, and Members of the 
Committee:
    Thank you for the opportunity to testify today about the 
U.S. Office of Special Counsel (OSC) and our ongoing work with 
whistleblowers at the Department of Veterans' Affairs (VA). I 
am joined today by Deputy Special Counsel Eric Bachman, who is 
supervising OSC's efforts to protect VA employees from 
retaliation.

I. The Office of Special Counsel

    OSC is an independent investigative and prosecutorial 
federal agency that protects the merit system for over 2.1 
million federal employees. We fulfill this good government role 
with a staff of approximately 120 employees - and the smallest 
budget of any federal law enforcement agency. Our specific 
mission areas include enforcement of the Hatch Act, which keeps 
the federal workplace free of improper partisan politics. OSC 
also protects the civilian employment rights for returning 
service members under the Uniformed Services Employment and 
Reemployment Rights Act (USERRA). Over the last three years, 
OSC has successfully implemented the USERRA demonstration 
project this Committee established as part of the Veterans 
Benefits Act of 2010. With limited resources, we have found 
innovative ways to resolve USERRA claims and ensure that 
service members are positioned to succeed upon their return to 
the civilian federal workforce.
    In addition to enforcing the Hatch Act and USERRA, OSC is 
also uniquely positioned in the federal government to receive 
whistleblower disclosures and protect whistleblowers from 
retaliation. We do this in two distinct ways.
    First, we provide a safe channel for federal employees to 
disclose allegations of waste, fraud, abuse, illegality, and/or 
threats to public health and safety. We receive approximately 
1,200 whistleblower disclosures annually. If the disclosure 
meets the high threshold required for triggering a government 
investigation, we then refer it to the agency involved. After 
an OSC referral, the agency is required to investigate and 
submit a written report to OSC. OSC analyzes the agency's 
report, receives comments from the whistleblower, and transmits 
our findings and recommendations to the President and Congress. 
OSC's work with whistleblowers often identifies trends or areas 
of concern that require greater scrutiny and/or systemic 
corrective action. Our testimony today will provide additional 
detail on OSC's June 23, 2014 letter to the President and 
Congress, which made recommendations in response to dozens of 
whistleblower disclosures from VA employees across the country.
    Second, OSC protects federal workers from ``prohibited 
personnel practices,'' especially retaliation for 
whistleblowing. OSC receives approximately 3,000 prohibited 
personnel practice complaints annually, a number that has 
increased 51% over the last five years. Most of these 
complaints allege retaliation for whistleblowing or protected 
activity, such as cooperating with an OSC or Inspector General 
investigation. In these cases, OSC conducts the investigation 
and determines if retaliation or another prohibited personnel 
practice has occurred. After an investigation, OSC has the 
ability to secure relief on behalf of the employee and to seek 
disciplinary action against any employee who has engaged in 
retaliation. Our testimony today will provide the Committee 
with a summary of OSC's efforts to protect VA employees from 
retaliation.
    Finally, we will discuss a number of encouraging 
commitments made recently by the VA, in response to our June 23 
letter. If implemented, these commitments will go a long way 
toward ensuring that whistleblowers feel free to step forward, 
and that their information will be used to improve the quality 
of care within the VA system.

II. Whistleblower Disclosures

    As stated in our June 23, 2014 letter to the President, 
which is attached to this testimony, ``The goal of any 
effective whistleblower system is to encourage disclosures, 
identify and examine problem areas, and find effective 
solutions to correct and prevent identified problems from 
recurring.'' Unfortunately, too often the VA has failed to use 
the information provided by whistleblowers as an early warning 
system. Instead, in many cases the VA has ignored or attempted 
to minimize problems, allowing serious issues to fester and 
grow.
    Our June 23 letter raised specific concerns about ten cases 
in which the VA admitted to serious deficiencies in patient 
care, yet implausibly denied any impact on veterans' health. As 
we stated in that communication, ``The VA, and particularly the 
VA's Office of the Medical Inspector (OMI), has consistently 
used a `harmless error' defense, where the Department 
acknowledges problems but claims patient care is unaffected.'' 
This approach hides the severity of systemic and longstanding 
problems, and has prevented the VA from taking the steps 
necessary to improve quality of care for veterans.
    To help illustrate the negative consequences of this 
approach, we will highlight three cases that were addressed in 
the June 23 letter.
        1. Ft. Collins, CO
    In response to a disclosure from a VA employee in Fort 
Collins, CO, OSC received an OMI report confirming severe 
scheduling and wait time problems at that facility. The report 
confirmed multiple violations of VA policies, including the 
following:

         A shortage of providers caused the facility to 
        frequently cancel appointments for veterans. After 
        cancellations, providers did not conduct required follow-up, 
        resulting in situations where ``routine primary care needs were 
        not addressed.''
         The facility ``blind scheduled'' veterans whose 
        appointments were canceled, meaning veterans were not consulted 
        when rescheduling the appointment. If a veteran subsequently 
        called to change the blind-scheduled appointment date, 
        schedulers were instructed to record the appointment as 
        canceled at the patient's request. This had the effect of 
        deleting the initial ``desired date'' for the appointment, so 
        records would no longer indicate that the initial appointment 
        was actually canceled by the facility, resulting in faulty wait 
        time data.
         At the time of the OMI report, nearly 3,000 veterans 
        were unable to reschedule canceled appointments, and one nurse 
        practitioner alone had a total of 975 patients who were unable 
        to reschedule appointments.
         Staff were instructed to alter wait times to make the 
        waiting periods look shorter. Schedulers were placed on a ``bad 
        boy'' list if their scheduled appointments were greater than 14 
        days from the recorded ``desired dates'' for veterans.

    In addition, OSC is currently investigating reprisal 
allegations by two schedulers who were reportedly removed from 
their positions at Fort Collins and reassigned to Cheyenne, WY, 
for not complying with the instructions to ``zero out'' wait 
times. After these employees were replaced, the officially 
recorded wait times for appointments drastically ``improved,'' 
even though the wait times were actually much longer than the 
officially recorded data. The chart below, which was provided 
in the report to OSC, clearly illustrates this phenomenon. 
After the new schedulers complied with orders to ``zero out'' 
wait times, the officially recorded percentage of veterans who 
were ``scheduled within 14 days of [their desired date]'' 
spiked to nearly 100%. There is no indication that actual wait 
times decreased.
    Despite the detailed findings in their report, OMI 
concluded, ``Due to the lack of specific cases for evaluation, 
OMI could not substantiate that the failure to properly train 
staff resulted in a danger to public health and safety.'' This 
conclusion is not only unsupportable on its own, it is also 
inconsistent with reports by other VA components examining 
similar patient-care issues. For example, the VA Office of 
Inspector General recently confirmed that delays in access to 
patient care for 1,700 veterans at the Phoenix Medical Center 
``negatively impacted the quality of care at the facility.''
    It is important to note that OSC first referred these 
allegations to the VA in October 2013, providing the VA with an 
opportunity to assess and begin to address the systemic 
scheduling abuses occurring throughout the VA health system. 
Yet, as discussed, the OMI report, which was issued in February 
2014, failed to acknowledge the severity of the identified 
problems, mischaracterized the concern as a ``failure to 
properly train staff,'' and then did not consider how the 
inability to reschedule appointments impacted the health and 
safety of the 3,000 veterans who could not access care. There 
is no indication that the VA took any action in response to the 
deeply troubling facts outlined in the February 2014 report.

        2. Brockton, MA

    In a second case, a VA psychiatrist disclosed serious 
concerns about patient neglect in a long-term mental health 
care facility in Brockton, MA. The OMI report to OSC 
substantiated allegations about severe threats to the health 
and safety of veterans, including the following:

     A veteran with a 100 percent service-connected psychiatric 
condition was a resident of the facility from 2005 to 2013. During that 
time, he had only one psychiatric note written in his medical chart, in 
2012, when he was first examined by the whistleblower, more than seven 
years after he was admitted. The note addressed treatment 
recommendations.
     A second veteran was admitted to the facility in 2003, 
with significant and chronic mental health issues. Yet, his first 
comprehensive psychiatric evaluation did not occur until 2011, more 
than eight years after he was admitted, when he was assessed by the 
whistleblower. No medication assessments or modifications occurred 
until the 2011 consultation.

    Despite these findings, OMI would not acknowledge that the 
confirmed neglect of residents at the facility had any impact 
on patient care. Given the lack of accountability demonstrated 
in the first OMI report, OSC requested a follow-up report. The 
second report did not depart from the VA's typical ``harmless 
error'' approach, concluding: ``OMI feels that in some areas 
[the veterans'] care could have been better but OMI does not 
feel that their patient's rights were violated.'' Such 
statements are a serious disservice to the veterans who 
received inadequate patient care for years after being admitted 
to VA facilities.
    Moreover, in its initial referral letter to the VA, OSC 
noted that the whistleblower ``believed these instances of 
patient neglect are an indication of large systemic problems 
present at the Brockton Campus.'' When the whistleblower was 
interviewed by OMI, the whistleblower stated his belief that 
these were not the only instances of neglect, and recommended 
that OMI examine all the patients receiving mental health care 
in the facility. However, when OMI was onsite, they limited the 
investigation to the three specific individuals treated by the 
whistleblower. OMI did not conduct a broader review. 
Additionally, there is no indication that the VA took action in 
response to the detailed factual findings in the OMI report, 
including ordering a broader review of patient neglect at 
Brockton or in other long-term mental health care facilities.

        3. Montgomery, AL

    Finally, in Montgomery, AL, an OMI report confirmed a 
whistleblower's allegations that a pulmonologist copied prior 
provider notes to represent current readings for veterans, 
likely resulting in inaccurate recordings of patient health 
information and in violation of VA rules. Rather than recording 
current readings, the pulmonologist copied and pasted the 
patients' earlier recordings from other physicians, including 
the patients' chief complaint, physical examination findings, 
vital signs, diagnoses, and plans of care. Despite confirming 
this misconduct, OMI stated that it could not substantiate 
whether this activity endangered patient health. The timeline 
and specific facts indicate a broader lack of accountability 
and inappropriate responses by the VAMC leadership in 
Montgomery.
    In late 2012, the whistleblower identified six instances in 
which a staff pulmonologist copied and pasted information from 
prior patient visits with other physicians. The whistleblower, 
a surgeon, was first alerted to the possible misconduct by an 
anesthesiologist during a veteran's preoperative evaluation 
prior to an operation.
    The whistleblower reported these concerns to Alabama VAMC 
management in October 2012. In response to the whistleblower's 
report, VAMC management monitored the pulmonologist's medical 
record documentation practices. After confirming evidence of 
copying and pasting in medical records, the pulmonologist was 
placed on a 90-day ``Focused Professional Practice Evaluation'' 
(FPPE), or a review of the physician's performance at the VA. 
Despite additional evidence of improper copying and pasting of 
medical records during the 90-day FPPE, VAMC leadership ended 
the FPPE, citing satisfactory performance.
    Meanwhile, the whistleblower brought his concerns to OSC, 
citing mismanagement by VAMC leadership in handling his 
complaint, and a threat to veterans' health and safety caused 
by the copied recordings.
    OSC referred the allegations to the VA in April 2013. OMI 
initiated an investigation in May 2013. Despite confirming the 
underlying misconduct, OMI did not substantiate the 
whistleblower's allegations of mismanagement by VAMC leadership 
or threats to patient care. However, to its credit, OMI 
recommended that the Montgomery VAMC review all consults 
performed by the pulmonologist in 2011 and 2012, and not just 
the six known to the whistleblower.
    Far worse than previously believed, the review determined 
that the pulmonologist engaged in copying and pasting activity 
in 1,241 separate patient records.
    Despite confirming this widespread abuse, Montgomery VAMC 
leadership did not change its approach with the pulmonologist, 
who was again placed on an FPPE. Montgomery VAMC leadership 
also proposed a reprimand, the lowest level of available 
discipline.
    OSC requested, and has not yet received, information from 
the VA to determine if the 1,241 instances of copying and 
pasting resulted in any adverse patient outcomes. Despite the 
lack of confirmation on this critical issue, Central Alabama VA 
Director James Talton publicly stated that the pulmonologist is 
still with the VA because there was no indication that any 
patient was endangered, adding that the physician's records are 
checked periodically to make sure no copying is occurring. As 
VA headquarters completes its review of the patient records, we 
encourage the VA to also review the specific actions taken by 
Montgomery VAMC leadership in response to the confirmed 
misconduct.
    Beyond these specific cases, OSC continues to receive a 
significant number of whistleblower disclosures from employees 
at VA facilities throughout the country. We currently have over 
60 pending cases, all of which allege threats to patient health 
or safety. OSC has referred 28 of these cases to the VA for 
investigation. This represents over a quarter of all cases 
referred by OSC for investigation government-wide. Moving 
forward, it is critical that VA leadership, including the 
Office of the Secretary, review all whistleblower reports and 
proposed corrective actions to ensure that outcomes such as 
those described above are avoided.

III. Whistleblower Retaliation

1. Overview and scope of the problem

    OSC has received scores of complaints from VA employees who 
say they have been retaliated against for blowing the whistle 
on improper patient scheduling, understaffing of medical 
facilities, and other dangers to patient health and safety at 
VA centers around the country. Based on the scope and breadth 
of the complaints OSC has received, it is clear that the 
workplace culture in many VA facilities is hostile to 
whistleblowers and actively discourages them from coming 
forward with what is often critical information.
    OSC currently has 67 active investigations into retaliation 
complaints from VA employees. These complaints arise in 28 
states and 45 separate facilities. Approximately 30 of these 67 
cases have passed the initial review stage in our intake 
office, the Complaints Examining Unit, and are currently in our 
Investigation and Prosecution Unit, where they are being 
further investigated for corrective and disciplinary action. 
The number of cases increases daily. By way of example, OSC has 
received approximately 25 new whistleblower retaliation cases 
from VA employees since June 1, 2014.

2. Actions OSC has taken to investigate and address these cases

    In addition to the ongoing investigation of nearly 70 
retaliation cases, OSC has taken a number of steps to address 
and attempt to resolve these widespread complaints of 
whistleblower reprisal.

         OSC has reallocated staff and resources to 
        investigating VA whistleblower reprisal cases. These cases are 
        the office's highest priority and more than 30 attorneys and 
        investigators are currently assigned to these whistleblower 
        retaliation cases (in addition to all 14 employees in the 
        Disclosure Unit). We have also implemented a priority intake 
        process for VA cases.
         OSC representatives have met personally with VA 
        officials in recent weeks, including Acting Secretary Gibson, 
        Chief of Staff Jose Riojas, White House Deputy Chief of Staff 
        Rob Nabors, attorneys from the Office of General Counsel, and 
        others.
         OSC representatives recently traveled to Phoenix, 
        Arizona to meet with FBI and VA Inspector General agents who 
        are investigating the Phoenix VA cases, and also met with a 
        number of the Phoenix VA whistleblowers.
         In addition to this testimony, OSC continues to brief 
        the House and Senate Committees on Veterans Affairs on an 
        ongoing basis, and provide information to individual Members of 
        Congress who have concerns about disclosures or retaliation 
        claims in their states or districts.

3. Examples of relief obtained

    We cannot speak today about the details of ongoing reprisal 
cases, because doing so would jeopardize the integrity of the 
investigations and could improperly reveal the confidential 
identity of certain whistleblowers. However, we would like to 
mention a few cases where OSC has recently been able to obtain 
relief for whistleblowers:
    An employee in a VA facility in Florida raised concerns 
about a number of issues, including poor patient care. The 
highlights of the employee's complaint are as follows:

         The employee had worked for the federal government for 
        over two decades, including over 15 years with the VA. 
        Throughout this lengthy service, the employee received 
        ``outstanding'' and ``excellent'' job performance ratings and 
        had never been disciplined.
         However, soon after the employee reported the poor 
        patient care and other issues to the VA OIG in 2013, the VA 
        removed certain of the employee's job duties and conducted a 
        retaliatory investigation of the employee.
         Notably, in 2014, the VA also attempted to suspend the 
        employee but OSC was able to obtain a stay of the suspension 
        pending OSC's investigation of the matter.
         Due to the retaliatory environment, the employee 
        decided to transfer to a VA facility in a different state in 
        order to help protect the employee's job status and retirement 
        benefits.

    In a VA facility in New York, an employee complained to a 
supervisor about a delay in reporting a possible crime in the 
VA facility, as well as another serious patient care issue. The 
key points of the employee's complaint are as follows:

         Prior to blowing the whistle on this alleged 
        misconduct, the employee received high job performance ratings 
        as well as a bonus.
         However, soon after reporting the misconduct to a 
        supervisor, this same supervisor informed the employee that an 
        investigation into the employee's job performance would be 
        conducted, which could result in the employee's termination. 
        The basis for the investigation and possible termination was 
        that the employee was ``not a good fit for the unit.''
         The investigation was set to convene in late June 
        2014, but OSC was recently able to obtain a stay pending OSC's 
        investigation of the matter.

    A VA employee in Hawaii blew the whistle after seeing an 
elderly patient improperly restrained in a wheelchair, which 
violated rules prohibiting the use of physical restraints 
without a doctor's order.

         Almost immediately after this disclosure, the employee 
        was suspended for two weeks and received a letter of 
        counseling.
         OSC investigated the matter and determined the VA had 
        retaliated against the employee. As a result, OSC obtained 
        corrective action for the employee, including a rescission of 
        the suspension, full back pay, and an additional monetary 
        award. At OSC's request, the VA also agreed to suspend the 
        subject official who was responsible for the retaliation.

    The severity of these cases underscores the need for 
substantial, sustained cooperation between the VA and OSC as we 
work to protect whistleblowers and encourage others to report 
their concerns.

IV. A New and Better Approach from the VA

    While this has been a difficult period for the VA, it is 
important to note several encouraging signs from VA leadership 
suggesting a new willingness to listen to whistleblower 
concerns, act on them appropriately, and ensure that employees 
are protected for speaking out.

         In a June 13, 2014 statement to all VA employees, 
        Acting Secretary Gibson specifically noted, ``Relatively simple 
        issues that front-line staff may be aware of can grow into 
        significantly larger problems if left unresolved.'' We applaud 
        Acting Secretary Gibson for recognizing the importance of 
        whistleblower disclosures to improving the effectiveness and 
        quality of health care for our veterans and for his commitment 
        to identifying problems early in order to find comprehensive 
        solutions.
         In response to OSC's June 23, 2014 letter to the 
        President and Congress, Acting Secretary Gibson directed a 
        comprehensive review of all aspects of the Office of Medical 
        Inspector's operation. And, in response to OSC's 
        recommendation, he stated his intent to designate an official 
        to assess the conclusions and the proposed corrective actions 
        in OSC reports. We look forward to learning about the results 
        of the OMI review and believe the designated official will help 
        to avoid the same problematic outcomes from prior OSC 
        whistleblower cases.
         In their June 27, 2014 report to the President, Deputy 
        White House Chief of Staff Rob Nabors and Acting VA Secretary 
        Gibson confirmed that a review of VA responses to OSC 
        whistleblower cases is underway, recommended periodic meetings 
        between the Special Counsel and the VA Secretary, and 
        recommended completion of OSC's whistleblower certification 
        program as a necessary step to stop whistleblower retaliation. 
        We look forward to working with the VA on the certification and 
        training process.
         At a July 2014 meeting at OSC, Acting Secretary Gibson 
        committed to resolving meritorious whistleblower retaliation 
        cases with OSC on an expedited basis. We are hopeful this will 
        avoid the need for lengthy investigations and help 
        whistleblowers who have suffered retaliation get back on their 
        feet quickly. In the very near future, we look forward to 
        working out the details of this expedited review process and 
        providing these whistleblowers with the relief and protection 
        they deserve. Doing so will show employees that the VA's stated 
        intolerance for retaliation is backed up by concrete actions. 
        We will keep this Committee fully-informed on significant 
        developments in this area.

V. Conclusion

    In conclusion, we want to applaud the courageous VA 
employees who are speaking out. These problems would not have 
come to light without the information provided by 
whistleblowers. Identifying problems is the first step toward 
fixing them. We look forward to working closely with 
whistleblowers, the Committee, and VA leadership in the coming 
months to find solutions.
    We would be pleased to answer any questions that the 
Committee may have.
                                 

                Prepared Statement of James Tuchschmidt

    Good evening, Chairman Miller, Ranking Member Michaud, and 
Members of the Committee. Thank you for the opportunity to 
discuss whistleblower claims at the Department of Veterans 
Affairs (VA). I am accompanied today by Dr. Edward Huycke, 
Deputy Medical Inspector for the Veterans Health 
Administration's (VHA) Office of the Medical Inspector.
    Our core values at VA are Integrity, Commitment, Advocacy, 
Respect, and Excellence--``I CARE.'' To get to excellence, we 
rely on the integrity, experience, observations, insights, and 
recommendations of VA's front-line staff, those who work 
professionally and compassionately with Veterans each and every 
day. We value that input and rely on it to help us better serve 
Veterans. Clearly, we are deeply concerned and distressed about 
the allegations that employees who sought to report 
deficiencies were either ignored, or worse, intimidated into 
silence. Let me be clear, VA will not tolerate an environment 
where intimidation or suppression of reports occurs.
    Leaders are responsible for establishing a workplace 
atmosphere in which employees are comfortable highlighting and 
sharing their successes--as well as identifying areas in which 
we can improve. Whether that means notifying managers and 
supervisors of isolated gaps or bringing attention to larger, 
systemic issues that impede excellence, it is important that 
all employees are encouraged to report deficiencies in care or 
services we provide to Veterans. Relatively simple issues that 
front-line staff may be aware of can grow into significantly 
larger problems if left unresolved. In the most serious cases, 
these problems can lead to and encourage improper and unethical 
actions.
    Across VA, we expect workplace environments that protect 
the rights and enable full participation of all its employees. 
To that end, we have implemented biennial Workplace Harassment 
Prevention and the Notification and Federal Employee 
Antidiscrimination and Retaliation Act of 2002 (No FEAR Act) 
training for all 330,000+ employees VA-Wide to ensure they are 
aware and educated on their rights and responsibilities in 
these areas. We also recognize that supervisors and managers 
bear a heightened responsibility in maintaining a fair, safe, 
and inclusive culture. Accordingly, five years ago VA 
implemented additional mandatory Equal Employment Opportunity 
(EEO), Diversity & Inclusion, and Conflict Management training 
for all VA executives, managers, and supervisors VA-Wide. VA 
monitors compliance with this requirement on an on-going basis.
    We expect employees to bring to the attention of their 
managers and supervisors shortcomings in the delivery of our 
services to Veterans, any perceived violations of law, rule or 
regulation, official wrongdoing, gross mismanagement, gross 
waste, fraud, abuse of authority, or any substantial and 
specific danger to public health or safety. Intimidation or 
retaliation against whistleblowers--or any employee who raises 
a hand to identify a legitimate problem, make a suggestion, or 
report what may be a violation of law, policy, or our core 
values--is absolutely unacceptable.
    We all have a responsibility for enforcing appropriate 
workplace behavior. Protecting employees from reprisal is a 
moral obligation of VA leaders, a statutory obligation, and a 
priority for this Department. We will take prompt action to 
hold accountable those engaged in conduct identified as 
reprisal for whistleblowing, and that action includes 
appropriate disciplinary action. VA notifies all employees of 
their Whistleblower Protection rights annually in the 
Secretary's EEO, Diversity & Inclusion, No FEAR Act, and 
Whistleblower Protection Policy Statement. \1\ We strongly 
encourage all supervisors to review this policy statement with 
their employees and ensure their full understanding. VA also 
conducts annual site visits to select facilities in the field 
to review their compliance with these policies and educate the 
leadership in these critical areas. Recently, we have taken 
steps to strengthen and expand the scope of these reviews and 
technical assistance visits.
---------------------------------------------------------------------------
    \1\ Available at http://www.diversity.va.gov/policy/statement.aspx.
---------------------------------------------------------------------------
    Employees have several avenues of redress if they are 
confronted with whistleblower reprisal. Employees may file a 
complaint with the Office of Special Counsel (OSC) or appeal 
directly to the Merit Systems Protection Board. Employees are 
also always free to report whistleblower reprisal to a VA 
management official, to VA's independent Office of Inspector 
General (OIG), and to the Congress. VA emphasizes the 
importance of employees bringing their concerns forward and 
strongly encourages these actions. Each concern is taken 
seriously and addressed to the best extent possible.
    We would like to address incidents where the OSC asks the 
Secretary of Veterans Affairs to conduct investigations into 
whistleblower cases about the Department. These are 
investigations conducted pursuant to 5 U.S.C. Sec.  1213 and 
require VA to investigate and prepare a report of its 
investigation into the whistleblower disclosures. We take these 
investigations very seriously and they are undertaken 
immediately, as required by law. First, VA leaders are reminded 
of the mandate to protect whistleblowers from retaliation and 
other prohibited personnel practices. VA initially interviews 
the whistleblower, and follows up with him/her as often as 
necessary. Then, an investigation is conducted, which includes 
a site visit consisting of a document review, interview with 
individuals identified by the whistleblower, and any other 
appropriate individuals as determined by OMI. Reports generated 
by these investigations are reviewed and approved by VA 
leadership. VA facilities or program offices are required to 
complete action plans to address each report recommendation. VA 
tracks these action plans until completion. If appropriate 
progress is not apparent, subsequent on-site visits may be 
conducted. VHA will initiate administrative processes, when and 
where appropriate, to pursue disciplinary actions.
    There is a second type of OSC whistleblower reprisal 
complaint that is investigated by OSC pursuant to 5 U.S.C. 
Sec.  1214. In these cases, OSC works with VA to coordinate 
document discovery and interview requests with VA employees. If 
OSC finds there is sufficient evidence to support an allegation 
of a prohibited personnel practice, VA works with OSC to 
develop a meaningful way to resolve the complaint, normally 
through a settlement agreement between the whistleblower and 
VA. If a resolution is not reached, OSC may seek remedial 
action by filing an appeal against the Department with the 
Merit Systems Protection Board.
    On June 23, 2014, OSC sent a letter regarding complaints 
about VA care across the country. In response to the OSC 
letter, Acting Secretary Gibson directed a comprehensive review 
of all aspects of the Office of Medical Inspector's operation. 
The VA Medical Inspector, John Pierce, M.D., has retired. 
Acting Secretary Gibson has met with Special Counsel Carolyn 
Lerner and a number of other staff-level meetings have also 
occurred. VA intends to regularly meet with OSC officials. We 
welcome OSC's insights, and we look forward to working closely 
with its staff to improve our process and culture regarding 
whistleblower complaints going forward.
    VA is committed to making the changes necessary to ensure 
that we, in conjunction with OSC and OIG, properly investigate 
all allegations. We also will not tolerate retaliation against 
any employee who raises a hand to identify a legitimate problem 
or suggest a solution.
Conclusion
    Mr. Chairman, we will continue to depend on the service of 
VA employees and leaders who place the interests of Veterans 
above and beyond self-interest; who serve Veterans with 
dignity, compassion, and dedication; who live by VA's core 
values of Integrity, Commitment, Advocacy, Respect, and 
Excellence; and who have the moral courage to help us serve 
Veterans better by helping make our policy and procedures 
better. I assure you that VA takes these issues very seriously 
and will do everything possible to ensure we cultivate an 
environment that empowers our employees and demands 
accountability in service to our Veterans. Mr. Chairman, this 
concludes my testimony. My colleague and I are now prepared to 
answer your questions.
                                 

                   MATERIALS SUBMITTED FOR THE RECORD

           Letter to Hon. Miller From DVA, Inspector General

    Dear Mr. Chairman:
    I respectfully request that this letter be included in the 
record for the July 8, 2014, hearing before the Committee 
entitled, ``VA Whistleblowers: Exposing Inadequate Service 
Provided to Veterans and Ensuring Appropriate Accountability.'' 
At that hearing information was provided by two witnesses that 
was not accurate regarding the Office of Inspector General 
(OIG).
    a. Dr. Katherine Mitchell on Claimed Disclosures to the 
OIG--Dr. Mitchell testified that she submitted a confidential 
OIG complaint in September 2013 regarding life-threatening 
conditions at the Phoenix VA Health Care System and that 
approximately 10 days after the national VA received her report 
she was placed on administrative leave for a month. She further 
testified that she was disciplined for misconduct for providing 
confidential information through the OIG channels. Her 
testimony is inaccurate in regard to her interactions with the 
OIG. The OIG first received information relating to complaints 
by Dr. Mitchell in April 2014, and that information was 
provided by the Senate Committee on Veterans' Affairs, not Dr. 
Mitchell. We determined through inquiries with relevant 
congressional and VA staff that Dr. Mitchell submitted her 
complaint to the office of Senator John McCain in September 
2013, and that Senator McClain's office sent that information 
to the VA Congressional Liaison Service. VA's Congressional 
Liaison Service assigned the correspondence to the Veterans 
Health Administration (VHA) and an investigative team from the 
Veterans Integrated Service Network 18 was tasked with 
conducting an investigation into her allegations. The OIG was 
not aware of and did not participate in any review or 
investigation conducted by VHA. Dr. Mitchell's testimony 
implies that the OIG breached her confidentiality, which is 
simply untrue because she did not file a complaint with the OIG 
in September 2013.
    b. Dr. Mitchell on Providing Protected Information to the 
OIG--Dr. Mitchell further states in her written testimony that 
``Disclosure of pertinent patient care information in support 
of whistle-blower activity through approved channels of VA 
oversight is not a patient privacy violation'' and further 
states ``Unfortunately, the Office of Inspector General has 
declined thus far to put that opinion in writing.'' Her 
statement regarding the OIG is not accurate because Dr. 
Mitchell never asked the OIG to put such a statement in 
writing. While Dr. Mitchell may be unaware, the OIG has 
provided both written and verbal advice to complainants and 
other employees that they can legally provide protected 
information to the OIG. As recently as June 25, 2014, we 
addressed this issue in our response to a June 20, 2014, letter 
sent by the American Federation of Government Employees (AFGE) 
to Mr. William Gunn, former VA General Counsel. Copies of this 
response were sent to the Chairman and Ranking Members of the 
House and Senate Committees on Veterans' Affairs. A copy of the 
letter from AFGE and our response are attached.
    c. Dr. Mitchell on Publication of Reports Involving VA 
Senior Executives--Dr. Mitchell testified during the hearing 
regarding OIG policy for releasing reports on members of VA's 
Senior Executives either on our Web site or through our Release 
of Information office. She also stated that neither she nor 
Senator McCain had been able to obtain a copy of an 
investigation. Similar testimony was provided by Dr. Christian 
Head. I can assure you that the OIG follows all applicable laws 
and rules regarding release of information in both forums. 
Reports dealing with allegations of misconduct by VA employees 
are posted on the OIG's public Web site. All reports are 
identified on our Web site within 3 days of being issued as 
required by the Inspector General Act. Unless we have received 
a request under the Freedom of Information Act (FOIA), to 
comply with applicable confidential legal requirements, only 
the title of the report and other summary information are 
posted on our Web site. However once the requisite number of 
FOIA requests are received, a redacted report is posted on our 
Web site.
    To comply with FOIA and applicable case law, it is our 
practice to redact the names of employees and other individuals 
below the GS-15 level. When the issues in the report relate 
directly to an employee's duties and responsibilities, applying 
the analysis required under FOIA, it is usually determined that 
the individual's right to privacy is outweighed by the public's 
right to know for employees at or above the GS-15 level. In 
those instances, the names are not redacted when the report is 
posted on the OIG website. In the last 7 years, we have 
published on our website 33 reports of administrative 
investigations, of which 16 included substantiated allegations 
against one or more members of the Senior Executive Service 
whose names were fully disclosed in the reports. Dr. Mitchell's 
testimony that neither she nor Senator McCain have been able to 
obtain a copy of a report relating to her complaint and that 
the OIG was stonewalling Senator McCain is also inaccurate 
because, as noted above, her complaint was not forwarded to the 
OIG. In addition, after listening to the testimony, we reviewed 
our files and have no record of any request by Dr. Mitchell or 
Senator McCain for a report or any other records relating to 
Dr. Mitchell.
    d. Dr. Mitchell on the OIG's Phoenix Office--Dr. Mitchell 
also made comments during her testimony that the OIG staff 
assigned to the Phoenix area had a history of not conducting 
good investigations. The basis for her statement is not clear 
since she has not been involved in any of the investigations 
conducted by that office. The OIG's only presence in Phoenix is 
an Office of Investigations Resident Agency office on the 
campus of the medical center staffed with four Criminal 
Investigators who are highly trained, competent, and objective. 
If Dr. Mitchell would have contacted them, they would have 
followed OIG procedures for reviewing a complaint and would 
have protected her confidentiality. It is not uncommon for VA 
employees in Phoenix to contact our onsite Criminal 
Investigators either in-person or by telephone when they have 
concerns. In the past 5 years, the work conducted by the 
Phoenix OIG office has resulted in 192 arrests, 108 
administrative actions, and $9.4 million in monetary 
recoveries. These statistics refute the assertion that the OIG 
office in Phoenix does not conduct good investigations.
    e. Dr. Head on a Prior OIG Administrative Investigation--
Dr. Head made comments in his testimony relating to his 
participation in an OIG administrative investigation that needs 
to be clarified. Dr. Head stated that he received a subpoena 
from the OIG to testify in a case, which is not correct. With 
the exception of the Department of Defense OIG, no Federal OIG 
has testimonial subpoena power. The subpoena authority granted 
to Inspectors General under the Inspector General Act is 
limited to records. When conducting an investigation, we notify 
VA employees that we want to conduct an interview with the 
expectation that they will appear for the interview as required 
by VA regulation. Although the regulation provides that the 
failure to cooperate with an official investigation may result 
in a disciplinary action, the VA OIG has no authority to 
propose or take such an action.
    The investigative report cited by Dr. Head, which was 
issued in March 2007, is identified on our website but as a 
restricted report. Information in the report, including the 
identity of the individuals who were the subjects of the 
investigation, is protected from disclosure under the Privacy 
Act. Without a FOIA request, we are prohibited by law from 
releasing the information in the report as it relates to 
individuals identified in the report. We have no record of a 
FOIA request by Dr. Head or anyone else for this report. Had we 
received a request, the report would have been reviewed for 
release under FOIA. Also, Dr. Head testified that medical 
center management did not follow the recommendations of the OIG 
to take a specific administrative action. As we have advised 
the Committee in the past, the OIG does not make 
recommendations to VA in our reports to take a specific 
administrative action because a concurrence by VA on the report 
would deprive the employee of his or her right to due process.
    The OIG takes seriously its mission to review allegations 
of poor quality of care and goes to great lengths to protect 
all sources of information who request confidentiality as 
required by the Inspector General Act.
    Thank you for your interest in the Department of Veterans 
Affairs.
Sincerely,
    Richard J. Griffin, Acting Inspector General

                                 

               Letter to AFGE From DVA, Inspector General

    Dear Mr. Borer:
    I am responding on behalf of Mr. Richard J. Griffin, the 
Acting Inspector General, to your June 13, 2014, letter to Mr. 
William Gunn, addressing the disclosure of medical information 
by whistleblowers to the Department of Veterans Affairs Office 
of Inspector General (VA OIG) and the Office of Special 
Counsel. Based on our review of the applicable laws, I believe 
that the VA OIG may be the only entity with the authority to 
investigate allegations relating to patient care to which VA 
employees can legally provide medical and other protected 
information and remain confidential.
    Your letter primarily addresses issues relating to the 
disclosure of medical information protected under the Health 
Insurance Portability and Accountability Act (HIPAA). With 
regard to HIPAA, the implementing regulations specifically 
permit disclosures to ``a health oversight agency for oversight 
activities authorized by law, including audits; civil, 
administrative, or criminal investigations; inspections. . . . 
'' 45 CFR Section 164.512 (d). Section 164.502 (G) addresses 
disclosures by workforce members and business associates who 
are whistleblowers. This section allows for disclosure if the 
individual:
    Believes in good faith that the covered entity has engaged 
in conduct that is unlawful or otherwise violates professional 
or clinical standards, or that the care, services, or 
conditions provided by the covered entity has engaged in 
conduct that is unlawful or otherwise violates professional or 
clinical standards, or that the care, services, or conditions 
provided by the covered entity potentially endangers one or 
more patients, workers, or the public.
    However, the disclosure must be made to a:
    Health oversight agency or public health authority 
authorized by law to investigate or otherwise oversee the 
relevant conduct or conditions of the covered entity or to an 
appropriate health care accreditation organization for the 
purpose of reporting the allegation of failure to meet 
professional standards or misconduct by the covered entity. . . 

    The VA OIG has been determined to be a health oversight 
agency for the purposes of these regulatory provisions. 
Therefore, any disclosure of HIPAA protected records would be 
authorized.
    However, in addition to HIPAA, there are other statutes 
that prohibit the disclosure of VA medical records. These 
statutes have associated criminal penalties for wrongful 
disclosure. In addition to the Privacy Act, 5 U.S.C. Section 
552, other relevant statutes that can be found in Title 38 of 
the United States Code include: Section 5701, which protects 
veterans claims records (including medical records), Section 
5705, which protects medical quality assurance records, and 
Section 7732, which protects records relating to the diagnosis 
and treatment of drug and alcohol abuse, HIV, and sickle cell 
anemia. As discussed below, VA employees and contractors can 
provide these protected records or information obtained from 
these records to the VA OIG, without violating any of these 
statutes.
    The Inspector General Act specifically states that the 
Inspector General has access to all agency records. 5 U.S.C. 
App. Section 6. Neither HIPAA nor any of the statutes cited 
above prohibits the disclosure of medical records to the VA 
OIG. Accordingly, an employee can legally provide any VA record 
to the VA OIG.
    The Whistleblower Protection Act (WPA) prohibits officials 
from taking, threatening to take, or failing to take a 
personnel action with respect to any employee or applicant 
because of: ``Any disclosure to the Special Counsel or the 
Inspector General of an agency. . . . '' 5 U.S.C. Section 2302 
(b)(8)(B). This subsection of the WPA does not include any 
restrictions on the nature of the information provided to the 
Inspector General or the Special Counsel. In contrast, the 
statute states that disclosures to other entities are only 
protected if the ``disclosure is not specifically prohibited by 
law and if such information is not specifically required by 
Executive Order to be kept secret. . . . '' 5 U.S.C. Section 
2302 (b)(8)(A). This section also makes it a prohibited 
personnel practice to take, threaten to take, or fail to take 
any personnel action against any employee for ``cooperating 
with or disclosing information to the Inspector General of an 
agency or the Special Counsel in accordance with the applicable 
provisions of law.'' 5 U.S.C. Section 2302 (b)(8)(C). This last 
provision not only protects employees who file a complaint with 
the VA OIG, it also protects employees who cooperate with a VA 
OIG investigation, audit, or other review and who provide 
information to us during those reviews.
    We understand that employees are reluctant to make 
disclosures for fear of retaliation. The Inspector General Act 
also mandates that the VA OIG maintain the confidentiality of 
employees and others who file a complaint or otherwise bring 
information to our attention. 5 U.S.C. App. Sections 7 and 8L. 
When employees contact the VA OIG Hotline they are advised of 
their right to remain confidential or be anonymous and, if they 
choose to waive these rights, are asked to do so in writing.
    As noted above, the VA OIG has the authority to investigate 
allegations of wrongdoing in the VA. While, like the VA OIG, 
the Office of Special Counsel's (OSC) Disclosure Unit has the 
authority to receive allegations of violations of law, rule, or 
regulation or gross mismanagement of funds, an abuse of 
authority, or a substantial and specific danger to public 
health or safety, OSC has no authority to investigate these 
claims. If after reviewing the information OSC determines that 
an investigation is warranted, OSC is required to transmit the 
information to the appropriate agency head for investigation. 5 
U.S.C. Section 1213. Although OSC will not identify the 
complainant if confidentiality is requested, this may impact 
the agency's ability to conduct a thorough and comprehensive 
investigation of the issues.
    As you note in your letter, our reports may state that an 
allegation cannot be substantiated. In some cases this is 
because we obtained and reviewed additional information that 
refutes an allegation. In other cases, this is because the 
complainant has not provided sufficient information on which to 
base an investigation. When an employee submits a complaint to 
the VA OIG and requests confidentiality, we contact that 
individual to obtain any additional information he or she may 
have regarding their complaint, which may include records that 
the employee may not have identified or submitted due to 
concerns about the confidentiality of the records. This allows 
the VA OIG to conduct a more thorough and complete 
investigation without disclosing the identity of the source of 
the information than may be possible if the complainant is 
anonymous or the matter is referred to the VA OIG through a 
third party and the identity of the complainant is unknown.
    I hope this addresses your concerns about the legal 
implications relating to the disclosure of protected 
information to the VA OIG.

Sincerely,

MAUREEN REGAN, Counselor to the Inspector General

    The Honorable Sloan Gibson, Acting Secretary, Department of 
Veterans Affairs; The Honorable Carolyn Lerner, Office of 
Special Counsel

    The Honorable Bernie Sanders, U.S. Senate, Chair, Committee 
on Veterans' Affairs; The Honorable Jeff Miller, Chair, House 
Veterans' Affairs Committee

    The Honorable Michael Michaud, Ranking Member, House 
Veterans' Affairs Committee; The Honorable Richard Burr, 
Ranking Member, U.S. Senate, Committee on Veterans' Affairs
    The Honorable Rob Nabors, White House Deputy Chief of 
Staff; The Honorable W. Neil Eggleston, White House Counsel
    The Honorable Sylvia Mathews Burwell, Secretary of Health 
and Human Services; The Honorable Eric H. Holder, Jr., Attorney 
General
    Mr. J. David Cox, Sr., National President AFGE, Ms. Alma 
Lee, Council President, NVAC

                                 

           Letter to President Obama From Hon. Carolyn Lerner

    Dear Mr. President:
    I am providing you with the U.S. Office of Special 
Counsel's (OSC) findings on whistleblower disclosures from 
employees at the Veterans Affairs Medical Center in Jackson, 
Mississippi (Jackson VAMC). The Jackson VAMC cases are part of 
a troubling pattern of responses by the Department of Veterans 
Affairs (VA) to similar disclosures from whistleblowers at VA 
medical centers across the country. The recent revelations from 
Phoenix are the latest and most serious in the years-long 
pattern of disclosures from VA whistleblowers and their 
struggle to overcome a culture of non-responsiveness. Too 
frequently, the VA has failed to use information from 
whistleblowers to identify and address systemic concerns that 
impact patient care.
    As the VA re-evaluates patient care practices, I recommend 
that the Department's new leadership also review its process 
for responding to OSC whistleblower cases. In that regard, I am 
encouraged by the recent statements from Acting Secretary Sloan 
Gibson, who recognized the significant contributions 
whistleblowers make to improving quality of care for veterans. 
My specific concerns and recommendations are detailed below.

Jackson VAMC
    In a letter dated September 17, 2013, I informed you about 
numerous disclosures regarding patient care at the Jackson VAMC 
made by Dr. Phyllis Hollenbeck, Dr. Charles Sherwood, and five 
other whistleblowers at that facility. The VA substantiated 
these disclosures, which included improper credentialing of 
providers, inadequate review of radiology images, unlawful 
prescriptions for narcotics, noncompliant pharmacy equipment 
used to compound chemotherapy drugs, and unsterile medical 
equipment. In addition, a persistent patient-care concern 
involved chronic staffing shortages in the Primary Care Unit. 
In an attempt to work around this issue, the facility developed 
``ghost clinics.'' In these clinics, veterans were scheduled 
for appointments in clinics with no assigned provider, 
resulting in excessive wait times and veterans leaving the 
facility without receiving treatment.
    Despite confirming the problems in each of these (and 
other) patient-care areas, the VA refused to acknowledge any 
impact on the health and safety of veterans seeking care at the 
Jackson VAMC. In my September 17, 2013 letter, I concluded:
    ``[T]he Department of Veterans Affairs (VA) has 
consistently failed to take responsibility for identified 
problems. Even in cases of substantiated misconduct, including 
acknowledged violations of state and federal law, the VA 
routinely suggests that the problems do not affect patient 
care.''
    A detailed analysis of Dr. Hollenbeck's and Dr. Sherwood's 
disclosures regarding patient care at the Jackson VAMC is 
enclosed with this letter. I have also enclosed a copy of the 
agency reports and the whistleblowers' comments.

    Ongoing Deficiencies in VA Responses to Whistleblower 
Disclosures

    OSC continues to receive a significant number of 
whistleblower disclosures from employees at VA facilities 
throughout the country. We currently have over 50 pending 
cases, all of which allege threats to patient health or safety. 
I have referred 29 of these cases to the VA for investigation. 
This represents over a quarter of all cases referred by OSC for 
investigation government-wide.
    I remain concerned about the Department's willingness to 
acknowledge and address the impact these problems may have on 
the health and safety of veterans. The VA, and particularly the 
VA's Office of the Medical Inspector (OMI), has consistently 
used a ``harmless error'' defense, where the Department 
acknowledges problems but claims patient care is unaffected. 
This approach has prevented the VA from acknowledging the 
severity of systemic problems and from taking the necessary 
steps to provide quality care to veterans. As a result, 
veterans' health and safety has been unnecessarily put at risk. 
Two recent cases illustrate the negative consequences of this 
approach.
    First, in response to a disclosure from a VA employee in 
Fort Collins, CO, OSC received an OMI report confirming severe 
scheduling and wait time problems at that facility. The report 
confirmed multiple violations of VA policies, including the 
following:

         A shortage of providers caused the facility to 
        frequently cancel appointments for veterans. After 
        cancellations, providers did not conduct required follow-up, 
        resulting in situations where ``routine primary care needs were 
        not addressed.''
         The facility ``blind scheduled'' veterans whose 
        appointments were canceled, meaning veterans were not consulted 
        when rescheduling the appointment. If a veteran subsequently 
        called to change the blind-scheduled appointment date, 
        schedulers were instructed to record the appointment as 
        canceled at the patient's request. This had the effect of 
        deleting the initial ``desired date'' for the appointment, so 
        records would no longer indicate that the initial appointment 
        was actually canceled by the facility.
         At the time of the OMI report, nearly 3,000 veterans 
        were unable to reschedule canceled appointments, and one nurse 
        practitioner alone had a total of 975 patients who were unable 
        to reschedule appointments.
         Staff were instructed to alter wait times to make the 
        waiting periods look shorter.
         Schedulers were placed on a ``bad boy'' list if their 
        scheduled appointments were greater than 14 days from the 
        recorded ``desired dates'' for veterans.

    In addition, OSC is currently investigating reprisal 
allegations by two schedulers who were reportedly removed from 
their positions at Fort Collins and reassigned to Cheyenne, WY, 
for not complying with the instructions to ``zero out'' wait 
times. After these employees were replaced, the officially 
recorded wait times for appointments drastically ``improved,'' 
even though the wait times were actually much longer than the 
officially recorded data.
    Despite these detailed findings, the OMI report concluded, 
``Due to the lack of specific cases for evaluation, OMI could 
not substantiate that the failure to properly train staff 
resulted in a danger to public health and safety.'' This 
conclusion is not only unsupportable on its own, but is also 
inconsistent with reports by other VA components examining 
similar patient-care issues. For example, the VA Office of 
Inspector General recently confirmed that delays in access to 
patient care for 1,700 veterans at the Phoenix Medical Center 
``negatively impacted the quality of care at the facility.''
    In a second case, a VA psychiatrist disclosed serious 
concerns about patient neglect in a long-term mental health 
care facility in Brockton, MA. The OMI report substantiated 
allegations about severe threats to the health and safety of 
veterans, including the following:
    A veteran with a 100 percent service-connected psychiatric 
condition was a resident of the facility from 2005 to 2013. In 
that time, he had only one psychiatric note written in his 
medical chart, in 2012, when he was first examined by the 
whistleblower, more than seven years after he was admitted. The 
note addressed treatment recommendations.
    A second veteran was admitted to the facility in 2003, with 
significant and chronic mental health issues. Yet, his first 
comprehensive psychiatric evaluation did not occur until 2011, 
more than eight years after he was admitted, when he was 
assessed by the whistleblower. No medication assessments or 
modifications occurred until the 2011 consultation.
    Despite these findings, OMI failed to acknowledge that the 
confirmed neglect of residents at the facility had any impact 
on patient care. Given the lack of accountability demonstrated 
in the first OMI report, OSC requested a follow-up report. The 
second report did not depart from the VA's typical ``harmless 
error'' approach, concluding: ``OMI feels that in some areas 
[the veterans'] care could have been better but OMI does not 
feel that their patient's rights were violated.'' Such 
statements are a serious disservice to the veterans who 
received inadequate patient care for years after being admitted 
to VA facilities.
    Unfortunately, these are not isolated examples. Rather, 
these cases are part of a troubling pattern of deficient 
patient care at VA facilities nationwide, and the continued 
resistance by the VA, and OMI in most cases, to recognize and 
address the impact on the health and safety of veterans. The 
following additional examples illustrate this trend:

         In Montgomery, AL, OMI confirmed a whistleblower's 
        allegations that a pulmonologist copied prior provider notes to 
        represent current readings in over 1,200 patient records, 
        likely resulting in inaccurate patient health information being 
        recorded. OMI stated that it could not substantiate whether 
        this activity endangered patient health.
         In Grand Junction, CO, OMI substantiated a 
        whistleblower's concerns that the facility's drinking water had 
        elevated levels of Legionella bacteria, and standard 
        maintenance and cleaning procedures required to prevent 
        bacterial growth were not performed. After identifying no 
        ``clinical consequences'' resulting from the unsafe conditions 
        for veterans, OMI determined there was no substantial and 
        specific danger to public health and safety.
         In Ann Arbor, MI, a whistleblower alleged that 
        employees were practicing unsafe and unsanitary work practices 
        and that untrained employees were improperly handling surgical 
        instruments and supplies. As a result, OMI partially 
        substantiated the allegations and made 12 recommendations. Yet, 
        the whistleblower informed OSC that it was not clear whether 
        the implementation of the corrective actions resulted in better 
        or safer practices in the sterilization and processing 
        division. OMI failed to address the whistleblower's specific 
        continuing concerns in a supplemental report.
         In Buffalo, NY, OMI substantiated a whistleblower's 
        allegation that health care professionals do not always comply 
        with VA sterilization standards for wearing personal protective 
        equipment, and that these workers occasionally failed to place 
        indicator strips in surgical trays and mislabeled sterile 
        instruments. OMI did not believe that the confirmed allegations 
        affected patient safety.
         In Little Rock, AR, OMI substantiated a 
        whistleblower's allegations regarding patient care, including 
        one incident when suction equipment was unavailable when it was 
        needed to treat a veteran who later died. OMI's report found 
        that there was not enough evidence to sustain the allegation 
        that the lack of available equipment caused the patient's 
        death. After reviewing the actions of the medical staff prior 
        to the incident, OMI concluded that the medical care provided 
        to the patient met the standard of care.
         In Harlingen, TX, the VA Deputy Under Secretary for 
        Health confirmed a whistleblower's allegations that the 
        facility did not comply with rules on the credentialing and 
        privileging of surgeons. The VA also found that the facility 
        was not paying fee-basis physicians in a timely manner, 
        resulting in some physicians refusing to care for VA patients. 
        The VA, however, found that there was no substantial and 
        specific danger to public health and safety resulting from 
        these violations.
         In San Juan, PR, the VA's Office of Geriatrics and 
        Extended Care Operations substantiated a whistleblower's 
        allegations that nursing staff neglected elderly residents by 
        failing to assist with essential daily activities, such as 
        bathing, eating, and drinking. OSC sought clarification after 
        the VA's initial report denied that the confirmed conduct 
        constituted a substantial and specific danger to public health. 
        In response, the VA relented and revised the report to state 
        that the substantiated allegations posed significant and 
        serious health issues for the residents.

    Next Steps
    The goal of any effective whistleblower system is to 
encourage disclosures, identify and examine problem areas, and 
find effective solutions to correct and prevent identified 
problems from recurring. Acting Secretary Gibson recognized as 
much in a June 13, 2014, statement to all VA employees. He 
specifically noted, ``Relatively simple issues that front-line 
staff may be aware of can grow into significantly larger 
problems if left unresolved.'' I applaud Acting Secretary 
Gibson for recognizing the importance of whistleblower 
disclosures to improving the effectiveness and quality of 
health care for our veterans and for his commitment to 
identifying problems early in order to find comprehensive 
solutions.
    Moving forward, I recommend that the VA designate a high-
level official to assess the conclusions and the proposed 
corrective actions in OSC reports, including disciplinary 
actions, and determine if the substantiated concerns indicate 
broader or systemic problems requiring attention. My staff and 
I look forward to working closely with VA leadership to ensure 
that our veterans receive the quality health care services they 
deserve.
    As required by 5 U.S.C. Sec.  1213(e)(3), I have sent 
copies of the agency reports and whistleblowers' comments to 
the Chairmen and Ranking Members of the Senate and House 
Committees on Veterans' Affairs. I have also filed copies of 
the redacted reports and the whistleblowers' comments in OSC's 
public file, which is available online at www.osc.gov.

Respectfully,
Carolyn N. Lerner, President

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