(1) 

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. 
2 

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. 
3 

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. 
4 

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. 
5 

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 41⁄2 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 re-
6 

sulted 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: 
7 

—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? 
8 

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. 
9 

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 
10 

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. 
11 

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. 
12 

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. 
13 

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 
14 

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. 
15 

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 
16 

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:] 
17 

1Scott 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-dyinghealth-care-delays/ (Downloaded July 27, 2015). 2Statement 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. 3Letter 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. 4Letter 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. 

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. 

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. 

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

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. 

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 
18 

5Letter 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. 6Letter from Richard Griffin, then-Acting Inspector General, Department of Veterans Affairs, 

to Project On Government Oversight, regarding subpoena to POGO, May 30, 2014. 7Department 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/valoversight/valoiglstatementlforlrecordl20150603.pdf. 8Department 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). 9Linda 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). 

substantial likelihood that the information that you provided to OSC discloses a 

substantial and specific danger to public health and safety.’’ 5

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. 

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

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

Furthermore, at the request of Chairman Kirk, Acting Inspector General Halliday 

dropped the subpoena against POGO. We greatly appreciate Chairman Kirk’s con-
19 

10Project 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-generalvacancies1.html. 11Testimony 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?’’) 12Testimony of POGO’s Jake Wiens on ‘‘Where Are All the Watchdogs?’’ 

tinued 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 
20 

13 Anne Joseph O’Connell, ‘‘Vacant Offices: Delays in Staffing Top Agency Positions,’’ Southern 

California Law Review, Vol. 82, 2009. 14Testimony 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 (Downloaded November 2, 2015). 

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. 

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. 

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. 
21 

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 them-
22 

selves 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.]