U.S. GOVERNMENT PUBLISHING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Publishing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

Fax: (202) 512–2104 Mail: Stop IDCC, Washington, DC 20402–0001

24–362 2017

FACT CHECK: AN END OF YEAR REVIEW OF ACCOUNTABILITY AT THE DEPARTMENT OF VETERANS AFFAIRS 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

WEDNESDAY, DECEMBER 9, 2015 

Serial No. 114–48 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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

Leonard.horne on VACREP0180 with DISTILLER

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Florida, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

DAVID P. ROE, Tennessee 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

JACKIE WALORSKI, Indiana 

RALPH ABRAHAM, Louisiana 

LEE ZELDIN, New York 

RYAN COSTELLO, Pennsylvania 

AMATA COLEMAN RADEWAGEN, American 

Samoa 

MIKE BOST, Illinois 

CORRINE BROWN, Florida, Ranking 

Minority Member 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

TIMOTHY J. WALZ, Minnesota 

JERRY MCNERNEY, California 

JON TOWERS, Staff Director 

DON PHILLIPS, Democratic Staff Director 

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records 

of the Committee on Veterans’ Affairs are also published in electronic form. The printed 

hearing record remains the official version. Because electronic submissions are used to 

prepare both printed and electronic versions of the hearing record, the process of converting 

between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process 

is further refined. 

Leonard.horne on VACREP0180 with DISTILLER

(III) 

C O N T E N T S 

Wednesday, December 9, 2015 

Page 

Fact Check: An End Of Year Review Of Accountability At The Department 

Of Veterans Affairs .............................................................................................. 1 

OPENING STATEMENTS 

Honorable Jeff Miller, Chairman ........................................................................... 1 

Honorable Corrine Brown, Ranking Member ........................................................ 8 

Prepared Statement ......................................................................................... 39 

WITNESS 

Honorable Sloan Gibson, Deputy Secretary, U.S. Department of Veterans 

Affairs .................................................................................................................... 1 

Prepared Statement ......................................................................................... 39 

Accompanied by: 

Meghan Flanz, Deputy General Counsel, Legal Operations and Accountability, U.S. Department of Veterans Affairs 

STATEMENT FOR THE RECORD 

Office of Inspector General ..................................................................................... 46 

Leonard.horne on VACREP0180 with DISTILLER

Leonard.horne on VACREP0180 with DISTILLER

(1) 

FACT CHECK: AN END OF YEAR REVIEW OF 

ACCOUNTABILITY AT THE DEPARTMENT OF 

VETERANS AFFAIRS 

Wednesday, December 9, 2015 

COMMITTEE ON VETERANS’ AFFAIRS, 

U. S. HOUSE OF REPRESENTATIVES, 

Washington, D.C. 

The Committee met, pursuant to notice, at 10:31 a.m., in Room 

334, Cannon House Office Building, Hon. Jeff Miller [Chairman of 

the Committee] presiding. 

Present: Representatives Miller, Lamborn, Bilirakis, Roe, 

Benishek, Huelskamp, Coffman, Wenstrup, Walorski, Abraham, 

Zeldin, Costello, Bost, Brown, Takano, Brownley, Titus, Ruiz, 

Kuster, O’Rourke, Rice, Walz, and McNerney. 

OPENING STATEMENT OF JEFF MILLER, CHAIRMAN 

The CHAIRMAN. Good morning, everybody. Thank you for being 

with us at today’s hearing entitled Fact Check: An End of Year Review of Accountability at the Department of Veterans Affairs. I 

want to welcome our first and only panel to the table this morning. 

With us is Deputy Secretary Sloan Gibson for the Department of 

Veterans Affairs, and he is accompanied by Meghan Flanz, who is 

the Deputy General Counsel for Legal Operations and Accountability at the VA. We thank both of you for being here this morning. And I want to get straight to the witness’ testimony and Ms. 

Brown is running a little bit behind. So I am going to allow Sloan 

to give his testimony before we give our opening statements. So 

Mr. Gibson, you are recognized now for five minutes. 

STATEMENT OF SLOAN GIBSON 

Mr. GIBSON. Thank you, Mr. Chairman. Let me get right to the 

point. In my many years in the private sector, I have never encountered an organization where leadership was measured by how 

many people you fired. And there is a simple reason for that, you 

cannot fire your way to excellence. I can promise you that a large 

and complex customer service organization will never deliver a 

great customer service experience, will never consistently deliver 

great outcomes if employees are living in constant fear of being 

punished for making a mistake. When enforcing discipline is the 

central element of accountability, an organization will not deliver 

sustained excellence. 

Having said all of that, consequences for behavior that is inconsistent with our values is part of effective leadership. In those 

Leonard.horne on VACREP0180 with DISTILLER

2 

cases we pursue disciplinary action appropriate to the offense and 

supported by evidence. I am committed and VA’s senior leadership 

is committed to taking those actions. 

We have asked this Committee to be one of our most important 

partners in the forward looking transformation of the department. 

We are all after the same ultimate objective, improving care and 

benefit outcomes for veterans. The only way we can achieve that 

shared objective is through strong forward looking leadership based 

upon what Bob and I call sustainable accountability. That is accountability that results in positive veteran outcomes, not just in 

the near term, but also in the long term. It is supervisors that are 

providing routine feedback to subordinates, recognizing what is 

going well and coaching where improvements are necessary. It is 

ensuring all employees understand how daily work supports our 

mission, values, and strategy. It is training leaders to lead and employees to exceed veterans’ expectations everyday. It means making 

things right for veterans quickly and responsively, and learning 

from mistakes, understanding what went wrong and then fixing it. 

It is candidly assessing performance based upon merit and achievements and rewarding exceptional results. And it is taking corrective action when warranted and supported by evidence. If we have 

all of that, we have sustainable accountability. The same comprehensive notion of accountability that you find in virtually every 

high performing organization in the private sector. 

I have often said that if VA was in the private sector it would 

be a Fortune 10 company, making enduring cultural and fundamental process changes in an enterprise of that size and complexity 

takes time. It takes persistence and some amount of patience. But 

investments in sustainable accountability are already paying off in 

improved veteran outcomes. Let me give you a very important example. 

SAIL, S–A-I–L, Strategic Analytics for Improvement and Learning. SAIL is a tool that we use to measure veteran health care outcomes at every VA medical center, measures around quality, safety 

and efficiency, among others. Shortly after I arrived at VA, I 

learned about SAIL and looked into the correlation between hospital directors’ performance ratings and the health care outcomes 

being delivered by their facilities as measured in SAIL. Here is 

what I found, stellar performance ratings at some of the lowest performing facilities. So beginning in October of 2014, we integrated 

veteran health care outcomes as measured in SAIL into every single medical center director’s performance objectives. What happened? 

Well for starters, SAIL became one of the most widely used management tools in the department, that tells you something to begin 

with. And roughly 60 percent of VA medical centers improved the 

health care outcome for veterans over the course of the year. How 

good is SAIL? The chief medical officer at one of the largest health 

care organizations in America told me that if he had SAIL in his 

organization he would implement it tomorrow. That is sustainable 

accountability. Delivering better outcomes for veterans, not just 

right now, but for the long term. 

I suspect Bob and I have visited more VA facilities, spoken to 

more veterans and VA employees in the last 18 months than any 

Leonard.horne on VACREP0180 with DISTILLER

3 

pair of top VA leaders in the department’s history. We find employees as we are out there who care about the mission, who want to 

do the right thing, and who work hard everyday to serve veterans. 

Yet, if we take rhetoric as fact then, particularly as it relates to 

scheduling and access, VA is rife with corruption. To review the 

record, of the more than 100 investigations the IG launched based 

on the access field audit that we conducted last year, to date, we 

have received reports and evidence relating to 77 of those. The IG 

substantiated intentional misuse of scheduling or other access data 

at six sites. In our follow-up, we substantiated misuse at four other 

sites, and we are reviewing evidence at two more. So far, some 20 

employees have been implicated and 20 disciplinary actions have 

been taken, from reprimand to removal. While our work is not 

done, and those numbers will change, it is not the widespread corruption and fraud pitched to veterans and the American people. 

But as we see it, if one veteran is not well served, we own it and 

we will work to fix it. 

The IG still owes us the remaining reports. We appreciate their 

work, but we cannot let issues languish unresolved while waiting 

for protracted IG or Department of Justice investigations for 

months and sometimes even years. Our past practice has been to 

wait for these investigations to be complete. We are done waiting. 

Where we can collect relevant evidence more quickly and effectively 

with VA resources, we will do so. Then where evidence warrants 

disciplinary action, we will take action. If new evidence warranting 

additional action is presented later, we will take additional action. 

Where necessary, employees under investigation will be detailed to 

other duties, not routinely placed on administrative leave. Administrative leave will be reserved on a by exception basis set for only 

those extreme circumstances. 

Let me shift to the recent IG report on relocation, which has garnered widespread attention. We agree with many of the process related findings and we have already made changes to address those 

issues. What is disturbing and indicative of the atmosphere in 

which we now operate is the gulf between the rhetoric in the IG 

report and the actual evidence. In the most important finding, the 

report concludes that two executives were coerced to relocate. The 

fact is that both executives testified under oath repeatedly, 16 

times in one instance, that they initiated talks leading to relocation. Neither provided any testimony consistent with the finding of 

coercion. The report in the Associated Press release emphasized 

criminal referrals to the Department of Justice. Yet as I have reviewed the evidence as collected by the IG, it does not support one 

violation of law, not one violation of rule, not even one violation of 

regulation related to relocation expenses. 

The easy option for me would have been to propose removal. 

That is what everybody wanted. I did not come to VA to do the 

easy thing, I came here to do the right thing. I did not find that 

the evidence supported an ethical violation. If I had, I would have 

removed the two executives. I did find that evidence supported a 

failure in judgment and therefore my decision was to propose demotion from the senior executive service, including a substantial 

reduction in pay. Rumor mills may have reported that we are negotiating some sort of settlement, not true. The fact is that we withLeonard.horne on VACREP0180 with DISTILLER

4 

drew the demotion action because of our administrative error and 

we have already reinstated the action. We want to make sure that 

all actions, including these, survive appeal. 

I will close with a very short story. Last Thursday at our Denver 

Medical Center’s mental health clinic, a veteran took Nurse Practitioner Kathy Rittenhouse hostage. Armed with a loaded pistol and 

two boxes of ammunition, the veteran’s stated purpose was to be 

killed by police, suicide by cop. Evidenced and highly trained, 

Kathy calmed the veteran, persuaded him to let her make a phone 

call. When VA Police Officer Greg Crenshaw arrived, Greg persuaded the veteran to take him as the hostage to protect Kathy. 

In taking Kathy’s place, Greg disarmed the veteran and resolved 

the crisis without any physical harm to anyone. The whole process 

took 13 minutes. 

I should mention that the vast majority of our police officers are 

veterans themselves, and they all are specifically trained to de-escalate volatile situations. It would have been very easy for Kathy 

and Greg to wait for the SWAT team and the hostage negotiators 

that were already on their way. But they did not. They acted based 

on their commitment to care for veterans, their desire to do the 

right thing, and their considerable training. And in doing so I believe they saved lives. 

A quick postscript, after the crisis, the team got together and insisted that this veteran not be sent somewhere else for his inpatient mental health care. They want to take care of him there. 

These are the kind of people that are being vilified day in and 

day out in broad brush strokes about VA employees. So for employees like Kathy and Greg, as well as for our veterans, we will continue to approach discipline squarely with a single objective in 

mind, to do what is right and in the process restore veterans’ confidence in VA. We will not hesitate to take corrective action when 

warranted and available evidence supports it. But we will not administer punishment based on IG opinions, referrals to the Department of Justice, recycled and embellished media accounts, or external pressure. It is simply not right and it is not in the best interest 

of the veterans we serve. 

We look forward to your questions. 

[THE PREPARED STATEMENT OF SLOAN GIBSON APPEARS IN THE

APPENDIX]

The CHAIRMAN. Thank you, Mr. Gibson. I think your statement 

is pretty dang inconsistent. Not a single Member of this Committee 

would ever say something about disciplining people like Kathy or 

Greg. I appreciate you bringing that to our attention, but to imply 

that we have is disingenuous and you know that. 

My statement this morning is based on the written statement 

that was sent ahead of time to us from VA, which is vastly different than what Mr. Gibson just laid out. So I hope you will all 

avail yourself to the written statement that was submitted for the 

record and is out for everybody to read on the table outside. 

I want to start by saying that I believe many of the elements in 

your written statement reflect a passive criticism of our efforts and 

the calls for change which have been made by this Committee, this 

Leonard.horne on VACREP0180 with DISTILLER

5 

Congress, and in fact many of the veterans service organizations 

that you so highly praise, and whose work we appreciate everyday. 

We are all educated enough to know what the definition of accountability is. You and the Secretary have now decided to change 

that definition. You say that we have changed it, but in fact, I do 

not think we need to be educated on what that word means as you 

did in your written statement. Holding somebody accountable is for 

their actions, actions that they are liable for and should have to 

transparently answer for. And it is not simply about being transparent about your goals and how to achieve them, as you stated in 

your testimony. According to Merriam-Webster’s Dictionary, accountability means an obligation or a willingness to accept responsibility or to account for one’s actions. Quite honestly, I think the 

tone of your written statement proves why we are so disappointed 

with the lack of accountability at the Department of Veterans Affairs because it illustrates that the department and its senior officials still refuse to take responsibility for the corrosive culture that 

is throughout the agency. 

In fact if you look at the Google definition of accountability as 

it is used in a sentence, it says, quote, ‘‘their lack of accountability 

has corroded public respect,’’ end quote. If you substituted the 

words ‘‘the Department of Veterans Affairs’’ for the word ‘‘their,’’ it 

would be 100 percent correct today. The Department of Veterans 

Affairs’ lack of accountability has corroded public respect. 

As evidenced by VA’s senior leaders’ unwillingness to aggressively root out that corrosion you continue to blame this Congress 

and the media, for undue pressure for VA’s problems in applying 

appropriate disciplinary measures. You even blame your own IG. 

For, and I quote from your statement, quote, ‘‘unfounded rhetoric 

that creates an unfounded expectation which does a distinct disservice to taxpayers and to veterans,’’ end quote. Obviously to this 

day there appears to be no real acceptance of responsibility for 

VA’s continued and pervasive failure to seriously discipline its employees and it seems as if there is no effort to change it. Words and 

actions matter. 

Neither I nor anybody on this Committee has ever said that accountability is only achieved through firing people. You have alluded to that in both your written statement and your verbal statement. We have instead always believed that the disciplinary actions taken against employees should be commensurate with the 

actions that warranted them, and that is something that is consistently lacking at the department. You stated in your written testimony that we need to, quote, ‘‘permit you to carry out the executive 

branch’s responsibility of proposing and deciding employee discipline independently,’’ end quote. So let us take a look at your 

track record of independently proposing and deciding employee discipline. 

In Alexandria, Louisiana a VA nursing assistant is charged with 

manslaughter in the death of a 70-year-old VA patient. VA officials 

originally deemed the death accidental. But a local coroner’s efforts 

helped bring about legal charges. According to VA, the employee in 

question has been on paid leave since December of 2013 and continues to be on paid leave to this day. 

Leonard.horne on VACREP0180 with DISTILLER

6 

At the heart of VA’s delays in care scandal in Phoenix no employees have been successfully disciplined for wait time manipulation. 

Even in the case of Sharon Helman, the former director of the 

Phoenix VA Medical Center, the VA found a way to botch her removal after the Merit Systems Protection Board determined that 

VA did not even attempt to, and I quote, ‘‘connect the dots of fault,’’ 

end quote, to Ms. Helman regarding the wait time issues. If VA 

had not lucked out and stumbled across Ms. Helman’s unethical behavior of accepting inappropriate gifts, she would still be more 

than likely working at the department firmly entrenched in the bureaucracy and on the payroll of the American taxpayer. Further, 

two senior managers who were also central figures there have been 

on paid leave since May of 2014. 

In Denver, the construction of a VA hospital was more than $1 

billion over budget, and to this Committee’s knowledge, VA has not 

disciplined a single employee in conjunction with this monumental 

failure. Instead, you rewarded those that were charged with overseeing the project with tens of thousands of dollars in performance 

bonuses. VA has completed an investigation into this matter but it 

is withholding the results from this Committee despite our repeated attempts to get the information. 

And at the Martinsburg, West Virginia VA Medical Center the 

department refused to discipline appropriately an employee who 

was convicted of dealing heroin off campus. These examples of VA’s 

lack of accountability demonstrate the importance of hearings just 

like this one. As Ms. Brown says, let me be clear; the constitutional 

role of Congress and this Committee is to conduct oversight of the 

executive branch and your department. And we will ask the questions and hold the necessary hearings to try to keep the department in check. That is basic government 101 and I am starting to 

believe that some of the senior leaders at VA missed that day in 

school. If we as Members of this Committee just sit idly by and do 

not hold hearings until it is convenient for the department, or do 

not request information that we need when we need it, or do not 

investigate your facilities, then we would not be fulfilling our constitutional role. And surely that is not what you are asking us to 

do. 

I believe that the Secretary and yourself both came into the roles 

that you currently occupy with the will to make real change and 

that you want to provide high quality care and services to our veterans and I have always said, always said, that I believe the majority of people that work at the Department of Veterans Affairs share 

the same commitment. But the pervasive lack of real accountability 

hinders these efforts and is quite frankly a slap in the face to each 

of these employees’ face. This has got to change. It gets tiresome 

to constantly be told by you and other VA leaders that things are 

changing for the better and that you are committed to sustainable 

accountability, but then to witness otherwise. 

The department publicly continues to tout inflated numbers of 

those it has held accountable, but then those numbers do not 

square with the truth. It is even more disappointing to receive 

push back from the administration when this Committee and Congress as a whole tries to move legislation to cut through the buLeonard.horne on VACREP0180 with DISTILLER

7 

reaucratic red tape and instill true accountability. In short, the defense of the status quo is unacceptable. 

Just last week, VA once again showed its inability to hold bureaucrats accountable when it announced a decision to rescind the 

demotions of Kimberly Graves and Diana Rubens, two individuals 

who have been at the center of this Committee’s attention for several months. It spurred the outrage of several veterans organizations and the general public following the IG report that found that 

they used their positions of authority to move into positions of 

lower responsibilities while maintaining their high pay, which allegedly enabled them to financially benefit for more than $400,000 

in taxpayer moving expenses. 

According to VA, one of the five binders containing evidence to 

support their demotions was not given to either individual when 

they received their proposed notice of demotion, thereby not giving 

them a fair opportunity to respond to the information that was documented in this particular binder. I find it ironic, Mr. Secretary, 

that you personally sent me two letters admonishing me for potentially damaging the cases against Ms. Graves and Ms. Rubens if I 

proceeded with hearings in October, yet in the end, their cases 

were damaged due to the inability of the VA’s lawyers to simply 

keep track of critical evidence. I was already sorely disappointed 

with your decision, but I am dumbfounded that with such a high 

profile case which included a criminal referral to the Department 

of Justice that VA still found a way to botch its decision to merely 

demote them. 

Frankly this ineptness clearly demonstrates that VA cannot even 

slap a wrist without missing the wrist. And it underscores the department’s overall lack of focus on properly disciplining employees. 

What is even more infuriating about the whole situation is that 

under the Choice Act authority, VA was not required to provide the 

notice to an employee and the department set this process up on 

its own, yet sadly lawyers, the 700 lawyers’ inability to properly 

execute their own self-created policies has left the American public 

disappointed. Now we must wait as you attempt to move through 

the disciplinary process for a second time. And I wish I could say 

that it does not worry me how this whole spectacle will affect 

Rubens’ and Graves’ impending appeals to the MSPB, but that is 

not the case. I just hope that VA’s lawyers find a way not to lose 

another binder in the process. 

VA’s decision to not even attempt to recoup the money inappropriately spent on moving Ms. Rubens and Ms. Graves is astonishing to me. This money that your IG had recommended that you 

attempt to recoup, and money I believe they took from the American taxpayers inappropriately. It is simple. The relocation benefits 

were the fruit of Ms. Rubens’ and Ms. Graves’ inappropriate behavior as determined by you, Mr. Secretary. VA’s decisions not to recoup these funds is akin to letting a bank robber off the hook with 

a mere slap on the wrist while allowing him to keep the money. 

It is concerning as well that your testimony today seems to completely disregard the conclusions made by the IG and instead 

states that Ms. Rubens and Ms. Graves merely exercised, and I 

quote, ‘‘less than sound judgment,’’ end quote. I would argue that 

two high level senior managers forcing their subordinates to move 

Leonard.horne on VACREP0180 with DISTILLER

8 

to other locations so they could then obtain these positions for 

themselves, and causing the American taxpayers to foot the bill for 

their exorbitantly priced moves, illustrates a little more than, 

quote, ‘‘less than sound judgment,’’ end quote. I know many of the 

veterans we represent would agree. 

In addition to discussing last Thursday’s announcement regarding Ms. Graves and Ms. Rubens, this hearing is an opportunity for 

the Committee to end this year with a review of VA’s legal ability 

and self-willingness to hold its employees accountable. It will also 

allow for us to discuss a variety of outstanding requests made by 

Members of this Committee. I sent a letter to the Secretary in October seeking information regarding a variety of instances reflecting VA’s inability or unwillingness to instill real accountability. I 

provided a copy of the letter in each of the Members’ packets for 

you to review. The letter looks at several circumstances including 

instances of whistleblower retaliations at an assortment of locations, unconscionable settlement agreements with several VA employees resulting in huge payouts by the department, investigations into the behavior of several senior VA central office executives, the Denver hospital construction project, and the remaining 

concerns with Phoenix. To date, the Secretary has not responded 

to my letter. 

As I said earlier, it is disheartening that Secretary McDonald 

continues to tout numbers of accountability that quite simply are 

not true. In February during an interview with Meet the Press, he 

claimed that 60 employees were fired for manipulating wait times, 

yet according to the Washington Post that was completely false. 

Earlier this year at a National Press Club event he announced 300 

people had been proposed for some type of disciplinary action for 

scheduling manipulation, but at the time it was only 27. Additionally, VA’s own staff has told Committee staff that several individuals identified as involved in patient wait time manipulation on 

the adverse action lists that VA provides to this Committee each 

week actually had nothing to do with wait time manipulation whatsoever. As the old saying goes, you cannot fix what you do not 

measure. And if the VA cannot even get its own data right about 

patient wait time manipulation, how will true accountability ever 

be achieved? 

Congress can provide VA tool after tool and hold hearing after 

hearing, but without the will of the VA senior leadership to make 

real changes across the department, the corrupt culture will continue. Veterans and their families, and the majority of VA’s employees who work hard every single day, deserve to be able to trust 

our VA. But that trust obviously needs to be earned. 

With that, I yield to Ms. Brown for her opening comments. 

OPENING STATEMENT OF CORRINE BROWN, RANKING 

MEMBER 

Ms. BROWN. Thank you, Mr. Chairman, and to the Committee, 

and to you, Mr. Secretary, and to the veterans that are watching 

this proceedings. 

Let me just say before I begin that I am a little uncomfortable 

with the quorum of this Committee and of the House at some 

times. In fact, I mentioned it to the Clerk. And I wanted to note 

Leonard.horne on VACREP0180 with DISTILLER

9 

when I came here, I have been on this Committee for 23 years. And 

for the use of profanity was just not something that was done in 

the Congress. This Congress, and this Committee in particular that 

I have been on for 23 years, have been very bipartisan. And I do 

not know what has happened to this Congress and what has happened to the Members. 

But let me just say that we are all here to serve the veterans 

and the VA serves over 50 million outpatients every year and we 

need to keep that in perspective as we do our due diligence. And 

we have attorneys on this Committee, and doctors, and I am sure 

you all will have all of the right questions that you want to ask. 

But I am concerned, and you mentioned something, because I am 

concerned when you mentioned that story in the end about security. I want to know how that veteran got on that facility with a 

gun and with bullets that could have caused a disaster there. And 

I am concerned why that veteran is in outpatient and not inpatient 

facility. So I hope at the end of your testimony that you can answer 

that question for me, because I am concerned about the security at 

the facilities. 

As we drill down on these issues I am most concerned about the 

veterans getting the care that they need. And also you mentioned 

in your report, and I asked the question about the year’s end, we 

are supposed to be drilling down on homeless veterans. You mention it in your report. I want to know where we are. I want the 

Members to know there are so many cities that have signed up. I 

want us to know whether our cities have signed up to participate, 

our mayors and our communities, to help with the homelessness as 

far as the veterans are concerned. 

We have also talked about having a health care day at the different facilities where we as Members can go in and have, bring 

in all of the people that have not had an appointment so they can 

get those appointments. I want to know about the health care for 

veterans. 

Yes, I do know that we need to talk about accountability and 

that we need to make sure that you all, the perception, and this 

Congress and we contribute to the perception that there is widespread problems in the VA. I need, we need to assure the veteran 

that that is not the case. I do know when I visit my facilities, 

whether it is in Orlando or Jacksonville or Gainesville, once they 

get into the VA they are happy with the services. And I want everybody in this country to have that kind of experience. And so I 

am going to just yield my time to you to answer those questions 

about the security at the VA facility. I am interested in knowing 

how somebody got in there with a gun and bullets. Do we not have 

the security there to protect our employees? Can you answer that 

question for me? 

[THE PREPARED STATEMENT OF CORRINE BROWN APPEARS IN THE

APPENDIX]

The CHAIRMAN. Ms. Brown, we will allow the Secretary to answer it in the normal questions. We cannot allow him to answer 

that question during your opening statement time. 

Ms. BROWN. Oh, I yield back the— 

Leonard.horne on VACREP0180 with DISTILLER

10 

The CHAIRMAN. Okay, the time has been yielded back. I will 

begin the questioning at this point with the Secretary. 

Who discovered the fifth binder of evidence that was not provided 

to Ms. Rubens and Ms. Graves? 

Ms. FLANZ. Certainly, I would be happy to explain what happened. The— 

The CHAIRMAN. No, I just want to know who discovered the binder was missing. 

Ms. FLANZ. The legal team, it is a group of four people. 

The CHAIRMAN. So you are saying VA discovered it? 

Ms. FLANZ. We discovered it upon receiving the electronic copy 

of the two employees’ appeals, yes. 

The CHAIRMAN. So in other words the employees that were appealing, their attorneys found it? 

Ms. FLANZ. No. They filed their appeals as they are required to 

and they included in their appeals all of the evidence they had received. Upon reviewing those, we realized that there, some of the 

materials were not included. 

The CHAIRMAN. Sloan, do you agree with that? 

Mr. GIBSON. It is, I am relying on Meghan for the details of what 

happened there. 

The CHAIRMAN. Okay. Because that is not what this Committee 

has been told. But I will take your testimony. And can you tell me 

what you think the legal ramifications will be with having to rescind their demotions, and begin the process again? 

Ms. FLANZ. Certainly, sir. The point of rescinding and reissuing 

is to cure what would otherwise be a due process violation. So the 

rescission and provision of the additional evidence should cure the 

problem entirely. 

The CHAIRMAN. Sloan, in your written statement you said, in regards to Ms. Rubens’ and Ms. Graves’ cases that and I quote, 

‘‘there were gaps between the rhetoric in the OIG report and the 

underlying evidence,’’ end quote. 

Mr. GIBSON. Yes, sir. 

The CHAIRMAN. Explain to us about that gap, how do you see it 

so differently from the way the Inspector General sees it? 

Mr. GIBSON. I cannot explain the Inspector General’s position. I 

would simply say that, and Meghan will recall the occasion, as I 

sat down over a weekend and reviewed all the evidence in the matter, I came back in the next morning on Monday morning and my 

question was, I do not understand how they have reached the conclusion that they have reached based upon this particular evidence. 

What am I missing here? 

The CHAIRMAN. Then how could they have made a referral to the 

Department of Justice? I mean, did the Inspector General’s Office 

just mess it up that bad? 

Mr. GIBSON. It is incomprehensible to me that they made that referral. I find no basis and our attorneys have found no basis for 

that referral. 

The CHAIRMAN. And I do not want to dwell on that, but you have 

also said that you do not have the ability to recoup, whether it is 

Ms. Graves or Ms. Rubens or anybody else, you have no way to go 

in and recoup any of their relocation expenses, can you cite the 

statutory reason that you cannot go back and get that money? 

Leonard.horne on VACREP0180 with DISTILLER

11 

Mr. GIBSON. I am going to lean on Meghan here again. 

Ms. FLANZ. Absolutely. The process for recouping any improper 

payment in, that is made by the government, is through the Improper Payments Elimination and Recovery Act of 2010. It is Public 

Law 111–204, Section 2F. When it comes to employees, a debt may 

be owed and collected if the employee receives an improper payment. An improper payment is any payment that should not have 

been made or was made in an incorrect amount. The legal determination of our team is that with respect to certain payments that 

were made to Ms. Rubens in the context of her move, her temporary quarters subsistence expenses, there were some improper 

payments for alcoholic beverages and for— 

The CHAIRMAN. I apologize. I appreciate that. The Committee is 

well aware. So it is your testimony that the other payments that 

were made to Ms. Graves and Ms. Rubens were appropriate payments? 

Ms. FLANZ. They were duly authorized under the law, yes. 

The CHAIRMAN. They were appropriate payments? 

Ms. FLANZ. They were approved by the senior leadership based 

on their belief that these individuals should make those moves, yes. 

The CHAIRMAN. Can you give us an update about Ms. Filipov and 

Mr. Hodge, who have been on paid leave since June? I am hearing 

a rumor, and you can dispel that rumor if you choose to do so 

today, that there has been a delay in a final decision because there 

were procedural mistakes there as well. Is that true or not? 

Ms. FLANZ. Those actions are being taken by the Veterans Benefits Administration, not by my office. I do not have specific information with respect to their status. 

The CHAIRMAN. Sloan? 

Mr. GIBSON. I am not aware of the status on those two either, 

but we will provide you an update. 

The CHAIRMAN. Okay. When? This afternoon? 

Mr. GIBSON. Today is Wednesday, before the end of the week? 

The CHAIRMAN. Yes? Okay. According to media reports, AFGE officials at VA central office completed and delivered a report to the 

Secretary alleging the misconduct of a number of VA executives. 

Has any action been taken with regards to the report? And can the 

department provide us an unredacted copy of the report? 

Mr. GIBSON. Every one of the allegations raised in the AFGE correspondence have been investigated. There is a report that has 

been delivered, I think it is dated the third of December. And based 

on the earlier request we are prepared to provide unredacted 

versions of both the AFGE letter as well as the report. 

The CHAIRMAN. Thank you. Ms. Brown? 

Ms. BROWN. Thank you. Mr. Secretary, would you please answer 

the question, how many veterans do you all serve per year? We had 

major discussions about the wait time. What is the status about 

the wait times? And also, what is the approval rating of the veterans once they get into the system? And then we will go on to the 

incident that you mentioned. 

Mr. GIBSON. Yes, ma’am. There are, we are seeing 6.5 million to 

7 million unique patients, individual patients, over the course of a 

year. Inside VA in 2015, I am going from memory here, they completed somewhere in the neighborhood of 56 million inpatient apLeonard.horne on VACREP0180 with DISTILLER

12 

pointments. There were roughly another 20 million—excuse me, I 

said inpatient, outpatient appointments. 

Ms. BROWN. Fifty-six million? 

Mr. GIBSON. Fifty-six million, yes, ma’am. 

Ms. BROWN. Outpatient appointments? 

Mr. GIBSON. Yes, ma’am, inside VA. And another roughly 20 million that are completed in the community over the course of the 

year. 

Ms. BROWN. Okay, with our stakeholders, our partners? 

Mr. GIBSON. Yes, ma’am. 

Ms. BROWN. Mm-hmm. 

Mr. GIBSON. And so the second question was wait times. 

Ms. BROWN. Yes? 

Mr. GIBSON. You may recall in earlier testimony we talked about 

the effort that we undertook over the course of more than a year, 

and still are undertaking, to improve access to care. In that roughly 12-month period of time following the outbreak on the issue, we 

completed both inside and outside VA about 7 million more appointments, roughly a ten percent increase in appointments, a very 

material increase in access to care. Unfortunately, or fortunately 

depending on the perspective, over that same period of time more 

veterans came to us for more of their care. So what we saw is veterans waiting more than 30 days back in May or June last year. 

That number has actually increased over the intervening period of 

time because more veterans are turning to us for care as we improve access to care. 

Ms. BROWN. Do you have the resources you need to serve those 

additional veterans? 

Mr. GIBSON. My expectation, what we have been doing, and you 

asked about the health day— 

Ms. BROWN. Yes. 

Mr. GIBSON [continued]. —and I know you are aware of the stand 

down that we had a couple of weeks ago all across VA, the focus 

there was on ensuring that we are providing care that is needed 

urgently to veterans, and that they are getting that urgent care 

timely. I would tell you that is more and more of a focus on Dr. 

David Shulkin’s leadership as Under Secretary for Health. I would 

tell you, I do not expect the wait times to come down. I think as 

we improve the quality of health care, as we improve access to 

care, as we improve the veteran experience, we are going to find 

more veterans coming to us for more care. And as long as there are 

economic incentives for veterans where they can come to VA for 

care at a lower out of pocket cost, we are going to find veterans 

coming to us for care. 

Ms. BROWN. Now would you go and talk about that security? Because that gun really disturbed me. 

Mr. GIBSON. Yes, ma’am. 

Ms. BROWN. And I want to know how someone could get in the 

facility. Do we not have at the entrance point of the kind of security that we have here in Congress? 

Mr. GIBSON. Absolutely not, ma’am. Not in any way, shape or 

form. We have enhanced security at two or three locations. They 

are in large metropolitan areas principally. If you look at the majority of VA facilities, they were built decades, in fact, the VA MedLeonard.horne on VACREP0180 with DISTILLER

13 

ical Center in Denver is 50 years old, 60 years old, something like 

that. There are multiple points of ingress and egress. The ability 

to secure every one of those, the ability to search and run every 

single veteran that comes in for care through those facilities is, 

would be an insurmountable obstacle to us being able to deliver the 

care that we need and the experience that veterans expect. So no, 

we do not have that. 

And you will recall several months ago we actually had a physician assassinated in our El Paso Medical Center. We continue to 

work to refine and strengthen our security posture to ensure that 

we are protecting not only employees but other veterans. But our 

ability to put in place a moat, if you will, a security moat around 

the VA is really limited by our need to provide the care for veterans that we need to provide. 

Ms. BROWN. Well I am just wanting to know, I mean, we have 

hardened as far as courthouses and this facility. I would like to 

know what it is that we need to do to protect the veterans at the 

facilities. I think this is major, given where we are. 

Mr. GIBSON. Yes, ma’am. Well, and we, as we build new facilities, we build hardened facilities as well, which unfortunately adds 

to the cost of those facilities. We also build in more limited means 

of access, ingress and egress, so that it is easier to secure premises. 

But when we are operating with facilities that are on average 50 

years old, it is very difficult for us to provide that kind of absolute 

security. 

Ms. BROWN. Thank you. 

Mr. GIBSON. Yes, ma’am. 

Ms. BROWN. I think this is a major issue that we need to, as a 

Congress, need to address. I yield back the balance of my time. 

The CHAIRMAN. Thank you. You mentioned the 50-year-old Denver facility not being constructed for safety reasons with multiple 

ingress and egress. Is the new hospital constructed to where you 

do not have an ingress and egress problem? 

Mr. GIBSON. I think it is less severe than the issue in the old 

Denver hospital. But it will still be an issue. 

The CHAIRMAN. Okay. Mr. Bilirakis? 

Mr. BILIRAKIS. Thank you very much. Welcome, Secretary Gibson. 

Mr. GIBSON. Yes, sir. 

Mr. BILIRAKIS. Back home I am still hearing employees that they 

fear retaliation. How do you ensure moving forward that these employees are not getting retaliated for wanting to do the right thing? 

Mr. GIBSON. That is a great question. 

Mr. BILIRAKIS. With regard to whistleblowing? 

Mr. GIBSON. Understand. Understand. We have come, I believe, 

a long way over the previous year in terms of dealing with the 

issue around whistleblowers and whistleblower retaliation. I mentioned earlier that the extent of the travels that Bob and I have 

made to VA facilities, we speak to employees at every single one 

of those facilities. We meet with whistleblowers at those facilities. 

In fact, I will be in Atlanta on Friday meeting with one of the principal whistleblowers down there as well as our staff. We make it 

clear consistently that retaliation against a whistleblower will not 

be tolerated and in fact we model behavior that says in fact what 

Leonard.horne on VACREP0180 with DISTILLER

14 

we are looking for are employees that will raise their hands and 

help us find ways to deliver better care for veterans. The administration of discipline as part of leadership is something that happens all over the organization. And so as we change the culture of 

the organization, we will reset that kind of benchmark for what 

represents appropriate disciplinary action as it relates to any misconduct whatsoever, including whistleblower retaliation. 

Mr. BILIRAKIS. Let me follow-up on this subject. 

Mr. GIBSON. Sure. 

Mr. BILIRAKIS. In September of this year, the Office of Special 

Counsel sent President Obama a letter which highlighted several 

high profile whistleblower cases. You are familiar with that letter, 

is that correct? 

Mr. GIBSON. I am familiar with it, yes sir. 

Mr. BILIRAKIS. Okay. What action has VA taken in response to 

this particular letter? And what additional legislative authority do 

you need to better protect whistleblowers and discipline those who 

retaliate against them? 

Mr. GIBSON. In fact, I met with Carolyn Lerner, the Special 

Counsel. We discussed the letter at length and the specific issues 

in detail. There are a couple of instances where their findings and 

our findings have not matched up and we have asked that our respective teams reconcile those. There are other instances where we 

have, as you may know, implemented expedited processes where a 

whistleblower who has been retaliated against is made whole for 

that retaliation. We do that in concert working very closely with 

the Office of Special Counsel. As we undertake to pursue the manager, the responsible manager for the retaliation, we are back to 

the evidentiary standards that we are required to adhere to in 

order to be able to enforce that accountability. And I would tell you 

that the evidentiary standards for the action that we take to restore a whistleblower and the evidentiary standard that we take to 

impose discipline are two different standards. And that is part of 

the conversation that we have had with the Office of Special Counsel as it relates to those specific cases. 

Mr. BILIRAKIS. Okay, I would like for you to follow-up, Sloan, on 

this issue— 

Mr. GIBSON. Yes, sir. 

Mr. BILIRAKIS [continued]. —with regard to the letter. 

Mr. GIBSON. Okay, sir. 

Mr. BILIRAKIS. And any recommendations you have and any possible legislation that we can actually present to— 

Mr. GIBSON. Yes, sir. 

Mr. BILIRAKIS [continued]. —and get passed. 

Mr. GIBSON. Yes, sir. 

Mr. BILIRAKIS. Okay. What type of message do you believe you 

are sending. I know we have been over this, but it is so very important, what type of message do you believe you are sending to the 

VBA employees when they read that the VA OIG’s recommendations, then see, they read the recommendations, then see the relatively light proposed punishment for Mrs. Rubens and Mrs. 

Graves? Again, how will their subordinates ever take them seriously? Please answer that question directly. 

Leonard.horne on VACREP0180 with DISTILLER

15 

Mr. GIBSON. Well I, you know, as I mentioned in my oral testimony, which obviously rubbed folks the wrong way, I believe what 

oftentimes happens today is there is an allegation made, whether 

substantiated or not. And what happens is investigations get 

launched and media gets contacted and there are stories. And at 

that point the individual becomes guilty until proven innocent. And 

I hope what the employees of VBA, the message that they will get, 

is that their leadership is committed to doing the right thing. That 

we are committed to holding senior leaders accountable for their 

behavior, but that we are also committed to doing what is supported by the evidence. 

Mr. BILIRAKIS. Well in your opinion, have Mrs. Rubens and Ms. 

Graves, do you think they have lost credibility within the VA? 

Mr. GIBSON. That is unavoidable. How do you go through all of— 

Mr. BILIRAKIS. Well how— 

Mr. GIBSON [continued]. —the public airing of the IG report and 

the reactions to the IG report and not lose face, not lose standing? 

It is impossible. It would be foolish to represent that. But I am not 

going to recommend, I am not going to propose a disciplinary action 

that is based upon a media coverage or an opinion that is expressed in an IG report if it is not supported by the evidence. That 

is just doing the right thing. It is that simple. And honestly, I 

meant what I said. When I went through this particular case, I 

knew that that proposed decision was not going to sit well with virtually everybody. And I own that. That is on me. But at least I can 

look at the mirror and be convinced that I made the right decision. 

I look forward, once this case is concluded and the appeal process 

has run its course, I look forward to meeting with any Member of 

this Committee to discuss in detail the substantiation of my decision and providing to any Member of this Committee the full body 

of evidence, unredacted, so that they can form their own opinion 

as to whether or not I made a decision that was appropriate. 

Mr. BILIRAKIS. I, I— 

Mr. GIBSON. I own that. That is part of the accountability of me 

coming here. 

Mr. BILIRAKIS. The bottom line is I am concerned about our veterans. 

Mr. GIBSON. Yes, sir. Yes, sir. 

Mr. BILIRAKIS. What type of service they receive. 

Mr. GIBSON. And I am concerned about that, too. Yes, sir. 

Mr. BILIRAKIS. Well thank you very much. I yield back, Mr. 

Chairman. 

The CHAIRMAN. Mr. Secretary, do you have any evidence that we 

do not have? 

Mr. GIBSON. Sir, I do not know what evidence you have. 

The CHAIRMAN. We got it from your office so I would think— 

Mr. GIBSON. I believe, I am told that what evidence you got, you 

got from the IG. I do not, I have no idea what the IG gave you. 

The CHAIRMAN. We have all the transcripts. And so will you give 

us the evidence at the end of the process? 

Mr. GIBSON. Absolutely, positively yes. Every single piece of evidence. 

The CHAIRMAN. How would you have evidence the IG would not 

have? 

Leonard.horne on VACREP0180 with DISTILLER

16 

Mr. GIBSON. I am sorry? 

The CHAIRMAN. How would you have evidence that the IG would 

not have? 

Mr. GIBSON. I do not think that we have evidence that the IG 

does not have. 

The CHAIRMAN. Okay, that is all. 

Mr. GIBSON. I just do not know what they gave you. 

The CHAIRMAN. That is fine. I— 

Mr. GIBSON. We are sort of back to the question of making sure 

that we got all the evidence. We will give you everything. 

The CHAIRMAN. I am sure the IG is much more transparent with 

us than you have been. Ms. Titus? 

Ms. TITUS. Thank you, Mr. Chairman. Thank you for being here, 

Mr. Gibson. 

Mr. GIBSON. Yes, ma’am. 

Ms. TITUS. You said in your very opening statement that, you 

know, accountability and just about firing anyone. Several months 

ago, I made a similar comment in a hearing, saying that all we talk 

about is firing people. Some of our problem at the VA is hiring the 

right people in the first place. And I think we ought to put some 

more emphasis on that. 

Mr. GIBSON. Yes, ma’am. 

Ms. TITUS. And indeed I have been pleased to work with Dr. 

Wenstrup and Dr. Benishek to look at the hiring process and thank 

you for your good work on that. 

Do you have, just shifting gears a little, do you have any suggestions of what we can do to help at that end of the process as well 

as the problems that you are having at the firing end of the process? 

Mr. GIBSON. On the hiring end, among the legislative priorities 

that we have set forth is a provision requesting that we deem medical center directors and VISN directors Title 38 employees as opposed to Title 5 employees, which will provide us substantial additional flexibility to be able to attract the kind of talent that we 

want to attract and need to attract to fill those critical positions, 

yes ma’am. 

Ms. TITUS. We had a round table the other day with some VA 

folks— 

Mr. GIBSON. Yes, ma’am. 

Ms. TITUS [continued]. —and then some representatives and the 

nurses association, and they were making just some bureaucratic 

suggestions of cleaning up the process, making it work, making the 

application simpler, quicker, more available. Are you all looking internally at some of those issues that you can do that we do not 

have to do, or might not be appropriate to do through legislation? 

Mr. GIBSON. Absolutely, positively yes. We have identified underneath the MyVA structure 12 absolutely critical priorities that will 

be a focus over the coming 13 months. And one of those has to do 

with hiring practices, filling these key positions and streamlining 

the hiring practices. Particularly in VHA, we have an organization 

that does not operate like an integrated enterprise. We have talked 

about this before in here. And so you will find variances in hiring 

practices all over the organization— 

Ms. TITUS. We heard that. 

Leonard.horne on VACREP0180 with DISTILLER

17 

Mr. GIBSON [continued]. —people that are not taking advantage 

of the authorities that are available to them— 

Ms. TITUS. Mm-hmm. 

Mr. GIBSON [continued]. —people that are going through extra 

steps that are not necessary to go through. We have got to identify 

the streamlined best practice that gives us all the authority that 

we possibly can exercise and then standardize that approach to hiring all across the department. 

Ms. TITUS. Well would you keep us apprised of that— 

Mr. GIBSON. Yes, ma’am. 

Ms. TITUS [continued]. —as it goes? And the staff for the three 

of us as we— 

Mr. GIBSON. Yes, ma’am. 

Ms. TITUS [continued]. —work on kind of a bipartisan bill? Because we do not want to wait a year and then get a report and then 

have to start all over. 

Mr. GIBSON. No— 

Ms. TITUS. It would be nice if we could kind of work this together 

as we go. 

Mr. GIBSON. We would love to do that. 

Ms. TITUS. All right. Thank you very much. 

Ms. BROWN. Would the gentle lady yield to me for a question? 

Ms. TITUS. Yes. Yes, I will yield. 

Ms. BROWN. In our round table discussion, one of the things that 

is a major problem is how long it takes for the VA to hire someone. 

And as we develop expediting the process, I hope we include in 

there, because basically, by the time VA hires someone, some other 

agency has taken that person. 

Mr. GIBSON. You are absolutely right, ma’am. And that is a critical component of what we have to do. You are absolutely right. 

Ms. TITUS. Taking my time back, yes, that was one of the things 

that we mentioned about speeding up the process. 

Mr. GIBSON. Yes, ma’am. 

Ms. TITUS. And making it simpler. 

Mr. GIBSON. Yes, ma’am. 

Ms. TITUS. So that, I would appreciate working with you on that. 

Mr. GIBSON. Yes, ma’am. 

Ms. TITUS. Thank you. 

The CHAIRMAN. Dr. Roe? 

Mr. ROE. I thank the Chairman, and thank you, Mr. Secretary, 

for being here. And you are correct, I did take a little offense to 

some of what you said. 

Mr. GIBSON. Yes, sir. 

Mr. ROE. And I can assure you that if some of these people had 

been working in your shop when you were in the private sector, or 

in my shop when I was in the private sector, they would have been 

fired. And you cannot have 320,000 employees and everybody is 

doing a great job. That is just too big of an organization. And I understand that and you understand that. 

Mr. GIBSON. Yes, sir. 

Mr. ROE. I think probably you will find most of us physicians on 

the panel up here are more interested in the access and the quality 

of care that veterans are getting. Let me just read you a text I got 

here nine minutes before this hearing started. Phil, sorry to bother 

Leonard.horne on VACREP0180 with DISTILLER

18 

you but we are doing—this is a general surgeon in Johnson City, 

Tennessee—we are doing VA critically ill patients that spill over 

when they are full. Unfortunately we are having trouble getting 

paid. Is there anything your staff can do to help us? This goes on, 

I get one of these once a week. And so everything is not good right 

now with the VA. There are a lot of issues and problems. And I 

think that is the problem. 

And the other thing that I think the VA could do tomorrow to 

help access and quality, I spent four hours at the VA two weeks 

ago, before Thanksgiving. I went down and walked through the 

electronic health record, looked at that, and talked to one of my 

former, one of my friends who is an orthopaedic surgeon, formerly 

in private practice, now at the VA. I looked at how long it took him 

to see one patient, what he had to go through. So it is impossible 

to pick up with the current system that you have their productivity. So as long as that system stays in place, my friend cannot 

see any more patients. He just cannot do it. It took him 30 minutes 

to inject a rotator cuff. It would have taken him ten in his office. 

But it took 30. And with the electronic health record, and all the 

documentation, and all the stuff he had to do to put in the record, 

he just cannot do it. So you are going to have these waits. And then 

when you do that, we are going to be on you, and you are going 

to have people so that the data does not look bad manipulate those 

times. That is exactly what has happened. And that is why we are 

sitting here and been having this conversation. 

So one of the things I would recommend you do is take people 

like myself and just make me a certified VA provider that sees patients on the outside and then pay them so I do not get these texts 

where in a timely fashion like most, like Medicare does, they are 

very good at it. They do not pay you very much, but at least they 

get the money to you and you can count on that. And I think when 

a physician, and I happen to know this physician very well. He operated on my wife. He is a very fine physician. And VA will not 

pay him. So why would you expect him to continue to bail the VA 

out and you are going to just back downstream, do exactly what 

you are talking about. Veterans cannot get in. 

So anyway, I have said enough about that. You could certify me 

as a private practitioner, as a certified VA provider, and we will 

provide that care if you would just pay us. That is not a difficult 

thing to do. And knock off your long waits right now, if you would 

just let the private sector help you out. And you would not have 

these hiring things. 

And Ms. Brown is absolutely right, it takes forever. And most of 

the, many of the good people get hired away by somebody else by 

the time the VA has made a decision to actually have them work. 

So the way you can fix that, if you cannot fix the hiring process, 

just take providers like myself, put a little thing at the bottom of 

my shingle that says Dr. Roe, certified VA provider. I will see the 

patients, get the information right back over there in a timely fashion, take care of them. If the veteran wants to do that. And many 

veterans do. Many veterans would like to have their care in the 

communities. So those are some suggestions I would make. I do not 

think everything is fine in Lake Woebegone, personally. 

Mr. GIBSON. It is not. 

Leonard.horne on VACREP0180 with DISTILLER

19 

Mr. ROE. You have got lots of problems. 

Mr. GIBSON. We do. 

Mr. ROE. And they are, I mean, and so to come up and accuse 

the Congress of, we did not create the problem. We are trying to 

find out what they are and resolve the problems because it is affecting veterans. I think that is our motivation. So I will finish 

with that. If you have any comments, I will be glad to hear them. 

Mr. GIBSON. Well as I said, I think we are all after the same 

thing, better health care and benefit outcomes for veterans. Payment promptness has been a problem at VA for years. We have 

made great strides over the last probably nine to 12 months. But 

we still have a long way to go. And many of the changes that we 

are making there is moving us toward much more what the private 

sector practice looks like. We, I thought we talked about this three 

weeks ago at the last hearing as we were talking about payment 

processing. 

Sixty percent of our payments are still processed on paper and 

we are encouraging our providers to do that electronically so that 

we can accelerate that timeline. 

Mr. ROE. What do I tell my friend after I have had this hearing 

today? When is he going to get paid? 

Mr. GIBSON. Please ask him, if you will email me his information, I will see that we are working on it today. 

Mr. ROE. Okay. Good. I will do that. Thank you. 

Mr. GIBSON. Please. 

Mr. ROE. I yield back. 

Ms. BROWN. Would the gentleman yield for me for a second? Was 

this physician prior approved before he saw the patient? 

Mr. ROE. Oh he is, I think so. This particular physician I know 

has worked with VA for years like Dr. Benishek did. 

Mr. GIBSON. Yes, I am sure he would have been. To be doing surgery, yes. Absolutely, positively yes. 

Mr. ROE. And taking care of critically ill people. 

Ms. BROWN. Well there should be no reason for slow pay. 

Mr. GIBSON. That is exactly right. You are right. 

The CHAIRMAN. Miss Rice, you are recognized. 

Miss RICE. Thank you, Mr. Chairman. 

Mr. Gibson, your testimony included reference to training that 

the VA’s Office of General Counsel and Office of Accountability Review received from the Office of Special Counsel regarding their 

ability to investigate whistleblower retaliation and also to hold 

those who retaliate against whistleblowers accountable. 

So just two questions regarding that. I know that you went into 

this a little bit with Mr. Bilirakis’ questions. Some anecdotal evidence as to how this training has improved those two offices’ operation, number one, and, number two, how do you implement these 

trainings at the level where it really matters, which is at the local 

level at an individual VA Medical Center or regional office. 

Mr. GIBSON. If I may, I would like to ask Meghan to respond, because she was directly involved in that. 

Ms. FLANZ. Thank you very much for the question. 

The goal was train the trainer training. We do have lawyers and 

human resource specialists all over the country who can be our 

arms and legs and mouths. So some folks from the Office of AcLeonard.horne on VACREP0180 with DISTILLER

20 

countability Review and some attorneys from the Office of General 

Counsel here in D.C. sat down with the Office of Special Counsel’s 

head trainer, got ourselves trained, produced the curriculum that 

is then being cascaded out to all supervisors, is the goal, by the 

people who are on the ground with the supervisors in terms of HR 

specialists and lawyers in the field. 

Miss RICE. And that is how it gets down to the local level? 

Ms. FLANZ. That is right. 

Miss RICE. So do you have a year-end compilation of the instances of the number of whistleblowers and any potential retaliation and, if there was retaliation, what was done vis-a-vis both the 

whistleblower and the person who retaliated against them, could 

you compile that information? 

Ms. FLANZ. We don’t collect it on a rolled-up basis, but certainly 

can put out a data call to provide that information to you, yes. 

Miss RICE. I think that that would go a long way in terms of 

changing the culture of whistleblowers wanting to come forward, 

because they know that they are not going to be retaliated against 

and, if they are, there will be immediate accountability and punishment. And I think you can only do that by being able—I mean, you 

can’t assume that someone in a VA in Texas knows about what 

happened to a retaliator in New York. 

Ms. FLANZ. Absolutely. Yes, I agree. 

Miss RICE. So I would make that suggestion. 

Mr. Gibson, I don’t recall if I have spoken directly to you about 

this, but I have asked for the Administrative Investigation Board 

report on the Denver construction project multiple times and that 

request has been repeatedly denied. Now, I understand that there 

is a review that is taking place, an evaluation as to whether or not 

there needs to be any administrative action taken against, you 

know, current personnel, but I don’t understand—and maybe it is 

a legal impediment, but I don’t understand why we, this Committee, can’t see that, because when more money is needed for that 

project you come here and we, with a gun to our head, have to say 

yes. And this has been a big issue for me, no one has been held 

accountable for the cost overruns on that project. 

And so I want to know if there is any way that this Committee 

can see that report. And I don’t see how that could possibly hinder 

what if any administrative action would be necessary to take 

against current personnel, if any. 

Mr. GIBSON. The position that I had taken previously as it relates to disciplinary actions in Denver was that we would look at 

any employees that continue to be at VA and any appropriate discipline following the completion of the IG’s report. The IG is still 

doing their investigation. Based upon the different approach that 

I have outlined in my testimony, I have instructed that we not wait 

any longer, that we go ahead and conclude any appropriate disciplinary actions as it relates to individuals that are still employed at 

VA. I directed that proposing and deciding officials be appointed, 

that we complete that timely. And as soon as we have done that 

process, I look forward to providing the unredacted AIB report to 

the Committee. So that we have gotten through just the decision 

process on non-SES employees, because the appeal process can take 

Leonard.horne on VACREP0180 with DISTILLER

21 

a very long, extended period of time. We feel like doing it immediately following the disciplinary decision is the appropriate time. 

And I would tell you, my expectation in the future is that we are 

able to provide that and information much more timely, because we 

are not going to wait months and months and months for an IG 

investigation to conclude. 

Miss RICE. Well, I guess we can look into why the IG’s report is 

taking as long as it is. But when you come to this Committee and 

ask for people to— 

Mr. GIBSON. Yes, ma’am. 

Miss RICE [continued]. —release, you know, a billion dollars for 

a project that we have absolutely no empirical data about why 

these costs overruns, why we are facing that, I think it might behoove the agency to make as much relevant information available 

to us as possible. 

Mr. GIBSON. Yes. As we mentioned on a hearing some time back 

on this particular subject, having read all the evidence, I continue 

to believe that the most authoritative, comprehensive account of 

what went wrong is the decision that was rendered by the court of 

the Civilian Board of Contract Appeal, CBCA, in which the decision 

was rendered last December and which is readily available, I would 

be glad to get a copy. That is the most comprehensive accounting 

of what happened and what went wrong that I have seen yet. 

Miss RICE. Does it conflict at all with the Administrative Investigation Board’s report? 

Mr. GIBSON. I would tell you, the Administration Investigation 

Board is more granular and gets down to the individual, by-name 

parties, than the CBCA finding does not. 

Miss RICE. Thank you. 

Mr. GIBSON. Yes, ma’am. 

Miss RICE. I yield back. Thank you, Mr. Chairman. 

The CHAIRMAN. Mr. Huelskamp. 

Mr. HUELSKAMP. Thank you, Mr. Chairman. 

Mr. Undersecretary, first, did I hear you correctly earlier that 

you stated wait times would not improve? 

Mr. GIBSON. I don’t expect wait times to go down, no. I think as 

we improve access to care, as we improve care quality, as we improve the veteran’s experience at VA, I think we are going to find 

that demand will outstrip our ability to supply that care, that is 

my expectation. 

Mr. HUELSKAMP. Do they need to improve? 

Mr. GIBSON. Do what need to improve? 

Mr. HUELSKAMP. Wait times. 

Mr. GIBSON. I would love to see wait times improve, but it is a 

false promise for me to sit here—I am looking at what happened 

over the previous year. We increased in-patient and out-patient appointments inside and outside VA by—not in-patient, out-patient 

appointments inside and outside VA by roughly ten percent in a 

year, that is huge. 

Mr. HUELSKAMP. Yet we had massive budget increases too, Mr. 

Undersecretary. 

Mr. GIBSON. And yet what we saw were more veterans coming 

to us for care, longer wait times. We have got to ensure that we 

Leonard.horne on VACREP0180 with DISTILLER

22 

are providing urgent care to those veterans that need care urgently 

and— 

Mr. HUELSKAMP. By your own definition, you have over 512,000 

veterans waiting more than 30 days for an appointment. 

Mr. GIBSON. Yes, yes. 

Mr. HUELSKAMP. And you are not going to improve that at all? 

You have got 142,000 waiting more than 60 days, by your own definition, and you can’t improve that at all? 

Mr. GIBSON. I would tell you that the dual focus, Dr. Shulkin has 

focused his organization very intensively on providing urgent care. 

The other area that I have pushed hard on and continue to push 

hard on are what I refer to as veterans waiting the longest for care. 

And so it starts at the longest wait times and works down. So that 

we are using the resources that we have to provide urgent care and 

to accelerate the access to care for those veterans waiting the longest. But for me to sit here and say that the 30-day wait list is going 

to go away, I don’t think that is going to happen. 

Mr. HUELSKAMP. And, Mr. Chairman, I am sure the Committee 

has received some information on this. But the definition and I 

want you to clarify, the preferred date, it is not the date they come 

in and ask for the appointment, you start the clock based on the 

date for the appointment deemed clinically appropriate; is that correct? 

Mr. GIBSON. Either the date, if it is provided, that the date is 

deemed clinically appropriate or the date that the veteran wants 

to be seen. The large majority of our appointments are return-toclinic appointments. 

Mr. HUELSKAMP. I understand that and it shouldn’t be a 60-day 

wait for those. But who determines what is clinically appropriate, 

who is the— 

Mr. GIBSON. That is a discussion between the clinician and the 

patient. 

Mr. HUELSKAMP. And the scheduler doesn’t play a role in that at 

all? So a request comes in, the scheduler talks to the physician, for 

example, and says, what do you think when we should schedule 

that? That doesn’t go to the clinician. 

Mr. GIBSON. The clinician provides that clinically appropriate 

date in the— 

Mr. HUELSKAMP. The scheduler or the provider? 

Mr. GIBSON [continued]. The provider, the clinician, the doctor or 

the nurse provides that date to the scheduler. So it is in the system. 

Mr. HUELSKAMP. So every call that comes in, the provider or the 

physician or a nurse actually makes the decision on scheduling? 

Mr. GIBSON. If a veteran is calling in for an appointment, then 

they are asking to be seen. And in that particular— 

Mr. HUELSKAMP. But that is not when the clock starts, correct? 

Mr. GIBSON. If the veteran says, I want to be seen today, that 

is exactly when the clock starts. And if the veteran is conveying a 

need, for example, I have severe chest pains, come in right now. 

Mr. HUELSKAMP. Or wait 60 days. 

Mr. GIBSON. So it is that kind of fundamental triaging that is 

happening. 

Leonard.horne on VACREP0180 with DISTILLER

23 

Mr. HUELSKAMP. Okay. I am trying to understand that and I 

don’t think it really gets to the point, because you are claiming a 

waiting date of only four days for mental health services. Is that 

actually the claim that you have today, you only have four days’ 

wait for mental health care? 

Mr. GIBSON. If you look at the average wait time for a completed 

mental health appointment, yes, that is correct. 

Mr. HUELSKAMP. No, not completed, waiting. What’s the perspective, how long will they expect to wait? 

Mr. GIBSON. I think the pending date is, you know, it is a few 

days longer than that on average. But I would tell you, what that 

doesn’t capture is the 23 percent of appointments that are completed on a same-day basis, 20 percent if you exclude the emergency department. 

Mr. HUELSKAMP. I understand that. So anyway, one last question 

about the VA wait time schedule problems. In Phoenix, you placed 

two, Mr. Curry and Mr. Robinson on administrative leave and been 

there since May of 2014. What is the status of any disciplinary actions against these two individuals? 

Mr. GIBSON. We are wrapping up those two cases right now. 

Both of those two individuals were placed on administrative leave 

at the request of IG, along with Sharon Helman. 

Mr. HUELSKAMP. IG doesn’t make that decision, you make the 

decision. You placed them on administrative leave. Can you explain 

how somebody can be on administrative leave— 

Mr. GIBSON. We made— 

Mr. HUELSKAMP [continued].—for a year and a half and they are 

still getting paid? 

Mr. GIBSON [continued]. We made the decision, we put them on 

administrative leave at the IG’s request. We have— 

Mr. HUELSKAMP. You told us here, Mr. Secretary— 

Mr. GIBSON [continued]. —within the last several weeks— 

Mr. HUELSKAMP. —the IG— 

Mr. GIBSON [continued]. —received the— 

Mr. HUELSKAMP. —makes recommendations— 

Mr. GIBSON [continued]. —evidence— 

Mr. HUELSKAMP. —and you don’t— 

Mr. GIBSON [continued]. —from the IG— 

Mr. HUELSKAMP. Mr. Chairman— 

Mr. GIBSON [continued]. —and have received the evidence from 

the IG, we are going to pursue disciplinary action. 

Mr. HUELSKAMP. Mr. Secretary— 

Mr. GIBSON. Yes, sir. 

Mr. HUELSKAMP [continued].—those are recommendations from 

the IG; is that correct? 

Mr. GIBSON. The recommendation from the IG— 

Mr. HUELSKAMP. You spent your testimony attacking the IG. You 

placed them on leave for a year and a half, paid by taxpayers the 

whole time, when will we get disciplinary actions against those two 

people that went after three brave whistleblowers that you have 

settled with in Phoenix, when will we get an answer, when will 

they be disciplined? 

Mr. GIBSON. Those disciplinary actions are in process now. We 

have received all the evidence. 

Leonard.horne on VACREP0180 with DISTILLER

24 

Mr. HUELSKAMP. When will they be done? 

Mr. GIBSON. Tens of thousands of pages of evidence that have 

been turned over to VA by the IG within the last 30 days and we 

are going through that evidence right now in order to be able to— 

Mr. HUELSKAMP. You have to be kidding me. 

Mr. GIBSON [continued]. —take action that can be sustained. 

Mr. HUELSKAMP. After a year and a half they are still getting 

paid by the taxpayers and you can’t figure out a way to discipline 

them. When will we know? You don’t know? 

Mr. GIBSON. As I said earlier, the practice changes now, because 

I am not going to wait any longer. 

Mr. HUELSKAMP. A year and a half, I would say you have waited 

long enough. 

Mr. GIBSON. We waited too long. 

Mr. HUELSKAMP. They should lose their job or be disciplined, but 

not— 

Mr. GIBSON. We waited— 

Mr. HUELSKAMP [continued]. —be sitting on their— 

Mr. GIBSON [continued]. —too long. 

Mr. HUELSKAMP [continued]. —you-know-whats, getting paid. 

Mr. GIBSON. We waited too long and we are not going to do it 

again, because I am not going to defer to the IG’s investigation or, 

frankly, to a Department of Justice investigation— 

Mr. HUELSKAMP. So you don’t know when it will be done? 

Mr. GIBSON [continued]. —because I can’t be assured when it is 

going to be completed. That is the change that we are talking 

about. It is unacceptable. It is not acceptable to me, it is not acceptable to veterans, and it is not acceptable to the American taxpayer. 

Mr. HUELSKAMP. Well, I agree. After a year and a half, it is time 

to do the job, take care of the Phoenix situation. 

Thank you. Mr. Chairman, I yield back. 

Mr. GIBSON. And the other change that I mentioned that we 

have imposed is, we will not routinely place employees that are 

subject to discipline action on administrative leave. They will be 

detailed to other duties, unless there is an egregious example 

where they need to be removed from all responsibility. 

The CHAIRMAN. Ms. Brownley. 

Ms. BROWNLEY. Thank you, Mr. Chairman. 

And thank you, Mr. Secretary. I, like all of my colleagues here, 

are most concerned and as you are, about our veterans and making 

sure that they are well served on a timely basis. 

Mr. GIBSON. Yes, ma’am. 

Ms. BROWNLEY. And I know this hearing is supposed to be about 

a review of accountability and the broader accountabilities within 

the VA, and I think really for me and my perspective, it is much 

less about the disciplinary process. I know that that sometimes can 

be frustrating to people, but we must have the due process of the 

people, employees that we hire and retain. So I get that frustration, I understand it. 

I think my personal frustration is more about sort of the broader 

accountabilities within the VA that we are changing procedures, 

doing what we can to close loopholes and other kinds of things, so 

that when we are hiring new employees, we are absolutely clear to 

them what their responsibilities are, what they are held accountLeonard.horne on VACREP0180 with DISTILLER

25 

able for. So in the event that we have to get to this place of disciplinary action, we have our facts really, really clear. And for me that 

is where the frustration lies. 

And I think my frustration also lies when I read your testimony, 

the testimony builds up about all of the progress that the VA has 

made. And I am not doubting that we have not made progress, and 

I believe in your leadership and the Secretary’s leadership, and I 

believe that you are in a mode of continuous improvement, I am 

not doubting that. But I think my frustration also lies in that you 

end up citing the very best data possible as it relates to wait times 

in your testimony. So if you look at pending wait times and so 

forth, the data, it paints a different picture. 

Now, you have just said in your testimony the demand outweighs 

the supply and I am not sure that we are ever going to be able to 

get there, but for me that is the kind of information that I want 

to be, you know, completely up-front with and not lead people down 

the path of look at this exceptional data, you know. The wait times, 

what did we say? I think you said the wait times right now, now 

I can’t remember, the national wait time is four days. And that 

sounds great. It is like, oh, my goodness, where we were before and 

where we are now on a national basis, only four days. That sounds 

like we have done extraordinary work, but yet we still know that 

the problem still exists. 

In my district, for example, the pending wait time is roughly 28 

days. You know, that doesn’t sound as good. And I know that we 

are down people in the district and that is causing those pending 

wait times to be longer. 

So I think that is my frustration. And I am really looking to you 

and the VA to come back to us with ways in which we can improve 

upon our systems and regulations, so that we can be abundantly 

clear of what our expectations are, so that we don’t run into—that 

we can minimize anyway, it will never be perfect, but that we can 

minimize some of these issues that we are talking about now, you 

know, with a Denver hospital, the Diana Rubens, Kim Graves 

issues. I think if we did it a little differently, maybe some of that 

would have been alleviated. 

So that is what I am posing to you as, if you can come back to 

us and show us how we can—and if we need legislative fixes to it, 

let us know that, so that we can move forward collectively and continue to make improvement. 

Mr. GIBSON. Yes, ma’am. There are differences in the numbers 

between pending appointments and completed appointments, as referred to earlier. One of the most powerful ways we can provide 

timely access to care is by allowing a veteran to be seen on the 

same day and 20-plus percent of our appointments are in fact accomplished and completed in that kind of a metric. So that represents a large portion of the difference between pending appointment wait times and completed appointment wait times. I am confident, even in the three-or-four-day metric, there are still veterans 

that are waiting too long for the care, waiting longer than they 

should be waiting. 

And so that is part of the emphasis of looking at those that are 

waiting the longest, those that have the most urgent need, to ensure that they are being prioritized and seen as urgently as— 

Leonard.horne on VACREP0180 with DISTILLER

26 

Ms. BROWNLEY. But you understand the point that I am making. 

Mr. GIBSON. I do understand. Yes, ma’am. 

Ms. BROWNLEY. I think there still are other improvements that 

can be made so that our expectations are clear and then, if we do 

get to a disciplinary situation, it should be clearer, because I think 

it takes that work up front. I mean, I was a school board member, 

you know, I have been through these processes before, and it is a 

matter of management doing their due diligence to make things 

abundantly clear, to make these processes clearer. 

Mr. GIBSON. And I would point to the changes that we made in 

every performance evaluation for every single medical center director as a good example of that. Where instead of just tracking some 

random activities, we are focused on the veteran health care outcomes that they are most directly responsible for and, where there 

is poor performance, they are held accountable for poor performance. 

Ms. BROWNLEY. Thank you. 

And, Mr. Chairman, I apologize and I yield back. 

The CHAIRMAN. That is okay. 

Mrs. Walorski? 

Mrs. WALORSKI. Thank you, Mr. Chairman. 

So, you know, I want to just describe what it is like in my office 

in Indiana. Veterans and a lot of other advocacy groups watch 

these hearings, they tune in, they track what the VA says, they 

track the questions we ask, and they will, oftentimes come in and 

be very excited about what the VA says. One of the issues that in 

my district has been really important is the Choice program, which 

has never really rolled out correctly. And, you know, the VA just 

held a town hall meeting a couple of nights ago in our district. And, 

again, you know, every time the town halls roll out, it is people 

talking about, you know, the need for service, you know, they are 

outside the area, they are in a rural area. And the answer from our 

VISN comes back that the Choice program, you know, isn’t really 

rolling out yet and it has got these issues. And the number of people that actually can apply for the program and actually receive 

any kind of help other than through the VA is very very small. We 

have continual turnover in our VISN with people that actually run 

the facilities have been expanded now all over the country. And one 

of the issues that happens in my district, though, and probably 

other districts as well, is we will get a veteran that walks in the 

front door of our district office and they will be carrying either a 

box or a bag and it is full of prescription drugs, high-powered opiates, psychotropic drugs. And they will come in and they will set 

this box down and they will say, I have all these drugs, I am in 

so much pain and the VA isn’t helping me, they are just giving me 

more drugs and I don’t know what to do. And they come in to us. 

And so we obviously pick up the phone, we call and make a congressional inquiry out of it and start asking questions. Who is taking care of this veteran? And, you know, we look at that when we 

look at the suicide rate and those kind of things, but I am curious, 

what is the policy, the oversight and the standard operating procedure that the VA uses when it comes to this issue of veterans that 

are either in-house or coming and going from someplace in the veteran community for mental health services, what kind of due diliLeonard.horne on VACREP0180 with DISTILLER

27 

gence is the VA doing to make sure that there is a tight control 

on policy and individual plans then for these veterans? 

Mr. GIBSON. I will take my best shot at that answer, being a 

non-clinician. I would tell you that one of the most powerful tools 

we have inside VA is the fact that we have integrated mental 

health care into the primary care practice. And so oftentimes, what 

we find, our veterans that have modest mental health care conditions are being treated inside the primary care team, and that is 

one of the ways that we improve access to care. 

I would say where we have veterans that are more significantly 

dealing with behavioral health challenges, one of the new tools, one 

of the new structures that has been rolled out across the department is, and I am not going to remember the exact name, it is a 

structure where, for the most seriously affected veterans that there 

is a whole team of mental health care professionals that look at 

that veteran from a holistic standpoint. So it could be a psychiatrist, it could be a social worker, it could be some group therapy 

provider that are all looking from a holistic standpoint at that particular veteran. 

Mrs. WALORSKI. Yeah, and I get you, that is probably the bestcase scenario. So for the folks that come in my office, though, and 

for the issues we have, we have a very very lack of mental health 

services, we have a lot of drugs being prescribed. 

Mr. GIBSON. Yes, ma’am. 

Mrs. WALORSKI. And so what happens then? So our answer to 

that veteran is what? They call the 800 number for help, they call 

the help line as a veteran with all these drugs? 

Mr. GIBSON. I would hope that— 

Mrs. WALORSKI. What does the VA do, though, when you find out 

that there’s either excess drugs being written, lack of supervision, 

lack of doctor-patient involvement? Because this is realtime, really 

happening. 

And then my second question is this, Secretary. When it comes 

to the prescription registries in individual states, like in the State 

of Indiana, there is a prescription registry that every single doctor, 

anybody prescribing any kind of heavy narcotic turns into that 

state and it is monitored. Do the VAs have a procedure that is nationwide that says that they work with those state units and they 

do the reporting as well? Or I think we had a piece of legislation 

last year that said that the VA may provide that to a state. Is that 

customarily provided to a state or is the VA pretty much self-contained? 

Mr. GIBSON. My understanding is that it is standard practice for 

us to participate in those state registries. And that is one of the 

ways that we are able to help improve the continuity of care for 

those veterans that are taking habit-forming drugs. 

Mrs. WALORSKI. And if there is a doctor violating that in a state, 

what is the role of the veteran? Does the veteran call the congressional office and we call the VA when we know or have some kind 

of suspicion that there is going on inside of the facility, over writing of prescriptions or lack of supervision? 

Mr. GIBSON. The focal point is the VA physician. I would tell you 

that as we have rolled out the opioid safety initiative all across the 

department, what we have built are dashboards for every single faLeonard.horne on VACREP0180 with DISTILLER

28 

cility and every single physician that allow us to see at all levels 

of the organization, the activity and intensity of opioid prescriptions. 

Mrs. WALORSKI. And has that led to greater compliance, the 

dashboard, has that led to greater compliance? 

Mr. GIBSON. It has, yes, and reduced incidents of opioid prescriptions. 

Mrs. WALORSKI. I appreciate that. 

I yield back my time, Mr. Chairman. 

The CHAIRMAN. Mr. O’Rourke, you are recognized. 

Mr. O’ROURKE. Thank you, Mr. Chairman. 

Mr. Secretary, thank you for being here and for answering all of 

our questions, and I think perhaps just as importantly listening to 

some of the concerns and suggestions on how we make improvements. I do want to make sure that this continues to be a collaborative relationship to the degree that it can with our oversight responsibility. 

Mr. GIBSON. Yes, sir. 

Mr. O’ROURKE. And I have got to tell you, I sympathize with the 

fact that you are managing, you know, an all-funds, all-accounts 

budget organization that controls $156 billion that has one of the 

most sacred responsibilities that this country has to fulfill, and you 

and Secretary McDonald, and actually you before Secretary 

McDonald, took this over at a time of unparalleled crisis. And so 

I am trying to figure out what the balance is between the Committee and the VA and the administration, I want to focus on outcomes. I want you to hit those things that are your commitment 

that I know you deeply believe in. I don’t want to get into personnel issues in a $156 billion organization. And yet because of the 

trust that was broken with this Committee, with this country, with 

the veterans, with the VSOs who represent them, I think it is very 

understandable that there is a heightened sensitivity on the part 

of the Committee when we see a Diana Rubens situation, when we 

see an egregious failure by a doctor or a prescriber in some part 

of the VA, there is going to be an intensive focus on that to see if 

it signals that in fact we are turning the corner or whether there 

are still systemic problems. And so I just think it is important to 

say that. 

And one other thing is just another imperfect analogy. I was on 

the city council in El Paso for six years and I was typically the dissenting vote on personnel issues that we would handle in executive 

session. The attorneys would always say, you know what, this employee whose violation was from the trivial to the more serious, it 

is much cheaper for us to settle with them, to put them in another 

job, to move them to the sanitation department instead of to fire 

them. I am always that one or maybe joined by one other colleague 

vote to spend perhaps, you know, two to three times what it would 

cost to keep the employee to send a signal throughout the organization and hopefully change the culture that, if you screw up here, 

you are out of here and we will take the extra expense. 

So just speaking for myself, there’s greater tolerance perhaps on 

the Committee, but certainly with me to spend a little bit more up 

front to get the culture right, even if it costs us in legal proceedings 

Leonard.horne on VACREP0180 with DISTILLER

29 

and, you know, protracted proceedings to get these bad actors out 

of there. 

Mr. GIBSON. Yes, sir. 

Mr. O’ROURKE. I want to also commend you and the Secretary 

and the Undersecretary for Health for the excellent plan that you 

presented to us, I guess it was last month, the end of last month, 

to reform the way that care is delivered. And I would challenge the 

conclusion that you have reached that we will never be able to keep 

pace with demand. I think the plan that you presented which maximizes what I think are the core competencies with the VA, with 

what we can have complementary in the community can help us 

to see more veterans more effectively, more efficiently, and I think 

we can get closer to a more reasonable wait time. And so, just I 

hope that that ultimately becomes your conclusion as well, or 

maybe I misinterpreted what you said. 

Mr. GIBSON. I hope we deliver on the outcome you have just described. 

Mr. O’ROURKE. Right. 

Mr. GIBSON. The question will be, how do veterans respond with 

their demand for care. You know, if you fix demand, I am confident 

that we can shorten wait times, absolutely confident. 

Mr. O’ROURKE. So I want to use this remaining year that you 

have and the administration has and the Secretary has to leave 

those indelible changes that are going to ensure that this culture 

that we have to change, the performance we have to change, the 

outcomes we have to change, you are not going to get them all to 

where they need to be in this year, but I want to do the most possible within this year to get us as far along on the path as possible. 

To that end, and I know I didn’t leave you a lot of time, in terms 

of going forward prospectively when we are hiring, what are you 

looking for, what kind of decisions are we making in hiring so that 

we don’t have these problems going forward? So that we are hiring 

the right people into the right culture for the VA. 

Mr. GIBSON. I would tell you my own personal perspective, you 

look at values, will and skill. And if you can’t find people that 

share your organizational values, if you have people that don’t have 

the willingness to do the job, then it is a nonstarter. People may 

or may not have the skill, in hiring you expect that people will 

have the skill, but as we bring people into the organization, I didn’t 

allude to this earlier, but in the majority of those instances where 

the IG did not find misconduct in locations where there were questions about scheduling, the conclusion was the people weren’t 

trained. And if you look across VHA, there is no standard training 

for a medical support assistant, it is all over the board. We have 

tried to plug that problem by rolling out, you know, many thousands of man hours of additional training. But the ultimate solution is to roll out an enterprise-wide, and we have got one identified, two-week, face-to-face, hands-on training program for schedulers. It is hard to justify firing somebody if you haven’t trained 

them to do their job. 

So that is one of the obligations that we have. We agree that we 

need to hire the right person, but I would also tell you we have got 

to make sure that we do our part to train them to do the work. 

The CHAIRMAN. Dr. Abraham, you are next. 

Leonard.horne on VACREP0180 with DISTILLER

30 

Mr. ABRAHAM. Thank you, Mr. Chairman. And thank you, Deputy, for being here with Ms. Flanz. 

Mr. GIBSON. Yes. 

Mr. ABRAHAM. I just want to kind of hit some points that you 

made during your opening statements. You alluded to that we need 

to have a little more patience, we need to get some more discipline 

established. And I think I could give you a good argument that 

both the veteran and this Committee has the patience of Job waiting for these things to occur. So we are still waiting. 

I want to appeal your previous life as a leader of combat troops, 

a leader of business. If you as a platoon leader had come to your 

company commander and say, if you had troops in combat and 

said, well, sir, give me more time and we need more discipline, the 

outcome would have been much more severe than the Committee 

is doling out now. And I don’t think it is too far of a stretch to say 

that our veterans now are like troops in combat. The longer that 

they are having to wait, ravaged with disease, whether it be diabetes, heart disease or anything, we are losing lives. And we don’t 

mind patience to a point, but it is to the point now that daily our 

veterans are dying, waiting for the VA, you as the leader, to get 

these things done, daily we know veterans are dying. And again, 

this is not making a better washing machine in business, these are 

actually lives we are dealing with. 

You alluded also in your statement that we need to look at more 

of the strategic, the broad, the long-term game, and I certainly 

agree with that. But again, going back to your role as a combat 

commander, you know if you didn’t have tactical victories, the strategical long game meant absolutely nothing. 

So I guess the questions are two. One, you alluded to the IG report. And I am a little concerned that, I guess you do have the authority to usurp what the IG recommends and I guess that is in 

your broad authority as Deputy Secretary and Mr. McDonald’s as 

being Secretary, but is there a standard operating procedure, as 

Mrs. Walorski alluded to, as when you get these reports, do you 

have to do certain things in the objective checkbox, so to speak, as 

to we have got to handle it this way, or can you go off on any road 

you want? 

And my second question, and then I will leave you all the time 

you want to answer. You also alluded in your opening statement 

about the Mr. Frederick Harris, the VA employee that has been 

charged with manslaughter at the Alexandria Hospital in Louisiana, that is in my district. I would just ask what his current status is at the department right now. 

Mr. GIBSON. If I can take that one first. I have no idea, but I assure you, before the day is out, I am going to find out. 

Mr. ABRAHAM. I would appreciate that. 

Mr. GIBSON. I would be glad to let you know too, because I am 

as interested as I suspect as you are. 

Mr. ABRAHAM. Okay. Thank you, sir. 

Mr. GIBSON. If I can make one quick comment about sense of urgency, believe me that we have a sense of urgency. 

Mr. ABRAHAM. And I don’t argue that. 

Mr. GIBSON. As we waded into the access crisis, it was all hands 

on deck, we are focused on improving access to care. My comments 

Leonard.horne on VACREP0180 with DISTILLER

31 

earlier go to really reenforce that to ensure that veterans that need 

care urgently are receiving care urgently. So— 

Mr. ABRAHAM. And I think we just want to see some tactical victories here. 

Mr. GIBSON. Believe me, we are—well, I would say seven million 

more completed appointments is at least a tactical victory. 

Mr. ABRAHAM. But my veterans, I know the four and five days 

for primary care, for mental health. But it is like, as you have 

heard here, when we go back in our districts, we don’t have one 

or two veterans come up to us and say we are waiting, we have 

dozens that say I cannot get an appointment. 

Mr. GIBSON. Yes, sir. 

Mr. ABRAHAM. And again, we throw our hands up in there and 

say, well, we are trying. Well, that is not good enough for our veterans. 

Mr. GIBSON. And I agree with that. And in your part of the country one of the things we have been doing is enhancing our facilities 

there, so that we can provide more ready access to care. That is 

part of what as a leader I have to do is to create the conditions that 

enable those front-line staff to meet or exceed the expectations of 

veterans and we are, believe me, focused on doing that. Focused on 

correcting the problems in care in the community, as we have discussed here two weeks ago, so that that is a more effective tool as 

well to ensure that veterans are getting the care they need when 

they need it. 

So there is, believe me, a sense of urgency. 

Your question as it relates to IG reports. There are essentially 

always a set of findings or conclusions or recommendations that the 

IG has, and we have a discipline process that we go through and 

respond to those and provide regular updates to those. In the case 

of this particular instance, there were recommendations that the 

Secretary or the Undersecretary consider whether or not there is 

any appropriate accountability action that needs to be taken. And 

I can assure you, whether they recommended it or not, we would 

have been doing that anyway. The mechanism by which we do that 

oftentimes involves launching a separate investigation. 

I would tell you in the particular case of the relocation, we found 

the information and the evidence that we needed in the investigative material that the IG gathered. So we did not have to go do a 

separate and independent investigation of those particular matters 

to move through a very deliberate process, but as expeditious as we 

can, notwithstanding the delay that we cost ourselves by our own 

administrative error to get to the appropriate conclusion. 

Mr. ABRAHAM. I am out of time, but we are continuing to wait 

impatiently, as you know. 

Mr. GIBSON. Yes, sir. 

Mr. ABRAHAM. Thank you, Mr. Chairman. 

Mr. GIBSON. I understand. 

The CHAIRMAN. Undersecretary, just for the record, we had written a letter to Secretary Shinseki back in 2013 and then I wrote 

a letter to Secretary McDonald in October of this year, Ms. Flanz, 

you may be aware of this in regards to that particular issue, and 

I have not gotten a response on either. So I appreciate your willingness to dig into it and let us know what is going on. 

Leonard.horne on VACREP0180 with DISTILLER

32 

Mr. GIBSON. I will do that. Yes, sir. 

The CHAIRMAN. Mr. Walz. 

Mr. WALZ. Well, thank you, Mr. Chairman. 

And, Deputy Secretary, as always, thank you for being here. 

Mr. GIBSON. Yes, sir. 

Mr. WALZ. And I thank my colleagues in building on what they 

are saying. I understand the complexity, Mr. O’Rourke was very 

clear about that, the complexity of your job, tens of thousands of 

personnel actions. We certainly don’t expect, nor it be not a good 

use of your time to be focusing on all of those. But I think you are 

hearing it from my colleagues, there are times when that large, 

systemic reform that we are all looking for is jeopardized, and it 

is the small chips in the things. 

And one of the things is, is that I think we do have a responsibility in this job to channel our constituents and that is what you 

are hearing. 

Mr. GIBSON. Yes, sir. 

Mr. WALZ. And my constituents say, when you see these guys, 

will you ask them this. And so while it may seem petty, it is not 

petty. Perceived reality is reality. 

And I have to say, I have tried to balance this accountability and 

due process, looking at pieces of legislation. As I heard, we didn’t 

need the SES reform bill because you had all the tools. Well, apparently we did. Others have been offered that I have pushed back 

against, but it is challenging when I see this happen. 

I am just trying to understand this latest issue. This was every 

veteran in the country was watching this. We did an unprecedented step that pained us to issue subpoenas. We were told that 

there would be accountability and now this plays out. And I have 

to tell you, my veterans have no faith that it is going to work, they 

don’t believe this. And I am just trying to understand. 

And in the midst of this for perceived reality, sending one of 

these people to Phoenix of all places afterwards? Can you take me 

through the personnel steps of how this unraveled? And I certainly 

understand things can happen, but in this one, this would have 

been one that I would have personally walked all the way through, 

I am just saying, because now we can’t get at stuff. 

And I think there is reason to be optimistic, I agree with Mr. 

O’Rourke. That hearing last week was the best hearing we have 

had in this Committee in two years. It was optimistic, it was visionary, it was getting at the heart of this. Veterans came up to 

me who watched it and said that they felt things were changing. 

And I haven’t been more optimistic on electronic medical records 

than maybe in eight years than I am right now. There are important things happening, positive things happening for veterans, but 

it is all being undermined. 

So how did we end up in this mess? And yes, it is parochial, it 

is in my backyard. I made the case of this and I promised my veterans there would be accountability. You heard the frustrations. 

And I will let you, as I said, you are the person who needs to do 

this, because you have earned and have the trust and faith of folks, 

but right now this thing is a mess. 

Mr. GIBSON. As I have said before, my careful review of the entire body of evidence does not support the conclusions reached in 

Leonard.horne on VACREP0180 with DISTILLER

33 

the IG. Folks that have no familiarity with this case other than the 

report that they read from the IG, I can understand precisely why 

they share the concern that you are expressing right now. And I 

made the decision that I made with the full, painful awareness 

that this was a decision that was not going to make people happy 

in any way, shape or form, but I did what I believed what was the 

right thing to do. 

And as I mentioned earlier, I look forward to coming back. I will 

sit down with any Member, come see you one-on-one, if you would 

like, or any Member one-on-one or the group in total to walk 

through the decision process, walk through the evidence, and share 

the entire body of evidence, unredacted, all the evidence that was 

used to substantiate the decision that was made. 

Mr. WALZ. Well, that may be important, because we have got to 

get this. And I have to go back, because you can’t do that for each 

and every veteran, I have got to go back and stand in front of 

them. And I am not interested in a witch hunt, I do believe that 

due process is important. It is a morale issue, it is a fairness issue. 

Mr. GIBSON. Yes, sir. 

Mr. WALZ. I can’t pass judgment and judge, jury and executioner 

on an employee of yours, I understand that. It is just a combination 

of things and it appears like the lack of a sense of urgency. And 

I don’t know how to convey that more to folks that this is changing, 

because it is undermining veterans’ faith in the really important, 

critical work you are doing. 

Mr. GIBSON. Thank you for raising that particular issue and, if 

I may, if I can mention two quick points. 

The first thing that I want to say to the entire Committee, my 

personal perception has been and continues to be that historically 

VA did not consistently take appropriate disciplinary action in the 

face of misconduct or management negligence, period. We have not 

historically done that. That is one of the reasons I created the Office of Accountability Review was because I did not have confidence 

that if I pushed those decisions out into the field, that we would 

get the outcomes that we needed. There was a resetting and recalibration of accountability actions and the process associated with 

that, and that is why I created the Office of Accountability Review, 

that is why I personally am the proposing and deciding official on 

every senior executive action, the serious actions for removal or removal from a senior executive service, because I am trying to model 

a leader’s behavior and accountability for those leadership actions. 

And a senior executive see themselves being held to that account, 

to that standard, I am hoping that then gets modeled elsewhere in 

the organization. And we certainly talk about that robustly. 

I agree with you that it takes too long, I agree with you that we 

are having to wait too long, and that is the impetus behind my decision to say we are not going to wait any longer. Where there is 

an issue—we knew that there was an issue around the relocation 

expenses months before the IG released their report. But what did 

we do? We waited for the IG to go through all the process. That 

is not how we are going to approach it. And I am telling you, we 

are already doing this. There are already AIBs underway or OMI 

inspections underway, Office of Medical Inspector inspections that 

are underway right now where we know that the IG is already in 

Leonard.horne on VACREP0180 with DISTILLER

34 

the facility, but we are in there as well. And I have said, please 

don’t get in our way, because we are going to go in, we are going 

to gather whatever evidence we need. If we can do that cooperatively with the IG, that’s great. But we are going to move ahead, 

we are going to take the action that we can take. If the IG comes 

back with a different finding and different evidence, fine, then it 

will give us the opportunity to consider any additional action. 

Mr. WALZ. Thank you, Mr. Chairman, for the extra time. 

And I know I am not telling you anything new, Deputy Secretary, but, boy, I would lean forward into this. 

Mr. GIBSON. Yes, sir. 

Mr. WALZ. If you don’t do it, I think you are going to jeopardize 

not only the public’s trust in this, you are going to violate the due 

process rights of others, because the hammer is going to come in 

a way that is not going to be helpful. 

Mr. GIBSON. Yes, sir. 

Mr. WALZ. I yield back. 

The CHAIRMAN. Mr. Coffman. 

Mr. COFFMAN. Thank you, Mr. Chairman. 

Secretary Shinseki resigned only after this, I think the White 

House saw that this Committee unanimously voted to subpoena 

records related to or communications related to the appointment 

wait time scandal. Then you and Secretary McDonald come in, 

really didn’t make changes in the bureaucracy, became part of the 

bureaucracy, defended the bureaucracy. Problems have only really 

come to light through either whistleblowers or through things just 

blowing up. 

Then you had a President who in the last State of the Union, 

after scandal after scandal, said of the VA one sentence in the 

State of the Union speech, he said that the Veterans Administration has had some bumps in the road, but veterans are getting 

state-of-the-art health care. That was it. 

I think you are doing the best you can do, I think Secretary 

McDonald is doing the best that he can do, but you are both 

placeholders and you don’t have the authority from the White 

House, you don’t have the support from the President to make the 

kind of changes that need to be made. You know what needs to be 

done, Secretary McDonald knows what needs to be done, but you 

absolutely don’t have the support nor the authority to do so. 

So this agency of the Federal Government was in crisis when you 

came in, it will be in crisis when you leave. You give great spin 

here, I appreciate it. I really think you are trying to do the best 

you can do. But again, you absolutely have no support from the 

White House, no ability to make a difference. We will just do the 

best we can between now and the next administration in terms of 

logging the problems. 

But if you take the issue, I mean, we had in my district the largest cost overrun in the history of the Veterans Administration in 

a construction. The problems were known since April of 2013 when 

there was a GAO report. Yet even since then the management on 

that project received bonuses. Nobody has been disciplined. The 

AIB has been done for five months, yet Congress has not received 

it. There is no confidence anymore in this Committee, there is no 

confidence and trust among the veterans of this country, nor 

Leonard.horne on VACREP0180 with DISTILLER

35 

should there be. We are just treading water and that is where it 

is going to be between now and the end. 

Can you tell me when the AIB, when you are going to give it to 

the Congress, this Committee, on the Aurora construction issue? 

Mr. GIBSON. As I mentioned to Congresswoman Rice earlier, the 

plan had been to wait until the IG completed their investigation, 

we are not waiting. I have directed that we move ahead with the 

evidence that we have, including that AIB, to consider any appropriate administrative actions on any employee that remains at VA, 

and we are doing that right now. I expect that that is not going 

to take an extraordinarily long period of time, but I don’t have an 

absolute deadline by which I have instructed folks to complete it, 

but it is relatively soon. We have waited too long for that already. 

Mr. COFFMAN. Mr. Chairman, I think it is a tragic situation we 

are in right now that the veterans of this country are not getting 

the benefits that they have earned and the taxpayers are not getting the value of their hard-earned tax dollar, and I just don’t see 

that changing between now and the next administration. 

I yield back. 

The CHAIRMAN. Dr. Benishek. 

Mr. BENISHEK. Mr. Chairman, thank you. 

Thanks for being here, Mr. Gibson. 

Mr. GIBSON. Yes, sir. 

Mr. BENISHEK. I was a little disturbed by your written testimony 

as well. I don’t think we really want to see people fired, we want 

to see the VA be successful. And, frankly, it seems to me that we 

have come to the conclusion that the VA is unable to remove people 

that are not doing their job as we see it to be done. 

I am just going to give you one example that really kind of eats 

at me and that is, you know, the Inspector General has told the 

VA eight separate times over the last 30 years they need a central 

plan to hire physicians. And each time the VA has agreed with the 

Inspector General that that is the case and that they are going to 

do it, but over 30 years there is no plan to hire physicians centrally. They each are hired by each individual medical center even 

today. And then in a Subcommittee hearing when I brought this up 

they said, well, we might have a plan to do it, that plan in three 

years. And then I said, well, who is in charge of that? And I could 

not get an answer. 

So that is the accountability that we are talking and I am talking 

about is that 30 years and this plan isn’t done. I know you weren’t 

here, but it is very frustrating to see that. And we want to see people who actually do the job and get these kind of things done. And 

I have got to assume that, unless somebody is removed and somebody is made accountable to make that happen, all kinds of stuff 

like this aren’t going to happen. So that is the frustration. 

I mean, last month Danny Pummill, the veterans benefits exec, 

said it is almost impossible to discipline most VA employees. Do 

you agree with that? 

Mr. GIBSON. I think there are processes that you have to follow, 

but I don’t think it is impossible. 

Mr. BENISHEK. What can I do as a Congressman, is there something legislatively that we can do to make it easier for you to get 

this kind of stuff done? 

Leonard.horne on VACREP0180 with DISTILLER

36 

Mr. GIBSON. The issue particularly as it relates to serious discipline actions has to do primarily with the evidentiary standard 

that we have to meet, because employees have the right to appeal 

those decisions. So when they are appealed, we appear before the 

MSPB, the Merits System Protection Board, and have to justify our 

actions based upon the evidence that was the foundation of those 

actions. 

Mr. BENISHEK. Well, it seems to me that you said this in the past 

too, that it is very difficult to fire somebody in the VA. I mean, can 

we change this? I think I asked that question already, but you kind 

of give me like long answers. I mean, what should be changed to 

make this easier? 

Mr. GIBSON. I think there are processes that cut across the entire 

Federal Government that are associated, long established and associated with disciplinary actions in the Federal Government that 

have lots of public policy implications associated with them, and we 

operate in that context. Some of the comments that were made earlier about ensuring that we have assigned the appropriate objectives and measurable goals that people need to have in their performance evaluation gives us the kind of quantitative information 

we need to be able to take that action. 

Mr. BENISHEK. Okay. Now, let me just go on, because we don’t 

have much time, Mr. Gibson. I know you said repeatedly that the 

VA won’t tolerate whistleblower retaliation. Has anybody been 

fired for whistleblower retaliation? 

Mr. GIBSON. There have been, and I will ask Meghan to correct 

me if I get it wrong, ten instances of retaliators that have been disciplined, up to including removal. 

Mr. BENISHEK. All right. Can we find out who that is then? Because we are just not aware of any of that here, I don’t think. 

Ms. FLANZ. I believe that was one of the data points requested 

in a letter from the Committee in October and we compiled some 

data that is getting ready to come over to the Committee. 

Mr. BENISHEK. All right. I will yield back, Mr. Chairman. 

The CHAIRMAN. Thank you very much. Members, we were not 

going to a second round, if that is okay. We will end with Ms. 

Brown and my closing comments. 

Ms. Brown? 

Ms. BROWN. Thank you. 

As we prepare to leave Washington, I know I am getting ready 

to date myself here, but when I was coming up it was a program 

on TV, ‘‘Badge 714,’’ and they used to say, ‘‘The facts, ma’am, just 

the facts.’’ And I think that this is what you are trying to say to 

us, Mr. Secretary, not what you read in the paper or the rumor 

mills, but you have to make your recommendation based on the 

facts. 

Can you respond to that? 

Mr. GIBSON. Yes, ma’am, you are right. Any deciding official is 

obligated to consider the evidence and the only evidence in taking 

a disciplinary action against the Federal employee. 

Ms. BROWN. I also want to extend this comment to all of the veterans that might be listening. You know, under this administration, under this President, we have had the largest increase in VA 

funding in the history of the United States of America. 

Leonard.horne on VACREP0180 with DISTILLER

37 

Mr. GIBSON. Yes, ma’am. 

Ms. BROWN. Now, this President has not gotten the credit for it. 

It was under this President and the Democratic House and the 

Democratic Senate. 

And I also want to extend season’s greetings to General Shinseki 

who, you know, he opened up the VA for additional people that did 

not have to prove their cases, but we as a Congress then beefed up 

to give the VA the additional resources that they need to take care 

of it. So it is a blame-blame game. But as we move forward, I do 

want to let the veterans know and the people that take care of our 

veterans that we appreciate them soldiering up, and that we need 

to let the veterans know and the people that work at the VA that 

we appreciate what they do to take care of our veterans. 

Mr. GIBSON. Yes, ma’am. And I would add my own expression of 

gratitude both for the President’s consistent and steadfast support 

of VA and veterans, and also this Committee, this Committee’s 

steadfast support. I know we don’t always see things exactly the 

same way, but I have never doubted the Committee’s motives and 

what are the ultimate objectives that we are trying to achieve here, 

and that is better outcomes for veterans. 

Ms. BROWN. And I agree with that. And I want to thank the 

Chairman for his leadership on this Committee. 

And in my last question to you, I am still concerned about the 

comments. I recently, last night, I went to the theater and, before 

I went in, they checked my purse. In addition to that, I had to have 

a clear bag going into the facility. So I would like to know how we 

can begin the dialect of guarding the VA facilities to make sure 

that we are proactive and that we don’t have another incident or 

we don’t have an incident that we are sitting here talking about, 

what is it we can do to give you the assistance that you need to 

make sure that we take care of the veterans and the employees 

and make it a very safe place to work? 

Mr. GIBSON. Yes, ma’am. What I would suggest is that perhaps 

we bring a couple of our key leaders over and walk through the 

comprehensive situation that we face and what some of the potential improvements are to the security posture of the department, 

because it is something that we have been very focused on particularly in the wake of what happened in El Paso. 

Before you got here, sir, I talked a little bit about what happened 

in Denver last week where we had a much different and more positive outcome than we had in El Paso, fortunately. 

Ms. BROWN. Thank you again for your service. 

And, with that, I yield back the balance of my time. 

The CHAIRMAN. Thank you very much, Ms. Brown. 

Mr. Secretary, would it be inappropriate for Ms. Brown and I to 

invite the President to join us on a visit to the central office? 

Mr. GIBSON. Sir, I can assure you that is your call. 

The CHAIRMAN. I think we will do that, because I have made the 

comment a couple times that he has not been to the central office 

and whether his schedule has allowed it or not. But we are all trying to resolve the issues that are out there. VA will never be perfect and we don’t expect you to be perfect. Anecdotal evidence is 

brought to us all the time. Somebody handed me a note a second 

ago about a combat helicopter pilot, Navy captain, PTSD for over 

Leonard.horne on VACREP0180 with DISTILLER

38 

20 years in San Diego, his psychiatrist has left. He couldn’t get his 

prescription renewed and was told that the next appointment he 

could get was 60 days. I mean, little things like that, you know, 

can turn into a huge snowball. 

Mr. GIBSON. Those are big things. That’s not a little thing, that 

is a big thing, and I know you see it that way. Please let me know. 

The CHAIRMAN. Well, we will get you the appropriate information. 

Mr. GIBSON. Thank you. 

The CHAIRMAN. And, again, nobody on this Committee expects 

you to be able to handle every single individual issue that is out 

there, because some cannot be handled. And Ms. Brown is correct, 

I used a curse word at the beginning, because I was a little upset. 

I don’t think you meant what you said, but maybe you did. But I 

would ask unanimous consent that you strike the word damn from 

the record and put dang, d-a-n-g. Hearing no objection, so ordered. 

And, again, I think we can all agree from a political perspective 

that we want VA to be the very best it can be. 

Mr. GIBSON. Yes, sir. 

The CHAIRMAN. We want to give you whatever tools are necessary. The whole idea on the disciplinary side, it just looks like 

it is so hard to do anything. Whether it is reprimands, I mean, I 

have been looking at your list, I see reprimands that are appealed 

by individuals. And, you know, I saw one where somebody was 

going to be suspended for less than 14 days and they left, they left 

the department. I mean, I just don’t get how that process works, 

if we can help streamline it. And I know it is all across, it is not 

just VA. It is all across the Federal Government, it is not just your 

rules and regulations. 

But I would ask unanimous consent that all Members would 

have five legislative days with which to revise and extend their remarks and add any extraneous material. And without—oh, Ms. 

Brown? 

Ms. BROWN. Yes, just in closing. Mr. Chairman, I think it should 

be a bipartisan meeting with the President, and maybe we all could 

maybe go to the White House because of security or vice versa, but 

I think that would be a good thing to do. 

The CHAIRMAN. Well, again, I think it is important that the 

President goes to the central office and that is why I asked the 

issue. And if he can walk across the street for lunch as he did a 

couple of weeks ago, he can certainly walk across the street to go 

to the central office. But it does need to be bipartisan and all the 

Members need to be there. 

Ms. BROWN. I mean the Senate, I mean bicameral. Yeah, we need 

to invite the Senators. 

The CHAIRMAN. I don’t know about the Senators. 

Mr. GIBSON. Just for the record, the President did come to the 

central office to announce Bob’s nomination. So he has been there 

before. 

Ms. BROWN. We are speaking of one of our town hall type meetings and discussions with him and I think that would be good, good 

for the country. 

The CHAIRMAN. This hearing is adjourned. 

[Whereupon, at 12:33 p.m., the Committee adjourned.] 

Leonard.horne on VACREP0180 with DISTILLER

(39) 

A P P E N D I X 

Prepared Statement of Corrine Brown, Ranking Member 

• Thank you, Mr. Chairman. 

• In order for veterans to receive the benefits and services we have promised 

them, it is essential that VA employees be treated fairly. 

• Part of this fairness, I believe, is that bad employees must be held accountable 

for their actions and for not doing all they should be doing for our veterans. 

• I am concerned that there is a perception that there is no accountability within 

VA, and that the agency is not using its current authorities to manage its workforce effectively. 

• There is no excuse not to hold employees accountable when their actions harm 

veterans. 

• Time and again, VA employees themselves have come forward to blow the whistle on wrongdoing at the VA. 

• We need to do all we can to protect whistleblowers. These brave VA employees 

have played a crucial role in shining a light on problems within the VA. 

• But in my view, providing VA with unfettered authority to remove employees 

will do more harm to whistleblowers than it will be effective in removing bad 

employees. 

• Employees who are brave enough to come forward to report problems should be 

thanked, not punished. 

• VA employees, like all federal employees, are guaranteed the Constitutional due 

process right to fair notice and an opportunity to respond before losing their 

jobs. 

• VA needs to do a better job of rooting out malfeasance, and setting up systems 

that incentivize all VA employees to provide veterans with the best possible 

care. 

• VA must take steps, today, to change the perception that there are no consequences for not doing your job. 

• Basic fairness and civil service protections do not prohibit VA from holding its 

employees accountable to veterans. 

• Today, we must demand accountability from VA leadership. 

• Accountability for protecting whistleblowers; accountability for rewarding good 

employees, and accountability for punishing bad employees. 

• Accountability, quite simply, for using the authorities that VA currently possesses to effectively manage the over 300,000 VA employees - one-third of whom 

are veterans themselves. 

• Let’s use the opportunity before us today to discuss how VA can do a better job, 

while protecting the basic concept of fairness that we all expect from our government. 

• Thank you, Mr. Chairman. I yield back the balance of my time. 

f 

Prepared Statement of Sloan Gibson 

Good morning, Mr. Chairman and Members of the Committee. I am grateful to 

have the opportunity this morning to provide an update on our efforts to reset accountability across the Department of Veterans Affairs. Accompanying me is 

Meghan Flanz, our Deputy General Counsel for Legal Operations and Accountability. 

Accountability Defined 

It seems the term ‘‘accountability’’ has taken on a new meaning. Instead of the 

dictionary definition - ‘‘providing a record or explanation of one’s conduct’’ - the term 

has become shorthand for firing people. 

Leonard.horne on VACREP0180 with DISTILLER

40 

Secretary McDonald and I want to reclaim the term ‘‘accountability’’ in its fuller 

meaning, in the sense of being transparent about what our goals are and how well 

we achieve them, what taxpayers can expect us to achieve with each dollar we receive, what Veterans can expect us to do for them, by when, and to what level of 

quality and satisfaction. 

Abraham Lincoln said ‘‘Commitment is what transforms a promise into reality.’’ 

Within that framework, we believe ‘‘accountability’’ is interchangeable with ‘‘commitment.’’ We hold ourselves accountable for making good on our promises to Veterans - to President Lincoln’s promise to care for those who have borne the battle 

and for their survivors - by providing timely, high-quality care and service to Veterans, while using taxpayer dollars wisely. 

In that fuller sense, accountability means setting the right goals, both as an organization and for individual employees, so the work we do produces the outcomes 

Veterans deserve. • It means ensuring our employees have the training and resources necessary to 

achieve those goals. • It means providing a work environment that is free of fear, so our employees 

feel safe raising concerns about the work we do and about the quality and safety of our programs and processes. • It means setting clear performance standards and expectations up front, and 

then assessing performance candidly, based on actual achievement • It means rewarding people for exceptional performance that furthers desired 

outcomes. • It means training our leaders to lead, and ensuring they understand our vision 

of a transformed VA that provides Veterans with a satisfying - even delightful 

- experience with VA care and services. • Accountability also means taking appropriate actions when things go wrong. It 

means taking the time to understand the reasons for a failure - whether it’s 

a systems failure, lack of clear policy or guidance, insufficient training, or an 

intentional act of misconduct. • It means responding to failures quickly, with a sense of urgency, to make things 

right for Veterans and to learn from our mistakes. • Accountability also means disciplining those who have done wrong, swiftly and 

meaningfully but in a way that is proportionate to the offense. Significant offenses and repeated misconduct may well warrant removal. Other offenses may 

warrant less severe, corrective penalties rather than terminating employment. 

If we define ‘‘accountability’’ only in the narrower way - in terms of the number 

of employees we remove from their jobs serving Veterans - then success on the accountability front means failure in our core mission, service to Veterans. Overemphasis on punitive measures prevents us from recruiting and retaining the best 

and brightest employees to serve Veterans. Secretary McDonald and I are not interested in a definition of success that requires us to decimate our workforce and, ultimately, to close our doors. 

We define ‘‘accountability’’ broadly, to include achievement of Veteran-centric 

goals and continuous improvement of VA programs and systems, because the narrower definition isn’t good for Veterans. 

With the Veteran-serving sense of ‘‘accountability’’ as our definition, here is what 

we have accomplished this year: 

Where we started 

In the context of patient access and scheduling data manipulation concerns that 

came to light at the Phoenix VA Medical Center, allegations of whistleblower retaliation, concerns about over-prescription of opioids at the Tomah VAMC, and cost 

overruns related to our construction of a replacement medical center in Denver, CO, 

VA has experienced a crisis of confidence. 

As a result, throughout 2015, VA’s Office of the Inspector General (OIG) remained 

extremely busy, investigating a wide variety of allegations raised by whistleblowers 

and others across the broad spectrum of VA programs and services. The VA OIG 

website lists 400 reports published in Fiscal Year (FY) 2015, with a large number 

of investigations still ongoing. 

What we have done 

Expanding access to VA care 

• Nationally, the Veterans Health Administration (VHA) completed 56.2 million 

appointments between June 1, 2014 and May 31, 2015, which is 2.5 million 

more than were completed in the comparable time period the year prior. 

• In October 2015, VA completed 97 percent of appointments within 30 days of 

the clinically indicated or Veteran’s preferred date; 91 percent within 14 days; 

Leonard.horne on VACREP0180 with DISTILLER

41 

87 percent within 7 days; and 24 percent are actually completed on the same 

day. 

• VA’s average wait time for completed primary care appointments is 4 days, specialty care 5 days, and mental health care 3 days. 

• VA is a national leader in telehealth services. VA Telehealth services are critical to expanding access to VA care in more than 45 clinical areas. At the end 

of FY 2014, 12.7 percent of all Veterans enrolled for VA care received Telehealth based care. This includes over 2 million telehealth visits, touching 

700,000 Veterans. 

Providing More Care in the Community 

• VHA created 2.4 million authorizations for Veterans to receive care in the private sector from November 19, 2014 through November 18, 2015. The average 

authorization generates 7 appointments. 

• Over 1.4 million appointments are completed per month through doctors and 

clinics in the community, which represents nearly 23 percent of total appointments. 

Recruiting and Hiring New Healthcare Professionals 

• From August 2014 to September 30, 2015, VHA has increased net onboard clinical staff by over 15,000. This includes over 1,500 physicians, 3,900 nurses, and 

566 psychologists for VHA’s clinical care to Veterans. 

Improving Healthcare Services for Women Veterans 

• VA has enhanced provision of care to women Veterans by focusing on the goal 

of developing Designated Women’s Health Providers (DWHP) at every site 

where women access VA. VA has trained over 2,200 providers in women’s 

health and is in the process of training additional providers to ensure that 

every woman Veteran has the opportunity to receive her primary care from a 

DWHP. 

• VA now operates a Women Veterans Call Center (WVCC), created to contact 

women Veterans and let them know about the services for which they may be 

eligible. As of June 2015, WVCC received over 24,000 incoming calls and made 

over 219,000 successful outbound calls. 

Ending the Claims Backlog 

• The Veterans Benefits Administration (VBA) completed 1.4 million claims in FY 

2015, nearly 67,000 more than last year and the highest completion rate in VA 

history. FY 2015 marked the sixth year in a row of more than 1 million claims. 

• VBA reduced its claims backlog 88 percent from a peak of 610,000 in March 

2013 to a historic low of 75,122; reduced inventory 58 percent from a 884,000 

peak in July 2012 to 369,328 (28 percent lower than FY 2014). At the same 

time, VBA has sustained claims-processing quality at 90.2 percent; issue quality 

at 96 percent; and above 98 percent in 7 of 8 categories in which we measure 

quality. 

• The average days a Veteran is waiting for a claims decision (pending) is 91 

days, a 191-day reduction from a peak of 282 days in March 2013 and the lowest average days pending in the 21st Century. VBA’s average days to complete 

is now 129 days - a 60-day reduction from FY 2014. 

Reducing the Number of Homeless Veterans 

• VA has worked with federal, state, and local partners to reduce the estimated 

number of homeless Veterans by 36 percent as noted in the Department of 

Housing and Urban Development (HUD) 2015 Point-in-Time Estimate of Homelessness. With the assistance of VA and other Federal partners, numerous communities, including the entire Commonwealth of Virginia, have now declared 

that they have ended Veteran homelessness. 

• In FY 2015 alone, nearly 65,000 Veterans obtained permanent housing through 

VHA Homeless Programs. In FY 2014, 50,730 homeless Veterans obtained permanent housing through these initiatives. 

• Through the homeless Veterans initiative, VA committed more than $1 billion 

in 2015 to strengthen programs that prevent and end homelessness among Veterans. 

Transforming the Customer Service Experience through MyVA 

• VA is working to reorganize the department for success, guided by ideas and 

initiatives from Veterans, employees, and all of our shareholders. This reorgaLeonard.horne on VACREP0180 with DISTILLER

42 

1Prouty & Weller v. General Services Administration, 2014 MSPB 90 (December 24, 2014), 

¶6. 2Prouty & Weller v. General Services Administration, 2014 MSPB 90 (December 24, 2014), 

¶6. 

nization, part of the MyVA initiative, is designed to provide Veterans with a 

seamless, integrated, and responsive customer service experience. • MyVA is our transformation from VA’s current way of doing business to one 

that puts the Veterans in control of how, when and where they wish to be 

served. Under MyVA, the Department has created a integrated regional framework to enhance services. 

Employee Discipline - Our Approach and the Overall Numbers 

We continue to approach employee discipline as we have done since Secretary 

McDonald and I took office - with a commitment to do what is right and necessary 

to rebuild Veterans’ trust in VA programs and services. 

Of course, punitive action against employees must be reserved for instances involving actual evidence of misconduct. This is not only the right way to impose discipline but it is the legal way. If VA does not have evidence of misconduct, any disciplinary action taken by VA will not be upheld on appeal. This remains true under 

the Senior Executive accountability provision of the Choice Act, and under the more 

traditional disciplinary procedures that apply to VA’s non-Senior Executive Service 

(SES) employees. 

It is important to note what constitutes evidence of misconduct—and what does 

not. 1 Materials such as documentary evidence, data, and witness testimony constitute evidence. VA works with its OIG to provide and compile evidence. But VA 

cannot rely wholesale on an OIG report to impose discipline. Under the law, ‘‘summary, unsworn, hearsay conclusions’’ in an OIG report will not support discipline. 2

For that reason, VA must carefully consider the evidence underlying adverse OIG 

reports to make sure there is substantiated evidence of misconduct upon which VA 

can rely to impose discipline. 

Similarly, the fact that VA OIG has referred a matter to DOJ for possible criminal 

investigation or prosecution does not constitute evidence of misconduct. Rather, referral simply means that VA OIG has asked DOJ to review the matter to determine 

whether any of the underlying allegations, if proven, might constitute a crime. Because, under the Constitution, individuals are presumed innocent unless and until 

proven guilty, we cannot support employee discipline on the basis of a pending 

criminal referral. 

It is also important to note that VA does not rely solely on OIG or DOJ to investigate misconduct. Though VA respects and appreciates the work of its partners, 

sometimes OIG and DOJ move at their own pace or are restricted by their own resource constraints. Thus, Secretary McDonald and I are committed to collecting relevant evidence quickly and effectively through our own resources, where necessary 

and appropriate, rather than allowing issues to remain unresolved throughout a 

protracted external investigation. When the evidence collected demonstrates misconduct warranting discipline, it is also important to understand the due process we 

are required to afford all VA employees, including Senior Executives. There is a long 

line of case law that tells us that Federal employees - like those who work for state 

and local governments - have a constitutionally-protected property right in continued employment. That doesn’t mean they can’t be fired for misconduct, but it does 

mean that they are entitled to due process before they are fired. Pre-decisional due 

process includes the right to provide a meaningful response to the charges and evidence against them before a decision is made. 

One thing that can undermine pre-decisional due process is inordinate pressure 

on the deciding authority to reach a particular decision. Where such pressure exists, 

it can be hard for the deciding authority to make an independent decision based 

solely on the evidence. In the military, this phenomenon is referred to as ‘‘unlawful 

command influence.’’ In our world, the pressure to reach a particular decision 

doesn’t come from our commander, but rather from Members of Congress and/or the 

press who react to an OIG report or a news story by demanding an employee’s termination. Whether such demands are actually intended to influence the decisionmaker or merely to express outrage, they challenge our ability to take fair, neutral, 

and sustainable actions. They also wrongly undermine Veterans’ faith in VA employees when - as sometimes happens - little or no discipline is taken because the 

underlying evidence does not support the story as reported. 

In early November, this Committee held an oversight hearing focused on issues 

underlying what were then two pending employee discipline matters. Secretary 

McDonald and I implored the Committee then to defer the hearing until after we 

Leonard.horne on VACREP0180 with DISTILLER

43 

had made our decisions in those matters. I reiterate the plea today that the Committee please permit us to carry out the Executive Branch responsibility of proposing and deciding employee discipline independently, without undue influence, to 

ensure that our actions are sustainable and that Veterans are not misled about the 

conduct of VA employees upon whom they depend. 

Senior Executive actions 

The Choice Act authorizes the Secretary to remove a Senior Executive from employment, or from the Senior Executive Service through demotion to a non-SES position. The Secretary has delegated that authority to me. We have used the Choice 

Act removal authority ten times since it took effect in August 2014. We have proposed removal of eight Senior Executives from Federal employment; three individuals’ removals were effected, and the others chose to resign or retire in lieu of removal. We had also removed two employees from Senior Executive Service to nonSES positions. Due to administrative error, these demotions had to be rescinded. We 

have corrected the error and proposed actions are now back in the employees’ hands. 

While the paperwork effecting a resignation or retirement in lieu of removal is 

coded to reflect the underlying circumstances, by law, any Federal employee who 

has the years of service and is of an age to retire is entitled to do so. By law, the 

only basis for terminating a Federal employee’s retirement benefits is if the individual has been convicted of espionage, treason, or one of the other national security 

offenses listed in 5 U.S.C. § 8312. 

Non-Senior Executive Actions 

VA provides a weekly report to the Chairmen and Ranking Members of the House 

and Senate Committees on Veterans’ Affairs in response to a June 3, 2014 request 

from this Committee for information related to employee discipline ‘‘taken on any 

basis related to patient scheduling, record manipulation, appointment delays, and/ 

or patient deaths.’’ The latest report, sent on Friday, November 27, shows 316 such 

actions proposed or decided between June 3, 2014 and November 25, 2015. This 

tally includes proposed penalties ranging from counseling through removal and is 

limited to the types of misconduct listed in the Committee’s June 3, 2014 request. 

The Department is frequently asked for information reflecting the total number 

of employees fired in a given Fiscal Year, or since Secretary McDonald’s July 2014 

confirmation. That number is currently over 2,400. However, as noted earlier, we 

believe such numbers to reflect only a small and less than useful fraction of the information needed to accurately assess the VA’s accountability activities. Moreover, 

we have seen the conversation about such numbers quickly devolve from a meaningful assessment of our accountability efforts to skeptical questions about why one set 

of numbers we report differs from another, or why we ‘‘allow’’ employees to resign 

or retire before a removal action can be completed. Of course the numbers we report 

depend upon the question asked, and - as has been noted - all Federal employees 

have the legal right to retire or resign with or without a proposed removal pending. 

Framed within that necessary context, the Fiscal Year 2015 count of employees 

who were for any reason removed, terminated during probation, or retired or resigned with a removal action pending is as follows: 

FY 2015 Adverse Action Totals 

Removals, Probationary Terminations, Resignations and Retirements effective within FY15 

Action Taken Number of Actions Taken 

Probationary Termination 950 

Removal 869 

Employee Resigned in lieu of 423 

Employee Retired in lieu of 106 

Total 2348 

Data current as of 11/18/2015 0700 

Discipline related to Scheduling/Access Data Manipulation 

With respect to employee discipline for scheduling and access data manipulation, 

we have relied upon the VA OIG to provide us the evidence they have collected 

Leonard.horne on VACREP0180 with DISTILLER

44 

through the approximately 120 VA health-care-site-specific investigations they 

began in 2014. Where that evidence is inadequate to answer all questions relating 

to individual employee misconduct, the VA Office of Accountability Review (OAR) 

initiates follow-up investigations to complete the evidentiary record. • OIG has provided the Department with reports and evidence relating to 77 VA 

sites. • At 62 of those 77 sites, OIG found no data manipulation had occurred. • At 6 sites - Phoenix AZ, Cheyenne WY, Ft. Collins CO, Dublin GA, Wilmington 

DE and Hines IL - OIG substantiated intentional misuse of scheduling or other 

access data. We have taken a total of 21 disciplinary actions, ranging from reprimand to removal, in connection with misconduct at these sites. There may be 

additional actions considered at Phoenix when OIG releases all of the relevant 

evidence to the Department. • At 9 sites, OIG found scheduling practices that were not in accord with VHA 

policy but did not make conclusive findings with respect to individual misconduct. OAR has convened administrative investigations at those sites to determine whether, and for whom, discipline is warranted. • We are still awaiting OIG’s reports relating to 43 VA sites. 

Discipline Related to Whistleblower Retaliation 

• We continue to work collaboratively with the Office of Special Counsel (OSC) 

to improve our supervisors’ understanding of the whistleblower protection laws 

and to speed relief to whistleblowers who believe they are experiencing retaliation. • OSC is the independent Federal investigative and prosecutorial agency authorized by the Whistleblower Protection Act to protect federal employees and applicants from prohibited personnel practices, especially reprisal for whistleblowing. • This past summer, OSC’s Director of Training and Outreach provided in-depth 

training to representatives from VA’s Office of General Counsel and Office of 

Accountability Review (OAR) to enhance VA’s capacity to investigate whistleblower retaliation and to hold those who retaliate accountable. • We are grateful to Special Counsel Carolyn Lerner and her staff for their continuing collaboration with OAR and VHA’s Office of the Medical Inspector to address unsafe or unlawful health care practices and support corrective measures, 

including discipline, where such deficiencies are found. • It is also worth noting that the large majority of allegations referred to OSC 

ultimately are not substantiated. • We share Ms. Lerner’s concern that discipline should not flow more swiftly and 

easily to whistleblowers than to retaliators. We are optimistic that our continued collaboration with OSC will ensure proper treatment for whistleblowers and 

for those who may retaliate against them. 

Discipline Related to Over-prescription of Opioids and Other Issues at the 

Tomah VA Medical Center 

• In January 2015, the Milwaukee Journal Sentinel and other publications ran 

an article about over-prescription of painkillers by the then-Chief of Staff of the 

Tomah VA Medical Center, who is a psychiatrist, and cited several former 

Tomah employees’ complaints about retaliatory behavior after they questioned 

the Chief of Staff’s prescribing practices. The article also cited an unpublished 

March 2014 VA OIG ‘‘administrative closure’’ report finding the Chief of Staff’s 

prescriptions were ‘‘at considerable variance compared with most opioid prescribers’’ and ‘‘raised potentially serious concerns.’’ 

• We acted quickly to prohibit the Chief of Staff and an affiliated nurse practitioner from providing care to Veterans and initiated a comprehensive evaluation 

of the quality of the care they provided. The then-interim Under Secretary for 

Health ordered a series of three clinical reviews to assess practice patterns, prescribing habits, and staff interactions at Tomah. In reports issued between 

March and August 2015, these review teams found that the Chief of Staff’s prescriptive practices were potentially unsafe and that an apparent culture of fear 

existed at the Tomah facility which comprised patient care and damaged staff 

satisfaction and morale. 

• Simultaneously, OAR began a series of administrative investigations into alleged mismanagement by Tomah VAMC leadership. Those reviews led to a 

number of leadership changes at the Tomah facility. The Chief of Staff lost his 

clinical privileges and was removed from Federal employment; his removal is 

currently pending appeal. The Former Medical Center Director and Associate 

Director both resigned. Madison VAMC Director John Rohrer, a native of La 

Crosse whose father receives his care from the Tomah VA, became acting 

Leonard.horne on VACREP0180 with DISTILLER

45 

Tomah Medical Center Director from mid-March through late September 2015. 

Mr. Rohrer worked closely with facility leaders, union leaders, employees and 

external stakeholders (including Veterans Service Organizations) to assure that 

ongoing investigations did not disrupt clinical care and that all voices were 

heard. 

Accountability Related to the Denver Construction Project Cost Overrun 

• In early 2015, VA engaged the U.S. Army Corps of Engineers (USACE) to 

evaluate four major construction projects to identify program weaknesses and 

opportunities for improvement in the management and execution of the program. • USACE identified a fundamental need for VA to undergo a ‘‘transformative 

change in organizational process’’ to be effective at controlling cost and schedule 

growth in the major construction program. VA agreed with this assessment and 

has issued new policy that identifies roles and responsibilities for the development of needs, requirements and control of design and construction. • One of the highest profile projects reviewed by USACE is the replacement Denver Medical Center. The considerable cost overruns and delays associated with 

building the Denver center cast doubt on the prospect of completing the project 

and raised difficult questions about the future of VA’s construction program. • In response to USACE’s findings, VA has instituted a process to assure that any 

change to the scope and/or budget of major construction projects are justified 

and approved as required to safely and effectively deliver health care before any 

resources are committed to executing the requirement change. • In addition to these process improvements, we have made sweeping changes in 

the leadership of our construction and acquisition programs, through retirements and resignations at the senior-most levels and reassignment of some 

lower-level employees to roles more consistent with their skill sets. • To look at individual accountability at all levels, we also convened an administrative investigation board, under the auspices of OAR but with assistance from 

an external expert from the Department of the Navy’s Medical Facilities Design 

Office and a construction contracting law expert from VA’s Office of General 

Counsel. That group has finished its work in July and it is being reviewed for 

any accountability actions that may be warranted against current VA personnel. 

Discipline Related to VBA’s Senior Executive Relocation Practices 

In an investigative report issued on September 28, 2015, VA OIG took issue with 

VBA’s policies and practices for reassigning Senior Executives between and among 

Regional Offices and other VBA leadership positions. 

The OIG report addressed both people and processes. While we agree with the 

findings with respect to processes and have already implemented improvements to 

address those findings, we were very disturbed to find that the underlying evidence 

does not support the report’s findings with respect to people. 

On the process side - 

• The report identified issues with VBA’s use of the Appraised Value Option 

(AVO) program, which helps relocating employees sell their primary residence, 

and with other aspects of the Permanent Change of Station (PCS) expense reimbursement process. 

o We have discontinued the AVO program and undertaken a review of PCS reimbursements across the Department to determine how best to administer 

those payments and to ensure we are making the best use of taxpayer money. 

• The report also identified inconsistencies in the way VBA pays relocation incentives and adjusts executives’ salaries upon reassignment. 

o While salary adjustments and other relocation incentives are a vital management tool for any geographically dispersed organization, we need to be sure 

VA is using those incentives wisely, when and where they are needed to attract top talent to challenging leadership assignments. We’ve undertaken a 

top-to-bottom review of our relocation incentive policies and practices to ensure we are using them properly. 

On the people side, the report asserted that two VBA Regional Office Directors 

were ‘‘inappropriately coerced’’ to leave their stations so their supervisors could 

come in and take their jobs, with their relocations inappropriately paid for at taxpayer expense., We found that there were significant gaps between the rhetoric in 

the report and the relocated employees’ testimony. Both of the subordinate Directors 

testified, repeatedly, that they had initiated the talks that led to their relocation. 

While one of them ultimately felt pressured to move to a different Regional Office 

than the one he preferred, neither provided any testimony consistent with the findLeonard.horne on VACREP0180 with DISTILLER

46 

ing that they were ‘‘inappropriately coerced’’ to leave assignments they wanted to 

keep, nor did the evidence establish that the superior leaders’ reassignments to 

their subordinates’ former positions was improper or contrary to law. Moreover, VA 

OIG could not identify any violation of law, rule, or regulation in the reimbursements the two higher-level executives received related to the costs of their moves. 

What the evidence did show - and what the higher-level executives have been disciplined for - was that these senior leaders’ failure to fully extricate themselves from 

the decisions surrounding their subordinates’ reassignments and relocation benefits 

created the appearance that the transactions were approved for reasons other than 

the best interests of Veterans. This was not ‘‘inappropriate coercion’’ nor, in our attorneys’ analysis, a criminal conflict of interest, but it did demonstrate less than 

sound judgment, warranting these leaders’ demotion. 

While the evidence did warrant the actions we have taken, Secretary McDonald 

and I remain disturbed by the gaps between the rhetoric in the OIG report and the 

underlying evidence because the published report, which expressly referenced pending criminal referrals, and OIG’s press release identifying the subject executives by 

name, created a public expectation that these two career employees should be fired 

and forced to repay large sums of money expended to support their moves. That unfounded expectation does a distinct disservice to taxpayers and to the Veterans we 

all serve. 

Last August, Congress gave VA expedited authority to remove Senior Executive 

leaders from Federal employment or from the Senior Executive Service to a lowerpaid position when their performance or misconduct warrants removal. It is a humbling thing to end someone’s career. It is one of the most difficult things I do in 

this role, but I have done it when it was warranted. I have removed a number of 

VA executives whose misconduct or poor performance put Veterans’ health or taxpayer dollars at risk. I will do that when it is the right thing to do, when the evidence supports it. 

But it does not help Veterans or taxpayers to fire a high-performing executive 

whose lapse of judgment warrants a less severe penalty. In light of all the facts and 

evidence - and notwithstanding the OIG report’s unfounded rhetoric - the right 

thing to do was to demote these executives rather than fire them. That is what I 

decided to do. 

As we told the Committee last week, an administrative error required us to withdraw the demotion actions to correct the incomplete evidence files that were initially 

provided to the employees. That was a very regrettable error occasioned by our 

haste to get the proposals issued quickly. We have corrected the error and the actions are now back in the employees’ hands. 

Looking Ahead 

I’d like to end as I began, with President Lincoln’s observation that ‘‘Commitment 

is what transforms a promise into reality.’’ 

Secretary McDonald and I are committed to sustainable accountability, to a VA 

in which employees know what is expected of them and do it, and then some. 

Sustainable accountability means VA uses taxpayer dollars wisely and well to improve post-military life for our war fighters and their families. 

Our commitment to sustainable accountability is reaping benefits today. 

We know it is working because Veterans now have easier access to VA care and 

to care in the community than they did before. 

We know it is working because claims take less time to process, and are more 

likely to be processed accurately than before. 

We know it is working because Veteran homelessness is down and health care 

provider hiring is up. 

Ultimately, you will know it is working when the number of disciplinary actions 

goes down, not up. 

Mr. Chairman, this concludes my statement. Thank you for the opportunity to appear before you today. We would be pleased to respond to questions you or other 

Members may have. 

f 

Statement For The Record 

OFFICE OF INSPECTOR GENERAL 

Mr. Chairman and Members of the Committee, thank you for the opportunity to 

provide a statement for the hearing record that will clarify the role of the Office 

of Inspector General (OIG) regarding VA’s actions to hold VA staff accountable in 

Leonard.horne on VACREP0180 with DISTILLER

47 

general and specifically with respect to the OIG’s recent report, Administrative Investigation: Inappropriate Use of Position and Misuse of Relocation Program and Incentives in VBA. 

As the Committee knows the OIG conducts many types of reviews-audits, inspections, evaluations, and administrative and criminal investigations. While most of 

our reports include specific recommendations for VA to take in response to our findings, with regard to administrative investigations or any report that has findings 

that may require individual accountability, we use more general language so as not 

to interfere with the due process rights of employees who may be subject to administrative action. We reiterated this position in our statement for the Committee’s October 21, 2015, ‘‘An Examination of the VA Office of Inspector General’s Final Report on the Inappropriate Use of Position and the Misuse of the Relocation Program 

Incentives’’ hearing when we said: 

Our statements and comments will be limited in order to preclude any allegation that our testimony unduly influenced VA or the Department of Justice 

regarding potential administrative or criminal action. 

We would like to clarify the role of the OIG with respect to the VA’s responsibility 

to hold people accountable. The OIG’s role is to provide oversight of VA’s programs, 

operations, and people. Inspectors General have no authority or responsibility for 

program functions. It is a VA program function to take any type of action, be it writing a policy, educating and training staff, or taking disciplinary or performance 

based administrative actions. 

We agree with VA’s statement that it ‘‘cannot rely wholesale on an OIG report 

to impose discipline.’’ Our reports are not evidence; rather they are a summary of 

the evidence obtained and reviewed by OIG staff. It is VA’s obligation to request 

and review all documentation and other evidence that the OIG obtained relating to 

the report and to conduct additional work if necessary before taking administrative 

action. We fully recognize that the standards for administrative action require this 

as well as applying the evidence for a different purpose. However, we take exception 

to the inference that we based the subject report on ‘‘unsworn hearsay conclusions.’’ 

All interviews conducted during the work on this report were sworn and taped interviews conducted by experienced senior OIG staff. 

The Inspector General Act requires that OIG’s post issued reports on their 

websites within 3 days. We cannot control nor can we be influenced by what the 

media and others publicly state about the report. There is nothing in the OIG’s 

press statement for the subject report that was not published in the report. Further, 

it is the longstanding practice to include the names of senior officials and this report 

is no different from other reports on OIG administrative investigations. 

We would also like to take this opportunity to clarify some information regarding 

the OIG’s investigations into scheduling and access data manipulations and differences in the number of investigative cases. We have been working diligently on 

finishing the investigations we opened on scheduling and wait time manipulations. 

We provided VA’s Office of Accountability Review with 77 reports related to 73 sites 

of care. However, in 52 of those 77 reports, we did substantiate some type of scheduling issue ranging from outright data manipulation to intentionally game the system to simply not following VA policies and procedures. We have 36 open investigations involving 33 sites of care remaining. These numbers in some cases reflect that 

the OIG opened more than one investigation at a particular Veteran Health Administration facility. Unrelated allegations pertaining to a unique site were worked 

under separate case numbers to ensure thorough tracking of each allegation and 

corresponding investigative work. Past experience has proven that rolling unrelated 

allegations into a single report is not only cumbersome and may delay the issuance 

of a report, it also unnecessarily creates Privacy Act concerns when the VA used 

evidence supporting reports of investigation to initiate multiple unrelated administrative actions. 

In conclusion, different views on the weight of evidence are indicative that the 

OIG work was conducted independently and without influence by VA. Now that VA 

has corrected their administrative errors by making all evidence available to the individuals involved, we expect VA to take appropriate steps to protect the due process rights of these individuals as well as all employees as they move forward with 

appropriate accountability actions. 

Æ 

Leonard.horne on VACREP0180 with DISTILLER