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S. Hrg. 114–484 

IMPROVING VA ACCOUNTABILITY: 

EXAMINING FIRST–HAND ACCOUNTS OF 

DEPARTMENT OF VETERANS AFFAIRS 

WHISTLEBLOWERS 

HEARING 

BEFORE THE

COMMITTEE ON 

HOMELAND SECURITY AND 

GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

SEPTEMBER 22, 2015 

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

Printed for the use of the 

Committee on Homeland Security and Governmental Affairs 

( 
(II) 

COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS 

RON JOHNSON, Wisconsin Chairman 

JOHN MCCAIN, Arizona 

ROB PORTMAN, Ohio 

RAND PAUL, Kentucky 

JAMES LANKFORD, Oklahoma 

MICHAEL B. ENZI, Wyoming 

KELLY AYOTTE, New Hampshire 

JONI ERNST, Iowa 

BEN SASSE, Nebraska 

THOMAS R. CARPER, Delaware 

CLAIRE MCCASKILL, Missouri 

JON TESTER, Montana 

TAMMY BALDWIN, Wisconsin 

HEIDI HEITKAMP, North Dakota 

CORY A. BOOKER, New Jersey 

GARY C. PETERS, Michigan 

KEITH B. ASHDOWN, Staff Director 

KYLE BROSNAN, Counsel 

GABRIELLE A. BATKIN, Minority Staff Director 

JOHN P. KILVINGTON, Minority Deputy Staff Director 

BRIAN F. PAPP, JR., Minority Legislative Aide 

LAURA W. KILBRIDE, Chief Clerk 

LAUREN M. CORCORAN, Hearing Clerk 
(III) 

C O N T E N T S 

Opening statements: Page 

Senator Johnson ............................................................................................... 1 

Senator Baldwin ............................................................................................... 14 

Senator Tester .................................................................................................. 16 

Senator Ernst .................................................................................................... 19 

Senator Ayotte .................................................................................................. 21 

Senator Carper ................................................................................................. 25 

Senator McCain ................................................................................................ 27 

Senator Peters .................................................................................................. 48 

Senator McCaskill ............................................................................................ 50 

Prepared statements: 

Senator Johnson ............................................................................................... 61 

Senator Carper ................................................................................................. 63 

WITNESS 

TUESDAY, SEPTEMBER 22, 2015 

Sean Kirkpatrick, Chicago Illinois ......................................................................... 3 

Brandon W. Coleman, Sr., Ph.D. (c), LISAC, Addiction Therapist, Phoenix 

VA Health Care System, Phoenix, Arizona ........................................................ 5 

Joseph Colon, Credentialing Program Support, VA Caribbean Healthcare System, San Juan, Puerto Rico ................................................................................. 7 

Shea Wilkes, Licensed Clinical Social Worker, Overton Brooks VA Medical 

Center, Shreveport, Louisiana ............................................................................ 9 

Hon. Carolyn N. Lerner, Special Counsel, U.S. Office of Special Counsel ......... 35 

Linda A. Halliday, Deputy Inspector General, U.S. Department of Veterans 

Affairs .................................................................................................................... 37 

Carolyn Clancy, M.D., Chief Medical Officer, Veterans Health Administration, 

U.S. Department of Veterans Affairs; accompanied by Michael Culpepper, 

Acting Director, Office of Accountability Review ............................................... 39 

ALPHABETICAL LIST OF WITNESSES

Clancy, Carolyn: 

Testimony .......................................................................................................... 39 

Prepared statement .......................................................................................... 117 

Coleman, Brandon, W.: 

Testimony .......................................................................................................... 5 

Prepared statement .......................................................................................... 72 

Colon, Joseph.: 

Testimony .......................................................................................................... 7 

Prepared statement .......................................................................................... 78 

Halliday, Linda A.: 

Testimony .......................................................................................................... 37 

Prepared statement .......................................................................................... 110 

Kirkpatrick, Sean: 

Testimony .......................................................................................................... 3 

Prepared statement .......................................................................................... 65 

Lerner, Hon. Carolyn N.: 

Testimony .......................................................................................................... 35 

Prepared statement .......................................................................................... 97 

Wilkes, Sean: 

Testimony .......................................................................................................... 9 

Prepared statement .......................................................................................... 82 

(1) 

1The prepared statement of Senator Johnson appears in the Appendix on page 61. 

IMPROVING VA ACCOUNTABILITY: 

EXAMINING FIRSTHAND ACCOUNTS OF 

DEPARTMENT OF VETERANS AFFAIRS 

WHISTLEBLOWERS 

TUESDAY, SEPTEMBER 22, 2015 

U.S. SENATE,

COMMITTEE ON HOMELAND SECURITY

AND GOVERNMENTAL AFFAIRS, 

Washington, DC. 

The Committee met, pursuant to notice, at 9:34 a.m., in room 

SD–342, Dirksen Senate Office Building, Hon. Ron Johnson, Chairman of the Committee, presiding. 

Present: Senators Johnson, McCain, Ayotte, Ernst, Carper, 

McCaskill, Tester, Baldwin, and Peters. 

OPENING STATEMENT OF CHAIRMAN JOHNSON 

Chairman JOHNSON. Good morning. This hearing will come to 

order. I want to welcome certainly our witnesses. Thank you for 

your thoughtful testimony. 

I am going to keep my opening statement very short because we 

have a lot of witnesses, two panels. I also want to make sure that 

the Committee Members understand we are going to keep questioning to 5 minutes as well—unless we have very few Senators, 

and then we might open it up again. But it sounds like we are 

going to have some pretty good attendance. 

I do ask that my written opening statement, be entered into the 

record,1 without objection. 

As I read the whistleblower testimony as well as the testimony 

from representatives from the Department of Veterans Affairs (VA) 

and the agencies, and as we have held these whistleblower hearings, the question I have—coming from the private sector where, 

literally, I would be hanging a medal on individuals in my organization that would go through the layers of management to let me 

know what was happening on the shop floor, it is extremely difficult when you are the top of an organization to get that real information. Those people ought to be rewarded, not retaliated against. 

And the question that I will be asking everybody is: Why is retaliation so rampant within the Federal Government? We are focusing 

on the VA and the VA health care system here, but it is not isolated to the VA. And what is amazing to me is it seems pretty simple, pretty easy, unfortunately, for mid-level managers, within 
2 

these agencies and the Department to retaliate and terminate 

whistleblowers, but then it is enormously difficult apparently for 

department heads, Secretaries, top-level management to hold those 

people that retaliate against whistleblowers accountable, much less 

potentially even terminate them. 

So, that is the problem, and from my standpoint, having run organizations, there is nothing more corrosive to an organization 

than when individuals within that organization get away with mismanagement, retaliation, and they are not held accountable. Nothing more corrosive. And we have a real problem with the VA health 

care system, problems that we all want to see fixed, and to me this 

is in many respects at the heart of those problems. If we cannot 

hold individuals in the VA health care system and, quite honestly, 

any manager within the Federal Government accountable, we are 

going to continue to have problems within all these agencies. 

So I do want to point out, because it also is somewhat baffling, 

we have had on the books whistleblower protection laws for decades. The first whistleblower protection legislation really was the 

Lloyd-La Follette Act of 1912, followed by the Civil Service Reform 

Act of 1978, followed by the Whistleblower Protection Act of 1989, 

followed by the Whistleblower Protection Enhancement Act of 

2012. So this is a protection that has been well known for decades, 

really more than a century, and yet we still see retaliation against 

whistleblowers rampant within the Federal Government. 

So, the purpose of this hearing is to lay these issues on the table 

with some anecdotal stories here, some pretty powerful ones, to 

talk to the people in the agencies, and in good faith try and figure 

out a way to actually provide the whistleblower protection that will 

actually work so that we can get government to work more efficiently and effectively. 

One last thing I want to point out is that within our Senate office, because we value whistleblowers, they are essential, we have 

set up a website, and I want everybody to understand in the 

Federal Government you can come to our office by using 

whistleblower@ronjohnson.senate.gov. I encourage whistleblowers, 

if you feel uncomfortable talking to your Office of Inspector General, if you feel uncomfortable talking to your direct supervisor 

about these things, come to our Committee, and we will certainly 

hear your story and will offer whatever protection we certainly can. 

With that, our Ranking Member is going to be a little bit late. 

We will let him offer an opening statement when he gets here, 

probably between the panels. But it is the tradition of this Committee to swear in witnesses, so if you will all rise and raise your 

right hand. Do you swear that the testimony you will give before 

this Committee will be the truth, the whole truth, and nothing but 

the truth, so help you, God? 

Mr. KIRKPATRICK. I do. 

Mr. COLEMAN. I do. 

Mr. COLON. I do. 

Mr. WILKES. I do. 

Chairman JOHNSON. Thank you. Please be seated. 

Our first witness will be Sean Kirkpatrick. Mr. Kirkpatrick is 

testifying today on behalf of his late brother, Dr. Christopher Kirkpatrick. Dr. Kirkpatrick was a psychologist at the VA Medical Cen-
3 

1The prepared statement of Mr. Kirkpatrick appears in the Appendix on page 65. 

ter in Tomah, Wisconsin, who raised concerns about patient overmedication. On the day of his termination, Dr. Kirkpatrick tragically committed suicide. Sean is joined in the audience this morning by his sister, Kathryn. Mr. Kirkpatrick. 

TESTIMONY OF SEAN KIRKPATRICK,1 CHICAGO, ILLINOIS 

Mr. KIRKPATRICK. Thank you. My family would like to thank the 

U.S. Senate Committee on Homeland Security and Governmental 

Affairs for holding this hearing. 

It is an honor to be invited here to speak on behalf of my late 

brother, Dr. Christopher Kirkpatrick. On July 14, 2009, hours after 

being fired from the Tomah VA Medical Center, Chris committed 

suicide. Our family found out the next day that he was fired from 

the Tomah VA the morning he died. The reason they told us they 

fired him was for missing too many hours. 

Last winter, my family learned what really happened to Chris. 

Ryan Honl, a brave VA whistleblower and former Tomah VA employee, reached out to my family after he heard my brother’s story 

from Lin Ellinghuysen, president of the American Federation of 

Government Employees (AFGE) in Tomah. Ryan put me in touch 

with Lin, who provided my family with documentation which 

proved Chris had raised concerns about possible overmedications 

and other issues affecting his patients while he was employed at 

the Tomah VA. If not for Ryan and Lin, my family would have no 

idea what the truth was behind the circumstances leading to his 

suicide. 

Chris was having difficulty treating patients in the post traumatic stress disorder (PTSD) and substance abuse programs he 

oversaw because they were unable to alert and engage in therapy 

due apparently to the high level and type of medications they were 

prescribed. Apparently, Chris had learned a physician’s assistant 

had complained to the chief of staff, Dr. David Houlihan, that my 

brother was inappropriate in discussing medications that patients 

they both see are prescribed. 

In an email to his union representative written on April 23, 

2009, Chris addressed his concern that he was now in the cross 

hairs of the chief of staff for suggesting that patients may be overmedicated. He stated, ‘‘I have had words with the physician’s assistant about medications and possible side effect/adverse reactions 

patients were experiencing, but these conversations happened 

months ago. These situations put me in an ethical dilemma. Why 

this comes up as an issue now is open to interpretation. Based on 

what others have told me, I have every reason to be very afraid of 

Dr. Houlihan. I have sacrificed a lot to move up here and do the 

kind of work I excel at and help people. I need help.’’ 

Chris was subsequently reprimanded by his supervisor at the 

order of Chief of Staff Houlihan in the form of a written counseling 

on April 30, 2009. One of the points he made in the written counseling was that Chris should not be ‘‘educating patients about what 

medications they are on, and that he should avoid advising on 

medications altogether.’’ It is evident that those in charge were 

more concerned about disciplining my brother for questioning medi-
4 

cation practices rather than properly investigating the problem of 

overmedicated patients. 

On July 14, 2009, 10 months after he was hired, Chris was directed to report to the human resources (HR) office. Chris’ employment at the Tomah VA Medical Center was terminated during this 

meeting. Chris was told his services were no longer needed due to 

performance issues. Several frivolous allegations were made, all of 

which had no bearing. Chris stated, ‘‘I know why this is happening. 

It is because of the note I put in the patient’s chart. He was difficult and violent. He did not belong in this program. He stood at 

my office door and told me that he intended to do harm to me and 

my dog. I told you about this. The team decided this patient needed 

to be discharged and released from the program. On Thursday, 

July 9, he was still here. I charted this.’’ 

Please note that Chris took a vacation day on Friday, July 10, 

and used a sick day on Monday, July 13, because that threatening 

patient was not discharged and still there. Chris was terminated 

that Tuesday, July 14. 

He was a recent graduate psychologist studying for his license 

with a full patient load, facilitating the group therapies on his own, 

hearing in great detail about horrific events experienced by his patients, but yet he had no guidance and support, despite going 

through the proper chain of command for assistance more than 

once. His life’s goal of helping our Nation’s veterans battle PTSD 

through innovative psychotherapy techniques was jeopardized because he questioned dangerous medication practices. He did what 

was ethical and right, but was only met with retaliation. 

My family began to have hope that Chris, would be vindicated 

after all these years since it seemed that the VA was now taking 

a serious look at the many cases of retaliation against Tomah staff 

and the dangerously high number of medications being prescribed 

to the veterans there. However, the Office of Inspector General 

(OIG) white paper report released this past June was nothing but 

slanderous toward my brother and insulting to my family. It suggested that he was a drug dealer and it did not take his death seriously. Apparently, the VA is still retaliating against Chris even to 

this day. For my parents to have to read this public document after 

everything they have been through is outrageous and unconscionable. 

Chris acted in the interests of the veterans at his own expense 

when he raised concerns about the overmedication of VA patients. 

His life was threatened by a hostile patient, and his superiors did 

not discharge the patient after he was told they would. His pleas 

for support and help managing the complex cases he had were 

never acted upon. Knowing this now leaves my family with the belief that the VA failed Chris. Furthermore, we learned that the VA 

never even did an investigation into the suicide of one of its psychologists. 

The last thing that Chris said to Lin as she walked him to his 

car after he was fired was, ‘‘Try to get a support system so that 

no one else has to go through what I did! Will you please do that?’’ 

We are asking the same thing of this Committee. Thank you. 

Chairman JOHNSON. Thank you, Mr. Kirkpatrick. 
5 

1The prepared statement of Mr. Coleman appears in the Appendix on page 72. 

Our next witness is Brandon Coleman. Mr. Coleman is a Marine 

Corps veteran and addiction therapist at the Phoenix VA 

Healthcare System. Mr. Coleman raised concerns about improper 

care for suicidal veterans. Mr. Coleman. 

TESTIMONY OF BRANDON W. COLEMAN, SR., PH.D.1 (c), LISAC, 

ADDICTION THERAPIST, PHOENIX VA HEALTH CARE SYSTEM, PHOENIX, ARIZONA 

Mr. COLEMAN. Thank you, Mr. Chairman. VA whistleblowers 

risk the destruction of their careers for simply telling the truth. 

During my time at the Phoenix VA, I have lost six veterans to suicide. Each one is like a punch in the gut. I have walked suicidal 

veterans to the Phoenix VA emergency room (ER) after hours only 

to have them not watched and walk away unaccounted for. 

In October 2014, Phoenix VA social worker Penny Miller admitted to improperly accessing my own Health Insurance Portability 

and Accountability (HIPAA)-protected Veteran Medical Records. 

This was only the start of improper and unlawful behavior that 

would persist over the following year. 

On December 6, 2014, I came forward to the Office of Special 

Counsel (OSC) regarding the unsafe treatment of suicidal veterans, 

along with my records being improperly accessed. 

On January 12 and 13, 2015, ABC 15 ran stories regarding my 

OSC complaints. On the 13, hospital director Glen Grippen held a 

meeting with leadership of the Phoenix VA, to include Chief of 

Staff Dr. Darren Deering and VA Legal Counsel Shelley Cutts. 

Grippen proposed to terminate me for being on TV. Cutts advised 

Grippen that it was illegal to remove me because of the Whistleblower Protection Act. But then Cutts stated, ‘‘Brandon could possibly be removed for unrelated misconduct.’’ The problem with her 

statement is I had an exceptional employment record. 

On January 20, my section chief, Dr. Carlos Carrera, questioned 

my mental health. Later that day, I had a social worker accuse me 

of threatening him. It was simply not true. 

On the 21st, Director Grippen met with me to share my OSC 

concerns. The director made an eerie comment. He stated, ‘‘Brandon, I just want you to know you are not being terminated yet.’’ 

He actually used the word ‘‘yet.’’ He admitted to saying this in his 

Equal Employment Opportunity Commission (EEOC) testimony. 

On the 23rd, Social Work Chief David Jacobson held a meeting 

for 15 to 20 employees. An employee made an audio recording. An 

ER social worker stated ‘‘five suicidal vets had walked out of the 

hospital during the past week,’’ and Jacobson responded, ‘‘We have 

been really lucky that nothing bad has happened yet. It was sheer 

luck.’’ This proved suicidal vets were walking out of the hospital. 

On February 2, I was placed on administrative leave for allegedly 

threatening other employees. The letter stated I could receive care 

as a vet, but I had to check in and out with the VA police. I immediately called the OSC to begin a retaliation investigation. 

On the 3rd, Grippen shut down my highly successful 52-week 

Motivation for Change treatment program. Seventy-one high-risk 
6 

veterans no longer had long-term substance use disorder treatment. Those who are still alive still do not. 

On the 4th, employee Jared Kinnaman came forward to the OSC 

stating suicidal veterans were being mishandled. 

On the 26th, I attended a fact-finding regarding my placement 

on admin leave. I was personally escorted by VA police Lieutenant 

Robert Mueller. Lieutenant Mueller made me walk in front of him 

through the main hospital like I was a criminal. I was told by the 

fact finders after the meeting I would be cleared of any wrongdoing. 

On March 6, employee Lisa Tadano came forward to the OSC 

claiming suicidal veterans were being watched by janitors and volunteers. She learned employee Penny Miller had also accessed her 

treatment records without reason. 

On the 12th, I met with Secretary Robert McDonald when President Obama came to Phoenix. I told the Secretary it was highly 

questionable that I can have a one-on-one meeting with the most 

powerful man in the VA, yet if I go to the Phoenix VA for medical 

care, I have to check in and out with the VA police. 

On the 16th, the Veterans Benefits Administrator (VBA) said my 

service-connected injuries had improved and proposed to reduce my 

disability benefits by over $300 per month. The timing was highly 

suspect. 

On the 19th, I received a letter from Grippen stating I was no 

longer required to have a police escort. To date, I have never received a letter clearing me of wrongdoing. 

On April 9, I had a second sensitive patient access report (SPAR) 

pulled and learned two additional coworkers had improperly entered my medical records. 

On the 14th, I was walking through the VA hospital on my way 

to a 12-step meeting with friend and former Navy SEAL Carl 

Higbee. We were confronted by Grippen. I told Grippen what I was 

doing and went to attend the meeting that was open to the public. 

Six days later, on April 20, I received a ‘‘gag order’’ from Grippen 

forbidding me from speaking to any other Phoenix VA employees 

but saying I could get medical care as a vet. How does a veteran 

get medical care without being allowed to speak to a VA employee? 

By the 24th, over a dozen media outlets contacted the hospital 

forcing Grippen to amend the letter acknowledging my right to free 

speech. 

On August 12, I pulled a third SPAR report and learned another 

administrative officer named Troy Briggs has accessed my records. 

I have not received care since January 2015 at the Phoenix VA 

when I got these eyeglasses, yet this employee was in my records 

on April 20, the same day Director Grippen placed a gag order on 

me. Mr. Briggs is even cc’d to the gag order letter. Why would he 

be in my record on this same date? 

In closing, it is a privilege to work for the VA, not a right. All 

employees, including directors, must be held accountable. Today I 

am calling on the Committee to ask for a Department of Justice 

(DOJ) investigation into the improper accessing of my HIPAA-protected veteran treatment records as retaliatory acts and as a criminal act. I am also asking the Committee to call for an investigation 

into Grippen’s retaliation against me, including placing me on 
7 

1The prepared statement of Mr. Colon appears in the Appendix on page 78. 

admin leave on baseless grounds, and for his attempting to manufacture grounds for my removal. His actions violated Federal whistleblower law. 

I find it sad that the only time Congress can get an honest answer from the VA is when whistleblowers are asked to testify. 

There is something deeply disturbing about that fact. 

Thank you for the allotted time today. 

Chairman JOHNSON. Thank you, Mr. Coleman. 

Our next witness is Joseph Colon. Mr. Colon is a Navy veteran 

and a credentialing support analyst at the VA Caribbean 

Healthcare System in San Juan, Puerto Rico. Mr. Colon raised concerns about unfair hiring practices, improper veteran care, and 

misconduct by upper management. Mr. Colon. 

TESTIMONY OF JOSEPH COLON,1 CREDENTIALING PROGRAM 

SUPPORT, VA CARIBBEAN HEALTHCARE SYSTEM, SAN JUAN, 

PUERTO RICO 

Mr. COLON. Good morning, Members of Congress. My name is Joseph Colon. I am a credentialing program support at the VA Caribbean Healthcare System in San Juan, Puerto Rico. I filed for whistleblower protection in August 2014, and my case settled in July 

2015. Despite the above, retaliation against me and others similarly situated continues at that facility. 

Before I provide my account of the events that have taken place 

with me, I would like to thank Senator Ron Johnson, Ranking 

Member Thomas Carper, and the Committee for their leadership 

and for allowing me the opportunity to be a part of the hearing and 

to explain what happens to a whistleblower that comes forward. 

The whistleblowers in Puerto Rico’s facility really need the help 

from this Committee to ensure that whistleblower retaliation does 

not keep on happening at our facility and that the supervisors are 

held accountable. Unfortunately, our resident commissioner, Pedro 

Pierluisi, does not even issue one statement against whistleblower 

retaliation that occurs very often at this facility. Without proper 

oversight from our representative in Congress, it makes it even 

more difficult for us whistleblowers in Puerto Rico. 

There were numerous issues that I reported: a physician who 

killed a veteran while doing an authorized procedure that his 

spouse needed for her residency program; Mr. DeWayne Hamlin’s 

arrest for drunk driving and having a controlled substance without 

a prescription; director absences; veterans mental health issues; 

chief of staff salary concerns; a physician that gave an improper 

dosage to a Veteran ordered the veteran’s medical record be documented with incorrect information; physicians practicing with expired medical licenses and without clinical privileges; Legionella 

found in the physical therapy pool; community living center director, who was the direct supervisor of the area that was not helping 

elderly veterans with bathing, using the bathroom, feeding, and 

drinking, was promoted to associate chief of staff of geriatrics and 

extended care; registered sexual offender that provides disciplinary 

recommendations to management; unfair hiring practices, and limiting opportunities for veterans from outside the facility to apply 
8 

for jobs; my immediate supervisor’s fraud with the travel voucher 

program; the retaliation that I experienced from top levels of management at the VA in San Juan; investigated four different times 

for the same allegations; I was illegally placed on a permanent 

work detail on two different occasions; issued a proposed removal 

on two different occasions; received a 3-day suspension; no performance appraisal issued to me for the 20 months when I was on detail; non-selections when I applied for other positions in the hospital. 

The retaliation and harassment that I have experienced after the 

Office of Special Counsel settled my retaliation claim include: 

moved the Credentialing and Privileging Department from the fifth 

floor of executive suite to an office area with no windows on the 

third floor; the afternoon prior to me returning to my position, the 

Human Resources Manager Mr. Omar Ahmed issued an email 

warning his personnel that share the same lounge with me to not 

discuss any Human Resources business in the lounge area; no electronic email access for over 2 weeks; no work assignments for 3 

weeks; expired my high blood pressure refill medication without 

notifying me; not selected for the clinical administrative specialist 

position, even though I was the most experienced member of the 

Department. The two panel members that interviewed me are the 

same members that I reported wrongdoing about. 

Unfortunately, at the VA Caribbean Healthcare facility in San 

Juan, this is not the only incident of retaliation that has occurred 

under Mr. DeWayne Hamlin’s and Miss Nayda Ramirez’s and Dr. 

Antonio Sanchez’s leadership. These three individuals are directly 

responsible for all cases mentioned in my statement. 

Miss Rosayma Lopez, was issued a termination letter because 

she would not fabricate anything against me in her fact-finding. 

Dr. Ivan Torres reported numerous concerns with the compensation and pension physicians who were not complying with the compressed time work schedule. Both cases are right now with the Office of Special Counsel. 

Management here in San Juan, Puerto Rico, actually reward people that actually help them build a case to fire a whistleblower. 

Miss Maritere Acevedo, who conducted the fact-finding against 

me, was rewarded as the quality management director, even 

though she stated in my fact-finding, ‘‘In terms of Mr. Colon going 

over the chain of command and gathering information, this is seen 

as a pattern that does have an impact on the efficiency and effectiveness of his unit.’’ She also believes there is a potential ethical 

issue for becoming a witness in a discriminatory case. 

Mr. Victor Sanchez was rewarded with a promotion as medical 

administrative supervisor in Mayaguez even though he sanitized 

and deleted a portion of the document that was used against me 

and he could not provide the original document when the investigator asked for it. 

As you can see, in Puerto Rico, both these people were rewarded 

with better positions, but Miss Rosayma Lopez was issued a termination letter. The difference is because Miss Rosayma Lopez was 

ethical and failed to do what management wanted her to do. There 

is no better example that shows management’s unethical behavior 

and what levels they will go to fire the whistleblower. The Sec-
9 

1The prepared statement of Mr. Wilkes appears in the Appendix on page 82 

retary of the Veterans Affairs must do the correct thing and place 

Mr. DeWayne Hamlin, Miss Nayda Ramirez, and Dr. Antonio 

Sanchez on detail until an accurate investigation is completed regarding their conduct and their behavior toward those who dare to 

bring into the light abuse and mismanagement. 

If the Secretary of the Veterans Affairs fails to do so, he actually 

is accepting that a whole executive team can participate in retaliation and he actually supports it. How many veterans are being hurt 

because employees live in fear of retaliation? How can you run a 

successful organization without accountability? 

It is easy to retaliate against someone when the supervisor does 

not have to pay for attorney fees, is not held accountable, and the 

American taxpayers foot the bill when compensatory damages are 

being paid. 

I truly believe that since the Secretary of Veterans Affairs has 

failed to impose discipline to his employees, Congress should give 

that authority to the Office of Special Counsel to discipline employees who are found to have retaliated against a whistleblower. It is 

time to really protect future whistleblowers and implement a zero 

tolerance policy in regards to whistleblower retaliation. 

Thank you again for this opportunity. I welcome your questions 

on the issues I have noted or any items I have submitted to the 

Committee. 

Chairman JOHNSON. Thank you, Mr. Colon. 

Our final witness on this panel is Shea Wilkes. Mr. Wilkes is an 

Army veteran and a licensed clinical social worker at the Overton 

Brooks VA Medical Center in Shreveport, Louisiana. Mr. Wilkes 

raised concerns about secret wait lists at his facility He is also the 

co-founder of the VA Truth Tellers, a group of VA employees nationwide who have suffered hardships since reporting wrongdoing 

within the VA. Mr. Wilkes. 

TESTIMONY OF SHEA WILKES,1 LICENSED CLINICAL SOCIAL 

WORKER, OVERTON BROOKS VA MEDICAL CENTER, SHREVEPORT, LOUISIANA 

Mr. WILKES. Ladies, gentlemen, fellow Americans, I appreciate 

the opportunity to speak with you today in our great Nation’s capital, a capital that symbolizes courage and a free way of life that 

so many have stood tall, strong, and given their life to protect. 

Your continued concern for the state of medical care being provided to our Nation’s veterans is greatly appreciated. I thank everyone in this room for their continued efforts to right the faltering 

Department of Veterans Affairs. 

Throughout history, the success and failures of countries across 

the world have often balanced upon how that country has cared for 

those who have borne the battle. I believe all of us here today can 

agree a country that does not care for its veterans can quickly become a rudderless ship destined for disaster, for a country that will 

not live up to its promises made to its veterans willing to give everything to protect a way of life will quickly forget promises to its 

people. 
10 

In our great Nation, there is an overwhelming support for our 

military and our veterans. From Bunker Hill to Helmand Province, 

Afghanistan, our Nation’s veterans have faced what seemed to be 

insurmountable odds only to succeed time and time again in protecting a way of life preserved in a sacred document that resides 

a short distance from where we sit this very day. 

For some time, we the people have entrusted the caring of our 

Nation’s veterans to the Department of Veterans Affairs. Unfortunately, reality here today is somehow this trust is being strained 

by what has become a bloated, unaccountable bureaucracy whose 

leadership is incompetent, often more concerned with its public 

image, and perpetrating its own existence than it is with providing 

first-rate medical care to our Nation’s veterans, which they have 

earned and deserve. 

I am here today to fight for accountability, leadership, and competency in our VA health care system. I am here for those Truth 

Tellers who have shown integrity, despite knowing for certain that 

despicable and hateful retaliation will be imposed for coming forward. I am here for my brothers and sisters at arms, both past and 

present, and future, to assure our Nation does not forget where it 

comes from, who is protecting it today, and who is going to assure 

it is protected forever: veterans. 

What has happened to Shea Wilkes will not even be a footnote 

in history. However, I hope my voice will be heard by our leaders 

and the American people. I hope that you will hear VA Truth Tellers’ voices within my voice and will unveil the truth hidden inside 

the walls and swept under the rugs of the VA system. 

I hope that our Truth Teller voices and your action will become 

a resounding chorus demanding and forcing change for our heroes. 

I was asked to tell you my story, but, no, I am not here for myself. If I were, my story would be of little interest. I can tell you 

that my story is not compelling because it has happened to Shea 

Wilkes; rather, it is compelling because it is a mirror image of how 

VA whistleblowers across this country have been treated. 

My situation, like other whistleblowers across this Nation, is a 

product of a contagious disease within the very fabric of the VA 

system itself. Whistleblowers are shunned, isolated, defamed, and 

accused of trying to destroy the VA. Those of us Truth Tellers that 

are also veterans have our VA personal medical records accessed 

and information in those records used in attempts to discredit us. 

We are placed in positions away from others, oftentimes below our 

ability levels. We are never given the same opportunities we once 

had. 

Truth Tellers are labeled problem children, troublemakers, crazy, 

and much more. We are put under criminal investigations for nonsense in an effort to scare and intimidate. Once a Truth Teller 

comes forward, they are alone, left gasping for air, and desperately 

trying to protect themselves from the good old boys of VA that have 

them in their cross hairs. 

I could continue, but we know the VA is still hiding issues and 

not being truthful. We know VA OIG has not been independent but 

yet working with the VA to damage control, whitewash, and intimidate Truth Tellers and potential whistleblowers. The VA OIG investigations have not been after the truth as they would attempt 
11 

to make us believe. VA OIG investigations have been half-assed 

and shoddy. We could line whistleblowers up from around this 

country out this door and around this building and ask about the 

VA OIG. The overwhelming majority would answer: ‘‘The VA OIG 

is a joke.’’ 

No longer are Truth Tellers allowing the VA OIG to dictate, intimidate, bully, and isolate, and they cannot stand it. VA Truth 

Tellers have the inside knowledge of how deeply embedded corruption is in the VA system, and we are going to continue to share it. 

VA Truth Tellers across the Nation are joining to have one voice, 

and it has made the knees of the VA giant shake. 

In closing, I say to those in this room, I say today the VA deception, deceit, and lies have gone on long enough. I speak to the leaders of Congress, OSC, new OIG leadership, VA Truth Tellers, potential whistleblowers, American taxpayers, and veterans, we must 

draw a line in the sand today and say, ‘‘No more.’’ No more will 

we allow VA leaders to take aim at whistleblowers brave enough 

to expose VA wrongdoings. No more will we allow the VA wasteful 

and fraudulent spending of American tax dollars. No more will we 

allow the VA to provide those that have borne the battle anything 

but the best care in this world. And no more will we allow the VA 

to chip away at the very foundation this country has stood on for 

generations, that our veterans have drawn a weapon to protect. 

The time has come for each of us in this room to stand 

together—E Pluribus Unum—and to tell the VA, ‘‘No more.’’ 

Thank you for your time. May God bless each of you and may 

God bless the United States of America. 

Chairman JOHNSON. Thank you, Mr. Wilkes, and thank you all 

for your powerful testimony. 

I will start with you, Mr. Wilkes. In reading your testimony, the 

written testimony, I was struck by the criminal investigation, the 

intimidation. Can you just talk to me a little bit about exactly what 

you did? My understanding is you took—you understood the wait 

list, that veterans were waiting and obviously not getting the care 

they deserved. But you presented that to the Office of Inspector 

General, which would have been the proper venue. And then later 

on you were really the target of a criminal investigation. Is that 

true? 

Mr. WILKES. Yes, sir. Let me state this: Wait lists are just one 

tool that was being used for manipulation of scheduling and numbers, and, I brought forward—I knew there were wait lists. I was 

actually, in mental health leadership, had done stuff for the directors, and I had heard about it in meetings, and I just kind of followed up with it and just kept seeing it. And probably about 10 

months before hand, in June 2013, 10 months before Phoenix came 

out, I reported it to the Inspector General (IG) and I never heard 

from it. Basically I was systematically removed from any leadership over time. 

Finally, when Phoenix came out, I said, ‘‘You know what? This 

is my shot. This is another shot that I may get.’’ And I did report 

that. After encouragement—— 

Chairman JOHNSON. But, again, reported it to the Office of Inspector General. 
12 

Mr. WILKES. Yes, sir, again, and I reported it and went to the 

media. And when they came in finally about a month and a half 

after all this, they called, they said they wanted to meet with me. 

I said yes. They asked, ‘‘Hey, you want to come off campus and 

meet?’’ And I said, ‘‘I am not bringing this list off campus.’’ I said 

no. And I said, ‘‘I have it here secured and everything. It is on my 

hard drive.’’ And then what happened after that is they came up, 

we talked, they secured the list, and then it went—they said, ‘‘We 

are going to go talk to people,’’ which they ended up talking to basically those that, if there was a list, would have something to lose. 

Then we found out later about some of the questions. They came 

back. I was, like, oh, this does not make any sense. So at that time, 

I contacted my lawyer, and we were told, yes, there was an issue 

with how I got the list and of that such. And basically after that, 

they never really asked anything about that. 

Chairman JOHNSON. So, again, you were expecting the Office of 

Inspector General to come in and be shocked at this wait list. But 

instead what you found is the Office of Inspector General was basically coming in and kind of laying the groundwork for a potential 

criminal investigation against you for revealing the wait list. 

Mr. WILKES. Right. My opinion—— 

Chairman JOHNSON. So it is basically retaliation by the Office of 

Inspector General against you. 

Mr. WILKES. Right. My opinion is they came in to basically damage control and scare the heck out of me and anybody else that 

knew about it and potentially—there are witnesses that know that 

it was there. There are witnesses that know they were going in and 

out of scheduling and doing that. But when they did that, everybody shut down. Stories changed. 

Chairman JOHNSON. So, obviously, one form of retaliation is intimidation. 

Mr. WILKES. Yes, sir. 

Chairman JOHNSON. To prevent you from and, by the way, prevent anybody else from coming forward, when you say damage control. 

Mr. WILKES. Yes. 

Chairman JOHNSON. Mr. Kirkpatrick, again, thank you for your 

powerful testimony. Were you aware, as you have gone through the 

records now and you have seen some of these things, were you 

aware—was your brother, Chris, ever given any warning before he 

was called in to that one meeting and fired? 

Mr. KIRKPATRICK. Not to my knowledge, no. I think he kind of 

felt that that was a potential outcome, but I think he was surprised 

when he saw it that day. And I believe he contacted Lin 

Ellinghuysen right away saying he was concerned about this, and 

then she mentioned that, well, we should prepare for the worst, 

that it might be, your termination. 

Chairman JOHNSON. And the termination was predicated, the rationale was he missed a few days or abused some free time. I 

mean, that is basically what the termination was about? 

Mr. KIRKPATRICK. Essentially, yes. One of the allegations was 

that he brought his dog into work one day, which they did not deny 

that he had permission to do so; but that when he stepped away, 

the dog, made a mess and somebody else had to clean it up. Other 
13 

things they pointed out were that he was taking a lot of vacation 

time. I wanted to include that in my statement but for time reasons I did not, but his response was that for his own well-being he 

had to take additional days off because he did not have the support 

or anybody to talk to, and he was being overloaded. He was a graduate psychologist, and from what I can tell, I mean, he had a full 

caseload, very complex cases, and—— 

Chairman JOHNSON. I am going to give you an opportunity right 

now to kind of lay out your recommendations based on that, but 

I just want to quickly drill down because I think it is tragic, quite 

honestly. It is to me just unbelievable. I come from the private sector. You always hear ‘‘at-will employment.’’ It is really not so. I 

mean, certainly as a private sector company, you have to go 

through a series of steps—warnings, counseling, talking to 

people—before you would even consider terminating someone just 

out of basic humanity, but also from a legal standpoint. And yet 

your brother was basically called into an office, terminated for 

what I would consider the flimsiest of reasons—and, again, from 

my standpoint, as a result it is obvious he was being retaliated 

against because he was raising the issue of drug overprescription 

resulting in real harm to our veterans. 

But in your testimony, you have a list of recommendations. 

Again, I think it is powerful testimony. 

Mr. KIRKPATRICK. I do. Thank you. 

Chairman JOHNSON. I want everybody to read it, about the pressures that those individuals like your brother who are trying to 

help our veterans deal with some very difficult psychological and 

mental issues and addiction issues, the pressures they are under 

and how there is just not much help for them. 

Mr. KIRKPATRICK. Thank you. I appreciate the time. 

Chairman JOHNSON. Please, talk a little bit about that and lay 

out those recommendations. 

Mr. KIRKPATRICK. Well, we have quite a few here. I will just read 

through them. And let it be known, too, that I consulted with Lin 

Ellinghuysen again and to kind of see what she thought would also 

be the most effective recommendations. 

No. 1, we encourage—I am sorry. We urge Congress to mandate 

the development of a comprehensive support system for VA medical 

and mental health care professionals that provide needed consultation services with trained professionals as part of their employment 

and not to be seen as private treatment. These support services 

and consultations must maintain strict confidentiality. Currently, 

all that is offered at the Tomah VA are one or two sessions with 

a VA-provided counselor; after that, employees are left to manage 

these very intense job duties on their own without time to debrief, 

refresh, or regroup. Particularly, psychotherapy with veterans is 

difficult and draining and can take a great deal out of a clinician 

emotionally and physically. 

No. 2, if not licensed when hired, graduate psychologists are required to be licensed within 2 years. They are not given adequate 

time to prepare for the exam. Mentors could ensure that there is 

appropriate patient care assignments and time set aside for study. 

Note: Prep for exam requires 20 hours a week of study time for 3 
14 

to 6 months. And that recommendation actually came from somebody who has completed it. 

As a graduate psychologist, Chris was expected to counsel veterans with complex needs, facilitate group therapy, participate in 

care planning team meetings, along with all of the required reporting and documentation. 

No. 3, develop Veterans Health Administration (VHA) protocols 

for investigation of suicides of employees and recently terminated 

employees. The Tomah VA management and police did not investigate my brother Chris’ death. 

No. 4, develop VHA protocols for addressing threats patients 

make against staff. 

No. 5, we also request that lawmakers investigate the pervasive 

use of extended temporary appointments within the VA health care 

workforce and the abusive use of terminations and other personnel 

actions against temporary and probationary employees and mandate additional protections, both statutory and administrative, for 

these most vulnerable employees who pay the heaviest price when 

they question the way of doing things. 

No. 6, we urge Congress to take steps to ensure greater accountability for VA front-line managers, mid-level managers, and upper 

management who engage in retaliation against whistleblowers and 

other front-line employees who speak up for veterans’ needs. 

Seven, additionally, we urge Congress to review the current reporting structure for the chief of police at VA medical centers. Currently, they report to the medical center director rather than a separate entity that can address mismanagement or staff concerns 

without interference, such as the alleged illegal drug activity at 

Tomah. 

Eight, we are thankful the Senators and Congressmen are addressing and putting into place checks and balances that will ensure the safe ordering of opioids as well as the development of 

guidelines for the safe combining of opioids with other addictive 

drugs in an earnest effort to keep veterans safe. 

And I would like to point out, in addition to that, that Jason 

Simcakoski, who died last year from mixed drug toxicity, he died 

from essentially the same thing that my brother was addressing, 

and it is just beyond tragic. 

Last, but immensely important to our family, is our request—and 

this is a personal one—that Chris’ Official Personnel File and all 

information be sent to myself, Sean Kirkpatrick. It is also requested that any and all Tomah VA supervisory notes, reports of 

contacts, et cetera, related to Christopher Kirkpatrick be sent to 

myself, Sean Kirkpatrick. 

Chairman JOHNSON. Thank you, Mr. Kirkpatrick. 

Mr. KIRKPATRICK. Thank you. 

Chairman JOHNSON. Senator Baldwin. 

OPENING STATEMENT OF SENATOR BALDWIN 

Senator BALDWIN. Thank you, Mr. Chairman. I want to thank 

you and the Ranking Member, Senator Carper, for holding this 

hearing, and I especially want to thank the witnesses for their 

powerful testimony that will, I think, guide us in our future actions. 
15 

As we have certainly seen in Tomah, Wisconsin, and, indeed, the 

rest of the Nation, the role of whistleblowers is critical—in fact, heroic—in running an effective organization. And agencies need to be 

much more open to accepting constructive criticism in order to improve an agency such as the VA, which has the tremendously important mission of taking care of our Nation’s veterans. 

Mr. Kirkpatrick, I want to thank you so much for your attendance here today and also for mentioning Ryan Honl in your testimony. 

I also want to appreciate the fact that in your written testimony 

you shared the specific recommendations that you just outlined for 

the Committee that are really key. One that I would like to have 

you speak to a little bit more is the issue you raise about temporary or probationary workers. 

As we saw in Tomah with many whistleblowers it should not 

matter if an employee has been employed for 10 days, 10 months, 

or 10 years in terms of our treatment of them if they step forward 

to help veterans. I know this is a factor you have become aware 

of. We are working on legislation to address this issue. I very much 

appreciate your family’s input but if you could speak more to the 

position that temporary or probationary workers are in when they 

come forward as whistleblowers. 

Mr. KIRKPATRICK. Thank you, Senator Baldwin. I find it curious 

that, probationary and temporary employees—and I am really just 

drawing from my brother’s experience, but the amount of responsibility that they are given and especially considering that they are 

lacking the support that I mentioned as well, that they can just be 

tossed aside really without any sort of third-party review, any sort 

of accountability. I mean, it is outrageous. 

In Chris’ case, as Chairman Johnson pointed out, I think any 

independent person who would have looked at the reasons why 

they were terminating him would have come to the same conclusion, that these were ridiculous reasons and that it was clearly a 

case of retaliation. He was not afforded that protection because of 

his probationary status, and something, I think, needs to change 

with that. 

I think if we are going to—I mean, really, as, it was pointed out 

before, serving veterans is a privilege, and if we are going to put 

people in that position, a privileged position like that, we should 

provide them with the protections that they deserve, especially considering, a lot of these people, my brother included, he was not in 

the military, yet he was hearing firsthand accounts, from people 

with PTSD and hearing very hard things to hear for somebody, especially as a graduate. 

I think when you also add into the fact that to take that extra 

step and to point out what you see is wrongdoing and bring that 

to the attention of people, knowing that you do not have those protections, it takes a little more guts, I think. But that should absolutely be changed, and I do not see why anybody would disagree 

with that. 

Senator BALDWIN. Thank you. 

Mr. KIRKPATRICK. Thank you. 

Senator BALDWIN. I want to note the repeated testimony we have 

heard today and on previous occasions about inappropriate access 
16 

to whistleblowing employees medical records. We have heard such 

stories also at the Tomah facility regarding other whistleblowers 

who have stepped forward. 

I would like to ask Mr. Coleman and Mr. Wilkes whether there 

is an information technology fix in VA’s recordkeeping systems that 

would make it more difficult for an employee to access a fellow employee’s medical records. What action needs to be taken with regard to this pervasive problem? 

Mr. COLEMAN. I think, Senator, one of the things that can be 

done is to have maybe a two-party or two-employee system where, 

if there is a sensitive record like mine, because I am a Marine 

Corps veteran, that if an employee goes to get in the record, that 

another employee or a supervisor has to approve it for that to happen. The reason that would be important is this has happened four 

times to me, and when it has happened, I mean, I have heard excuses such as it was an innocent mistake—this is from the 

VA—or they were trying to get into a veteran’s record with a similar name, and ‘‘I do not recall being in the record.’’ Those were excuses that were actually given. And I do not know if any of the 

Senators have ever had a young puppy dog, but that first day when 

you leave a puppy dog in your apartment or your house and you 

go off to work and you come home and it has chewed up your shoes 

or it is wet on your floor, and you look at that puppy dog, and that 

puppy dog cowers like it has done something wrong, that is the 

same look that I got from Phoenix VA administrators after they 

gave me those excuses. They sat there quiet, all balled up, hoping 

that I would just stop talking about it and it would go away. It reminded me so much of a puppy I had one time, and that is what 

has to stop, ma’am. 

Mr. WILKES. I have been fortunate to talk to 50-plus whistleblowers across the country, and 100 percent of those that are veterans have had their records accessed—100 percent, every single 

one of them. And, what can we do? There is no accountability. I 

was under investigation for a year, for having a list that was not 

supposed to exist, for possible privacy violations, but yet these people went into our records, and they face nothing. They do nothing. 

The whole thing with accountability, somewhere along the line 

there has to be accountability. And if you do it, there has to 

be—you have to say, ‘‘Hey,’’ and show those others that they are 

going to do something to them. There are ways that they have in 

place to say, hey, there is a big thing that pops up, this person is 

also an employee, so-and-so accessed—it tells them before they 

even go in there. I mean, 100 percent of whistleblowers/veterans 

that I have talked to have had their records accessed by people. 

Chairman JOHNSON. Thank you, Senator Baldwin. Senator Tester. 

OPENING STATEMENT OF SENATOR TESTER 

Senator TESTER. Yes, thank you, Mr. Chairman, and I want to 

thank Ranking Member Carper also for holding this hearing, and 

I want to thank you all for your testimony. I very much appreciate 

it. 

I just want to follow-up on Senator Baldwin’s question with either you, Mr. Wilkes, or you, Mr. Coleman, and that is, why—and 
17 

maybe I am just not seeing it. Why are they accessing your 

records? What are they doing? 

Mr. COLEMAN. What they do, Senator, is they access our records. 

Some of us have had mental health treatment after coming home 

from our time in the service. Really, it is none of their business to 

be in there. However, as Shea can tell you further about, what they 

do is they go into our records, and such as in my case, on January 

20, when everything was kind of hitting the fan, I was called into 

a meeting with my section chief, who happens to be a psychiatrist, 

Dr. Carlos Carrera, and he asked me, he goes, ‘‘I just want to find 

out about your mental health,’’ and he started questioning me 

about my mental health. And I said it was highly suspect that he 

waited until after I was a whistleblower to ask me about my mental health. However, he never came to me after each of the six veterans committed suicide, he never once asked me about my mental 

health. So the timing is always highly suspect with these people. 

Senator TESTER. But it is accessed to see if you have had mental 

health treatment? That is what they are doing. 

Mr. COLEMAN. I do not know, sir. I do not know exactly what 

they are getting at with that. I just know that they are violating 

HIPAA in doing it. But I know that they do use it against us, such 

as they have done with me. 

Senator TESTER. By the way, I think your recommendation is 

well founded. I think it is a good recommendation. 

Mr. COLEMAN. I think it is a simple one. 

Senator TESTER. Yes. Mr. Wilkes, would you—— 

Mr. WILKES. In my case, yes, I mean, I was brought in by my 

boss and sat down with him one on one, and he flat out asked me, 

‘‘Have you seen this mental health provider?’’ And I had. I mean, 

I am an Afghanistan veteran, and, I had come back and I was seeing those, and I had quit sometime before, before I even came back 

to work at the VA from the vet center. And he basically told me, 

he said, ‘‘Well, some of your colleagues are questioning your stability.’’ 

Senator TESTER. And this was after you were a whistleblower 

they did that? 

Mr. WILKES. This was after I had turned it in June 2013, yes. 

‘‘They question your stability and are saying you are unfit to lead.’’ 

Senator TESTER. I got you. How long did you work for the VA before all this came down? I just want to try to get a timeline here. 

Mr. WILKES. 2007. 

Senator TESTER. 2007 you started, and you put forth some problems at what point in time? 

Mr. WILKES. I had brought forth problems starting in 2012. 

Senator TESTER. Got you. And they never talked about your mental health until after you brought forth problems. 

Mr. WILKES. Until I reported it to the IG. 

Senator TESTER. Cool. Not cool, but thank you. 

Mr. Kirkpatrick, I just want to say thank you for your recommendations. Oftentimes we get a lot of panelists in here, and to 

be proactive and talk about what you see as potential solutions is 

very helpful. So I want to just thank you for that. 

And this is for any one of you, Coleman, Colon, or Wilkes. What 

is the formal feedback mechanism for VA employees who want to 
18 

bring forth a grievance to the attention of management? Is there 

a formal feedback mechanism? Go ahead, Shea, if you want. 

Mr. WILKES. There is in place—I mean, they always want you to 

keep it and follow your chain of command, and they always suggest 

that you do that. 

Senator TESTER. Yes. 

Mr. WILKES. But, unfortunately, that is not working. And, unfortunately, when you report to the IG, if you take that step, the IG 

only takes a certain number of cases, and a lot of times they will 

send the report back to the Veterans Integrated Service Network 

(VISN), which goes back to the director, and then you are in trouble. 

Senator TESTER. Right. So there is a mechanism. Are you told 

about the mechanism for grievances and are you told about whistleblower rights in any sort of training that the VA offers up? 

Mr. WILKES. We do have a lot of Talent Management System 

(TMS) trainings, which is our online training system that we go 

through, and you do have classes on those. You do every year. 

Senator TESTER. And it does cover whistleblower, it does cover 

how you report a grievance and all that? I am just curious. 

Mr. WILKES. It does cover whistleblower. I am not sure about the 

union grievance process. 

Senator TESTER. OK. 

Mr. COLEMAN. Can I add to that, Senator? 

Senator TESTER. Absolutely. 

Mr. COLEMAN. The problem between our front-line supervisors 

and ourselves is that when all this happened with me, I told my 

front-line supervisor, because, once again, we are veterans, I believe in my chain of command. 

Senator TESTER. Right. 

Mr. COLEMAN. It is just grilled into you. And when I came forward to my front-line supervisor, the first thing out of her mouth 

when I said I was coming forward regarding suicidal vets, she goes, 

‘‘That is how people get fired.’’ 

Senator TESTER. Oh, my God. 

Mr. COLEMAN. Instead of suicidal veterans walking out of our 

hospital that everyone knew and we needed to fix it. 

The next time, I was walking through the hospital on my way 

to a meeting with the director when one of the assistant social 

work chiefs said, ‘‘Do not rock the boat,’’ as I walked by him. This 

is the kind of comments and wrongdoing that we are getting in our 

own hospitals by our front-line people that we are told to come 

through. That is where the disconnect is at, and that is the cancer 

that we have to fix within each of these facilities. 

Senator TESTER. I agree. It makes me wonder what kind of training—other than professional training, what kind of training the VA 

does for your front-line supervisors. 

Look, mental health is a huge issue. You guys know that. I think 

every one of you are in that field, right? And you have come out 

of the military. You understand the impacts that are going on with 

the wars in the Middle East, how it is a signature injury coming 

out. But denial is not a solution, and so my time is up, but I just 

want to express my appreciation for you folks coming forward and 
19 

bringing forth problems and solutions to those problems. I very 

much appreciate that. Thank you. 

Chairman JOHNSON. Thank you, Senator Tester. Senator Ernst. 

OPENING STATEMENT OF SENATOR ERNST 

Senator ERNST. Thank you, Mr. Chairman. Thank you, gentlemen, so much for being here today. 

I will state again—I have said this many times in the short 8 to 

9 months that I have been here—that this is one of my priorities, 

is working with veterans and mental health issues. The first bill 

I proposed was working with veterans that have mental health 

issues and allowing them greater access. And so I do want to thank 

you. My condolences on the loss of your brother, Sean. It is very 

sad. 

Mr. KIRKPATRICK. Thank you. 

Senator ERNST. This is an issue I am extremely passionate 

about, and I think today’s hearing just is reemphasizing to me that 

we have a corrupt and broken VA system. And when I hear that 

supervisors, other workers are more concerned about their own jobs 

than they are about the veterans, we have an issue. We have an 

issue, folks, that needs to be fixed. And I do not know how many 

hearings we are going to have until we get to actually addressing 

the situation. I hear a lot of talk, but we need to figure this out. 

So, again, I am very passionate about this issue, and thank you for 

coming forward, for being brave and doing the right thing. 

When it comes to accessing your health records, I just want to 

state, just for everybody, it does not matter what the reason is. 

They should not be accessing your health records. That would be 

like saying it is OK for us to access anyone here in the audience, 

their health records. It is wrong. It should never, ever occur. Never 

without your authorization. So I just want to emphasize that. It 

does not matter why. 

Mr. Coleman, do you believe there are many alternatives for veterans who feel they are not receiving timely or adequate mental 

health care at their local VA? 

Mr. COLEMAN. Thank you for asking me the question, Senator. 

I do not know if you read the article by Dave Phillips, the front 

page of the New York Times on Sunday. It was about the plight 

of Second Battalion, Seventh Marines, who have lost, I believe it 

is, 13 members to suicide after their deployments in Iraq and Afghanistan. The picture I have in front of me is me and my two Marine Corps sons. Not only am I a former Marine, but I make Marines. The one on the right is with 2–7 currently. 

In that article, they talk about how many of these veterans came 

to the VA for health care and were turned away. In one instance, 

they had a 22-year-old female social worker or whatever that told 

him that the loss of his buddies was like breaking up with a 

girlfriend and he just had to get over it. Well, we do not just get 

over it. And that is not right. And that is why I think that these 

guys and girls, when they come home from theaters of war, should 

have the right to go wherever they feel comfortable. We owe it to 

them to send them anywhere they feel comfortable. If it is a counselor in another town that they want to go to and they are going 

to open up and talk, then we should allow them to do that, because 
20 

once they have committed suicide, it is too late. There are no second chances. 

Senator ERNST. That is right, and you do believe that opening up 

for greater access, whether it is at the VA or whether it is through 

a community clinic, peer-to-peer supports, those are ways to address it. 

Mr. COLEMAN. Any of those, ma’am. And the reason I do not 

agree with the number of 22 per day—I think that is a number of 

suicides—I believe that is a number fed to us in the hopes that we 

will all shut up and make it go away. That study was sponsored 

by the VA. It did not include the States of California, Texas, and 

Illinois. And I do not know about you folks, but when I was in the 

Marine Corps, over half of us were from California and Texas. 

Some of the guys written about in that article that have committed 

suicide are from California. They also do not count the phenomenon of suicide by cop. I have had two veterans that were 

killed by police officers. I am not saying it is the police officers’ 

fault, but they pretend to have a weapon or they pull a weapon. 

The VA does nothing to report those as suicides. The number of 22 

per day is inaccurate, and we need an independent third party to 

come in and do a complete study to show us what the real number 

is so we know. Once we get a real number, then we will know what 

a big deal it is, and then we can fight it together. 

Senator ERNST. And I use that 22-a-day number all the time, and 

I think that is appalling enough. But I think you are probably correct, Mr. Coleman, in your assessment. 

And for all of you, in your experience, do you believe the VA 

management takes seriously ideas for reform, the implementation 

of the IG recommendations, or recommendations from staff members when they are seeking to improve these services at the VA? 

Do you think they take them seriously? 

Mr. WILKES. VA leaders, it is a system of cronyism that has gone 

on for so long, and they protect each other. Rules and regulations 

oftentimes, they do not care. They use them when it benefits them. 

And I will tell you, one of the reasons why is because nothing ever 

happens to them. Even if you catch them—I have put policies in 

front of folks and said, ‘‘You cannot do this. This is the policy.’’ 

They still do it. But nothing ever happens to them. 

And, the IG makes recommendations, but they do not have to 

hold—I mean—— 

Senator ERNST. Who is holding their feet to the fire? 

Mr. WILKES. Right. 

Senator ERNST. Right. We should be doing that. Thank you, Mr. 

Wilkes. Mr. Colon. 

Mr. COLON. I have always stated that it is great to have all these 

hearings, all new policies, all new recommendations and solutions. 

But since this scandal has broken, since Phoenix, we have not held 

one person accountable for any wrongdoing at the VA as far as 

whistleblower retaliation. The VA, what they do is the IG—I reported a couple things to the IG. The IG sent it back to the agency 

to investigate itself. And then they give it to the supervisor. The 

supervisor already knows who the whistleblower is. 

So what I always truly believe is that you cannot police yourself. 

It is not the solution that you should do it. Like I said, the key 
21 

component that everything is failing to make the VA better and to 

do service for our veterans is start holding people accountable. 

Senator ERNST. Very good. Well, I know my time is up. Do you 

have any other comments? Please. 

Mr. KIRKPATRICK. If I may, with regards to that, I know that the 

people who seem to have been responsible for retaliating against 

my brother, as far as I am aware, are still employed at the VA. I 

do not know if that is a pending investigation, but that is unacceptable. 

Senator ERNST. It is unacceptable. 

Mr. KIRKPATRICK. And that is Dr. David Houlihan. And the 

human resources representative David DeChant. 

Senator ERNST. Thank you. Again, my condolences. 

Mr. Coleman, do you have any closing thoughts, very quickly? 

Mr. COLEMAN. Ma’am, really quickly, I was just going to say the 

retaliation investigations, I was removed on hearsay. I was on paid 

administrative leave for 206 days until I was ordered back into the 

same retaliatory environment on August 17, which I refused to go 

until it is safe. So they are able to remove me on hearsay; whereas, 

we have a sworn affidavit from the H.R. chief showing that the director held this meeting to propose to fire me on January 13, and 

he is still showing up to work every day. I love my job helping vets 

get clean and sober. I would do it for free. And they removed me 

from that or took me out of that position to investigate hearsay, 

which was proven untrue in late February. 

Senator ERNST. Thank you again, gentlemen. 

Thank you, Mr. Chairman. 

Chairman JOHNSON. Thank you, Senator. 

Let me assure everybody, Senator Ernst, all the witnesses, everybody in the audience, there is a process to solving a problem, and 

this is the first step. We have to properly define it. We have to lay 

these things out. We have to highlight these problems. And, of 

course, the purpose of these hearings we have been holding—and 

they have been multiple; we also have our own investigation under 

way with Committee staff—is to highlight the problem, to get 

agreement. And let us face it, what you are seeing is bipartisan 

agreement. These are problems that have to get fixed. So now that 

we understand and we have highlighted it, we will solve it. We will 

be introducing legislation certainly under the jurisdiction of this 

Committee. It will get reported out, and we will put pressure on 

the system to get the things passed. So this is not just talk. This 

will result in action, and your testimony is powerful and will result 

in that kind of action. And the fact that we have representatives 

of the VA here, as they were in Tomah when we held the hearing 

in Tomah, and we listened to the powerful testimony of the survivors of the abuse there, this is what will result in concrete action 

to start solving these problems. So, again, thank you all. Senator 

Ayotte. 

OPENING STATEMENT OF SENATOR AYOTTE 

Senator AYOTTE. Thank you, Chairman. 

Mr. Kirkpatrick, let me just add my condolences for the loss of 

your brother. And let me just say to all of you, in listening to the 

exchange you had with Senator Ernst, it is appalling, frankly, that 
22 

they can retaliate against you for really doing the right thing for 

our country and coming forward with a focus on making sure that 

our veterans are served based on things like hearsay when you 

have at heart what we want to have in our VA, the best to serve 

those who have served us, and that the people who have done this 

to you are still merrily on their jobs. And so I think the accountability piece is the key to all of this, people who are not focusing 

on caring for our veterans and those—we need to reward people 

like you who want to serve our veterans. And those people who retaliated against you should be fired, and I think the problem we 

have seen with all that we have heard of the deaths of our veterans 

and our veterans who have suffered, there have been very few, if 

anyone, held accountable for it. 

And so within the organization it seems like the message being 

sent is, hey, keep covering everything up because, do not worry, 

you will keep your job; if you come forward, you are going to lose 

your job—which is the absolute wrong message. 

And so, Mr. Chairman, I hope that we make sure that the legislative tools are there and that we hold people accountable. So I just 

want to thank you all for being here and for your courage in what 

you have done. 

I also wanted to follow-up, just the one thing that many of us 

have focused on here is where is the priority. We have not even 

had a permanent Inspector General for the VA since December 

2013. It has been 631 days. So if we look at where priorities are, 

it seems to me that that is being put low on the totem pole when 

we will not even put a permanent individual in that position. And 

many of us on this Committee—and I am going to do it again 

today—have called on the President, because he needs to appoint 

that individual and say this is a priority for our country. 

And I would like to ask all of you, what would you like to 

see—rather than the Inspector General, obviously we need to get 

someone there with the importance of it, of a permanent position 

and back that person up. But once those recommendations are 

made and the investigation is done, what more teeth can we give 

that process so it is not just turfed back to the same group of people in the VA where there may be a good investigation done, but 

nothing is followed up on it. So I wanted to get your thoughts on 

what could we do, ideas you have for us, to make sure there is 

more teeth in that process. I will turn it over to whoever wants to 

go first. 

Mr. COLEMAN. That is what we are here for today, is to get some 

teeth in the process, because like you have all stated, we continue 

to talk, and we all know there is a problem. However, they give 

their answers, and then we give them 3 more months, and then 

some new whistleblowers come back, and we do it all over again. 

The time for action is now. 

Senator AYOTTE. Right. 

Mr. COLEMAN. We are here to help. I think being part of the 

process, the nice thing about it is you have some front-line VA employees here. I was a grunt in the United States Marine Corps. I 

know both—— 

Senator AYOTTE. Semper fi. 
23 

Mr. COLEMAN. And I know that with some of these committees 

and stuff, such as Secretary Robert McDonald when he did the 

MyVA, a lot of these people that he selected—do not get me wrong. 

It is great, all these generals and stuff were there. But I have 

never seen a general have to use the VA for health care. I have 

never seen a general drive 150 miles and have an appointment canceled when he had to take a day off of work to feed his family. And 

no disrespect to the general and his service at all, but there needs 

to be more front-line people. There needs to be more grunts. There 

needs to be more, enlisted people involved in the process. 

Senator AYOTTE. This has to be grassroots. They need to understand what is happening on the ground. 

Mr. COLEMAN. They do, ma’am. And what the problem is is they 

are not listening to us. We are talking, and we are all about respecting the chain of command. However, when there is a breakdown in the chain of command, that is where you all come in, and 

that is where we need your help. And I agree with you. We need 

a permanent IG. It needs to happen. But from the grassroots part 

of it, we allow them to have their own investigations. The VA gets 

to investigate itself, and there is—I am sorry to laugh, but it is 

just—it is a sad joke. We have an audio tape of them admitting five 

suicidal vets walked out of my hospital right after I came forward. 

Someone should have said, ‘‘You know what? We messed up.’’ They 

did not. They destroyed me when I told the truth. It played on 

CNN with Jake Tapper. It is just amazing. 

So how much more evidence do we need on these people before 

we are able to take action? And that is why I hope you all are 

upset and I hope you are able to take action, because it is enough. 

It is enough today. 

Senator AYOTTE. I am upset, and I know that many on this Committee are upset. 

Mr. COLON. One of my recommendations in the statement that 

I provided, I think once the OSC concludes that a person retaliated, that they are given the authority to fire that person, because 

it seemed that the VA does not want to fire anybody. 

Another thing that Mr. Brandon Coleman had touched on, I requested through the Freedom of Information Act (FOIA) to see how 

many directors, deputy directors, and associate directors are actually veterans working in the VA. Seventy-six out of 479 are veterans that are in executive positions for the VA, and that is a problem. 

I stopped getting care at the VA for one reason 3 years ago. Once 

I came forward, I knew the type of behavior I was dealing with. 

So the care that I earned, I stopped going there, because I know 

if they access my record or they did anything, that they would not 

be held accountable. But I think the IG should make recommendations. Maybe they should have the authority if they found somebody that has found misconduct, that they should be the ones that 

should issue disciplinary actions. 

One thing I have noticed through all this ordeal is the VA has 

failed to hold people accountable. And if that identity does not 

want to hold people accountable, then maybe we need to move forward with the IG and the OSC to start holding people accountable. 

Thank you. 
24 

Mr. WILKES. I will say this: The bottom line is the VA is going 

to have to start telling the truth, and somehow we have to make 

them do that. Their PR machine puts out more propaganda than 

the Republic of North Korea. I am serious about that. And the 

problem with that is they are not accepting any responsibility. It 

is still going on. The facility I work at told me there are no—after 

I came forward, no access to care problems. But in March of this 

year, I had a consult put in for my yearly eye appointment. They 

scheduled me an appointment in June. I did not even know about 

it. They did not offer me any kind of outside fee-based. I put in another one in May. They had canceled the one in June because the 

doctor had quit, moved it to August. Still nothing. I called down to 

the clinic, and I said, ‘‘Are you all not going to offer me fee-based 

service or something?’’ They said, ‘‘Well, we do not do that. We do 

not do the Choice program.’’ I said, ‘‘Look, you do not know who 

I am, but I am very familiar with this stuff.’’ I said, ‘‘That cannot 

be right.’’ 

Now, I will give credit. When I called the chief of staff and the 

director, they got my appointment, and they said they were going 

to correct that. But it is still going on. It is still going on, and they 

are still putting out these numbers, and they say, ‘‘Well, we have 

97 percent new leadership.’’ Yes, you moved this director from this 

hospital to this hospital, and this one here to here. That is the kind 

of numbers they put out. They are very misleading. 

Senator AYOTTE. Unfortunately, I am hearing those stories from 

my constituents also. 

Mr. KIRKPATRICK. Well, being the only civilian here, I do not 

really have a lot of personal insight but since I have learned a lot 

about this since my brother died, it seems very apparent that there 

is a lack of transparency, accountability, and in a way, it is like the 

ugly side of war, almost the ugliest side, is, the people who return 

from it broken. They have put their life on the line. They have paid 

the highest cost. And, they should be given everything from this 

country, to hear 22 people, and that is probably way underestimated, it is outrageous. 

It seems like the VA behaves as if it is above the law, and that 

is unacceptable. Personally, I have to say, this Committee is really 

the only entity out there that has taken my brother’s case seriously, and I just want to let you guys know, on behalf of my family, 

we are eternally grateful for that. But, I hope at the same time 

that there is some power that you guys hold where, some change 

can be made here, a culture change or something. I mean, people’s 

lives are on the line, and it gets swept under the rug. You do not 

hear about it, yet every day people are dying, people are suffering. 

So I do not really have anything specific to say, but I think it 

is worth pointing out. 

Senator AYOTTE. What you said today has been heard, and it has 

been loudly heard, so we appreciate your being here. 

Mr. KIRKPATRICK. Thank you. 

Chairman JOHNSON. Thank you, Senator Ayotte. 

The power we hold is the power of your testimony, and I just 

want to underscore the point of this is just a basic first step because we have to have a transparent and independent Office of Inspector General. That is just a basic first step. And, again, we do 
25 

not have a permanent Inspector General. I wrote a letter to the 

President on January 22, 2015 asking for an appointment of a permanent one. Other Committee Members have asked for the same 

thing. We will ask again. We need a permanent Inspector General 

so we have a transparent and independent Office of Inspector General. That is just a basic first step. 

So, again, let me call on the President of the United States to, 

as quickly as possible, appoint an independent permanent Inspector General for the Veterans Administration. We need one, and we 

need one now. Senator Carper. 

OPENING STATEMENT OF SENATOR CARPER 

Senator CARPER. I want to thank each of you for being here 

today. I want to thank a number of you for wearing the uniform, 

and thank you for that service, and thank you for your continued 

service to our veterans. 

I spent 5 years in a hot war in Southeast Asia as a naval flight 

officer (NFO), and after that was over, I came back to the States 

and went to college on the GI bill. And the first week I was back 

in the States—I had moved from California to Delaware, and the 

first week I was back, I got in my Volkswagen Karmann Ghia with 

a rebuilt engine, and I drove from Newark, Delaware, to a VA facility in Elsmere, Delaware, about 12 miles away. And I had my 

DD214 with me, and I presented it to the folks there, and I said, 

‘‘I think I am eligible for some benefits.’’ And they checked me out, 

and they said, ‘‘Yes, you are. And if you will come back in a week, 

you are eligible for some dental benefits. You can have a checkup.’’ 

And a week later, I came back, met a fellow, a dentist named Jerome Kayatta, and he took care of my dental needs. And at the end 

of my visit, he said to me, he said, ‘‘This is not a very good health 

care facility. The morale is not good. The quality of the service is 

not good. If I were you, I think I would get my medical care from 

someplace else.’’ 

Ironically, 40 years later, he is still my dentist. He works parttime pro bono in the Delaware correctional system, providing dental care for folks that are incarcerated, some of whom are veterans. 

But I never thought of him as a whistleblower, but he did more to 

bring my attention to the need to make changes at that facility and 

health care provided for veterans all over our State. And I worked 

very hard to make sure that that was a hospital that we could be 

proud of, that they could be something closer to the gold standard 

than where they were in, gosh, 1973–74. And we have outpatient 

clinics—we only have three counties in Delaware, but we have VA 

facilities in all three counties. Do they provide perfect service? Absolutely right, no, they are not. None of us are perfect. But if you 

talk to the veterans in our State who use the VA, those outpatient 

clinics and our VA hospital—I call it the ‘‘mother ship’’ in Elsmere. 

I think for the most part they tell you that the people who work 

there are caring, dedicated men and women and dedicated to ensuring that veterans get the kind of service that they deserve. I 

would just sort of start off by saying that. 

The other thing I would say, we have a big air force base in my 

State, Dover Air Force Base. We are very proud of the work they 

do. They are an airlift base, have C–17s and C–5 aircraft. They 
26 

travel all over the world every day, delivering people and cargo 

wherever it is needed. 

They also have a special responsibility, Dover Air Force Base, because that is the mortuary for our country, and it is where the remains of our fallen heroes are brought throughout the year for 

years to Dover Air Force Base. It is a sacred mission. A sacred mission. 

About a half dozen years ago, we heard from a whistleblower at 

the mortuary at the Dover Air Force Base that some of the practices and procedures there were inappropriate. Things were happening that should not have happened in the carrying out of their 

responsibilities, and it indicated that there was a problem of leadership, leadership at the military level, colonel, full-bird, and at the 

civilian level, top civilian level leadership. And there were some 

people who thought, well, this person is just a malcontent. Well, as 

it turned out, there were a couple more people who came and 

shared their experiences with us. Our congressional office got involved, the congressional delegation got involved, and the 

Office of Special Counsel got involved. And the Office of Special 

Counsel—I think there is somebody here today from the Office of 

Special Counsel. They did a very good job. 

I once shared this with my colleagues. Two years ago, I was 

back—I go to the air force base a lot, but 2 years ago, I was back 

for a special visit and tour of the mortuary. I want to tell you, the 

hardest work I have ever seen anybody do in the military is in that 

mortuary, the people who deal with those remains and piece body 

parts back together. I mean, we think we have had tough jobs. Oh, 

my God, they have tough jobs, really tough jobs. 

But I went back, and it was interesting. They had a whole delegation of civilian and military folks there at the entrance to greet 

me. And foremost, right at the front of the group was Mr. Z, one 

of the original whistleblowers. Surrounding him were the other 

whistleblowers. And they were there to welcome me back. And do 

you know who was not there? The full-bird colonel. He was gone. 

And you know who else was not there? The civilian leadership of 

the mortuary. They were gone. And you know who was still there? 

The whistleblowers. 

So I just want to say sometimes whistleblowers were this Jerry 

Kayatta all those years ago in an unofficial role as a whistleblower, 

and more recently Dr. Z and the whistleblowers at the Dover Air 

Force Base. Sometimes—the parable of the seeds? Some of the 

seeds fall on the hard ground and in the thorns and so forth. Some 

of the seeds fall on fertile ground. In those cases, I think in Delaware, better things have happened. 

So I just wanted to share that with you. I have a couple of questions for you. We will maybe have a second round here, but I wanted to raise that. 

I also wanted to say as much as we appreciate your being here 

and look forward to hearing more from you today and I look forward to asking some questions, I just need to make a note that I 

have raised a concern of this at other hearings we have had for 

whistleblowers. I just think we need to respect the independent, objective process that Congress has set up in the Office of Special 
27 

Counsel, which I have alluded to before, the Merit System Protection Board, and elsewhere. 

The last thing I want to say is this: Leadership. I wrote a note 

down here, and the Chairman looked at it. I wrote down the word 

‘‘leadership.’’ The most important element in the success of any organization I have ever been a part of is leadership. Whether it was 

a military unit, a VA facility, here, business, even a sports team, 

leadership is always the key. And the guy that the President nominated to be the leader of the VA a couple of years ago is a fellow 

who was a West Point graduate, a fellow who was a Ranger, and 

who understands the military from the inside out. And what needs 

to happen at VA facilities across the country is the quality of leadership that I think exists at the top needs to permeate and come 

down to the local level. 

And I want to second again what the Chairman has said. We 

have sent many letters to this President saying we need more permanent IGs, Senate-confirmed IGs. And to the administration’s 

credit, they have done a better job in the last year or two. And this 

IG has been vacant for almost 2 years. Way too long. We have had 

an opportunity to meet just in the last week or so with the current 

leadership of the Inspector General’s Office acting person. We need 

permanent Senate-confirmed leadership, and I would just urge our 

Committee to continue to write to the administration again and 

again and again, call and say this is a problem, this needs to be 

addressed. 

Thank you. I look forward to asking some questions in a few 

minutes. Thank you all. 

Chairman JOHNSON. Senator McCain. 

OPENING STATEMENT OF SENATOR MCCAIN 

Senator MCCAIN. Thank you, Mr. Chairman. I want to apologize 

for not being here for the entire hearing. I am chairing a hearing 

in the Armed Services Committee at the moment. But I wanted to 

come up here to mention my appreciation for the witnesses. I 

thank you. I thank you for your courage. I thank you for your 

steadfastness. And this is a very important hearing, and I want to 

thank the Chairman for having it. 

I also want to give a special thanks to Mr. Coleman. I want to 

thank him for his willingness to reach out to my office to share 

with me and my staff his experience at Phoenix as a whistleblower. 

We all know, Mr. Chairman, that this whole scandal began to unfold at the Phoenix VA where 50 of our veterans allegedly died because of a failure to receive—because of being on some kind of 

phantom waiting list. 

I think, Mr. Chairman, from what I have briefed, that we are 

finding out that there is a viewpoint or an environment in the VA 

that discourages and even punishes whistleblowers. Is that your 

conclusion? Then I would just like to ask the witnesses one question. What can we do to better protect you and others who are willing to come forward and willing to risk their careers in order to get 

better treatment or even in some cases treatment for our veterans 

who, in the view obviously of the treatment in the past has been 

less than acceptable? Maybe I can begin with Mr. Coleman and 
28 

then you, Mr. Kirkpatrick, and then the others, Mr. Colon and Mr. 

Wilkes. 

Mr. COLEMAN. Senator McCain, I just want to thank you and 

your staff. They are amazing, and you guys have been with me 

from the beginning, from the first letter you wrote to the Secretary, 

and I just wanted to thank you for that in person. 

The word that comes to mind when you asked the question is 

‘‘accountability.’’ When there is wrongdoing committed, it does not 

matter if the VA employee is a janitor or food service worker or a 

hospital director. When they are caught doing wrongdoing and 

breaking Federal law, they should be fired. When these employees—— 

Senator MCCAIN. And to your knowledge, there is none of that? 

Mr. COLEMAN. Senator McCain, the director had a meeting on 

the 13th of January asking to terminate me, was told he could not 

terminate me by legal counsel Shelly Cutts, and she said, ‘‘But we 

can come up with other employee actions to get rid of him.’’ On the 

27th, I was taken out of my position. The H.R. chief, Laurie Butler, 

came forward and gave a sworn deposition—she is also a retired 

Navy officer, has no reason to lie; I never met her before in my 

life—showing that this meeting happened. We have asked for a full 

investigation into Director Glen Grippen’s actions. It is amazing, 

the corruption that goes. 

So if you wanted an answer from me, my answer is accountability. When we catch these directors doing wrongdoing, they need 

to be fired, just like they do to us when we come forward. 

Senator MCCAIN. And if they are not fired, then the leadership 

should be fired. 

Mr. COLEMAN. I agree. I agree, sir, because how can you trust 

your commanders in chief, all the way up the chain of command. 

These are not people you are ready to run into combat with, because they are out for themselves. So, all of us here, the three of 

us are all veterans. And I believe in my chain of command, and I 

also believe in good leadership, as you guys were saying before. 

There is not good leadership currently. We do not trust the leadership, because look at what they can do to us. 

Mr. KIRKPATRICK. I would second what Mr. Coleman said. I 

think, accountability for the people who have been proven to be the 

problem is certainly what should happen. 

I also realize that this process here is a long, tedious one that 

requires gathering evidence, hearing testimony, as we are doing 

now. As I pointed out, the chief of staff at the hospital where my 

brother worked as far as I know is still employed by the VA, and 

it appears that he ran that hospital through intimidation, forced 

some good people out there—my brother, who really wanted to help 

people and sacrificed everything to be able to do that. It seems like 

the people who are the bad ones here, they lack that ingrained 

compassion and desire to help the veterans. 

It is difficult for me because, I am not a veteran myself, and I 

am speaking on behalf of my brother, who cannot speak for himself, but—— 

Senator MCCAIN. Well, could I just say to you, sir, that I know 

this Chairman and I know the Ranking Member, and I want to 

support them every way possible. We will do everything we can to 
29 

hold them accountable. And what bothers us is that what happens 

to you is a strong disincentive for others to act with your courage. 

Is that right, Mr. Colon. 

Mr. COLON. That is totally correct, Senator. And, first of all, I 

want to thank you for your service. 

Senator MCCAIN. Thank you. 

Mr. COLON. Like Mr. Brandon Coleman said and Mr. Kirkpatrick, there has been no accountability for the whole team that 

retaliated against me in San Juan, Puerto Rico. 

Another thing that I find astonishing, there is a table of penalties from a center memorandum that is a VA directive that 

States on page 38 to 42 that they can remove people for retaliation. 

But they failed to use their own table of penalties to hold executives or managers or supervisors that are retaliating against whistleblowers. So I find the main key thing, I think, to fix everything 

is to hold people that are found guilty of retaliation to be removed 

from the VA. 

Senator MCCAIN. Thank you. 

Mr. WILKES. Senator, it is good to see you again. I know we 

talked when you were in Shreveport with Senator Cassidy, and you 

had told me—and I think this is very telling. You said to me that 

day, when I said I am one of the whistleblowers, you said, ‘‘Thank 

you.’’ And you said, ‘‘Do you know that I sat in front of that director, and they looked me in the eye, and they said nothing was 

going on’’ ? And, if they will lie to you and try to cover this up, 

there is no accountability, and they do not fear it. You can just see 

that they do not fear that anything is going to happen to them because they have gotten away with it for so long. 

Until we are able to show that whistleblowers will be protected 

and that something is going to be able to be done, you are never 

going to know the depth of this corruption. There are people that 

want to come forward but are scared. They need their jobs. They 

come and they pull Brandon and me aside, and they say, ‘‘Thank 

you for coming forward.’’ And then, some of the schedulers said, 

‘‘Hey, you brought this forward, and, are they going to go back and 

change our evaluations? ’’ And I said, ‘‘What do you mean? ’’ They 

said, ‘‘Well, they marked us lower, and they told us, ‘You made this 

many appointments over 14 days, and we are marking you down.’ ′′ 

And I want to tell them, ‘‘Yes, they are,’’ but I cannot because 

I know they are not. They want to come forward and say—they 

have told me, ‘‘I would tell the IG if they came and asked me.’’ The 

IG does not want to ask them. 

Senator MCCAIN. Well, I thank you, and I thank you, Mr. Chairman, and Senator Carper for this hearing and your untiring efforts. 

We have to stop this. We just must stop it. 

I thank you, Mr. Chairman. 

Chairman JOHNSON. Well, thank you, Senator McCain. And just 

to kind of answer your question in terms of how rampant, it is almost epidemic proportions, but in subsequent testimony by the Office of Special Counsel, she is laying out the facts, that there are 

4,000 prohibited personnel practice complaints in 2015 to the Office 

of Special Counsel. Four thousand. That would be the retaliation 

complaints. Fourteen hundred of those, about 35 percent, come 
30 

from the VA. So this is rampant, this is a problem, and it is a problem we are going to address. 

Let me just say we are going to have votes at 11, and I think 

what I will do, because the Ranking Member, Senator Carper, did 

not get a chance to ask questions, I will turn it over to him. He 

can ask questions. I would say, Senator Baldwin, if you would like 

to stay here and ask questions while I go vote—I am not going to 

recess. We will just keep this thing going. But then when I come 

back, we will seat the next panel. So if you guys want to take it 

from there and ask questions. 

Senator CARPER. Thanks. 

Chairman JOHNSON. And, again, thank you. I will be back. 

Senator CARPER. Thanks. 

Chairman JOHNSON. I heard there was one vote. 

Senator CARPER. I think there are two. 

Chairman JOHNSON. OK. That will complicate things. I will still 

quickly vote, and we will get going. 

Senator CARPER. [Presiding.] OK, good. Again, our thanks to you. 

Please bear with us as we try to do our jobs here and do our jobs 

voting. Sometimes it gets a little complicated. 

I believe one of the goals of this Committee needs to be understanding how the process really works for whistleblowers and what 

we can do to improve it. 

I would just ask each of you just one thing that is working, one 

thing that is working that you have seen working with respect to 

whistleblowers, whistleblower protection, and share a best practice 

with us. And if the answer is, ‘‘I have never seen anything that 

works’’—the Office of Special Counsel I am convinced works. We 

have seen it ourselves at Dover Air Force Base. But just share with 

me one thing, very briefly, one thing that you have seen work. And 

I do not care who goes first. 

Mr. WILKES. With me, the Office—— 

Senator CARPER. I like to say: Find out what works. Do more of 

that. 

Mr. WILKES. I think you are right. The Office of Special Counsel 

helped me. I would probably still have a looming criminal investigation over my head today if they had not stepped in when I filed 

my—— 

Senator CARPER. OK. Thank you. 

Mr. COLON. I just wanted to say one thing. I think it is the Office 

of Special Counsel—if it was not for the Office of Special Counsel, 

I would have been terminated. I think they worked. That is why 

I think we have to give them broader authority to hold these people 

who retaliate against us. And I would say just the Office of Special 

Counsel. 

Senator CARPER. All right. Thank you, sir. Mr. Coleman. 

Mr. COLEMAN. Senator, I would echo their statements with the 

Office of Special Counsel when I came forward. What I would say 

is they need more help. The Office of Special Counsel I believe is 

overwhelmed, because I get, just like Dr. Katherine L. Mitchell, 

one of the whistleblowers from 2014, she and I speak just about 

every day, and I get anywhere from one to three calls from whistleblowers. I have had two since I have been in D.C. where I listen 

to these employees cry and tell me what is going on, and I always 
31 

take that call, because I wish someone would have been able to do 

that for me. 

So I believe that the Office of Special Counsel needs more help, 

because I think some of these people that are coming forward, I 

just think it is an overwhelming task to ask the Office of Special 

Counsel to be able to help everybody. I do not think they have the 

manpower currently. 

Senator CARPER. All right. Thanks so much. Mr. Kirkpatrick. 

Mr. KIRKPATRICK. Unfortunately, I do not have the status of 

being a whistleblower myself, so I cannot really confidently comment on that. But I would say with the people that I know and 

have met, Ryan Honl, Noelle Johnson, and others, I think—and I 

know this may not be the answer you are looking for, but, they 

found sympathetic people within the media. They reached out to 

other whistleblowers, and as I stated before, I would not know any 

of what happened to my brother without Ryan and Lin, and that 

is really all I can say about that, and this Committee as well. 

Senator CARPER. Thank you. 

Mr. KIRKPATRICK. Thank you. 

Senator CARPER. Let me just ask, for those of you who are whistleblowers, when you first thought you were being retaliated 

against, were you aware of your rights as a whistleblower and the 

processes and resources that were available to you? Mr. Wilkes, 

would you start with that? 

Mr. WILKES. I had taken the trainings, and I was somewhat 

aware of it. But the overall process and how to do it and things 

like that, I have had to figure out on the go, who to file with, what 

you can file. A lot of times when you have a complaint in the VA, 

what I found is that you want to say, ‘‘Hey, let us go to EEOC,’’ 

or, ‘‘Hey, let us go to Office of Special Counsel,’’ or, ‘‘Hey, let us go 

to the IG.’’ I went to the IG first because I thought that is what 

to do. I never heard from them on the first one I did, and then the 

second one, it took them a month and a half after I reported it 

again. 

I went to the Office of Special Counsel after they told me that 

I was under investigation criminally, and I learned about that process. So I was not aware—it is a lot of steps to it, and that is kind 

of why we kind of started a support group, the Truth Tellers and 

stuff, to kind of help each other and share our stories with each 

other to let each other know exactly how to file, what you want to 

make sure, I mean, because it is very emotional, and you are isolated. I mean, they isolate you, and that is how they kind of keep 

you that way. 

Senator CARPER. All right. Thank you. 

Mr. Colon, same question, please. Were you aware of your rights 

as a whistleblower and the processes and resources available to 

you? 

Mr. COLON. Negative, sir. But I was well aware that once I came 

forward that I would be retaliated against, because I had a good 

friend in 2010 that came forward about the reusable medical equipment that happened down in San Juan, Puerto Rico, and he was 

removed from his position. I do not think there is enough training 

of it. I know the American Legion visited our facility, and they 
32 

found a bunch of posters that were up in the office that were never 

posted. 

When people come talk to me, I am very honest with them. I tell 

them, ‘‘If you are willing to come forward, expect this to happen,’’ 

because as long as—like, I keep on reiterating this famous 

word—there are two words, and I do not wear the ‘‘I Care’’ pin for 

two reasons, because I am an advocate, he is an advocate, he is an 

advocate for veterans, and we have become—look what they have 

done to us. And then they do not use the ‘‘A’’ for the accountability. 

So I will never wear that ‘‘I Care’’ pin until I see actual change. 

But there is nothing. They do not tell you how to do this. It is like 

the other fellow, a friend over here that just stated there is no 

training for us from the get-go. 

Senator CARPER. OK. Thanks. Mr. Coleman. 

Mr. COLEMAN. I think, sir, even the training that there is limited, and it has changed so much in the last 2 years since this 

scandal has been going on. 

I think one thing that is important to point out is that we as 

whistleblowers, we should have the right to defend against retaliatory actions before the VA goes on the witch hunt. That is from the 

time that I came forward to the Office of Special Counsel regarding 

the systemic issues in early December, and then the retaliation 

was nonstop. However, the Office of Special Counsel was unable to 

take action until I was walked out from my employment on January 27th, crying. I had no one to call. I called the OSC attorney, 

David Tuteur, literally in tears. I did not know what to do, because 

I had just been taken out of a job that I loved. So, there is no way 

to defend ourselves, and the OSC, their hands are kind of tied as 

far as the retaliation goes until an act like that occurs, the overt 

acts of retaliation are going on every day. I asked for mediation on 

November 26th, because that is what I was told to do. My directline supervisor, who retaliated against me, waited until December 

16 to get back to me, 20 calendar days. I know that is not right. 

It is my full written 188-page testimony that you have, sir. 

Senator CARPER. All right. Thank you. Some of you have already 

answered this question, but I just want to throw it out there anyway. Based on your experience—and if you have already answered 

it, you do not have to answer it again. But based on your experience, what do you think could be done to make the information 

about whistleblowers’ rights and the processes and resources available to whistleblowers, what could be done to make the process 

work better for future whistleblowers? And if you have already answered that, that is fine. But if you have just a nugget or two you 

would like to share with us, please do. 

Mr. COLEMAN. I think I would like to share on that, Senator, if 

I could. I think that not enough is being done to get the word out, 

and I do not know what the answer is, because I have thought 

about this. I enjoy helping veterans get clean and sober. That is 

what I think I was put on this Earth to do professionally. It is just 

amazing. 

Senator CARPER. Isn’t it great to know what you were put on this 

Earth to do? Isn’t that great? 

Mr. COLEMAN. It is, and to actually get paid for it, that is the 

trick having a job you would do for free. 
33 

However, I would say that I am very passionate about whistleblower rights, and it has kind of grown just because of what I have 

been through. I think more needs to be done. I do not think we can 

count on the VA to have us set up, but I think groups like the 

Truth Tellers, having ways to have whistleblowers available, because like I said, just getting these calls, these calls from other 

whistleblowers, is just heart-wrenching. And they have nowhere to 

go. And I am telling them to contact certain Senator or Representative’s offices, sometimes out of their home State, because I have developed relationships with them, and I am telling them which 

media outlets to contact because the media is kind of your best 

friend in defending yourself. If it was not for the media and the 

Senate offices and the OSC, I would have been fired long ago? And 

so you kind of have to fight that battle, and each one of our battles, 

while they are so similar, are also so different, because like 

Shea—like Mr. Wilkes said, we are isolated. They isolate us. I had 

read all the articles from Tomah and, from Shreveport and from 

Puerto Rico, and I knew these guys existed. But I never knew that 

they went through the same thing as me, and that is where the 

power is, us coming together to be able to help future whistleblowers. There needs to be help there until we figure out a way to 

fix the VA. I do not know how long that is going to take, but there 

needs to be more to protect these people under Federal law when 

they are brave enough to come forward. That is what I think, sir. 

Senator CARPER. Yes, the media can play a valuable role here. 

The media takes a lot of abuse. They hand out a lot of abuse. 

Mr. COLEMAN. They protected me. 

Senator CARPER. But they also can play a very valuable role 

here. 

A real quick one, if I could, for Mr. Wilkes, and then the Chairman is going to come back and I am going to run over and vote, 

and we will play tag. I understand you are the founder of the group 

VA Truth Tellers. Could you just take a minute and explain to us 

what motivated you to get it started and how does it work? 

Mr. WILKES. Basically it took off on its own. I kept reading, like 

Brandon said, these articles, and I am, like, ‘‘Oh, my gosh, this is 

going on to a lot of us all over the country. And, like Dr. Mitchell 

and her thing, she had said that the IG was more worried about 

her making privacy things, and that was like me. They were more 

after me, investigating me for privacy violations. 

And I just started reading stories, and I reached out to Brandon 

and actually a lot of the media. And he is correct. The VA is more 

worried about their image, and that is one way that you can get 

the attention, is to try to tarnish their image and get your story 

out. And, actually, a lot of the media reporters got me in touch 

with all them, gave me their email addresses, gave me their phone 

numbers, and we started reaching out. And I had four. And then 

I met Germaine Clarno, and she had been trying to do the same 

thing on the other side. And it started out, we had 10 people, and 

basically it was in email. We were emailing just supporting each 

other. 

And, it kept growing, and people started coming in, and I was, 

like, ‘‘Oh, my gosh,’’ I did not expect it. And then we knew we had 

something. And then when those reports came out in Tomah and 
34 

we had seen it and they whitewashed them and they started attacking whistleblowers, we had had enough. And I told the group 

and Germaine and I told them, I said, ‘‘We got to do something 

about this.’’ And then that is when we came out with the letter to 

the President about, the IG Director at the time we were calling 

for him to be dismissed. And that afternoon, after that letter, he 

announced his retirement that Saturday. And since then, it has 

kind of grown even more. I mean, every day Brandon—I get emails, 

text messages from whistleblowers all over the country and it is 

the same thing. It is the same story. It is absolutely amazing how 

each of our situations are unique, but how the retaliation is so 

similar. It is like the VA leaders have a book they developed on 

how to retaliate and this is how you do it, because it is the same. 

Senator CARPER. Over the last, gosh, 40-some years, maybe 50 

years, in this country we have tried to figure out in a health care 

delivery system how do we get better results for less money, and 

for years we kept seeing the percentage of health care costs in this 

country as a percentage of GDP go up, up, up, up, double-digit increases in the rate of inflation in health care delivery, and not always with better results. A couple years ago, we had a situation 

where it was widely reported that about 100,000 people died in 

hospitals every year. It is not VA hospitals, but like hospitals 

across the country, which is a sad commentary. It is a sad commentary. Some people said we need to do health care reform in 

order to slow the growth of health care costs, and we did. Some 

people said we needed to do it in order to better ensure that we 

do not have 40 million people that go to bed at night without any 

health care coverage. We did. And we also said we had to get better 

results, and we do. And I think in some respects we are. The number of people without health care coverage is down from about 40 

million to maybe closer to 10 million now, headed in the right direction. Health care costs as a planning of gross domestic product 

(GDP) is no longer going up double-digit rates of inflation. In fact, 

health care costs as a percentage of GDP are actually coming down 

now slightly. But we still have a lot to do in terms of getting better 

results for less money. 

I am going to run and vote; otherwise, I miss my chance. But I 

will be back, OK? Thank you. Thanks, Mr. Chairman. 

Chairman JOHNSON. [Presiding.] Thank you, Senator Carper. 

Again, I want to thank the witnesses for taking the time coming 

here, and let me underscore again that our ability—and you are 

seeing, I think, some bipartisan agreement, which is really what 

we need to do. Let us concentrate on the areas of agreement that 

unite us rather than exploit our division. So you are seeing some 

bipartisan agreement. Our ability to take action, to pass legislation, will be due in large part because of the courage of your actions and the power of your testimony. 

So, again, I want to thank all of you for coming forward. Obviously, we offer our condolences, Mr. Kirkpatrick, to you and your 

family. But, again, thank you for coming forward. We will act. We 

will act. 

Thank you. Let us seat the next panel now. 

[Pause.] 

Thank you. I appreciate your patience. 
35 

1The prepared statement of Hon. Lerner appears in the Appendix on page 97. 

As I said in the earlier panel, it is the tradition of this Committee to swear in witnesses, so if you will all rise and raise your 

right hand. Do you swear that the testimony you will give before 

this Committee will be the truth, the whole truth, and nothing but 

the truth, so help you, God? 

Ms. LERNER. I do. 

Ms. HALLIDAY. I do. 

Dr. CLANCY. I do. 

Mr. CULPEPPER. I do. 

Chairman JOHNSON. Thank you. Please be seated. 

Our first witness on the second panel will be Carolyn Lerner. 

She is Special Counsel at the Office of Special Counsel. Ms. Lerner. 

TESTIMONY OF THE HONORABLE CAROLYN N. LERNER,1

SPECIAL COUNSEL, U.S. OFFICE OF SPECIAL COUNSEL 

Ms. LERNER. Thank you, Chairman Johnson, Ranking Member 

Carper, and Members of the Committee. Thank you for the opportunity to testify today about the U.S. Office of Special Counsel and 

our work with VA whistleblowers. I also want to thank you or your 

work founding the Senate Whistleblower Caucus. OSC has already 

started to work with this caucus and looks forward to doing so 

more in the future. 

The Office of Special Counsel helps whistleblowers, and helps 

employees who make disclosures of wrongdoing and those who experience retaliation after doing so. There are separate processes for 

these two types of cases. I just want to go over them briefly. 

If an employee discloses a health or safety concern or a violation 

of law, rule, or regulation, and it meets a very high standard of review, I send the matter to the agency for investigation. After investigating, the agency must then provide an investigative report to 

my office. The whistleblower is given an opportunity to comment. 

I then determine whether the agency report contains the information required by statute and also whether the agency’s findings appear reasonable. This includes whether appropriate corrective action, including discipline, has been taken. I then send the information and our findings to the President and Congress and post them 

on our website. That is the process for disclosures. 

OSC also protects Federal workers from prohibited personnel 

practices, especially retaliation for whistleblowing. Unlike disclosure cases where we do not have independent investigative authority, in retaliation cases OSC conducts the investigation and determines if retaliation occurred. We can get relief for the employee, including a stay of disciplinary action, reversing a termination, and 

damages for losses that are suffered as a result of the retaliation. 

So that in a nutshell is our process for we believe disclosures and 

retaliation complaints. 

Over the past 18 months, there has been a tremendous surge in 

cases from the VA. I will talk now about how our agency is addressing them, some signs of progress, as well as some areas of ongoing concern. 

OSC has about 140 employees with jurisdiction over the entire 

Federal Government. We are stretched pretty thin. But we have re-
36 

allocated our resources to prioritize VA cases. Perhaps most significantly, we implemented an expedited review process for retaliation 

cases. This process allows OSC to present strong cases to the VA 

at an early stage, saving resources and getting quicker relief for 

employees. 

In the past year, we have obtained approximately 30 corrective 

actions for VA whistleblowers through this expedited process, including a settlement on behalf of Mr. Joseph Colon, who testified 

just now. We also worked to secure relief for Mr. Ryan Honl of the 

Tomah VA. 

These are important victories for employees who risk their professional lives to improve VA operations and quality of care provided to veterans. My written testimony summarizes a number of 

other cases resolved through the expedited program, including an 

employee who was fired for requesting assistance from Congress. 

It is a sign of progress that the VA leadership agreed to the expedited review process. It has also agreed to resolve many more cases 

through regular processes, including mediation, through which we 

have gotten VA employees full or partial relief 84 times this year. 

On the disclosure side, our work has led to important improvements at the VA as well as discipline for 40 officials. This is an important step toward greater accountability and deterring future 

misconduct. However, our review of several recent disclosure cases 

indicates that disciplinary actions are being inconsistently imposed 

and are often of little consequence. The failure to take appropriate 

discipline where there is clear evidence of misconduct can undermine accountability, impede progress, and discourage whistleblowers from coming forward. 

I highlighted these concerns last week in a letter to the President 

and the Chairmen of the VA committees. I believe you all have that 

letter now. In the letter, I contrasted the lack of discipline in response to confirmed mismanagement at the Phoenix VA and other 

locations with the penalties imposed on whistleblowers for minor 

indiscretions. For instance, one whistleblower faced termination for 

eating a few expired sandwiches worth $5. I hope that VA leadership will review these cases and determine whether systemic 

changes to discipline could correct the inconsistent imposition of 

penalties. 

Based on the VA leadership’s positive responses to prior recommendations, I am hopeful that they will work to address this 

problem. In fact, just last week, Deputy Secretary Sloan Gibson 

outlined a new process for responding to OSC whistleblower referrals. They will now be routed through the VA Executive Secretariat. This should ensure high-level review of all whistleblower allegations and investigations, and I am hopeful that the centralized 

process will help to address the concerns I outlined in my September 17 letter. 

Other ongoing issues of concern which I have previously noted 

include retaliatory investigations of whistleblowers, improper accessing of whistleblowers’ medical records, the role of regional 

counsel, and the VA IG’s unwillingness to provide OSC with information. 

In conclusion, we appreciate the Committee’s interest in our efforts to protect VA whistleblowers and for all you are doing to ad-
37 

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

vance whistleblower rights. The stories we have heard today from 

the four witnesses on the first panel are the stories that we hear 

every day at the Office of Special Counsel from hundreds of VA employees. We appreciate your support for our efforts. 

Thank you for the opportunity to testify, and I am happy to answer any questions you may have. 

Chairman JOHNSON. Thank you, Ms. Lerner. 

By the way, I think that is an extremely important point that we 

just had four stories but they are typical. 

Ms. LERNER. Hundreds. 

Chairman JOHNSON. They are not outliers. This is what you are 

dealing with, so I appreciate your efforts. 

Our next witness is Linda Halliday. Ms. Halliday is the Deputy 

Inspector General at the Department of Veterans Affairs Office of 

Inspector General. Ms. Halliday. 

TESTIMONY OF LINDA A. HALLIDAY,1 DEPUTY INSPECTOR 

GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS 

Ms. HALLIDAY. Mr. Chairman and Members of the Committee, 

thank you for the opportunity to discuss the fundamental importance of whistleblowers to the VA OIG’s mission and how the OIG 

works to protect and encourage Federal employees to come forward 

with allegations of waste, fraud, abuse, and mismanagement. I am 

accompanied by Mr. Quentin Aucoin, our Assistant Inspector General for Investigations. 

Whistleblowers are the lifeline of OIG organizations. Our OIG is 

committed to protecting their identities, understanding their concerns, objectively seeking the truth, and ensuring VA pursues accountability and corrective action for wrongdoing. Individuals who 

at times risk their reputations and careers to report suspected 

wrongdoing should be afforded all the protections available by law. 

Whistleblowers have played a vital part in revealing serious 

problems in need of corrective action at VA. For example, we recently acknowledged the instrumental efforts of whistleblowers who 

exposed extensive, persistent data integrity issues at the VHA’s 

Health Eligibility Center and serious mismanagement and operational performance issues at the VA Regional office in Philadelphia. 

Federal laws dictate that veterans have both a right and an expectation that VA employees will not compromise the security of 

their sensitive personal information, even during the course of 

making a whistleblower disclosure. While we strongly encourage 

the reporting of wrongdoing, we equally encourage employees to do 

it in a responsible manner consistent with the applicable laws. 

After assuming the position of the Deputy Inspector General 3 

months ago, I made it my first priority to reinforce that the OIG 

values whistleblowers and that we are hearing and learning from 

the more recent complaints. We go to great lengths to protect their 

identity. We encourage them to report suspected wrongdoing to the 

IG. And any reprisal for doing so is absolutely unacceptable. 

I took steps to strengthen our Whistleblower Protection Ombudsman program and our internal whistleblower training program. 
38 

OIG is also in the process of completing the U.S. Office of Special 

Counsel certification program which will ensure that all OIG employees can assist complainants in educating them on their right 

to be free from retaliation for whistleblowing. 

But our efforts to improve the OIG business processes and encourage whistleblowers to come forward do not stop there. I have 

also directed my staff to assess our own communications and feedback with individuals who report suspected wrongdoing, especially 

when the complaints involve complex and lengthy reviews, and to 

take action to update with VA their current policy on managing external referrals to VA. We are assessing opportunities to change 

our existing process for referring lower-risk complaints to VA that 

we lack the resources ourselves to do, to include assessing the feasibility of repositioning our resources to perform more reviews with 

our own resources rather than relying on a process that makes external referrals to VA. We want to provide greater assurance of 

confidentiality to whistleblowers and to enhance the quality of our 

own investigations and reviews performed. 

I have also reinvigorated the OIG rewards program, but make no 

mistake about it: We recognize the critical role complainants and 

whistleblowers play in exposing serious problems and deficiencies 

in VA programs and operations, and I will continue to review and 

evaluate ways in which OIG can enhance its interactions with complainants and promote greater confidence. 

In addition, I have done outreach to meet and establish strong 

relationships with several of the large Veterans Service Organizations to enlist their input on programs that may not be serving veterans’ needs well. While we are thankful that the Congress has facilitated growth in OIG resources, I want to conclude by leaving 

the Committee with the understanding that there is a serious discrepancy between the size of our workforce and the size of our 

workload. The OIG is not right-sized to respond to all of the complaints we currently receive. We have approximately 660 multidisciplinary professional staff conducting criminal investigations, 

audit, health care and benefits inspections, and contract and financial reviews for an agency with more than 354,000 employees and 

$163.5 billion in their operating budget in Fiscal Year 2015. In fact, 

OIG’s Fiscal Year 2015 budget is less than 1 percent of VA’s budget. The resources pale in comparison to VA’s massive decentralized 

and diverse facilities and the number of employees and the amount 

of funding needing regular oversight. 

Mr. Chairman, this concludes my statement, and I would be 

happy to answer any questions. 

Chairman JOHNSON. Thank you, Ms. Halliday. 

Our final witness is Carolyn Clancy. Dr. Clancy is the Chief 

Medical Officer at the Veterans Health Administration within the 

Department of Veterans Affairs. She is accompanied by Mr. Michael Culpepper, the Acting Director of the VA Office of Accountability Review. Dr. Clancy. 
39 

1The prepared statement of Ms. Clancy appears in the Appendix on page 117. 

TESTIMONY OF CAROLYN CLANCY, M.D.,1 CHIEF MEDICAL OFFICER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY MICHAEL 

CULPEPPER, ACTING DIRECTOR, OFFICE OF ACCOUNTABILITY REVIEW 

Dr. CLANCY. Good morning, Mr. Chairman and Members of the 

Committee. Thank you for inviting us here today to discuss the 

ways that Congress and VA can further encourage Federal employees to come forward with their concerns regarding quality of care, 

patient safety, and waste, fraud, and abuse. 

We exist at VA to serve veterans, and we depend on our frontline employees to serve veterans with dignity, compassion, and 

dedication. And I want to thank you and the Members of the Committee and other colleagues for recognizing just how passionate and 

dedicated the vast majority of our employees are. 

We depend on these same employees to be vigilant about actual 

and potential sources of harm to patients and to voice their concerns if a patient’s safety is at risk. We recognize very clearly the 

important role that whistleblowing plays and addressing the express concerns in bringing issues to light. 

As the whistleblowers today have demonstrated, the Department 

has had problems with ensuring that whistleblower disclosures receive prompt and effective attention and that the whistleblowers 

themselves are protected from retaliation. 

Secretary Robert McDonald, Deputy Secretary Sloan Gibson, and 

other VA senior leaders, including myself, have made it our practice to meet with whistleblowers when we travel to VA facilities 

and to engage directly with those who have raised their hands and 

voices to identify problems and proposed solutions. 

For example, I am personally invested in ensuring that the quality of care at the Tomah VA is of the highest order and that any 

and all circumstances that led to problems at that facility have 

been diagnosed, addressed, with a sustainable path forward. 

Retaliation against whistleblowers who have demonstrated the 

moral courage and at great personal risk to share their concerns 

is unacceptable and cannot and will not be tolerated. We are making progress, and under Secretary Robert McDonald’s leadership, 

we are confident we will reach our goal of ensuring that every employee feels safe in raising concerns and is protected from retaliation when they choose to do so. Monitoring the environment and 

whether people feel safe speaking up is something that we watch 

very, very closely. 

All health care systems require a wide array of feedback from 

multiple sources to ensure the best clinical outcome for patients. In 

addition to many formal mechanisms, the Department has taken 

several important steps in recent months to improve the way we 

address operational deficiencies and to ensure that those who disclose such deficiencies are protected. For example, we have communicated regularly to employees and managers about the importance 

of whistleblower protection. We track corrective actions, require annual training, and we have an online way to gather employee feedback and are now certified by the Office of Special Counsel. 
40 

In addition, just over a year ago, the Secretary reorganized and 

assigned new leadership to VA’s Office of the Medical Inspector 

(OMI). OMI moved quickly to establish clear policies to ensure that 

whistleblower allegations are investigated objectively, thoroughly, 

and promptly. Since that time, this office has completed 30 new 

whistleblower investigations and prepared more than a dozen supplemental reports to follow-up on earlier investigations. 

We have also improved our collaboration with the U.S. Office of 

Special Counsel, to step up to the challenge before us. We have collaborated with OSC to design and implement training for VA General Counsel and the Office of Accountability Review (OAR). This 

will eventually be rolled out across the Department, and as has 

been noted, last summer VA and OSC agreed upon an expedited 

process to speed corrective action for employees who have been subjected to retaliation. As of September 9, we had received 22 expedited cases and resolved 11. 

We understand that we can improve on the timeliness of ensuring individuals found responsible for retaliation are disciplined appropriately and that deficiencies with programs and underlying 

issues are addressed. 

One approach that we do want to raise is for Congress to fund 

OSC at a level that enables that office to hire more investigators 

to complete this work. OSC has traditionally fulfilled this charge, 

and increasing their staffing to a level to assist VA in this endeavor would allow VA’s limited investigative assets and resources to 

focus more in our area of expertise. 

To say it a different way, if we are successful in encouraging 

whistleblowers to step forward, we will have many more to deal 

with, and that is a good thing. That means that the people who are 

now currently fearful of stepping forward, as we heard from the 

first panel, will indeed feel that it is not only OK but a really great 

thing that they step forward and share their concerns. And it is anticipating that future that makes us raise this suggestion. It is very 

important that we hold individuals guilty of retaliation accountable 

for their actions and that we do so as timely as possible. And we 

welcome OSC’s additional assistance on this front. 

The courageous and really heroic witnesses you heard from earlier today, and many, many others, underscore the importance of 

ensuring that all veterans receive the highest quality of medical 

care. I acknowledge today that VA is still working toward the full 

culture change we must achieve. We need to listen better the first 

time employees raise concerns. We need to ensure that all employees feel safe disclosing problems, and we need to guarantee that all 

supervisors who engage in retaliatory behavior are held promptly 

and meaningfully accountable. And, last, we need to work on establishing a culture where everyone recognizes that whistleblowing is 

not only beneficial, it is a gift to the organization. 

We continue to work with whistleblowers, OSC, and the Congress to resolve these issues and are very committed to these endeavors. 

Mr. Chairman, that concludes my testimony, and we look forward to your questions. 

Chairman JOHNSON. Thank you, Dr. Clancy. 
41 

Now, you were all three sitting in the audience for the previous 

testimony, correct? 

Dr. CLANCY. Yes. 

Chairman JOHNSON. I just want to ask each of you—and I guess 

we will start with Ms. Lerner—what was your gut reaction? What 

was going through your head? I mean, outside of your testimony, 

as you were listening to that testimony, what was going through 

your head? What was your initial reaction? Ms. Lerner. 

Ms. LERNER. I wish I could say that it was news, but it was not. 

As I said in my opening statement, the stories, several of them we 

have been working with, so we are very familiar with these gentlemen’s stories. And as you said, they are not atypical. These folks 

are representative of the hundreds of VA employees who come to 

the Office of Special Counsel. We have hundreds of matters just 

like that that we are dealing with now. 

I think you may have been out voting when Senator Carper went 

down the line and said, ‘‘What can we do? What is working?’’ And 

each one of them said, I was very pleased to hear, that the Office 

of Special Counsel had helped them. So I was proud of that. I am 

really proud of my staff. Many of them are here today. They are 

doing, the Lord’s work, really. They spend time on the phone with 

these folks who are in crisis, and they are doing an excellent job 

putting together reports of investigation that allow us to report to 

you and the President what is going on. 

We are building cases, which together are sort of—not to mix 

metaphors, they are all parts of the puzzle that we can see what 

is going on all over the country. And so my recent letter said, look, 

this is a pattern that we are seeing everywhere. We are seeing 

folks getting slaps on the wrist who are engaging in serious misconduct, not really being disciplined, all over the country. Compare 

that with the folks who are taking sandwiches or, sending out one 

email about doing taxes. They are facing termination. There is 

something wrong here. 

Chairman JOHNSON. Thank you again. I just wanted your initial 

reaction. 

Ms. LERNER. Sorry. It was a long answer. 

Chairman JOHNSON. Ms. Halliday, again, just initial reaction. 

Ms. HALLIDAY. My initial reaction is I am really disheartened 

that VA is in the state of affairs it is in today. I have dedicated 

my entire career to serving veterans. The fact is if somebody brings 

an issue forward that can move positive change, why you would 

take actions against that individual is beyond me. When you do 

that, it is bad management. 

Chairman JOHNSON. OK. Dr. Clancy. 

Dr. CLANCY. Profound appreciation for the individuals who were 

here before and the work they are doing to support others. A lot 

of pain listening to Mr. Kirkpatrick talk about his brother. And 

continued concern personally about the people who are fearful of 

speaking up even as we sit here today. And, frankly, a lot of impatience. We need to speed up our actions in terms of our disciplinary 

processes. 

Chairman JOHNSON. OK. I appreciate those answers. 

Ms. Halliday, you heard Mr. Wilkes in his testimony say that the 

VA Office of Inspector General is a joke. In your testimony, you 
42 

said whistleblowers are a vital part, the Office of Inspector General 

values whistleblowers, reprisals are unacceptable. I want to talk 

about a white paper that was issued on really the investigation of 

this Committee and really the events that were revealed through 

press reports with the Tomah VA health care facility. 

Were you at all involved in the writing of that white paper? 

Ms. HALLIDAY. I was not. 

Chairman JOHNSON. Were you aware it was being written and 

issued? 

Ms. HALLIDAY. I was not. 

Chairman JOHNSON. It strikes me as, quite honestly, reprehensible. We issued a subpoena to the Office of Inspector General because we were not getting cooperation in this Committee’s investigation of the events at Tomah and, quite honestly, as that blossomed with other whistleblowers, what is happening around this 

country in terms of opioid overprescription, drug diversion, retaliation, and we were not getting cooperation under the previous Acting Inspector General, so we had to issue a subpoena at the end 

of April. 

Now, the Office of Inspector General then issued this white paper 

a little more than a month later. Now, this is the same Office of 

Inspector General that basically deep-sixed 140 reports and an Office of Inspector General that was so concerned, as am I, as is this 

Committee, about not releasing personal information, particularly 

health care records. And yet the Office of Inspector General issues 

this white paper, and I want to quote some of the more outrageous 

parts of this white paper. And this speaks, first of all, to the family 

of the Kirkpatricks. 

This is from the white paper: ‘‘I strongly recommend a thorough 

review of the in-depth sheriff’s report, a publicly available document that is included in the documents produced, records produced’’—pages whatever—‘‘with specific attention to the pages detailing the voluminous amounts and types of marijuana and what 

appears to be other illegal substances found in Dr. Kirkpatrick’s 

residence, as well as other items including a scale and used devices 

containing marijuana residue.’’ 

I want that to sink in. This came from the Office of Inspector 

General who says whistleblowers are a vital part, the OIG values 

whistleblowers, reprisal is unacceptable. That sounds like a reprisal to me to a dead person. I want that sinking in. 

Second, in referring to another whistleblower, pharmacist Noelle 

Johnson said her termination was because she had poor interpersonal skills and was caustic with clinicians. Again, this is a 

white paper from the Office of Inspector General. I can only conclude from this white paper—by the way, this was also directed to 

this Committee’s investigation, but I could care less. But I care 

deeply about the intimidation, the retaliation, the reprisal coming 

from the Office of Inspector General. 

So, listen, I appreciate the testimony. I appreciate the assurances 

that whistleblowers are a vital part, that the OIG values whistleblowers, that reprisals are unacceptable. But that is not the record. 

What will the Office of Inspector General, what will the VA do 

to make good on this, to make up for this reprisal, for this reprehensible reprisal? What action are you willing to take? And you 
43 

heard Mr. Sean Kirkpatrick asking for the records for the family 

so that they understand what is happening. I want assurances that 

the VA will release those records to the family. I want assurances 

that this will be corrected, that amends will be made for this reprehensible reprisal. Ms. Halliday? 

Ms. HALLIDAY. As I stated, I did not prepare that document. 

Chairman JOHNSON. Who did? Do you know the individuals within the Office of Inspector General that wrote this? Who did this? 

I want to know. This Committee wants to know who is involved in 

this. 

Ms. HALLIDAY. The prior—— 

Chairman JOHNSON. I want to know every individual who was 

involved in writing this report. 

Ms. HALLIDAY. I would have to take that for the record. 

Chairman JOHNSON. We will leave that as an open question for 

the record. 

Dr. Clancy, what can the VA do to make amends for this? 

Dr. CLANCY. I noted very clearly a number of very important suggestions that Mr. Kirkpatrick made, including the personal request 

about receiving his brother’s official personnel file. I do not know 

and my colleague is not clear on whether we can do that, but if we 

can, we will certainly do so. 

Chairman JOHNSON. OK. Listen, let me apologize for showing 

such passion up here. Let me tell you what my gut reaction was 

in this hearing to these witnesses. I was upset coming in here, and 

you can tell I have become more upset. I think every member of 

this Committee has become more upset as we hear this. 

Ms. Lerner, you look like you want to say something. 

Ms. LERNER. The only thought I have is possible disciplinary action that might be taken against the person who is responsible. 

That is, I think, an avenue that could be explored. 

Chairman JOHNSON. Well, I will work with your office to find out 

exactly who those were and exactly what the proper accountability 

and the proper disciplinary action should be taken from those 

members in the Office of Inspector General, remember, that transparent, that independent watchdog over these agencies. My time 

has expired. Senator Baldwin. 

Senator BALDWIN. Thank you, Mr. Chairman. 

First, a comment. On the situation in Tomah the Chairman has 

just discussed, the IG’s various publications, I want to state for the 

record a conversation that we have had in delegation conference 

calls as well as private meetings on the importance of making VA’ 

investigation into Tomah public. You can tell, by this hearing and 

the many other opportunities we have had to receive testimony 

that we have a greater ability to ask questions when we have a 

document we can read. I know you are working on that, but certainly we are very eager to see the work product; you have given 

us verbal assurances that you have spoken with each and every 

whistleblower whose name I have forwarded. 

Beyond Tomah and looking more globally, I have two questions. 

One relates to the testimony we heard earlier and what I have 

heard from whistleblowers at Tomah concerning the ability of veterans to look into medical records and use what they have found 

to publicly assail the credibility of a whistleblower. 
44 

Based on the testimony that we are hearing, not only is this 

prevalent, but it sounds as though there have been virtually no instances of accountability for inappropriate access of those records. 

You have heard some fairly basic suggestions for how to make that 

right. One suggestion was that two parties have to be involved in 

accessing a record; another that we use information technology to 

uncover inappropriate access; and, third, that the folks who inappropriately access this data be held accountable. And I have not 

heard much of that. 

I would like to hear your comments on tangible things that we 

can do to put an end to this. It seems to me one of the more simple 

things that we can address in all of this. 

The other question I want to put out there—the testimony that 

we heard earlier suggests that it is really easy to fire somebody 

who is a whistleblower and really difficult to fire somebody who is 

the subject of a whistleblower complaint, to oversimplify the process. And the one thing that I want to make sure is, as we make 

it easier for the VA to hold people accountable, that we also do not 

make it easier for the VA to terminate the employment of those 

courageous individuals, some of them temporary employees or probationary employees. 

Those are two big questions I want to ask, especially with this 

illegal access to veterans’ medical records in the context of whistleblowing. This seems like a straightforward fix. I would open it up 

to you to respond. 

Dr. CLANCY. So as Senator Ernst said very clearly, it is illegal 

to do that. It is also painful to hear about, particularly when the 

issues related to discrediting a whistleblower around the issue of 

having sought care for mental health problems, if for no other reason than the stigma and the very fact that someone who works for 

us would be using that to discredit someone else at a time when 

we recognize that as a huge barrier to reaching all the veterans 

who need to be reached, is very painful for me to hear. 

Right now, veterans who are employees and use our system, as 

one of the earlier witnesses noted, their records are flagged. So 

there is no mistake if I stumble into a record of somebody with the 

same last name. This is not subtle. I am going to bring back and 

we will look into the issue of a two-step process. That seems to me 

to be potentially promising. But beyond that, it cannot be done, 

that is all, and it has to be—we can also track who accessed those 

records. 

Ms. HALLIDAY. One of the challenges for the OIG is when information is inappropriately accessed, we always try to ensure the 

veteran’s information is protected first, regardless of whether this 

is a whistleblower or an individual. In many of the cases that we 

have discussed and some of the cases that I have gone over the 

past year, veterans’ information has been put at unnecessary risk 

for using outside systems to process veterans’ personnel information and those inappropriate access to it. 

So I would think that a control that allows for a dual signature 

for when a medical record is being accessed would be very appropriate based on the need to have that information associated with 

doing their job. 
45 

The second thing is the underlying controls within VA’s system 

have to have the audit trails turned on, or you really cannot identify clearly who touched the record. And throughout many of the 

OIG reviews, we have found that key audit trails were turned off. 

They were turned off in Tomah. They were turned off in Phoenix. 

And we have told Office of Information Technology (OIT) officials 

they have to be on. You cannot monitor these 100 percent of the 

time. There is some responsibility for the Department to make sure 

those trails are in place. You just have to have that in this day 

when people can get access to records. 

Ms. LERNER. If I could just add a couple of things. In February, 

I first notified the VA that it needed to consider a systemwide corrective action to avoid these types of breaches. Through our disclosure process, 12 employees have been disciplined as a result. We 

have pending investigations in multiple cases where this is a problem. The VA’s position that we have heard so far is that the 

searches were justified because they were just getting demographic 

information, things like mailing addresses from the files. Even if 

that is the case, the system is broken, and it should be a fairly easy 

fix. All they really need to do is make it harder to access these 

medical records, put a better lock on the system. Doctors need to 

have access to medical records, but colleagues and co-workers 

should not. 

The second thing is they are storing information right now so 

that medical information is commingled with demographic information. They are using the VistA system for both medical and personnel information, and that seems to me to be a pretty easy fix 

as well. 

Chairman JOHNSON. Thank you, Senator Baldwin. I just want to 

quickly follow-up. Isn’t there an easier place to get addresses other 

than from medical records? 

Ms. LERNER. Well, they have a system for employees who are not 

also using the system for medical care, so you would think they 

could just use that system. 

Chairman JOHNSON. I mean, there is an alternate system you 

can get addresses from, which if you are looking for an address, 

you go to that system. 

Ms. LERNER. One would think. 

Dr. CLANCY. There are many systems, and, in fact, right now 

there is a group pushing hard to get one reliable source so that we 

have contact with all veterans, period. 

Chairman JOHNSON. My point is that excuse I would term a lie. 

Senator Carper. 

Senator CARPER. I want to thank all of you for joining us today. 

Carolyn, I do not know if you were in the audience when I talked 

about the whistleblowers at Dover Air Force Base and the great job 

that you and your team did there making sure that we found out 

the truth. And what do they say? The truth will make us free. As 

it turns out, you guys played an invaluable role, and we are grateful for that. I do not know if you were here when I asked the first 

panel maybe what is working and what we should do more of; find 

out what works and do more of that. And almost everybody mentioned the work that is being done in the Office of Special Counsel. 
46 

Ms. Halliday, thank you for stopping by and visiting with me last 

week with some of your team and mine as well. 

Dr. Clancy, I spoke to you by phone this week. I would just say 

to my colleagues, we have something in Delaware called the Delaware Health Information Network, which is just a great way to get 

better health care results for less money. It encourages collaboration and sharing by all kinds of providers all over a State, and but 

for Dr. Clancy’s support in the early days, that might not exist. So 

we thank you for that. 

Mr. Culpepper, I do not have anything good to say about you, but 

I am sure if I were to dig down, there is a lot I could say. I just 

do not know you. But we are glad that you are here. 

I think a lot of times in terms of shared responsibilities and who 

is responsible for fixing a problem. In most cases, it is a shared responsibility. And in our own VA health care delivery system in 

Delaware, which I talked about earlier, where the mother ship is 

the hospital and the nursing homes just outside of Wilmington, a 

town called Elsmere, and we have two outpatient clinics in our two 

southern counties. But sometimes the veterans will tell us when 

things do not go well, and I am in and out of our veterans’ facilities 

throughout the year. My staff is as well. And there is a lot we can 

learn from those visits, and we need to do that. So just by our demonstrating by our presence, it sends a message to the folks that are 

running the VA in our States that we care about this. 

Families, family members, they contribute. Patients can tell us 

if things are not going well. They can tell our staff. I am going to 

be meeting with our Veterans of Foreign Wars (VFW) folks, representatives from Delaware, later this afternoon, and they are omnipresent, in and out of our hospital in Elsmere, Delaware. And 

they hear things that are going well and those that are not, and 

they can be very helpful in this. 

We have also as a Congress the opportunity through funding to 

make sure that we are funding VA health care, writ large, that we 

are funding your operation, the Office of Special Counsel, that we 

are funding the IG’s office. And you have a huge burden to carry, 

also to make sure that you heard us talking about the Senate. We 

still have too many folks that are serving as an IG in an acting capacity. God bless you for those who are willing to do that, but we 

ought to have Senate-confirmed IGs, and we are going to keep 

pressing this administration until we do. 

We have a bunch of committees that have oversight over what 

is going on in the VA. We have a VA authorizing committee, Veterans Administration. We have an Appropriations Subcommittee 

whose focus is VA. This Committee is an oversight committee over 

the whole Federal Government. That is a whole lot to say grace 

over, so it is hard for us to cover every single piece of that. The 

Budget Committee has some jurisdiction over this. We are going to 

be going through in the next week or so a spending plan for our 

country, and the question is: Are we going to hold harmless the Department of Defense (DOD) budget and for the non-defense part of 

our Congress continue to expose many of those elements to sequestration? Is there some compromise there? Is there some way to do 

a deal? 
47 

So we have plenty of opportunity ourselves here to try to effect 

a better outcome in the health care delivery system. And we have 

a bunch of watchdog organizations that have sort of popped up and 

are good enough to share information with us and with others. And 

then there is the media. So there is a lot of shared responsibility, 

and we need to take that seriously. 

Here is a short, easy question for each of you, and I will start 

with you, Mr. Culpepper, if you do not mind. But just give us one 

thing that you think could be done, should be done to ensure that 

whistleblowers—we will say just at the VA, whistleblowers at the 

VA—are better protected from retaliation? Either something we are 

already doing that we need to do more of, tell us what it is, or 

something we are not doing that we should be doing. Please, one 

thing. 

Mr. CULPEPPER. Thank you, Senator. I think really education of 

our workforce, especially our managers. So recently our Office of 

General Counsel and our Office of Accountability Review has actually gone over and got some training from OSC that we are looking 

forward very much to rolling out in a much more robust fashion 

than just the online training system you heard from the last panel. 

Education is key. It is no excuse for managers that retaliate. It is 

not tolerated. It will not be tolerated. But we do need to make sure 

they are educated so it happens less frequently. 

Senator CARPER. All right. Thank you. Dr. Clancy. 

Dr. CLANCY. I would not disagree with that. I do think that we 

need better training for front-line managers, and that is a pretty 

high priority for us at the moment. 

In addition to that, I think that we need to publicize and celebrate the good things that come out of people blowing the whistle. 

One of our former—— 

Senator CARPER. We did that. We did that, thanks to—— 

Dr. CLANCY. Yes. 

Senator CARPER. That is what we did at the Dover Air Force 

Base. 

Dr. CLANCY. And I have to say that Deputy Secretary Sloan Gibson this year, I believe, was the first time—I do not know if it was 

in history, but I think in many years; I have not been at the VA 

that long—actually attended the OSC Special Counsel’s award 

ceremony for whistleblowers for VA, which I think is the right step. 

But in addition to that, I think we actually need to make it really 

clear: This person blew the whistle, here is what we learned, and 

here is why veterans are better off. Because without that, I do not 

think we get the cultural change. Other than that, it feels so uncomfortable that the instinctive reaction is to withdraw. 

Senator CARPER. All right. Thanks. 

Ms. Halliday, just one example, please. 

Ms. HALLIDAY. I think we need to spend our time on the education on the ranks of the people that are managing these whistleblower complainants. There is a lack of leadership. There are clearly problems with how they are addressing situations. Education 

there and an investment in how to properly lead is absolutely necessary. 

Senator CARPER. All right. Thanks. 

Ms. Lerner, please, same question. 
48 

Ms. LERNER. Everything they said, but since it has not been 

touched on and since it was the subject of my letter last week to 

the President and Congress, I think discipline is really key and has 

to be an area where we start shifting our focus. We have done a 

lot, we have seen a lot of progress, but the one area that I think 

remains to be really attacked is discipline. Senator Johnson said in 

his statement for this hearing the touchstone quality that makes 

any organization successful is accountability. And that is the missing piece, I think, right now. 

Senator CARPER. [Presiding.] Senator Peters, you are next. 

Thanks. 

OPENING STATEMENT OF SENATOR PETERS 

Senator PETERS. Thank you, Senator Carper. And I would like to 

thank Chairman Johnson and Ranking Member Carper for holding 

this hearing, and I certainly appreciate the testimony from the witnesses. I think we all agree we heard some very disturbing testimony earlier this morning about the whistleblower process and the 

need to make some significant changes. Certainly as a country, we 

are all committed and have a solemn duty to take care of those 

who have taken care of us and who have kept us safe, and that 

duty certainly includes an obligation to take care of our Nation’s 

veterans, and the 650,000 veterans that call my home State of 

Michigan their home. 

But we also have a responsibility to support the VA employees 

who serve our Nation’s veterans honorably and those who are willing to come forward to identify problems, despite the risk. Apparently from what we are hearing, there are significant risks within 

the VA to come forward to identify those problems. 

So, with that in mind, Ms. Lerner, you stated in your testimony 

that complaints from VA employees make up between 35 and 37 

percent of the complaints that your office gets governmentwide. I 

mean, those are striking numbers, one agency, 35 to 37 percent. So 

if you would tell this Committee—and I know you have mentioned 

some things, but elaborate—why you believe the VA accounts for 

such a large proportion of the complaints. And that certainly tells 

us an awful lot about the culture, but drill down a little bit for me 

and tell me why this is just an overwhelming number from the VA. 

Ms. LERNER. Sure. And, I think that there are a lot of possible 

reasons for the increasing number of complaints. Let me just give 

you a few. 

First, the VA is really big, and there are a lot of people who work 

there who are in health care facilities, so doctors, nurses, other 

health care workers who care really deeply about the mission of the 

VA, and because of the type of work that they are doing and because they are seeing people who are not getting the treatment 

that they need, they feel obligated to come forward. So it is an environment that is really ripe for disclosures. 

Second, I think employees may be feeling now in the last year 

or two that they could really make a difference, and we know that 

the No. 1 reason that whistleblowers do not come forward is not 

fear of retaliation, but it is because they do not believe that it is 

worth the risk if it is not going to make a difference. Why expend 
49 

the time and energy and hope that goes into filing a complaint if 

you feel like it is going to fall on deaf ears? 

So if there is a silver lining to the increase in complaints, it may 

be that people feel that they are going to be heard and they believe 

that their disclosures are going to be acted upon. And OSC is really 

getting results. So a third reason is they are more familiar with my 

agency, with the Office of Special Counsel, and they know that they 

will be protected from retaliation if they come to us. We have been 

doing a lot more outreach and training, and the number of whistleblowers who are getting relief at our agency is at an all-time high. 

We have over 100 corrective actions for VA employees compared to 

about 29 cases over the entire government just 5 years ago. So 

there has been an exponential growth in the work that we have 

been able to do to help whistleblowers. 

So, in short, results matter. I think we are getting more of them. 

Whistleblowers know that they will make a difference when they 

come to us, and so I think it is a combination of those factors that 

is causing our increase in filings. 

Senator PETERS. Thank you. 

Ms. Halliday, in your prepared remarks, you also cited some 

similar capacity concerns that Ms. Lerner mentioned in her testimony as well. In fact, you said, ‘‘We receive far more allegations 

than we have the resource capacity to review, thus the OIG must 

be highly selective in the cases we accept.’’ So could you elaborate 

for me how you prioritize those cases and exactly how quickly are 

they triaged? You obviously have to have some sort of management 

of those, and I would just like to get a sense of how that works. 

Ms. HALLIDAY. Yes, I would. We get approximately 40,000 to 

42,000 complaints on our hotline annually. We are probably one of 

the largest hotlines in the Federal Government, most active. We 

look at those complaints. They come in to an intake group who 

triages complaint, whether they belong to Criminal Investigations, 

have a flavor that a crime has been committed, or fraud; or they 

will go to Health Care Inspections if it is a health care quality of 

care issue. It would go over to the audit groups or contract groups, 

depending upon what the nature of the complaint. 

At that point, the line offices take a very close look at whether 

the allegations are clear enough that we can do enough work to 

make a difference. In some cases, when a caller asks to be anonymous and they say, ‘‘It is happening in my health care facility,’’ you 

might only know where the facility is. You do not know if it is in 

surgery or how to drill down in the allegation. So we try to find 

enough information that we can review the complaints. We take all 

allegations against Senior Executive Service (SES), which are VA 

senior executives and your GS–15 levels, and we take the majority 

of the allegations when they have a high risk of financial risk or 

risk to patient safety, and it is triaged from that point. We are 

looking at that bottom group right now to see is there a way to 

take more of these. 

Senator PETERS. All right. Thank you. 

Senator CARPER. Thank you, Senator. Senator McCaskill. 
50 

OPENING STATEMENT OF SENATOR MCCASKILL 

Senator MCCASKILL. Thank you. 

I have a piece of legislation that would require the firing of anyone found to be retaliating against whistleblowers. Have either the 

Office of Special Counsel or the IG’s office found that there has 

been retaliation within the Department of Veterans Affairs against 

whistleblowers? Have you found incidents of retaliation? 

Ms. LERNER. In our letter, we outlined a number of cases where 

employees who blew the whistle were subjected to disciplinary action, up to and including termination. 

Senator MCCASKILL. And you determined that was, in fact, retaliation? 

Ms. LERNER. I think it is fair to say yes. 

Senator MCCASKILL. OK, and were those people fired, Dr. 

Clancy? 

Dr. CLANCY. Many were disciplined. I do not—— 

Senator MCCASKILL. I did not ask that. Were they fired? 

Dr. CLANCY. I think one person was fired? 

Senator MCCASKILL. Out of how many? 

Dr. CLANCY. I would have to get you the numbers. 

Senator MCCASKILL. I need the numbers. 

Dr. CLANCY. Sure. 

Senator MCCASKILL. I need to know if there is a determination 

either by the IG or by the Office of Special Counsel that retaliation 

has occurred. I need to know how many instances that determination has been made and someone was disciplined as opposed to 

fired. Do you believe if this bill passes and it requires the firing of 

someone who retaliates, that it would have the impact that we are 

looking for here in this very troubling area? 

Dr. CLANCY. So knowing how much work probably went into developing this legislation, I would actually like to read it before rendering an opinion. And I am always—— 

Senator MCCASKILL. It is simple. It just requires firing. What 

about the idea of requiring the firing of an employee who has been 

found to retaliate? Do you believe that idea—forget about the details of the legislation. It is pretty simple. Just assume it says just 

that. Do you believe that this is a good idea? 

Dr. CLANCY. I believe in serious discipline. I worry a lot about 

more fear plummeted onto leaders who right now are feeling pretty 

fearful because what they feel like is if someone raises their hand 

or there is something that goes wrong at their facility, instead of 

saying, ‘‘This is great that you brought it to me, bring it on, we can 

solve these problems.’’ They are worried that they are going to lose 

their job. 

Senator MCCASKILL. But isn’t that a culture issue, Doctor? 

Dr. CLANCY. It is a culture issue. 

Senator MCCASKILL. I mean, this is the problem. 

Dr. CLANCY. Yes. 

Senator MCCASKILL. They are more willing to hide the problem 

because they are worried about their bonus or they are worried 

about how it is going to look to people above them than they are 

the problem. 

Dr. CLANCY. I agree with you completely. 
51 

Senator MCCASKILL. OK. That is why they have to be fired if 

they retaliate. 

Dr. CLANCY. More firings I worry about. That was the reason I 

said reading the details would be helpful. 

Senator MCCASKILL. OK. And I will look forward to your input 

after you read it, but I would like the numbers. How many people 

who have been found to retaliate were fired? 

What if we had a clock, Deputy Inspector General Halliday? 

What if we had a clock that if the administration—this is putting 

you on the spot. Let me just put this on the record. I believe it is 

time to think about having a clock, and if the administration has 

not appointed an Inspector General after 6 months at an agency 

that has 35 percent of the whistleblower complaints in all of the 

Federal Government, then Ms. Halliday gets the job. She becomes 

the Inspector General because the administration has failed to act. 

I do not know how else to do this. We went for months without 

an Inspector General at DOD, which really is a problem, a huge 

problem. 

Finally, let me just ask this on budgets. Budgets matter. I assume that if you said in your opening testimony, Ms. Halliday, that 

you are one percent of the VA budget, and I know, Ms. Lerner, 

your caseload has increased dramatically. I believe your caseload 

has increased over the last 5 years by 58 percent. I guarantee you 

your budget has not increased by 58 percent. I know we are looking 

at long delays in terms of these investigations because my office 

deals with whistleblowers every day and many of them have waited 

over a year to have their complaints looked at. 

Tell me what sequestration does to your budget, Ms. Lerner. 

Ms. LERNER. So right now I have about 140 employees. We cover 

the entire Federal workforce, all civilian workforce more or less, 

over 2.1 million employees. During sequestration last time, we 

went down to 104 employees. I had to let 15 people go. 

Now, I think if we tell Federal employees that they are going to 

be protected from retaliation if they come forward and make disclosures and that those disclosures are really important, we ought to 

be able to back that up. I personally feel really responsible for 

making sure that when people come to us, we are able to help them 

when they need help. It pains me when they have to wait and 

when we have to make triaging decisions about who are we going 

to help first. 

Senator MCCASKILL. I think we should have a buzzer, and every 

time anybody in the Senate talks about that, it is OK to go to sequestered levels of funding for the budget. We should ring the 

buzzer and talk about what comes out of the other side of their 

mouth about expecting you not to have any delays when someone 

comes forward and files a complaint. You cannot have it both ways. 

You cannot expect the VA to do its work well. You cannot expect 

the IRS to have customer service. You cannot expect Inspectors 

General to do their jobs thoroughly. You certainly cannot expect 

whistleblowers to have their cases adjudicated fairly and in an efficient manner if we are cutting the money that provides the necessary personnel to do the work. 

So I appreciate all of you very much, and I will look forward to 

getting the follow-up information from you. I have more questions 
52 

for the record, but since we are voting right now and the vote is 

just about over, I will say thank you for your testimony today, and 

in particular, thank you to the whistleblowers on the first panel 

that I was unable to question. 

Senator CARPER. Senator McCaskill, thank you so much. 

Senator Johnson is going to be back momentarily. He is voting, 

and I am going to recess the hearing for just a minute or two until 

he arrives. 

I again want to thank you all for joining us today, and it is especially good to see you, Ms. Lerner and Dr. Clancy. Thank you for 

the difference you have made in the State of Delaware. Thank you 

so much. 

Chairman JOHNSON. [Presiding]. Thank you, Senator Carper, for 

holding down the fort here. 

I have just got a couple more questions, and I will give everybody 

an opportunity at the very end to make a closing comment. 

Dr. Clancy, first of all, let me acknowledge, because this is true, 

I think the vast majority of people, doctors, nurses, administrators, 

from the lowest part of the organization all the way to the top, are 

definitely dedicated individuals doing everything they can to honor 

the promises made to the finest among us. I think that is just basically true, but we obviously have a systemic problem here, and the 

question I want to ask to you is: What is so difficult about holding 

the people that are retaliating, that are engaging in reprisals, what 

is so difficult about holding those people accountable? Because as 

you and I spoke yesterday in my office, there is nothing more corrosive to an organization than allowing bad apples to just get away 

with it and not being able to hold people accountable. So can you 

just kind of speak on why is it so easy, on the one hand, for the 

retaliators to retaliate and get away with it versus holding people 

accountable from the top of the agency down? 

Dr. CLANCY. So I do not think it is that difficult. I think what 

is difficult is that it takes time to get all the facts together. It is 

rare that a story of retaliation is pure black and white. For example, people who are frustrated because they feel like they have been 

trying to make their voices heard and may not have been effectively doing so; people were not listening, their issues were blown 

off, may not always behave in a wonderful manner. 

Supervisors do retain a responsibility to hold people accountable 

for the various functions of their job. We have heard some examples today which I think are horrifying. I agree with you on that. 

But there are other times when it is a little bit harder to sort out 

the actual facts. 

So if there is a fair process, people should be held accountable, 

period. But I think the process needs to be fair, or people will be 

overwhelmed by fear. 

Chairman JOHNSON. Again, having managed people for 30-some 

years, I understand the gray areas and sometimes the difficult nature of getting to the truth. But do you believe that we are holding 

people properly accountable? 

Dr. CLANCY. No. And we are taking too long to do it, and we are 

committed to doing better on that front. 

Chairman JOHNSON. Ms. Lerner, I would kind of like your assessment on that same question. 
53 

Ms. LERNER. Well, the reason that I wrote this letter to the 

President last week is because of these very concerns. We have 

learned that even in cases where the VA has substantiated wrongdoing by officials that implicates patient health and safety issues, 

the VA has done very little to impose discipline. Sometimes, they 

will do a slap on the wrist or a written reprimand. But very little 

is done to those who are responsible. 

Chairman JOHNSON. But let me ask you, what is your assessment, your judgment of why that is? I know I am asking for an 

opinion here, but, why do you think that is? 

Ms. LERNER. I am speculating. It is hard—— 

Chairman JOHNSON. I am asking you to speculate. 

Ms. LERNER. But, the folks who are in positions of power and authority are higher up along the food chain, and the folks who are 

getting the punishment and the discipline tend to be lower on the 

food chain. And I think that, there may be more of a reluctance 

and resistance to go after folks who are more powerful in the organization. 

I can tell you that headquarters VA, when I have had conversations with the Deputy Secretary and the General Counsel and the 

folks in Accountability and Review, the folks in D.C. really, I think, 

understand the importance of discipline and holding people accountable. They get it. The problem is it is down in the regions, 

and the regional counsel who have to enforce the disciplinary actions and bring them that are reluctant to do so. That is my sense, 

is that the problem is not at headquarters. It is really down at either the individual facilities or in the regions. And the regional 

counsel just are not willing to go after folks. But I do not have 

independent evidence of that. 

Chairman JOHNSON. And, again, I have had enough contact with 

Dr. Clancy, who I think is a very good person. I think your heart 

is in the right place. But it does speak—it really is a top management problem. I mean, top management is going to have to enforce 

that middle layer where we are not holding people accountable. 

That is what is going to be required. And, again, from my standpoint, it is going to require an independent and transparent Office 

of Inspector General to provide that information to the public, to 

Congress, to put the pressure so that actually happens. Dr. Clancy. 

Dr. CLANCY. Yes, the one point I was going to add is I think one 

of the challenges we have, not just in this arena but in almost 

every aspect of what we do, is enormous variability. It is a huge 

system. We meet veterans’ needs wherever they happen to choose 

to reside in this country and a few other places. And I think the 

issue of discipline is not different from other areas. 

So when then-Acting Secretary Sloan Gibson created the Office 

of Accountability and Review, a very, very big goal was to make 

sure that there was a far more consistent process. And I think that 

that is starting to work, but as I said, we need to pick up the pace. 

Chairman JOHNSON. Let me ask another question, because I 

think this is just a real problem. When somebody would come to 

me kind of leaping over layers of management with a complaint, 

it is difficult to deal with because how do you go and take care of 

it without kind of tipping off the manager who just might engage 

in retaliation? And certainly what we heard in testimony is that in-
54 

dividuals have come to the Inspector General’s office and/or the 

Office of Special Counsel, frequently those complaints are 

heard and then they are turned right back over to the agency, 

thereby—maybe not revealing the name, but, people are smart and 

they certainly can make assumptions. 

Ms. Lerner, I would like your assessment of to what extent that 

is a problem, and what can we do to correct that? 

Ms. LERNER. When whistleblowers come to us, they have the option of remaining anonymous. It is not as effective sometimes because we really like when we refer a case for investigation for the 

IG or the Office of Medical Inspector to actually interview the whistleblower. So it is not ideal when they stay anonymous. But they 

can. They can remain anonymous. 

Chairman JOHNSON. And then you do not go back to the agency 

or the department, correct? 

Ms. LERNER. No; we still do. We still do, absolutely. And you are 

right, sometimes they can still be identified, but not always. When 

we send our letters, when we send our referrals to the agency for 

investigation, we have language in there that specifically says we 

expect you to take steps to make sure that no retaliation occurs. 

And the minute we get a phone call from one of our whistleblowers 

saying, ‘‘OK, they found out who I am, and I am being retaliated 

against,’’ we then take action. We are on it. We do the best we can. 

And we can get stays of disciplinary action. We have been very active doing so, both informal stays and formal stays. Generally, if 

we contact the VA and let them know that someone is being retaliated against, they have been pretty good about holding off on taking disciplinary action. But it should not require the Office of Special Counsel to get involved. 

Chairman JOHNSON. Ms. Halliday, why don’t you speak to that 

potential problem? 

Ms. HALLIDAY. I consider one of the major risks to the OIG and 

to the Department is our ability not to take all of the complaints 

that come in and process them. I think that there is a fear with 

whistleblowers and a perception that VA will not be fair in the 

process as complaints are reviewed and fear of potentially disclosure of their confidentiality. We are probably in the best position 

to review but it is a resource issue given the volume that has come 

in post-Phoenix on these complaints. 

But I think that my executive staff clearly sees that as the major 

risk, and if we can work to get more controls over those more serious complaints that are coming into our office that absolutely need 

OIG’s independent review, I think that it goes a long way to help 

the Department and it helps veterans. 

Chairman JOHNSON. So I appreciate Senator Ayotte coming here, 

but I will beg her indulgence for one final question, because you 

raised the issue that I wanted to ask this question about, the overwhelming nature of the volume of complaints coming in. How overwhelming is it? Ms. Lerner, you gave us some sense of that. But 

I would like both of you to kind of speak to the volume coming in, 

how you are trying to deal with it, how you try to prioritize the 

complaints, and what are you going to do with these? We will start 

with you, Ms. Lerner. 
55 

Ms. LERNER. Sure. We are inundated and overwhelmed with 

complaints from the VA making up about 35 to 40 percent of our 

total caseload. As you said, we have gotten about 1,400 prohibited 

personnel practice complaints, most of which are retaliation; about 

2,000 disclosures from the VA. So we are overwhelmed. 

What we have done is set up our own sort of triage system. We 

have a senior counsel who is assigned to just the retaliation cases 

and working with the Office of Accountability Review at the VA to 

work on expedited settlements. We have worked with the VA to set 

up this expedited settlement process so that cases that have a lot 

of merit that we can identify quickly do not have to go through the 

full investigation process. 

We have a VA team at the Office of Special Counsel that meets 

once a week and talks about the VA cases. I get updates every 

week on every new VA retaliation case that is filed. So we are 

doing everything we can to make these a priority. 

That being said, we truly are overwhelmed and wish we could do 

a lot more. 

Chairman JOHNSON. And, again, you are just dealing with the retaliation on whistleblowers. Ms. Halliday, then your office is dealing with all the whistleblower complaints. 

Ms. LERNER. Well, we also deal with disclosures, too. So there 

are two tracks: one is disclosures of waste, fraud, wrongdoing, 

health and safety issues; and then also the retaliation cases. 

Chairman JOHNSON. OK. Ms. Halliday, tell me about the caseload that you are dealing with here. 

Ms. HALLIDAY. The caseload now is about 40,000 to 42,000 contacts a year. As I said earlier, the OIG VA’s hotline, is one of the 

largest in the Federal Government, and the types of complaints 

that we get in are diverse. We have done exactly what OSC has 

done to perform better triage to make sure that we are gleaning 

out enough information at the complaint intake stage that we can 

understand the seriousness of the complaint so that we can process 

it effectively. 

Chairman JOHNSON. So how many of 42,000, how many do you 

view as serious enough to actually take action on? 

Ms. HALLIDAY. The number is very low, and that is why I have 

asked my hotline team to divide up for me exactly what is in the 

40,000 contacts so I can take a look at it by risk. I would say the 

last numbers I thought I saw was 3,200 or so complaints were actually taken in the last fiscal year. So you can see the delta is 

huge. 

Chairman JOHNSON. You have how many people adjudicating 

those complaints or looking into those? 

Ms. HALLIDAY. Well, it is spread over three different directorates, 

depending upon if it is criminal, health care, or audit, and that 

would represent about 660 performing all OIG requirements. 

Chairman JOHNSON. OK. 

Senator Ayotte, I apologize, but you are up. 

Senator AYOTTE. Thank you, Chairman. 

I wanted to, first of all, associate myself with the comments that 

Senator McCaskill made earlier. It is just absurd that it has been 

631 days that we have not had a permanent Inspector General at 

the VA, and I will join—I have written numerous times to the 
56 

President of the United States, but if the President really cares 

about getting this right, then he will nominate a permanent Inspector General. And I think it says a lot, unfortunately, that people on both sides of the aisle have asked him to do that, and we 

are 631 days into it, and I think our men and women in uniform 

deserve better than that so that you can have permanent leadership on this very important oversight issue. 

And I agree with Senator McCaskill. If the IG positions are going 

to go vacant, then, I previously also sponsored the Vacant IG Act 

that she and Senator Boozman have introduced that would put 

Congress in a position to actually nominate these positions if the 

executive branch abdicates its responsibility. 

I wanted to follow-up on the wait lists because, Dr. Clancy, the 

VA, of course, with what we went through last summer with the 

revelations of the wait list and the manipulated wait list and veterans literally who died waiting for care, and you talked about the 

fact that the VA is making progress. But as I understand it—there 

have been different estimates—only a handful of people have actually been fired as a result of what happened. And I regularly hear 

from veterans in New Hampshire who are really frustrated with 

the lack of action and accountability. And we heard that earlier 

with our panel of whistleblowers who felt that there was no accountability for the people who were not doing their jobs in serving 

veterans. 

What is being done in terms of this accountability issue? Why 

hasn’t there been more accountability over the wait list manipulations? 

Dr. CLANCY. So, first, I want to emphasize that since this whole 

scandal broke out, we have taken the issue extremely seriously and 

have literally for over a year sat down with the Deputy Secretary 

every single day of the week to go over data, to look at which facilities are having the worst time, and often bringing them in by videoconference to find out what is the problem, what is the barrier, 

how can we help and so forth. No senior leaders got bonuses. No 

one can have in their performance plan performance metrics related to wait times and so forth. And what we found was that we 

provided a lot more care, both within VA through extended hours 

and so forth, and also buying it. 

Senator AYOTTE. But just so we are clear for the record, because 

I have a separate bill on this clawback of the bonuses issue, there 

were many people who received bonuses who are in positions 

where, unfortunately, they were engaged in this issue. And, obviously, they received them, and so that is why Senator McCaskill 

and I actually have a bill to claw that back. But please go on. 

Dr. CLANCY. Yes. Well, I was speaking for 2014 because Secretary McDonald came in 2014, so that had been already declared 

by his predecessor, and Secretary McDonald carried that through. 

And, very importantly, I think the shift was toward do not hide 

this information, tell us. Tell us how we can help. Do you need 

more space? Do you need more people? How is it that we at headquarters can actually help you address some of these barriers and 

so forth? So we have seen facilities all across the system step up 

to this challenge, but we have also seen increasing demand as we 

have gotten better at getting veterans in to be seen. Either in our 
57 

system, virtually by telehealth, or by buying care in the community, more and more veterans have come in. So we are still working 

this hard, and I have to say it is the No. 1 priority for our new 

Under Secretary, Dr. David Shulkin. So we are working that very, 

very hard. 

As you know, or I think are likely to be aware, there was a huge 

array of investigations brought. Some are still ongoing. I would 

have to get back to you with numbers so that I am really confident 

about how many senior leaders are still under investigation for 

wait list issues. It has taken quite a bit of time. 

Senator AYOTTE. Well, I would appreciate it, and I think that for 

all of us, there is great frustration in not hearing the accountability. And so it is great to look at data. 

Dr. CLANCY. Yes. 

Senator AYOTTE. But real people were involved, unfortunately—— 

Dr. CLANCY. Absolutely. 

Senator AYOTTE [continuing]. In manipulating these wait lists, 

and when you think about the people not being held fully accountable at all levels of the VA for this atrocity, what it does is it sends 

a message through the organization, through these other cases we 

have heard about, that is one, to Ms. Lerner’s point, of not accountability at each level. And if you are not held accountable for what 

happened with these wait lists, I mean, what will people be held 

accountable for I think is a question. So I think all of us want to 

see more accountability and more people being held accountable, 

and, by the way, the people who are doing a good job rewarded, 

and instead of being in a position where they bring misconduct to 

light, supported by saying let us work to solve the problem that 

you brought to light, as we heard from our earlier panel. 

Dr. CLANCY. Yes, and I was not, I hope, contradicting that, and 

we will get you an up-to-date accounting of where all this stands. 

I was just acknowledging that thorough investigations take time, 

and really our first priority was to make sure that veterans got 

seen as soon as possible—in other words, to address the patient 

care issue and then get into the accountability. And, frankly, how 

do we get there? The Secretary through his efforts has really led 

a number of other important areas, really strongly encouraging, actually requiring facility leaders to get out and talk to the clerks on 

a regular basis. 

Senator AYOTTE. So I know my time has expired, but Ms. Lerner 

testified that, as I understand it, if I am correct in this, 35 to 40 

percent of the complaints you receive just pertain to the VA? 

Ms. LERNER. That is correct. 

Senator AYOTTE. And this is across the whole of government, correct? 

Ms. LERNER. Yes. 

Senator AYOTTE. Well, that is a huge number. So I guess what 

I also want to understand is what are we doing in terms of looking 

at the number of complaints systematically in terms of what issues 

they repeatedly raise and making sure that there is systematic 

change being driven by the huge volume that clearly speaks for 

itself as you look at the whole of government for Ms. Lerner to be 

receiving 35 to 40 percent from, one agency. 
58 

Dr. CLANCY. Well, I think Ms. Lerner—and if I misquote you, 

please speak up—did acknowledge that there might be a bit of a 

silver lining there, and I would actually agree with that, if people 

actually do feel free to contact her office. But, ultimately, there are 

a lot of other ways that people can make their voices heard. 

Senator AYOTTE. So, systematically, what are you doing with 

this? Let us say you have whatever percentage of whistleblower 

issues, of retaliation, whatever percentage in terms of waiting for 

care. I am just coming up with different categories. What is the VA 

leadership and at all levels doing to incorporate the complaints? 

Obviously, individually they need to be investigated, but systematically, how is that feedback being addressed by the VA? 

Dr. CLANCY. Systematically, certainly we address the feedback 

once the whole set of investigations has been completed, but in addition to that, we are not waiting for that. We are also looking at 

data all the time. And we have identified a tool and built a tool 

to let supervisors and front-line managers as well as their directors 

know if there are scheduling irregularities. This is not saying that 

you are wrong. What it is saying is we are seeing something in the 

data that looks really funky here; you need to go look at it. And 

we are encouraging a lot of engagement with front-line employees 

so that we can hear from them directly. 

We also look at things as to whether people report issues of patient safety that do not actually go to the Office of Special Counsel. 

We have seen an increase in that this past year, which I actually 

think is a good thing if we are acting to follow-up on it and address 

those issues. 

Senator AYOTTE. Well, Mr. Chairman, as you know, we could be 

on this topic for a long period, but this is something—I can think 

of no more important issue for this Committee to address in terms 

of more accountability, and obviously the issues we heard earlier 

with the panel on the whistleblowers as well and support for them 

within this organization. And so I look forward to working with you 

on this. 

Chairman JOHNSON. Thanks, Senator Ayotte. 

Again, I will give everybody an opportunity to make a closing 

comment. Before I do that, I do want to talk to Dr. Clancy. This 

is really a subject for another hearing, but I would be interested 

in Senator Ayotte confirming this as well. I am hearing repeatedly 

from veterans that their requests for the Veterans Choice Act are 

being denied. And, again, I just want to say I appreciate your willingness to take up a particular case. I cannot really reveal the individual’s name. I am not sure we have the disclosure yet. But this 

is a Vietnam era veteran who early in August was diagnosed with 

Stage IV pancreatic cancer, really cannot travel the 120-plus miles 

to where the VA tells him he needs to get treated, and his request 

for treatment closer in a very high-quality private sector hospital 

in Green Bay is still being denied. 

It is an issue I am hearing repeatedly. They are adjudicating 

every one of these issues, but I really do want to make sure that 

you are aware that it is a real complaint I am hearing, but I truly 

appreciate you being willing to take a look at this one particular 

case, because this gentleman’s time is precious, and it really does 
59 

need taking a look at, so thank you very much for doing that. With 

that—— 

Dr. CLANCY. Let me just say very briefly, we have been buying 

more and more care in the community over the past 10 to 12 years, 

and what we have gotten to is a place where we have six or seven 

different pathways to do that, including the new Veterans Choice 

Act. We will by November 1 be bringing a plan to the Congress to 

say we are integrating them all into one, which I think is going to 

be a very big step toward our becoming a high-performing network 

where VA focuses on what we do really, really well and relies on 

community partners to actually help us with those other issues. 

Chairman JOHNSON. And I do think that really should be the 

long-term direction. I realize this is not easy, but, again, I appreciate your efforts there. 

We will start with you, Dr. Clancy, if you would like to make a 

closing comment. 

Dr. CLANCY. Again, I want to express profound appreciation because we need to hear from employees all the time. I think of whistleblowers as one end of the spectrum, and if they feel like they 

need to exercise that option, then we should take that with the utmost seriousness. We are, but we need to pick up the pace. 

But we also need to have many, many different outlets for employees and, frankly, we need to thank them when they speak up 

about those concerns and make that clear to others. We have started down this path. I am confident that we are going to get there, 

because I think Secretary McDonald and all of our leadership want 

nothing less. 

Chairman JOHNSON. Thank you, Dr. Clancy. Ms. Halliday. 

Ms. HALLIDAY. Yes, I definitely am trying to change the culture 

within the OIG to make sure that we reward whistleblowers when 

they come forward. I see the risks to them, to their career, as significant. I know as an IG we have to look at all the underlying 

facts, weigh the evidence, but it is so important for us to do that. 

I want veterans, I want VA employees to have trust in the OIG. 

I know they come to us for help, and they deserve nothing less. 

Chairman JOHNSON. Well, I appreciate that. 

I also want to make sure that you look at this Committee as an 

ally in that type of transparency, trying to accomplish your task 

and making sure that whistleblowers are not retaliated against. 

Again, I would ask you to work with us in our investigation, complying with the subpoena that has been issued that is not 

yet—again, we are all concerned about private health care information. We are willing to work with you. But we really do need to get 

this information. 

Ms. HALLIDAY. We are working it. Your suggestion to work with 

Mr. Michael Horowitz at DOJ was a very good one. I have followed 

through, and we have gone through several of the obstacles. There 

are still a few remaining. And I have no problem working with Mr. 

Brewer and his team. 

Chairman JOHNSON. To the extent of your good faith, I would say 

you still have a problem within the organization that continues to 

be a road block. That is just my honest assessment of it. Ms. 

Lerner. 
60 

Ms. LERNER. We have heard some terrible stories today, a lot of 

negative information, but I wanted to say I feel very optimistic that 

we are on the right path forward. The message from the VA leadership over the last year and a half has been very consistently positive and supportive of whistleblowers. The Secretary and Deputy 

Secretary are meeting with whistleblowers when they go out to facilities, and I think those are really positive signs, and it is going 

to trickle down, I hope, to the regions and the facilities. And identifying the problem is really the first step. They say light is the best 

disinfectant, and shining light on the problem is terrific. Working 

in partnership with this Committee, I am really confident that we 

can solve this problem, and I look forward to working with you in 

doing so and working with the VA and doing so. 

Chairman JOHNSON. Well, thank you. One thing I always repeat—this is from my business background—is try and find the 

areas of agreement, and I think what you are seeing here is there 

is obviously enormous agreement that we have a problem here. 

There is also an enormous agreement that we do need to honor the 

promises to the finest among us. 

So working with this Committee, working with the Office of Special Counsel, the Office of Inspector General, and the VA system, 

we need to address this problem. We need to come up with solutions. We need to act. And so, again, the commitment from this 

Committee is to work with you in good faith to find those solutions 

to honor those promises. Let us, again, concentrate on the areas of 

agreement that unite us rather than exploit the division. So that 

is certainly my commitment. 

Again, I want to thank all of you, all the witnesses for their 

thoughtful testimony, their thoughtful answers to our questions. 

The hearing record will remain open for 15 days until October 

7th at 5 p.m. for the submission of statements and questions for 

the record. 

This hearing is adjourned. 

[Whereupon, at 12:44 p.m., the Committee was adjourned.] 
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