```

[Senate Hearing 114-609]
[From the U.S. Government Publishing Office]

 
     MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES 
                  APPROPRIATIONS FOR FISCAL YEAR 2016

                              ----------                              

                        FRIDAY, NOVEMBER 6, 2015

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.

    The subcommittee met at 1:08 p.m., in Everett McKinley 
Dirksen Federal Courthouse, court room 1903, 219 South Dearborn 
Street, Chicago, Illinois, Hon. Mark Kirk (chairman) of the 
subcommittee, presiding.
    Present: Senator Kirk.

 A REVIEW OF WHISTLEBLOWER CLAIMS AT THE DEPARTMENT OF VETERANS AFFAIRS

                 OPENING STATEMENT OF SENATOR MARK KIRK

    Senator Kirk. We will bring this hearing to order.
    We would not have a country without our veterans. The best 
way to care for our men and women in uniform is to provide for 
their healthcare after they have finished Active Duty.
    I was so disappointed to hear that veterans had been 
mistreated in Department of Veterans Affairs (VA) hospitals by 
those charged with providing their care. Dedicated nurses and 
doctors reporting poor treatment of our vets should be heard 
and not silenced. Instead, these brave Americans are being 
victimized for reporting on the culture of corruption that 
currently exists in the VA.
    As chairman of this subcommittee, I want to do all I can to 
help the professionals who are serving our veterans. We must 
protect the protectors of our veterans.
    I will soon be introducing a VA Patient Protection Act in 
the Senate, to make sure that abuse and wrongdoing is reported 
immediately and fixed right away, with the truth-tellers coming 
forward without fear.
    This week, I won a great victory in the Senate for 
veterans' healthcare when the Senate agreed to move forward on 
the VA appropriations bill that I wrote with funding for our 
veterans. In that 93-0 vote, we won the support of every single 
voting Democrat in the Senate. This was a true bipartisan 
victory for my bill, which has the highest level ever for 
funding for our veterans and makes sure that it provides more 
than $1 billion more than the President even requested for his 
budget.
    I ask that we go quickly to the President's desk and that 
he sign it as quickly as possible.
    I do want to thank my ranking minority member, Senator 
Tester of Montana, for working so well with me in a bipartisan 
manner.
    In Illinois, we have several veterans' facilities, like in 
Marion, Danville, Jesse Brown, and North Chicago. I would argue 
that Lovell VA is the best in the State because it is half Navy 
and that my fellow sailors who staff that facility would never 
mistreat their fellow veterans like some VA bureaucrats have 
treated our veterans.
    I have the most concerns now with the Hines VA, where we 
know that people are hurting veterans. We will hear stories 
today from a cardiologist who was stripped of her career for 
coming forward with stories about how veterans have been 
mistreated.
    I would like to now recognize Dr. Lisa Nee to describe the 
culture of corruption at the Hines VA.
    Dr. Nee, you are recognized.
STATEMENT OF DR. LISA NEE, M.D., FORMER CARDIOLOGIST AT 
            EDWARD HINES, JR. VA HOSPITAL, CHICAGO, 
            ILLINOIS, DEPARTMENT OF VETERANS AFFAIRS
    Dr. Nee. Thank you. Chairman Kirk, thank you for the 
opportunity to testify today regarding the ongoing issues of 
retaliation against truth-tellers within the Veterans Affairs 
system. I wish to extend my gratitude to you and your staff for 
the continued attention to the alarming matter of increasing 
whistleblower retaliation.
    Although there is significant rhetoric from various 
branches of Government that this type of behavior is 
detrimental to the care of the veteran, there seems to be no 
end in sight for those who continue to face retribution for 
taking the courageous step of coming forward.
    A September 2015 report from the Committee on Homeland 
Security and Governmental Affairs stated the Office of Special 
Counsel has received 35 percent of its entire retaliation 
caseload from VA employees. Despite its efforts to prioritize 
investigations, special counsel Carolyn Lerner testified before 
Congress in August of this year that the volume of incoming VA 
complaints remains overwhelming.
    This clearly demonstrates the severe dysfunctional culture 
within the VA that encourages retaliation against the very 
individual who has exposed harm to the veteran in an attempt to 
improve the healthcare delivery process.
    There are many journeys we all participate in during the 
course of our lifetime. Some are arduous. Many are attainable. 
But none has been more agonizing and unfulfilling than the 
current process of obtaining justice for the men and women who 
have fought for our freedom.
    I realize that not every complex situation in life presents 
itself with moral clarity. However, this is not one of them. 
Caring for our veterans should be elementary. There should 
never be a single instance where a physician must choose 
between self-preservation and the life of a patient, or suffer 
an assault to their character in order to obtain accountability 
for criminal and inhumane acts against patients and fraudulent 
behavior toward the taxpayer.
    The amount of bureaucratic gymnastics coupled with agency 
corruption can render the strongest individual forlorn and 
exhausted. Knowing when to lose with grace is an honorable 
skill and one that requires precise timing. This is not that 
time.
    Armed with veracity for equity, an insatiable appetite for 
the truth, and a colossal amount of evidence, I am prepared to 
continue this battle until there is responsibility from 
leadership and transformative action, which will hold those at 
fault accountable.
    My personal journey began over 4.5 years ago with exposure 
to the corruption at the Hines VA Medical Center regarding 
patients who died of cardiac complications while awaiting their 
cardiac ultrasound to be read. Unfortunately, for them, the 
tests were hidden in bankers boxes left unread for a year.
    The mere questioning of such an egregious act resulted in 
significant retaliation, which went unabated the entire 2 years 
I was employed at Hines. But hell hath no fury like a VA 
administration scorned, and retaliation continued, even after I 
left VA, by the Office of Inspector General (OIG) and its 
pervasive culture of disparaging the truth-teller.
    Multiple allegations regarding deficiencies in 
cardiovascular care were made, including but not limited to 
patients having their chest sawed open for unnecessary 
procedures, disparity in care based on ethnicity, procedural 
diagnostic errors resulting in arm, and pervasive billing 
fraud.
    These allegations have resulted in an initial deficient OIG 
investigation, a subsequent Office of Special Counsel (OSC) 
investigation, a second contemptible OIG investigation, 
insistence from the OSC for an authentic and thorough 
investigation, and culminating with an ongoing Office of 
Medical Inspector's (OMI's) investigation.
    It is a mind-numbing process to not only keep track of the 
endless agency acronyms but also calculating the amount of 
wasted taxpayer dollars consumed by these ineffectual 
inquiries. They are not true investigations, for they lack 
experienced subject matter experts and have a predetermined 
conclusion, which maintains the status quo.
    The path this case has taken over the last 4 years has been 
objectively obfuscated and its bureaucratic oscillations can 
only be the result of stunning deficiencies at all levels of 
Veterans Health Administration (VHA) leadership. The task has 
become the exercise within itself. To engage in multiple 
investigations by varying internal agencies, which have 
substantiated patient harm as well as criminal activity, and to 
never mention one single word regarding accountability, one can 
only conclude this maladjusted behavior is designed to serve 
the agency itself and not the veterans.
    It is the VHA leadership attempting to gain credit for 
oversight that the agency has failed to provide. Duplicitous--
no other word can describe it.
    The OMI report from July 2015 substantiated some of my 
allegations regarding deficiencies in cardiovascular care; 
deficiencies in echocardiogram processing; failure to disclose 
deficiencies in care and harm to patients; inflated 
productivity measures by cardiologists; and evidence that 
veterans were inappropriately charged copayments for care they 
never received, otherwise known as billing fraud.
    In regard to this billing fraud, the report states, ``We 
found that these actions possibly violate 18 U.S. Code 208, 
acts affecting a personal financial interest.'' The OMI 
referred this criminal matter to the OIG, who has declined to 
open an investigation.
    Interestingly, the bulk of the report is dedicated to the 
fraudulent billing practices, including in-depth statistical 
analysis, diagrammatic explanations, and extensive billing 
pattern documentation right. This provides a glaring contrast 
to the lack of investigative fervor and expertise when dealing 
with patient morbidity and mortality.
    However, all this effort is for naught as the end result 
once again allows the documented criminal activity to go 
unpunished.
    For the agency to demand an OMI investigation yet deny the 
credibility of criminal findings is administrative misconduct. 
The OIG must adhere to the quality standards for investigations 
issued by the Counsel of Inspector General on Integrity and 
Ethics, and the Attorney General guidelines for OIG with 
statutory law enforcement authority.
    You do not get to be above the law just because you work 
for the VA. Or do you?
    An equally compelling question is, if the OMI substantiated 
findings and then those are ignored, why do we need any of 
these investigative arms within the VA? They are redundant and 
wasteful and should be restructured.
    To sum up the totality of all the reports to date is to 
call them a mismatch between words and deeds, a failed promise 
to treat and protect the veterans while instead protecting 
hundreds of useless report generators who will then retire with 
benefits. The investigators have gone so far out of their way 
to protect the VHA leadership that it has rendered every 
investigator impotent and every investigative finding 
ineffectual.
    They are highly skilled at one part of their job: 
generating a paper trail designed to justify their professional 
existence. But they have failed at their original mission 
statement and severely compromised the health of the men and 
women who have fought for our freedom.
    In order for any type of transformative action to begin to 
take shape and halt systemic corruption, there must be 
protection for truth-tellers, accountability for those who fail 
at their duties, and transparency to eliminate both operational 
deficiencies but also properly analyze collected data.
    These are far from novel concepts and are most certainly 
codified in policy and procedure.
    Chairman Kirk's VA Patient Protection Act will demand 
accountability for those who retaliate against truth-tellers 
and empower those who can begin to make a positive impact on 
the outcomes of patient care. Preventing retaliation in the 
current defective culture of the VA requires deterrence, which 
should be timely, formidable, and indelible.
    This bill would properly punish VA supervisors who have 
been found to take retaliatory actions against whistleblowers. 
There can be no saving of an agency as large as the VA if the 
employees operate from a constant position of fear rather than 
conviction and collaboration.
    An additional step toward agency accountability which 
should be addressed by Congress is extending legislative 
authority to the OSC in two arenas: one, allow the agency to 
embark on a criminal investigation or partner with the 
Department of Justice, if the preponderance of evidence 
suggests illegal activity; and two, grant the OSC the necessary 
authority to determine the corrective action and punishment 
once the allegations are substantiated.
    They currently have independent authority to determine if 
conduct constitutes a violation of law, rule, gross 
mismanagement, and a substantial and specific danger to public 
health. If they can determine the crime, they should be allowed 
to determine the punishment.
    Many people have asked me why I continue to fight for the 
veterans even though I have left the VA. ``What can you do?'' 
they ask. I want the American public to contemplate that 
question for a moment and then consider an alternative 
perspective and perceive it as, ``What should I do?'' With 
that, the only acceptable response would be to strive for 
social justice and search for the truth, which brings us to the 
truth--a glorious, unadulterated supreme reality holding the 
ultimate meaning of values of existence corroborated by 
evidence. It does not change over time, and it never has to 
rely on anyone else's interpretation.
    As a Nation, we can achieve this goal for the genuine 
protectors of truth, our veterans. Thank you.

    [The statement follows:]
                 Prepared Statement of Dr. Lisa M. Nee
    Chairman Kirk, thank you for the opportunity to testify today 
regarding the ongoing issues of retaliation against truth tellers 
within the Veterans Affairs (VA) system. I wish to extend my gratitude 
to you and your staff for the continued attention to the alarming 
matter of increasing whistleblower retaliation. Although there is 
significant rhetoric from various branches of government that this type 
of behavior is detrimental to the care of the veteran, there seems to 
be no end in sight for those who continue to face retribution for 
taking the courageous step of coming forward. A September 2015 report 
from the Committee on Homeland Security and Governmental Affairs stated 
the Office of Special Counsel (OSC) has received 35 percent of its 
entire retaliation caseload from VA employees. Despite its efforts to 
prioritize investigations, Special Counsel Carolyn Lerner testified 
before Congress in August of this year that the volume of incoming VA 
complaints remains overwhelming. This clearly demonstrates the severe, 
dysfunctional culture within the VA that encourages retaliation against 
the very individuals who expose harm to the veteran and attempt to 
improve the healthcare delivery process.
    There are many journeys we all participate in during the course of 
our lifetime. Some are arduous, many are attainable, but none has been 
more agonizing and unfulfilling than the current process of obtaining 
justice for the men and women who have fought for our freedom. I 
realize that not every complex situation in life presents itself with 
moral clarity, however this is not one of them. There should never be a 
single instance where a physician must choose between self-preservation 
and the life of a patient. Or suffer an assault to their character in 
order to obtain accountability for criminal and inhumane acts against 
patients and fraudulent behavior towards the taxpayer. The amount of 
bureaucratic gymnastics coupled with agency corruption can render the 
strongest individual forlorn and exhausted. Knowing when to lose with 
grace in an honorable skill and one that requires precise timing--this 
is not that time. Armed with voracity for equity, an insatiable 
appetite for the truth and a colossal amount of evidence, I am prepared 
to continue this battle until there is responsibility from leadership 
and transformative action which will hold those at fault accountable.
    My personal journey began over 4\1/2\ years ago with exposure to 
the corruption at Hines regarding patients who died of cardiac 
complications while awaiting their cardiac ultrasound to be read. 
Unfortunately for them the tests were hidden in bankers boxes and left 
unread for a year. The mere questioning of such an egregious act 
resulted in significant retaliation, which went unabated the entire 2 
years I was employed at Hines VA Medical Center. But hell hath no fury 
like a VA Administration scorned, and the retaliation continued even 
after I resigned, with the Office of Inspector General (OIG) and its 
pervasive culture of disparaging the truth teller. Multiple allegations 
regarding deficiencies in cardiovascular care were made including, but 
not limited to: patients having their chest sawed open for unnecessary 
procedures, disparities in care based on ethnicity, procedural 
diagnostic errors and billing fraud. These allegations have resulted in 
an initial deficient OIG investigation, a subsequent OSC investigation, 
a second contemptible OIG investigation, insistence from the OSC for an 
authentic and thorough investigation, and culminating with an ongoing 
Office of Medical Inspector's (OMI) investigation. It is a mind-numbing 
process to not only keep track of the endless acronyms but also 
calculating the amount of taxpayer dollars this course of action has 
taken.
    The path this case has taken over the last 4 years has been 
objectively obfuscated, and its bureaucratic oscillations can only be 
the result of stunning deficiencies at all levels of the Veterans 
Health Administration (VHA) leadership. The task has become the 
exercise within itself. To engage in multiple investigations by varying 
internal agencies which have substantiated patient harm as well as 
criminal activity, and to never mention one, single word regarding 
accountability, one can only conclude this dysfunctional behavior is 
designed to serve the agency itself, and not the veterans. It is the 
VHA leadership attempting to gain credit for oversight that the agency 
has failed to provide. Duplicitous. No other word describes it.
    The OMI report from July 2015 substantiated my allegations 
regarding deficiencies in cardiovascular care, deficiencies in 
echocardiogram processing, failure to disclose deficiencies in care and 
harm to patients, inflated productivity measures by cardiologists, and 
evidence that veterans were inappropriately charged copayments for care 
they did not receive, otherwise known as billing fraud. In regards to 
the billing fraud, the report states, ``We found that these actions 
possibly violate 18 U.S. Code 208--Acts affecting a personal financial 
interest''. The OMI referred this criminal matter to the OIG who has 
declined to open a criminal investigation.
    Interestingly the bulk of the report is dedicated to the fraudulent 
billing practices, including in depth statistical analysis, 
diagrammatic explanations and extensive billing pattern documentation. 
This provides a glaring contrast to the lack of investigative fervor 
and expertise when dealing with patient morbidity and mortality. 
However all this effort is for naught as the end result once again 
allows the documented criminal activity to go unpunished. For the 
agency to demand an OMI investigation yet deny the credibility of 
criminal findings is administrative misconduct. The OIG must adhere to 
the Quality Standards for Investigations issued by the Council of 
Inspectors General on Integrity and Efficiency (CIGIE) and the Attorney 
General Guidelines for OIG with Statutory Law Enforcement Authority. 
You don't get to be above the law just because you work for the VHA. Or 
do you? An equally compelling question is, if the OMI substantiated 
findings are ignored, why do we need any of these investigative arms 
within the VA?
    To sum up the totality of all the reports to date is to call them a 
mismatch between words and deeds. A failed promise to treat and protect 
the veterans, while instead protecting hundreds of useless report 
generators who will then retire with benefits. The investigators have 
gone so far out of their way to protect the VHA leadership that it has 
rendered every investigator impotent and every investigative finding 
ineffectual. They are highly skilled at one part of their job, 
generating a paper trail designed to justify their professional 
existence. But they have failed at their original mission statement and 
severely compromised the healthcare of the men and women who have 
fought for our freedom.
    In order for any type of transformative action to begin to take 
shape and halt systemic corruption, there must be protection for truth 
tellers, accountability for those who fail at their duties and 
transparency to illuminate both operational deficiencies but also 
properly analyze collected data. These are far from novel concepts and 
are most certainly codified in policy and procedure. Chairman Kirk's VA 
Patient Protection Act will demand accountability for those who 
retaliate against truth tellers and empower those who can begin to make 
a positive impact on the outcomes of patient care. Preventing 
retaliation in the current dysfunctional culture of the VA requires 
deterrents, which should be timely, formidable and indelible. This bill 
would properly punish VA supervisors who have been found to take 
retaliatory actions against whistleblowers. There can be no saving of 
an agency as large as the VHA if the employees operate from a constant 
position of fear, rather than transparency and collaboration.
    An additional step towards agency accountability that can be 
addressed by Congress is extending legislative authority to the OSC in 
two arenas:
  --Allow the agency to embark on a criminal investigation or partner 
        with the Department of Justice if the preponderance of evidence 
        suggests illegal activity and
  --Grant the OSC the necessary authority to determine the corrective 
        action and punishment once the allegations are substantiated.
    They have independent authority to determine if conduct constitutes 
a violation of law, rule, gross mismanagement and a substantial and 
specific danger to public health. If they can determine the crime, they 
should be allowed to determine the punishment.
    Many people have asked me why I continue to fight for the veterans 
even though I have left the VA. ``What can you do?'' I want the 
American public to contemplate that question for a moment and then 
consider an alternative perspective, and perceive it as ``What should I 
do?''--the only acceptable response would be to strive for the truth.
    Which brings us to the truth. A glorious, unadulterated supreme 
reality, holding the ultimate meaning and value of existence, 
corroborated by evidence. It does not change over time, as it never has 
to rely on anybody else's interpretation.

                         UNREAD ECHOCARDIOGRAMS

    Senator Kirk. Thank you, Dr. Nee.
    So to summarize, the thing that you found when you went to 
work for Hines, as a cardiologist, you found boxes and boxes of 
echocardiograms. For someone having an echocardiogram, that 
means they have some signs of heart disease.
    And if I can summarize, when you looked through these boxes 
and boxes of echocardiograms, you had found some of the 
veterans had passed already?
    Dr. Nee. That is true. Looking up their names to initiate a 
report, the system tells you if someone has expired or not.
    Senator Kirk. And when you said that, hey, we should follow 
up with these patients because they have heart disease, what 
did the VA at Hines say?
    Dr. Nee. Hines wanted me to be readily aware that they 
already knew that the boxes were there and that it was my job 
to be quiet and continue to read.
    That is nothing even remotely close to what you would 
experience in the private sector. A risk management team would 
have been involved. There would have been accountability. 
Patients would have been notified. Patients would have been 
offered additional testing in an urgent manner.
    Senator Kirk. In a normal civilian hospital, if the 
hospital did not read the echocardiogram and the patient died, 
would that be grounds for a malpractice lawsuit?
    Dr. Nee. Absolutely. Absolutely.
    Senator Kirk. So many of these veterans had no idea that 
they had severe medical heart issues because the VA never even 
bothered to read the echocardiogram?
    Dr. Nee. That is correct. And you are taking advantage of a 
population in two manners. You are taking advantage because 
they have no choice for their healthcare, so they are 
presenting to you and expecting you to react in a responsible 
manner. And now they are not even being notified that there may 
be something wrong or harm may come to them because of this 
delay.
    Senator Kirk. Could you estimate for the subcommittee how 
many patients' echocardiograms were in those boxes that were 
never read?
    Dr. Nee. There were hundreds, so my best estimation would 
be----
    Senator Kirk. So they were doing echocardiograms and not 
even looking at them?
    Dr. Nee. Correct.
    It was just another box to check. The test was ordered. We 
will do it. Put it in the box. Do not worry about it.

                     RETALIATION TO WHISTLEBLOWERS

    Senator Kirk. You were also confirmed by the Office of 
Medical Inspector, who said this was an improper thing. What 
was the follow-up when the Office of Medical Inspector said 
that you were right in calling out this problem?
    Dr. Nee. Well, the problem with all these agencies is even 
if you can get the allegation substantiated, the report then 
goes back to the agency itself. So Hines VA received the report 
from the OMI before I ever knew about it. And unfortunately, 
the people who came forward to testify to the OMI were 
retaliated against.
    So not only are you not holding people accountable, you are 
placing a chilling effect on the entire institution that people 
should never come forward because nothing will change and they 
will be harmed along with the patient.
    Senator Kirk. Before when you testified before my 
subcommittee, you described this retaliation mechanism that 
they have against physicians where they would try to pull your 
Statewide credentials, so you would not be able to practice as 
a cardiologist.
    Dr. Nee. Well, I think what they do to you is, your first 2 
years as a physician, you are probationary. So even if you 
recognize problems and/or the retaliation is so bad you want to 
leave, if you leave before that 2 years, they will alter your 
H.R. record, and it will be listed that you were fired, which 
pretty much puts an end to your career. So you have to stay the 
2 years, regardless of what is going on, to make sure that your 
record is clean.
    Senator Kirk. So if you report a problem like you reported, 
they will put in your H.R. record that you were fired?
    Dr. Nee. Correct.
    Senator Kirk. And you will lose accreditation to practice 
medicine in another hospital?
    Dr. Nee. It would look very suspicious to anyone else 
hiring, why you were fired from the Veterans Administration.
    Senator Kirk. Let us go to our next witness, Germaine 
Clarno. Let me call Germaine Clarno to the table.
    Germaine is the president of Local 781 of the American 
Federation of Government Employees, the union that represents 
the workers at Hines.
    Germaine, if you could continue your statement.
STATEMENT OF GERMAINE CLARNO, LCSW, PRESIDENT, AFGE 
            LOCAL 781, EDWARD HINES, JR. VA HOSPITAL, 
            CHICAGO, ILLINOIS, DEPARTMENT OF VETERANS 
            AFFAIRS
    Ms. Clarno. Thank you. Senator Kirk, I want to thank you 
for the opportunity to provide my testimony to discuss the 
culture of continued fear and retaliation at the Edward Hines 
Jr. Hospital.
    I also want to personally thank you for your support. If it 
wasn't for your involvement, I don't know if I would have the 
strength to withstand the constant retaliation I continue to 
experience.
    You have also shown me that it is possible for a Republican 
and a Democrat, who is also a union leader, that we can work 
together. So thank you.
    I am a social worker and local president of the American 
Federation of Government Employees (AFGE), and a very proud 
whistleblower and truth-teller. I have worked at Edward Hines 
Jr. Hospital in Illinois for 6 years, 2 years after receiving a 
master's in social work.
    Social work is a second career, and it was important to me 
that I work with veterans, so I was elated with the opportunity 
to work at the VA. It has been an honor and a privilege to 
serve our Nation's veterans in the capacity of a mental health 
provider.
    I worked alongside amazing, dedicated employees that shared 
the same passion for helping our veterans heal from the 
invisible wounds of war.
    Unfortunately, I experienced early in my career the toxic 
culture of fear. Asking a simple question or a suggestion can 
result in career sabotage. I witnessed good-intentioned, 
professional employees be retaliated against for simply wanting 
to raise issues that interfered with quality care for our 
veterans.
    After 3 years working in mental health, I had experienced 
and witnessed deplorable treatment of employees that dared to 
speak up against fraud, waste, and abuse. My dedication to our 
veterans convinced me to explore means to improve the culture 
at Hines. The root cause was mistreatment of frontline 
employees that did not have a voice or an advocate.
    I then became chief steward of Local 781 at Hines. With 
determination and the union contract, I optimistically marched 
onward with an honored mission to change the culture at Hines. 
The master agreement, our union contract, states in our 
preamble the department and the union agree that a constructive 
and cooperative working relationship between labor and 
management is essential to achieving the department's mission 
and to ensuring a quality work environment for all employees. 
This agreement is not honored by the leadership at Hines.
    They spend more time finding loopholes of the contract and 
ways not to comply with this simple agreement, which is also an 
element of Secretary McDonald's Blueprint for Excellence. He 
states, ``The VA will become an organization where employees 
are comfortable raising issues and concerns. Only then can we 
truly thrive and innovate.'' This plan for change was published 
a year ago, and employees are still afraid more than ever.
    During my time as a union representative, I have seen 
firsthand the obstacles for employees to perform at the highest 
level due to an environment that is not conducive to enhancing 
employee morale or efficiency.
    In the fall of 2012, after exhausting all avenues with our 
chain of command, Dr. Lisa Nee came to me, as other employees 
have, with overwhelming evidence of wrongdoing by leadership at 
Hines.
    The severe retaliation that Dr. Nee experienced as a result 
of her disclosure is not unique. Retaliation at Hines is a 
systematic campaign of interpersonal destruction that 
jeopardizes employees' health, careers, and the jobs they once 
loved.
    These forms of retaliation are a nonphysical form of 
violence. But because it is violence and it is abusive, 
emotional harm often is the result.
    It has been over a year since I disclosed wrongdoing at 
Hines in regard to the wait list, scheduling manipulation, and 
excessive wait time for veterans requesting individual therapy 
for post-traumatic stress disorder (PTSD) on the CBS Evening 
News. The very next day after my disclosure, the Hines 
leadership had a meeting without my knowledge in the chapel of 
the hospital with approximately 300 of my coworkers from Mental 
Health.
    That day, 300 employees were taken away from their work 
areas and were not serving veterans. The purpose of this 
meeting was to discredit my claims and turn my coworkers 
against me.
    The same day, I received emails and voicemails from my 
supervisor ordering me to contact and report to the Criminal 
Division of the OIG on Hines' campus.
    What was more outrageous is the leadership's attempt to 
discredit a veteran who was also in this news story by sharing 
information from his medical chart, blaming him for the delays 
by saying that he canceled appointments and was a no-show. 
Veterans are not immune to the retaliation at Hines.
    I wish I could report that things have improved at Hines 
but the sad truth is, it has not. Just the past couple weeks, 
employees have been severely retaliated against.
    One of these employees is Jasmine Ramakrishna. Jasmine has 
given me permission to tell her story today. Jasmine is a 
dental hygienist at Hines. Like most of our frontline 
employees, she is dedicated to serving veterans. She has 
reported wrongdoing on issues in the dental clinic to include 
unnecessary procedures for the purpose of increasing 
productivity, and issues with assessments and coding 
procedures.
    As a result of her raising concerns, she is currently being 
retaliated against. Jasmine has always been rated outstanding 
on her performance appraisal, but when she received her 
performance appraisal a few weeks ago, her rating was lowered.
    Jasmine and I met with her supervisor to discuss her 
rating, and he responded that she violated the VA Code of 
Conduct. Jasmine has never been counseled or informed of any 
wrongdoing. But in this meeting, he referenced a folder that 
contained information that he said he has on her and is 
refusing to share with the employee.
    As you can imagine, this is devastating for this employee. 
This is an example of a supervisor using his power to make 
false allegations and violate the law to harass and intimidate 
an employee.
    The union has filed grievances, and he is refusing to 
respond. As a result, the union has filed two separate unfair 
labor practices with the Federal Labor Relations Authority 
against the agency.
    The same supervisor, the chief of the dental clinic, is 
also harassing another employee, a dentist. The supervisor is 
asking coworkers to do surveillance on him. After a meeting I 
had with the supervisor to notify him that asking coworkers to 
surveillance other employees is not appropriate and it is 
illegal, he called the police on me and made false reports that 
I was aggressive and threatening him.
    This event took place just this past Monday. Ironically, 
Senator Kirk, one of your staff members was in my office when 
the police came and witnessed the harassment.
    That same day, I notified Hines leadership of this 
disgraceful conduct, and I have not received a reply.
    Another form of retaliation is to ignore the complaint or 
justify the supervisor's behavior.
    My concern is for our veterans. Employees are being 
intimidated and retaliated against for speaking up for quality 
care. The Nation's veterans pay that price. In order to retain 
the best and brightest healthcare providers to serve the needs 
of our Nation's heroes, we must rid our workplace of the toxic 
retaliatory practices engaged by this management. Thank you.

    [The statement follows:]
                Prepared Statement of Germaine M. Clarno
    Senator Kirk, thank you for the opportunity to provide my testimony 
to discuss the culture of continued fear and retaliation at Edward 
Hines, Jr Hospital.
    I also want to personally thank you for your support. If it wasn't 
for your involvement I don't know if I would have had the strength to 
withstand the constant retaliation I continue to experience. You have 
also shown me that it is possible for a republican and democrat, who is 
also a union leader that we can work together.
    I am a social worker and local president of the American Federation 
of Government Employees (AFGE). I have worked at Edward Hines, Jr. 
Hospital in Illinois for 6 years, 2 years after receiving a masters in 
social work. Social work is a second career, it was important to me 
that I work with veterans so I was elated with the opportunity to work 
at the VA. It has been an honor and privilege to serve our Nation's 
veterans in the capacity of a mental health provider. I have worked 
alongside amazing dedicated employees that share the same passion for 
helping our veterans heal from the invisible wounds of war.
    Unfortunately, I experienced early in my career the toxic culture 
of fear. Asking a simple question or suggestion can result in career 
sabotage. I witnessed good intentioned professional employees be 
retaliated against for simply wanting to raise issues that interfered 
with quality healthcare for our veterans. After 3 years working in 
mental health, I had experienced and witnessed deplorable treatment of 
employees that dared to speak up against fraud, waste and abuse. My 
dedication to our veterans convinced me to explore means to improve the 
culture at Hines. The root cause was mistreatment of frontline 
employees that did not have a voice or an advocate. I then became a 
chief steward for Local 781 at Hines, with determination and the union 
contract, I optimistically marched onward with an honored mission to 
change the culture at Hines.
    The Master Agreement (our union contract) states in our preamble 
``The Department and the Union agree that a constructive and 
cooperative working relationship between labor and management is 
essential to achieving the Department's mission and to ensuring a 
quality work environment for all employees''.
    This agreement is not honored by the leadership at Hines. They 
spend more time finding loop holes of the contract and ways not to 
comply with this simple agreement, which is also an element of 
Secretary McDonald's ``Blue Print for Excellence.'' He states ``VA will 
become an organization where employees are comfortable raising issues 
and concerns. Only then, can we truly thrive and innovate''. This plan 
for change was published a year ago and employees are still afraid, 
more than ever.
    During my time as a union representative I have seen firsthand the 
obstacles for employees to perform at the highest level due to an 
environment that is not conducive to enhancing employee morale and 
efficiency. In the fall of 2012, after exhausting all avenues with in 
her chain of command, Dr. Lisa Nee came to me, as other employees have 
with overwhelming evidence of wrongdoing by the leadership at Hines.
    The severe retaliation that Dr. Nee's experienced as the result of 
her disclosure is not unique. Retaliation at Hines is a systematic 
campaign of interpersonal destruction that jeopardizes employee's 
health, careers, and the jobs they once loved. These forms of 
retaliation is a non-physical form of violence, but because it is 
violence and abusive, emotional harm often is the result.
    It's been over a year since I first disclosed wrong doing at Hines 
in regards to waitlist, scheduling manipulation and excessive wait time 
for veterans requesting individual therapy for PTSD on CBS evening 
news. The very next day of my disclosure the Hines leadership had a 
meeting without my knowledge, in the chapel, with approximately 300 of 
my coworkers from mental health. That day 300 employees were taken away 
from their work areas and were not serving veterans. The purpose of the 
meeting was to discredit my claims and turn my co-workers against me. 
That same day I received emails and voicemails from my supervisor 
ordering me to report to the criminal division of the OIG on Hines 
Campus.
    What was more outrageous is that leadership attempted to discredit 
a veteran that also was in this news story by sharing information from 
his medical chart. Blaming him for the delays by saying that he 
cancelled appointments or was a no show. Veterans aren't immune to 
retaliation at Hines.
    I wish I could report that things have improved at Hines but the 
sad truth is it has not. Just in the past couple of weeks employees 
have been severely retaliated against. One of these employees is 
Jasmine Ramakrishna. Jasmine gave me permission to tell her story 
today. Jasmine is a Dental Hygienist at Hines, like most of our front 
line employees she is dedicated to serving veterans. She has reported 
wrongdoing on issues in the dental clinic to include unnecessary 
procedures (for the purpose of increasing productivity) and issues with 
assessments and coding procedures. As a result of her raising concerns, 
she is currently being retaliated against. Jasmine has always been 
rated outstanding on her performance appraisals but when she received 
her performance appraisal a few weeks ago her rating was lowered. 
Jasmine and I met with her supervisor to discuss her rating and he 
responded that she has violated the VA Code of Conduct. Jasmine has 
never been counseled or informed of any wrongdoing but in this meeting 
he referenced a folder that contained information that he ``has on 
her'' and is refusing to share with the employee. As you can imagine 
this is devastating for this employee. This is example of a supervisor 
using his power to make false allegations and violate the law to harass 
and intimidate an employee. The union has filed grievances and he is 
refusing to respond. As a result, the union has filed two separate 
Unfair Labor Practices with the Federal Labor Relations Authority 
against the agency.
    This same supervisor, the Chief of the Dental clinic is also 
harassing another employee, a dentist. This supervisor is asking co-
workers to surveillance him. After a meeting I had with this supervisor 
to notify him that asking co-workers to surveillance other employees is 
not appropriate and is illegal, he called the police and made a false a 
report that I was aggressive and threatening him. This event took place 
just this past Monday. Ironically, one of Senator Kirk's staff members 
was in my office when the police arrived and witnessed the harassment. 
That same day I notified Hines leadership of this disgraceful conduct 
and I have not received a reply. Another form of retaliation is to 
ignore the complaint or justify the supervisor's behavior.
    My concern is for our veterans. When employees are being 
intimidated and retaliated against for speaking up for quality care, 
the Nation's veterans pay the price. In order to retain the best and 
brightest healthcare providers, to service the needs of our Nation's 
heroes, we must rid our workplace of the toxic, retaliatory practices 
engaged in by management.

                       PROTECTING THE PROTECTORS

    Senator Kirk. Germaine, let me just follow up. That is 
pretty brazen. Senate staff is in with you, and they are 
sending in the police to harass you. That is a pretty brazen 
feeling that nobody can touch them.
    Ms. Clarno. Right.
    Senator Kirk. In your case, as president of the union, let 
me ask you how many union members do you have at 781?
    Ms. Clarno. We represent approximately 1,000 bargaining 
unit members. I represent the professionals at the hospital.
    Senator Kirk. So you have 1,000 people taking care of our 
veterans at Hines.
    Ms. Clarno. Yes.
    Senator Kirk. In your job of protecting the protectors, I 
would think you are particularly vulnerable to retaliation. 
Given the fact that this is a Democratic administration that is 
very pro-union, do you feel any benefit by being a union 
leader, that you are simply carrying out your duties that you 
were elected to do to care for union members?
    Ms. Clarno. I do, and it is because of the union I belong 
to. That is the reason that I took on these roles, because I 
thought I could proceed, bring up issues of fraud, waste, and 
abuse and illegal actions, and be able to----

                          HINES VAMC WAIT LIST

    Senator Kirk. Germaine, let me get into our work together. 
I have been able to get you to meet with the Secretary of 
Veterans Affairs Robert McDonald. Since you have met with 
Robert McDonald and the White House Deputy Chief of Staff 
Robert Nabors, has the wait list problem improved at Hines at 
all?
    Ms. Clarno. Well, the VA is very good at, when they get 
caught doing one thing, they create another way to manipulate. 
So they are not doing the same tactics, because they got 
busted. But now what they are doing is they are overbooking and 
double-booking.
    I just talked to a scheduler yesterday who came to me and 
said she has veterans coming into the clinic, four veterans 
scheduled for one appointment, say 9 o'clock in the morning, 
three veterans for 10, 11. So what happens is, the experience 
of the veteran is that they wait all day to see a provider.
    So that is now the gaming system that they are doing. So 
now they can say we are meeting the benchmark of 30 days, and 
we are getting the veteran an appointment. But the appointment 
is to come and spend the day at Hines. If they do not get seen, 
and most of them do not, they are sent home and then it is on 
them. They canceled the appointment.
    Dr. Nee. And those no-shows are counted against them.
    Senator Kirk. Even though the veteran is there in the 
hospital, it is listed as an appointment canceled by a patient.
    Ms. Clarno. Right.

                           PERFORMANCE AWARDS

    Senator Kirk. You have gone through extensively the bonus 
program, which I have looked into, in which the Hines VA paid 
over $16 million in bonuses to employees there. And you have 
told me that to get these bonuses, they have been falsifying 
work, claiming to have done work that they did not actually do. 
Can you describe the bonus system, how it works, and the 
culture of corruption at Hines?
    Ms. Clarno. Well, all employees in their performance 
appraisal, whether you are a physician, a chief of staff, a 
director, a social worker, a pharmacist, we all have critical 
elements, standard elements. One of them is access to care. 
That is a critical element that they look at. It is the first 
element that they look at.
    So you are being rated on access to care. So that 
translates into getting veterans appointments, not access to 
real care, but to just get them an appointment on the books.
    Senator Kirk. Germaine, as a social worker, I would think 
that you are pretty much on the frontline of making sure that 
veteran suicide is as low as possible. In your case, I think 
that frontline job is to make sure a veteran never makes that 
tragic decision to end his own life.
    Ms. Clarno. Absolutely.

                        MENTAL HEALTH TREATMENT

    Senator Kirk. If people are manipulating the wait times, 
then somebody in crisis could make that decision and you could 
have avoided it. I want to make sure people understand just how 
important your work is at the VA.
    Ms. Clarno. Absolutely. And I think that, in mental health, 
one of the issues that I disclosed was in mental health and 
veterans accessing individual treatment for PTSD.
    They are placed in groups, and I consider them holding 
pens, so that they are waiting for individual appointments. If 
I was to seek a therapist in the private sector, and I was 
having thoughts and nightmares and having the effects of PTSD, 
I could get in to see someone within 24 hours.
    Senator Kirk. Did any of your veterans commit suicide while 
in one of your holding pens when they could not see you?
    Ms. Clarno. No, not that I am aware of. But they should not 
have to suffer.
    Senator Kirk. Right.
    Ms. Clarno. They are barely holding onto life. Their family 
no longer knows who they are. With PTSD and traumatic brain 
injury (TBI), there are anger issues. They have a hard time 
focusing. They are losing their job. Domestic violence is a big 
piece, because they do not know how to handle civilian life. 
And they are suffering.
    It is our job and responsibility when a veteran, first of 
all, has the courage to come and say, ``I need help,'' that is 
not always an easy thing for our soldiers. Immediately, they 
should be taken in to see an individual therapist for crisis.
    Senator Kirk. If an individual veteran says, ``Hey, I am 
thinking about committing suicide,'' is there a way to make 
sure that you see him right away?
    Ms. Clarno. In Hines, I have to be honest, we do a good job 
of that, because of the frontline employees, because we care. I 
know social workers that will sit in the waiting room for hours 
with a veteran because they have exhibited some signs of 
suicide ideation and they do not want to leave them alone. So 
they will sit there and wait and wait and wait long hours until 
they are seen.
    Senator Kirk. I would like to now hear the testimony of 
Lydia Dennett from the Project on Government Oversight, who has 
flown in from Washington, an investigator.
    Lydia, you are recognized by the subcommittee.
STATEMENT OF LYDIA DENNETT, INVESTIGATOR, PROJECT ON 
            GOVERNMENT OVERSIGHT
    Ms. Dennett. Chairman Kirk, thank you for inviting me to 
testify today, as well as for your leadership and ongoing 
interest in this issue.
    My name is Lydia Dennett, and I am an investigator at the 
Project on Government Oversight (POGO), a nonpartisan, 
independent watchdog that champions good government reforms. I 
personally have been working on issues at the Department of 
Veterans Affairs since the allegations at Phoenix first came to 
light. I have been the point of contact at POGO for hundreds of 
whistleblowers who shared their stories with us.
    If it were not for whistleblowers, none of us would be 
aware of the extent of problems at the VA. The bravery of 
Doctors Mitchell and Foote from Phoenix caused an avalanche of 
reports from whistleblowers at VA facilities across the 
country.
    Last year, POGO held a joint press conference with Iraq and 
Afghanistan Veterans of America, asking whistleblowers within 
the VA to share with us their inside perspective. In our 34-
year history, POGO has never received as many submissions from 
a single agency.
    In little over a month, nearly 800 current and former VA 
employees and veterans contacted us. We received multiple 
credible submissions from 35 States and the District of 
Columbia, and a recurring and fundamental theme became clear. 
VA employees across the country feared they would face 
repercussions if they dared to raise a dissenting voice, but 
they came forward anyway.
    I want to emphasize this means there were extraordinary 
numbers of people who work inside the VA system who care so 
much about the mission of the department that they were willing 
to put their lives at risk to come forward in order to fix it. 
Some were willing to be interviewed by POGO and to be quoted by 
name, but others said they contacted us anonymously because 
they are still employed at the VA and are worried about 
retaliation.
    For example, from right here in Illinois at the Hines 
Hospital, we received several allegations of scheduling 
manipulations. These whistleblowers described VA staff members 
improperly canceling and rescheduling veteran appointments, as 
well as fake waiting lists hiding the fact that some vets were 
waiting 4 or more months for an appointment.
    The majority of the current or former Hines employees 
decided to remain anonymous out of fear of retaliation. One 
stated, ``I can't reveal my name as I fear retribution from my 
supervisors and other staff members. I need my job and would 
surely lose it for telling you any of this.''
    VA whistleblowers are supposed to be able to turn to the 
VA's Office of Inspector General, but many have come to doubt 
the VA Inspector General's willingness to protect them or to 
hold wrongdoers accountable. These fears appear to be well-
founded.
    We believe the VA Inspector General has been an example of 
oversight at its worst. Last year, in the midst of our 
investigation, the VA Inspector General issued a subpoena to 
POGO demanding all records we received from current or former 
VA employees. Of course, POGO refused to comply with the 
subpoena. However, it was understandably cause for concern for 
many of the whistleblowers who had come to us and caused a 
chilling effect.
    It was only thanks to your interest and support, Chairman 
Kirk, that the new Acting Inspector General dropped the 
subpoena against POGO 3 months ago.
    In comparison, the Office of Special Counsel has been 
working to investigate claims of retaliation and get favorable 
actions for many of the VA whistleblowers who have come 
forward. In 2014 and 2015 alone, the OSC has achieved favorable 
actions for 116 VA whistleblowers. Last year, the VA surpassed 
the Defense Department in the number of cases filed with the 
OSC for the first time, even though the Defense Department has 
twice the number of civilian employees as the VA.
    We commend the OSC's good work and commitment to helping VA 
whistleblowers. But merely addressing isolated incidents is not 
enough. The cultural shift that is required inside the VA 
cannot be accomplished without legislation that codifies 
accountability for those who retaliate against whistleblowers.
    POGO is extremely pleased to note that this has been 
included in your Veteran Patient Protection Act, as it has been 
missing in other pending VA legislation. This bill would punish 
VA supervisors who have been found to take retaliatory actions 
against whistleblowers first with a 12-day unpaid suspension, 
and if a second offense is committed, the removal of the 
supervisor.
    Additionally, we are glad to see that how supervisors 
handle whistleblower complaints will be included as criteria 
for their annual review and that bonuses will not be awarded to 
those who have retaliated against whistleblowers.
    It is POGO's hope that this legislation will ensure that 
whistleblowers can expose wrongdoing confident that it will not 
result in retaliation. Your bill, Chairman Kirk, gives teeth 
for protecting VA employees. But Congress should also extend 
whistleblower protections to contract employees and veterans 
who raise concerns about medical care provided by the VA.
    We have heard countless stories from veterans who fear 
reporting problems to their doctors or even patient advocates 
because they worry their medications will be stopped or they 
will not be able to get another appointment for months.
    Additionally, we urge the Senate to vote and, if found to 
be qualified, confirm the President's recent nomination for a 
permanent VA Inspector General as soon as possible.
    POGO also recommends that VA Secretary McDonald make a 
tangible and meaningful gesture to support those whistleblowers 
who have been trying to fix the VA from the inside. Secretary 
McDonald should personally meet with whistleblowers and elevate 
their status from villain to hero.
    The Government has failed in its sacred responsibility to 
care for our veterans. It is our collective duty to help the 
whistleblowers who have taken the risks to fix this broken 
agency and improve care for our veterans across the country.

    [The statement follows:]
                  Prepared Statement of Lydia Dennett
    Chairman Kirk, thank you for inviting me to testify today, as well 
as for your leadership and ongoing interest in the care of our 
veterans. I am Lydia Dennett, an investigator at the Project On 
Government Oversight (POGO). Founded in 1981, POGO is a nonpartisan 
independent watchdog that champions good government reforms. POGO's 
investigations into corruption, misconduct, and conflicts of interest 
achieve a more effective, accountable, open, and ethical Federal 
Government.
       fear and retaliation at the department of veterans affairs
    I want to first point out that if it were not for whistleblowers, 
none of us would be aware of the extent of the problems at the 
Department of Veterans Affairs. Early last year, whistleblowers came 
forward to expose that managers at the Phoenix, Arizona, VA facility 
were falsifying records of extensive wait times in order to get 
personal bonuses.\1\ Quickly, news of similar wrongdoing at VA 
facilities began to pop up in other parts of the country. Although POGO 
had never investigated the operations of the Department of Veterans 
Affairs before, we were deeply concerned about what we were seeing in 
these reports. In an unusual move for us, POGO held a joint press 
conference with Iraq and Afghanistan Veterans of America asking 
whistleblowers within the VA to share with us their inside perspective 
in order to help us better understand the issues the Department was 
facing.
---------------------------------------------------------------------------
    \1\ Scott Bronstein, Drew Griffin and Nelli Black, ``Phoenix VA 
officials put on leave after denial of secret wait list,'' CNN, May 1, 
2014. http://www.cnn.com/2014/05/01/health/veterans-dying-health-care-
delays/ (Downloaded July 27, 2015).
---------------------------------------------------------------------------
    In our 34-year history, POGO has never received as many submissions 
from a single agency. In little over a month, nearly 800 current and 
former VA employees and veterans contacted us. We received credible 
submissions from 35 States and the District of Columbia.\2\ A recurring 
and fundamental theme became clear: VA employees across the country 
feared they would face repercussions if they dared to raise a 
dissenting voice. But they came forward anyway--the sheer number was 
overwhelming. I want to emphasize this important point: this means 
there were extraordinary numbers of people who work inside the VA 
system who care so much about the mission of the Department that they 
were still willing to risk their livelihood to come forward in order to 
fix it.
---------------------------------------------------------------------------
    \2\ Statement for the Record, Project On Government Oversight 
(POGO), for the House Committee on Veterans' Affairs' Subcommittee on 
Oversight and Investigations Hearing on ``Addressing Continued 
Whistleblower Retaliation Within VA,'' April 13, 2015. http://
www.pogo.org/our-work/testimony/2015/pogo-provides-statement-for-house-
hearing-on-va-whistleblowers.html.
---------------------------------------------------------------------------
    Based on what POGO learned from these whistleblowers, we wrote a 
letter to Acting VA Secretary Sloan Gibson in July last year, 
highlighting three specific cases of current or former employees who 
agreed to share details about their personal experiences of 
retaliation.\3\
---------------------------------------------------------------------------
    \3\ Letter from Project On Government Oversight to Sloan D. Gibson, 
then-Acting Secretary of the Department of Veterans Affairs, about Fear 
and Retaliation in the VA, July 21, 2014. http://www.pogo.org/our-work/
letters/2014/pogo-letter-to-va-secretary-about-va-employees-
claims.html.
---------------------------------------------------------------------------
    From right here in Illinois, at the Hines VA Medical Center, we 
received several allegations of scheduling manipulations. These 
whistleblowers described VA staff members improperly canceling and 
rescheduling veteran appointments, as well as fake waiting lists hiding 
the fact that some vets were waiting four or more months for an 
appointment. The majority of the current or former Hines employees 
decided to remain anonymous out of fear of retaliation. One stated, ``I 
can't reveal my name as I fear retribution from my supervisors and 
other staff members. . . . I need my job, and would surely lose it for 
telling you any of this.''
    In California, a VA inpatient pharmacy supervisor was placed on 
administrative leave and ordered not to speak out after raising 
concerns with his supervisors about ``inordinate delays'' in delivering 
medication to patients and ``refusal to comply with VHA [Veterans 
Health Administration] regulations.'' \4\ In one case, he said, a 
veteran's epidural drip of pain control medication ran dry, and in 
another case, a veteran developed a high fever after he was 
administered a chemotherapy drug after its expiration point.
---------------------------------------------------------------------------
    \4\ Letter from Kelly Robertson, Pharmacy Service Chief at Palo 
Alto VA Health Care System, to Earl Stuart Kallio, Pharmacy Service, 
about Direct Order--Restricted Communication, June 20, 2014.
---------------------------------------------------------------------------
    In Pennsylvania, a former VA doctor was removed from clinical work 
and forced to spend his days in an office with nothing to do, he told 
POGO. This action occurred after he alleged that, in medical 
emergencies, physicians who were supposed to be on call were failing or 
refusing to report to the hospital. The Office of Special Counsel (OSC) 
shared his concerns, writing ``[w]e have concluded that there is a 
substantial likelihood that the information that you provided to OSC 
discloses a substantial and specific danger to public health and 
safety.'' \5\
---------------------------------------------------------------------------
    \5\ Letter from Karen Gorman, Deputy Chief, Disclosure Unit Office 
of Special Counsel, to Dr. Thomas Tomasco, about Dr. Tomasco's 
allegations OSC File No. DI-13-0416, March 21, 2013.
---------------------------------------------------------------------------
    In Appalachia, a former VA nurse was intimidated by management and 
forced out of her job after she raised concerns that patients with 
serious injuries were being neglected, she told POGO. In one case she 
was reprimanded for referring a patient to the VA's patient advocate 
after weeks of being unable to arrange transportation for a medical 
test to determine if he was in danger of sudden death. ``Such an 
upsetting thing for a nurse just to see this blatant neglect occur 
almost on a daily basis. It was not only overlooked but appeared to be 
embraced,'' she said. She also pointed out that there is ``a culture of 
bullying employees. . . . It's just a culture of harassment that goes 
on if you report wrongdoing,'' she said.
    That culture clearly isn't limited to just one or two VA clinics. 
Some people, including former employees who are now beyond the reach of 
VA management, were willing to be interviewed by POGO and to be quoted 
by name, but others said they contacted us anonymously because they are 
still employed at the VA and are worried about retaliation. One put it 
this way: ``Management is extremely good at keeping things quiet and 
employees are very afraid to come forward.''
    This kind of fear and suppression of whistleblowers who report 
wrongdoing often culminates in larger problems, as the VA has been 
experiencing.
    VA employees who have concerns about management or fear retaliation 
are supposed to be able to turn to the VA's Office of Inspector General 
(OIG). But whistleblowers had come to doubt the VA Inspector General's 
willingness to protect them or to hold wrongdoers accountable.
                         oversight at its worst
    These fears appear to be well-founded. In May 2014, the VA 
Inspector General's office issued an administrative subpoena to POGO 
that was little more than an invasive fishing expedition for 
whistleblowers who had come to us in confidence. The Inspector General 
demanded ``All records that POGO has received from current or former 
employees of the Department of Veterans Affairs, and other individuals 
or entities.'' \6\ Though POGO refused to comply with the subpoena, 
such an action was cause for concern for many of the whistleblowers who 
had shared information with us. We believe this extraordinary step 
created an understandable chilling effect, and the number of VA 
whistleblowers coming to POGO slowed to a trickle in the following 
months.
---------------------------------------------------------------------------
    \6\ Letter from Richard Griffin, then-Acting Inspector General, 
Department of Veterans Affairs, to Project On Government Oversight, 
regarding subpoena to POGO, May 30, 2014.
---------------------------------------------------------------------------
    In June of this year, the VA Inspector General's office attacked 
POGO again. In an unusual step, the VA OIG submitted a statement to the 
Senate Homeland Security and Governmental Affairs Committee raising 
concerns about POGO's investigation into the VA.\7\ However, the OIG 
could provide almost no relevant or specific evidence to support its 
own claims or rebut POGO's arguments. The very next day the VA OIG sent 
a white paper to all HSGAC members as well as 22 other Members of 
Congress publicly attacking victims and whistleblowers at the VA 
Medical Center in Tomah, Wisconsin.\8\
---------------------------------------------------------------------------
    \7\ Department of Veterans Affairs, Office of Inspector General, 
statement regarding the Senate Homeland Security and Governmental 
Affairs Committee's hearing, ``Watchdogs Needed: Top Government 
Oversight Investigators Left Unfilled for Years,'' submitted on June 
25, 2015, p. 3. http://www.pogoarchives.org/m/va_oversight/
va_oig_statement_for_record_20150603.pdf.
    \8\ Department of Veterans Affairs, Office of Inspector General, 
``OIG Releases White Paper on Evidence Supporting Administrative 
Closure of 2014 Tomah, WI, VA Medical Center Inspection on Opioid 
Prescription Practice,'' June 4, 2014. (Downloaded July 22, 2015).
---------------------------------------------------------------------------
    Less than a month later, Acting Inspector General Richard Griffin 
suddenly stepped down from his position. We were pleased to see that 
the new Acting Inspector General, Linda Halliday, released two 
statements detailing steps she plans to take to improve the Inspector 
General's whistleblower protection program, including seeking 
certification by the Office of Special Counsel.\9\
---------------------------------------------------------------------------
    \9\ Linda Halliday, Department of Veterans Affairs, Office of 
Inspector General, ``Deputy Inspector General Announces Steps to 
Strengthen Whistleblower Protection Training for OIG Employees,'' July 
10, 2015. http://www.va.gov/oig/pubs/press-releases/VAOIG-
WhistleblowerProtections
PressRelease.pdf (Downloaded July 22, 2015); Linda Halliday, Department 
of Veterans Affairs, Office of Inspector General, ``Deputy Inspector 
General Announces Steps to Strengthen OIG Whistleblower Protection 
Ombudsman Program,'' http://www.va.gov/oig/pubs/press-releases/VAOIG-
%20Ombudsmen-%2007-15-15.pdf (Downloaded July 22, 2015).
---------------------------------------------------------------------------
    Furthermore, at the request of Chairman Kirk, Acting Inspector 
General Halliday dropped the subpoena against POGO. We greatly 
appreciate Chairman Kirk's continued support and applaud his commitment 
fixing these issues at the VA, perhaps best evidenced by the VA Patient 
Protection Act he introduced just this week.
                       va patient protection act
    The cultural shift that is required inside the Department of 
Veterans Affairs cannot be accomplished without legislation that 
codifies accountability for those who retaliate against whistleblowers. 
This important piece has been missing in other pending VA legislation 
but is one of the strongest aspects of Chairman Kirk's VA Patient 
Protection Act.
    This bill would punish VA supervisors who have been found to take 
retaliatory actions against whistleblowers, first with a 12-day unpaid 
suspension, and if a second offense is committed, the removal of the 
supervisor. Additionally we are glad to see that how supervisors handle 
whistleblower complaints will be included as criteria for their annual 
review, and that bonuses will not be awarded to those who have 
retaliated against whistleblowers.
    Preventing retaliation is also key to fixing the culture at the VA. 
We are pleased to see that The VA Patient Protection Act requires 
annual training for all VA employees on prohibited personnel actions, 
which includes retaliating against whistleblowers as a prohibited 
action. Further, VA employees will receive an explanation of all the 
methods they can use to report wrongdoing. This bill would also create 
a new formal process for VA whistleblowers to file complaints within 
the VA, to be handled by a new Central Whistleblower Office, separate 
from the VA's General Counsel Office. This office will be required to 
report to Congress the number of complaints filed and how the Secretary 
addressed those complaints.
    It is POGO's hope that this legislation will ensure that 
whistleblowers can step forward to expose wrongdoing, confident that it 
will not result in retaliation.
                            recommendations
    In POGO's 2014 letter, we recommended concrete steps incoming VA 
Secretary McDonald could take in order to demonstrate an agency-wide 
commitment to changing the VA's culture of fear, bullying, and 
retaliation. Neither then-Acting Secretary Sloan Gibson nor Secretary 
McDonald responded to our multiple requests for a meeting.
    POGO also recommended that Secretary McDonald make a tangible and 
meaningful gesture to support those whistleblowers who have been trying 
to fix the VA from the inside. Once the OSC has identified meritorious 
cases, Secretary McDonald should personally meet with those 
whistleblowers and elevate their status from villain to hero. These 
employees should be publicly celebrated for their courage, and should 
receive positive recognition in their personnel files, including 
possibly receiving the types of personal bonuses that managers who had 
been falsifying records received in the past. This should not be an 
isolated event done in response to recent criticisms but an ongoing 
effort. Whistleblowing must be encouraged and celebrated or wrongdoing 
will continue.
    Although then-Acting Secretary Gibson did attend an OSC event 
honoring VA whistleblowers, such high-profile recognition of 
whistleblowers needs to take place at the VA facilities themselves. For 
the culture at the VA to change, we believe this is a simple but 
meaningful step.
    Additionally, the VA still does not have a permanent Inspector 
General in place. That position has been vacant for over 670 days--over 
a year and a half.\10\ Our own investigations have found that the 
absence of permanent and competent leadership can have a serious impact 
on the effectiveness of an Inspector General office.\11\ Acting 
Inspector Generals do not undergo the same kind of extensive vetting 
process required of permanent Inspector Generals, and as a consequence 
usually lack the credibility of a permanent Inspector General. Acting 
Inspector Generals also often seek appointment to the permanent 
position, which can compromise their independence by giving them an 
incentive to curry favor with the White House and the leadership of 
their agency.\12\ Perhaps most worrisome, given the significant 
challenges facing the VA Inspector General, a 2009 Southern California 
Law study found that vacancies in top agency positions promote agency 
inaction, create confusion among career employees, make an agency less 
likely to handle controversial issues, result in fewer enforcement 
actions by regulatory agencies, and decrease public trust in 
government.\13\ POGO urges the Senate to vet and, if qualified, confirm 
President Obama's nomination for a permanent VA Inspector General as 
soon as possible.
---------------------------------------------------------------------------
    \10\ Project On Government Oversight, ``Where Are All the 
Watchdogs?'' http://www.pogo.org/tools-and-data/ig-watchdogs/go-igi-
20120208-where-are-all-the-watchdogs-inspector-general-vacancies1.html.
    \11\ Testimony of POGO's Jake Wiens on ``Where Are All the 
Watchdogs? Addressing Inspector General Vacancies,'' May 10, 2012. 
(Hereinafter Testimony of POGO's Jake Wiens on ``Where Are All the 
Watchdogs?'')
    \12\ Testimony of POGO's Jake Wiens on ``Where Are All the 
Watchdogs?''
    \13\ Anne Joseph O'Connell, ``Vacant Offices: Delays in Staffing 
Top Agency Positions,'' Southern California Law Review, Vol. 82, 2009.
---------------------------------------------------------------------------
    On the other hand, the OSC has been working to investigate claims 
of retaliation and get favorable actions for many of the VA 
whistleblowers who have come forward. In 2014 and 2015 alone, the OSC 
has achieved favorable actions for 116 VA whistleblowers. But the OSC 
still has nearly 100 pending VA reprisal cases for disclosing concerns 
about patient care or safety, among the highest of any government 
agency, according to Special Counsel Carolyn Lerner.\14\ POGO 
recommends that Congress consider appropriating additional funds to 
this agency to help with the increased workload.
---------------------------------------------------------------------------
    \14\ Testimony of Carolyn Lerner, Special Counsel U.S. Office of 
Special Counsel on ``Improving VA Accountability: Examining First-Hand 
Accounts of Department of Veterans Affairs Whistleblowers,'' September 
22, 2015. http://www.hsgac.senate.gov/hearings/improving-va-
accountability-examining-first-hand-accounts-of-department-of-veterans-
affairs-whistleblowers (Down-
loaded November 2, 2015).
---------------------------------------------------------------------------
    But it's not just the OSC, VA Secretary, or Inspector General who 
can work to fix this problem. Congress should enact legislation, like 
Chairman Kirk's VA Patient Protection Act, to increase protections for 
VA whistleblowers and hold their retaliators accountable.
    POGO also urges Congress to extend whistleblower protections to 
contractors and veterans who raise concerns about medical care provided 
by the VA. POGO's investigation found that both of these groups also 
fear retaliation, which prevents them from coming forward. Contractors 
are only currently protected under a pilot program, but need permanent 
statutory protections. In addition, a veteran who is receiving poor 
care should be able to speak to his or her patient advocate without 
fear of retaliation, including a reduction in the quality of 
healthcare. Without this reassurance, there is a disincentive to report 
poor care, allowing it to continue uncorrected.
    The VA and Congress must work together to end the culture of fear 
and retaliation. Whistleblowers who report concerns that affect veteran 
health must be lauded, not shunned. And the law must protect them.
    The Government has failed in its sacred responsibility to care for 
our veterans. It is our collective duty to help the whistleblowers who 
have taken risks to fix this broken agency.

                       VA RETALIATION COMPLAINTS

    Senator Kirk. Let me follow up, Lydia, to sum up, as I 
understand it, POGO got about 800 whistleblowers who contacted 
it about problems in the VA. The Inspector General demanded you 
hand over the names of all those whistleblowers.
    In your view, what would have happened if you had given the 
Inspector General the names of all those whistleblowers?
    Ms. Dennett. We believe that they would have been 
retaliated against. We have heard from several whistleblowers 
who did not contact the Inspector General anonymously and the 
Inspector General went back to their hospitals and revealed 
their names, and they were subsequently retaliated against by 
their supervisors.
    Senator Kirk. So since the hearing that we had with the 
Acting Inspector General, they have now backed down on that 
subpoena and you have not provided those names. So we could say 
that those 800 whistleblowers are all protected, and the 
Inspector General does not even know who they are.
    Ms. Dennett. Yes, correct.
    Senator Kirk. Let me pull up a board that we have made, 
showing the rising number of retaliation complaints at the 
Department of Veterans Affairs, rising from about 291 to 712. 
It is a pretty alarming rising there.
    Lydia, could you comment on that?
    Ms. Dennett. Yes. It is not surprising based on what we 
have been hearing ever since the doctors in Phoenix came 
forward in 2014. I think that gave some confidence to other 
employees there that they could also come forward, or should 
come forward to report the kinds of problems at Phoenix and 
other kinds from all over the country.
    Senator Kirk. Germaine, I would just say, normally, you 
would not expect people who work at Hines VA would get a 
highway sign. You guys have been responsible for this sign that 
says, ``VA is lying and veterans are dying.'' What led you to 
get the sign to be put up?
    Ms. Clarno. It really came from VA employees who wanted to 
help the cause, but were too afraid to come forward in any 
other way. So this came from an idea from a VA employee. And I 
contacted Ron Nestler, who is a veteran who has a Facebook 
page. We collected funds. It is not an inexpensive thing to do, 
to put a billboard up in Chicago. But we collected money and 
the Facebook group also contributed to helping.
    Senator Kirk. So how many folks do you have on Facebook 
with you after this sign went up?
    Ms. Clarno. Part of not only being a local president, a 
social worker, after I made my disclosure on CBS Evening News, 
I got calls from all around the country from whistleblowers. I 
started a Facebook page----
    Senator Kirk. Germaine, I wanted to get into that. You have 
talked to a number of employees around the country who are also 
in your union, and they have described the same kind of 
retaliation. You suspect there is a retaliation memo, and that 
they all get retaliation of the same kind. Can you describe the 
disturbing similarities that you have seen?
    Ms. Clarno. Sure. We often joke that there must be a manual 
on how to retaliate against whistleblowers, because it is the 
same. They will start with the harassment and intimidation, and 
it will just proceed from there to such a point that there are 
whistleblowers around the country that have been hospitalized 
in psychiatric wards for suicide ideation, for depression. It 
is shocking.
    The sacrifices that truth-tellers make to protect our 
veterans is very alarming, and the numbers are very high.
    Senator Kirk. I want to present one last board where we 
have seen that the Department of Justice has decided to 
prosecute a number of people at the VA for poor medical care. 
At places like Florida and Ohio and Tennessee, we have seen 
people prosecuted for poor care.
    Lisa, could you comment on that, this lack of prosecution 
that we have seen?
    Dr. Nee. Well, it is glaringly obvious. Health and Human 
Services has partnered with the Department of Justice to go 
after physicians who commit fraud, so they can recover the 
funds. It is clear that the exact same law that is used by them 
for prosecuting people is ignored in Hines.
    Many physicians at Hines have committed these exact acts 
word for word. Not only are they not prosecuted, the Hines VA 
is allowed to then investigate itself to make any corrective 
action, which is ludicrous. You would never allow a criminal to 
investigate themselves and then come back to you with their 
plan of action to not do that again.
    It is a very scary thought, I think, for good physicians 
and for any patient.
    Senator Kirk. All right, I will start to wrap up. Let me 
finish with a closing statement.
    It is totally demoralizing for us to hear all of this about 
our own VA taking care of the best of the best, the men and 
women of the greatest generation that saves civilization who 
get terrible treatment like this.
    We need to focus on legislation to protect the protectors 
and to make sure that medical professionals like the ones we 
heard from are able to report mistreatment of a veteran and 
ensure high quality for that veteran.

                         CONCLUSION OF HEARINGS

    Senator Kirk. I will close this hearing. We are adjourned.
    [Whereupon, at 1:53 p.m., Friday, November 6, the hearings 
were concluded, and the subcommittee was recessed, to reconvene 
subject to the call of the Chair.]
```