```

[Senate Hearing 114-686]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 114-686

       TOMAH VAMC: EXAMINING PATIENT CARE AND ABUSE OF AUTHORITY

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

                              FIELD HEARING

                               BEFORE THE

                              COMMITTEE ON
               HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               ----------                              

                              MAY 31, 2016

                               __________
                               
                    

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        COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

                    RON JOHNSON, Wisconsin Chairman
JOHN McCAIN, Arizona                 THOMAS R. CARPER, Delaware
ROB PORTMAN, Ohio                    CLAIRE McCASKILL, Missouri
RAND PAUL, Kentucky                  JON TESTER, Montana
JAMES LANKFORD, Oklahoma             TAMMY BALDWIN, Wisconsin
MICHAEL B. ENZI, Wyoming             HEIDI HEITKAMP, North Dakota
KELLY AYOTTE, New Hampshire          CORY A. BOOKER, New Jersey
JONI ERNST, Iowa                     GARY C. PETERS, Michigan
BEN SASSE, Nebraska

                  Christopher R. Hixon, Staff Director
              David N. Brewer, Chief Investigative Counsel
                        Kyle P. Brosnan, Counsel
                  Brian M. Downey, Senior Investigator
                    Scott D. Wittmann, Investigator
              Gabrielle A. Batkin, Minority Staff Director
           John P. Kilvington, Minority Deputy Staff Director
         Brian F. Papp, Jr., Minority Professional Staff Member
                     Laura W. Kilbride, Chief Clerk
                   Benjamin C. Grazda, Hearing Clerk
                            
                            
                            C O N T E N T S

                                 ------                                
                                                                   Page

                         TUESDAY, MAY 31, 2016

Opening statements:
    Senator Johnson..............................................     1
    Senator Baldwin..............................................     3
    Congressman Kind.............................................    17
    Congressman Walz.............................................    19
Prepared statements:
    Senator Johnson..............................................    33
    Senator Carper...............................................    37
    Senator Baldwin..............................................    40

                               WITNESSES

Hon. Sloan D. Gibson, Deputy Secretary, U.S. Department of 
  Veterans Affairs; accompanied by Dr. Gavin West, Senior Medical 
  Advisor, Clinical Operations...................................     6
Hon. Michael J. Missal, Inspector General, U.S. Department of 
  Veterans Affairs; accompanied by Dr. John D. Daigh Jr., 
  Assistant Inspector General for Healthcare Inspections.........    10

                     Alphabetical List of Witnesses

Gibson, Hon. Sloan D.:
    Testimony....................................................     6
    Prepared statement...........................................    44
Missal, Hon. Michael J.:
    Testimony....................................................    10
    Prepared statement...........................................    58

                                APPENDIX

Majority Staff Report............................................    63
Minority Staff Views Memorandum..................................   439
Responses to post-hearing questions for the Record from:
    Mr. Gibson...................................................   443
    Mr. Missal...................................................   454

 
       TOMAH VAMC: EXAMINING PATIENT CARE AND ABUSE OF AUTHORITY

                              ----------                              

                         TUESDAY, MAY 31, 2016

                                     U.S. Senate,  
                           Committee on Homeland Security  
                                  and Governmental Affairs,
                                                         Tomah, WI.
    The Committee met, pursuant to notice, at 10 a.m., at 
Cranberry County Lodge, 319 Wittig Road, Tomah, Wisconsin, 
54660, Hon. Ron Johnson, Chairman of the Committee, presiding.
    Present: Senator Johnson, Senator Baldwin, Hon. Tim Walz, 
and Hon. Ron Kind.

            OPENING STATEMENT OF SENATOR RON JOHNSON

    Senator Johnson. This hearing will come to order.
    I think it would be appropriate to start the day, in light 
of Memorial Day being yesterday, and in light of the tragedies 
of some of the finest among us, suffering at the hands of 
people that should be taking care of them, if we can start this 
hearing with a moment of silence?
    If you will please join me?
    Thank you.
    I would also like to ask anybody who has served in 
military, and, quite honestly, their family members as well, 
because this is a service and sacrifice that affects the entire 
family, if you could please rise and be recognized?
    Thank you all for your service and sacrifice. The purpose 
of this hearing is to make sure that the rest of America honors 
its promise to you. That's what really is the heart of this 
hearing. I truly want to thank everybody who as appeared and 
attended this hearing today.
    I want to, in particular, thank the surviving family 
members of Jason Simcakoski, Thomas Baer, Chris Kirkpatrick, 
and Kraig Ferrington.
    In March of 2015, we held a hearing where the family 
members stepped forward and whistleblowers stepped forward and 
provided powerful testimony. And, it was powerful testimony. We 
heard from Dr. Noelle Johnson, Mr. Ryan Honl, Marv and Heather 
Simcakoski, and Candace Delis. I have to believe that their 
testimony had an effect on the officials that were present that 
day from the U.S. Department of Veterans Affairs (VA).
    It is that type of testimony, it is that type of 
highlighting a problem that is going to be required if we are 
going to honor the promises of the finest among us.
    I do want to thank my staff for doing, I think, an 
extraordinary job of laying out the findings of a very 
rigorous, a very comprehensive investigation into how exactly 
the problems within the Tomah healthcare facility went on for 
so long without being corrected.\1\
---------------------------------------------------------------------------
    \1\ The Majority Staff Report appears in the Appendix on page 63.
---------------------------------------------------------------------------
    I do encourage everybody, because I think we have a couple 
of hundred copies, to grab one and read all 359 pages. It lays 
out exactly what happened with, quite honestly, not all the 
information.
    I do want to say that certainly it has been my experience, 
because I have traveled around the State of Wisconsin and 
visited VA healthcare facilities, the vast majority of the 
doctors, of the nurses, of the administrators are doing an 
excellent job. They are highly concerned about the finest among 
us, about our veterans. And, they are doing everything they can 
to honor those promises.
    But the fact of the matter is, they are working within a 
single-payer, government-run bureaucratic healthcare system and 
there just are inherent problems. For example, inherent 
problems of accountability. Inherent problems, unfortunately, 
within an Office of Inspector General (OIG) that was not living 
up to its mission. Who, I would say, was captured by the VA 
itself.
    So, the Office of Inspector General under Richard Griffin 
was loyal to the VA instead of being loyal to the finest among 
us and to the American public.
    This Committee, in particular, the Senate oversight 
committee, relies on independent and transparent Inspectors 
General (IGs). Government relies on them. The only hope we have 
of fixing problems is if you have an Inspector General's office 
be the independent, transparent watchdog actually doing its 
job.
    And, what is very apparent in our 350 page report and the 
almost 4 or 5,000 supporting documents is that for years the 
Office of Inspector General from the VA did not do its job.
    And, what is an even greater tragedy is that these 
tragedies here at Tomah, I believe, could have been prevented, 
had the Office of Inspector General done its job.
    As far back as 2004, Dr. David Houlihan had been referred 
to as Candy Man. A number of people, as far back as 2008 and 
2009, were trying to raise the alarm to a number of 
Departments, a number of Agencies, a number of Offices. And 
yet, somehow those alarms did not go public.
    I do want to play real quickly, if people are ready, and 
you can follow along on page 48, there were logs that Heather 
Simcakoski asked us to basically use the Capitol Police to get 
into her husband's cell phone to get a record of his call logs.
    Now, during the course of our investigations, we contacted 
the Federal Bureau of Investigation (FBI) about potential 
contacts as it related to Tomah VA. They claimed there was no 
contact. And yet, we actually have a voice from a message left 
by a member of the FBI, which I would like to play right now if 
we can.
    [Audio]. Jason, this is Andy Chapman from the FBI returning 
your call. My phone number is (608) 782-6030. Thank you. [End 
of audio].
    Now, we asked representatives of the FBI and the Drug 
Enforcement Agency (DEA) to appear today and they declined. 
They also continue to convey to this Committee, to our staff, 
that they have no record of ever having been contacted by Jason 
Simcakoski. I find that puzzling. I find it troubling.
    Again, the failure of the Office of Inspector General to 
live up to its mission was really at the root cause of why 
these problems continued to go on for so long.
    I do want everybody to refer to page 208 and 209, because I 
think this is a classic example of how the Office of Inspector 
General, in their inspection, in their investigation here, 
narrowed its scope, refused to look beyond its scope, and, as a 
result, did not do its job.
    In 2008, according to our report, during its site visit, 
this is the first site visit directed by Dr. Alan Mallinger to 
the Tomah VA following reports that began in 2011. The hotline 
reports. During its site visit to the Tomah Veterans Affairs 
Medical Center (VAMC), VA Office of Inspector General officials 
interviewed both Dr. Houlihan and Deborah Frasher. During the 
interviews, both Office of Inspector General physicians and 
Special Agent Porter of the VA OIG's criminal division observed 
that Dr. Houlihan and Ms. Frasher appeared to be impaired.
    Now, unfortunately, during that initial investigation 
visit, Mr. Mario DeSanctis was not present. So, the Inspector 
General's team held a phone conference with Mr. DeSanctis, and 
in 2009 you can read how they informed Mr. DeSanctis about 
their concern with Dr. Houlihan and Nurse Frasher potentially 
being impaired, potentially being drug users. There are 
numerous whistleblower reports that also suspected that Dr. 
Houlihan and Nurse Frasher were drug users.
    I want people to read exactly what they Office of Inspector 
General did. All they did was inform Mr. DeSanctis and suggest 
that Mr. DeSanctis perform drug tests on those two individuals. 
We have no idea whether those drug tests were ever performed. I 
would think, if they were, back in 2012, these tragedies might 
have been prevented.
    So, again, the bottom line of what this report shows is it 
was the failure of the Office of Inspector General and the 
failure of other agencies and offices to actually highlight the 
problems that they were made aware of that allowed these 
tragedies to occur.
    And, we will get into this further in terms of the 
testimony and our questions to it.
    I do ask that my written prepared statement be entered into 
the record\1\ without objection.
---------------------------------------------------------------------------
    \1\ The prepared statement of Senator Johnson appears in the 
Appendix on page 33.
---------------------------------------------------------------------------
    And, with that, to Senator Baldwin.

              OPENING STATEMENT OF SENATOR BALDWIN

    Senator Baldwin. Thank you. Thank you, Chairman Johnson. I 
want to thank you for organizing this hearing today and I also 
want to add my words of appreciation to your staff, Senator 
Carper's staff and to my staff in terms of the undertaking that 
resulted in this work product. It is a very significant 
investment on their part and we appreciate that.
    I think the fact that we are both here again today sends an 
important message to this community that we will continue to 
work across the partisan aisle in order to address the problems 
at the Tomah VA. In fact, I would describe it as: there is no 
aisle.
    As Americans, we are united. We are united by an eternal 
bond with the families and friends of our fallen. And, we are 
also united by the sacred trust that we have with our veterans 
and their families.
    Today, as we hear the story of how that sacred trust with 
our veterans and their families has been broken, it is 
important for us to keep in mind what unites us.
    One profound thing that I have learned about the tragic 
problems at the Tomah VA is that veterans, their families, and 
whistleblowers all want the same thing. They want answers and 
accountability, but most importantly they want solutions to the 
problems at the Tomah VA so that these sort of tragedies never 
ever happen again.
    What I am committed to is fixing what has been broken. What 
I am focused on is restoring the sacred trust that we have with 
our veterans and their families.
    The Committee's reports makes clear much of what we have 
known for some time. The problems at the Tomah VA have had 
tragic and preventable consequences.
    The report sheds light on the failures surrounding the 
deaths of Kraig Ferrington, Dr. Christopher Kirkpatrick, Jason 
Simcakoski and Thomas Baer. What this report can never do is 
repair the damage that their losses have had on families, many 
of whom are here with us today.
    It is just as clear to me today, as it was a long time ago, 
that the VA prescribed Jason Simcakoski a deadly mix of drugs 
that led to his death. And, those responsible at the Tomah VA 
for this tragic failure should have been held accountable long 
ago. In fact, they should have been accountable before Jason's 
death.
    The record is clear, for far too long, serious problems 
have existed at the Tomah VA and they were simply ignored or 
not taken seriously, as they should have been, by the VA and 
the VA Inspector General.
    My office was just one of many voices who were trying to 
expose the problems at the VA.
    When my Senate office was first contacted in March 2014 
with complaints about the Tomah VA, including prescribing 
practices, they came from an anonymous whistleblower. Someone 
who still remains anonymous today.
    We immediately brought those concerns to the Tomah VA and 
then to the VA Office of Inspector General, and then to the 
U.S. Department of Veterans Affairs headquarters in Washington, 
D.C.
    Four months prior to Jason's death, I called for a full 
review and investigation from the Tomah VA.
    Two months prior to Jason's death I called for a full 
review and investigation from the U.S. Department of Veterans 
Affairs and the VA Office of Inspector General.
    On August 30, 2014, Jason tragically died at the Tomah VA 
as a result of what was medically deemed, mixed-drug toxicity.
    The Simcakoski family lost a son, a husband, a father, and 
we lost somebody who faithfully served his country.
    If there is one thing that I want to come out of this 
hearing and one thing that comes from this report, I want it to 
be this. I want everyone to hear the voice of Jason's wife 
Heather who said, and I quote, ``When I look back at the past, 
I want to know we made a difference. I want to believe we have 
leaders in our country who care. I want to inspire others to 
never give up because change is possible.''
    Jason's family, just like veterans and their families in 
this community and communities across Wisconsin, are not 
interested in finger pointing and a blame game and neither am 
I. That is why over the past year I have focused on solutions 
to the problems at the VA. I have worked across party lines to 
advance reforms that will improve transparency, strengthen 
protections for whistleblowers, and to provide stronger 
oversight of VA prescribing practices.
    I authored a reform that was recently signed into law which 
requires the VA Inspector General to submit reports to Congress 
and make them available to the public. That is the standard 
that must now be met.
    Last year, I had the honor of working with Jason's family 
to develop legislation to provide the VA with the tools that it 
needs to prevent this type of tragedy from occurring to other 
veterans and their families.
    One year ago, I introduced this bipartisan legislation in 
Jason's name that earned the support of many veterans service 
organization. And, I am so proud, Senator Johnson, to have you 
join in this effort.
    I am pleased that the House of Representatives recently 
passed a version of Jason's bill and I am equally grateful to 
members of the Senate Veterans' Affairs Committee for their 
bipartisan support of Jason's bill, the Jason Simcakoski 
Memorial Opioid Safety Act. It is a critical reform and it 
continues to move forward. Families like Jason's have a story 
to tell, and it needs to be heard, and the movement of their 
legislation is strong evidence that their voice is being heard.
    My goal is to put these reforms in place to prevent Jason's 
tragedy from ever happening to another veteran or any of our 
veterans' families.
    Change is indeed possible. Heather's words inspire me and 
it is my hope that they will inspire all of us to work together 
and to prevent these problems and tragedies from ever happening 
again.
    I thank you, Senator Johnson, for providing me with this 
opportunity to join you today and I look forward to continuing 
our work together.
    Senator Johnson. Thank you, Senator Baldwin.
    Senator Carper, who is our Ranking Member of the Committee, 
has a statement\1\ and a Minority Views Memo\2\ that he would 
like in the record without objection.
---------------------------------------------------------------------------
    \1\ The prepared statement of Senator Carper appears in the 
Appendix on page 37.
    \2\ Minority Views Memo submitted by Senator Carper appears in the 
Appendix on page 439.
---------------------------------------------------------------------------
    It is the tradition of this Committee to swear in 
witnesses, so if you will all four rise and raise your right 
hand?
    Do you swear that the testimony that you will give before 
this Committee will be the truth, the whole truth and nothing 
but the truth, so help you, God?
    Dr. West. I do.
    Mr. Gibson. I do.
    Mr. Missal. I do.
    Dr. Daigh. I do.
    Senator Johnson. Please be seated.
    Our first witness is Sloan Gibson. Mr. Gibson is the Deputy 
Secretary of the Department of Veterans Affairs. Deputy 
Secretary Gibson is accompanied by Dr. Gavin West, Senior 
Medical Advisor of Clinical Operations, Department of Veterans 
Affairs. Mr. Gibson.

TESTIMONY OF THE HONORABLE SLOAN GIBSON,\1\ DEPUTY SECRETARY OF 
  THE U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY DR. 
GAVIN WEST, SENIOR MEDICAL ADVISOR OF CLINICAL OPERATIONS, U.S. 
                 DEPARTMENT OF VETERANS AFFAIRS

    Mr. Gibson. Let me begin by expressing my heartfelt 
sympathy to the Simcakoski family. I know that no words can 
ease the pain of your loss, but I would be remiss if I did not 
recognize the courage and the compassion and the deep devotion 
that you have displayed in all the work that you have done 
since Jason's death to make real difference in the lives of 
many other veterans.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Gibson appears in the Appendix on 
page 44.
---------------------------------------------------------------------------
    Thank you and God bless you.
    I am accompanied today, as you mentioned by Dr. Gavin West. 
I wanted to point out, prior to his appointment to the 
responsibilities you have described, Dr. West served as the 
Chief of Primary Care and Associate Chief of Medicine, 
accountable for the delivery of evidence-based, high-quality, 
patient-centered care across VA. He continues to practice 
medicine at the Salt Lake City VA Healthcare System where he 
teaches medical students and treats veterans in primary care 
with a focus on pain management and substance abuse.
    He understands the issues and challenges we are facing at 
Tomah from years of traveling across the country working to 
optimize clinical care at many site visits to VA Medical 
Centers, including visits here at Tomah.
    Most importantly, perhaps, is that Dr. West served as the 
co-chair of VA's National Opioid Safety Program.
    Jason's death forced us to dive deeply into the Tomah 
system. What we found was an organization facing numerous 
challenges in dire need of change and new leadership.
    The problems at Tomah have been well documented. Failures 
related to the prescribing practices of controlled substances, 
examples of inadequate oversight appear, and failure related to 
culture.
    We own those challenges and problems, those failures. I own 
those problems, those failures.
    Avoidable harms to veterans are not acceptable. When they 
do occur, our obligation is to act with urgency to investigate 
and prevent a recurrence.
    At Tomah there was a clear and inexcusable lack of 
leadership that created and exacerbated these serious problems.
    The excellent frontline staff here at Tomah--that you have 
acknowledged in your comments, Mr. Chairman--working under new 
leadership, is fixing those problems.
    On October 5, we appointed Victoria Brahm as Acting 
Director. In her new role, Vicki did not wait to take action to 
improve veteran care. On November 27, she began executing 
Tomah's 100-Day Plan. For those of you that are unfamiliar with 
this concept, 100-Day Plans are a best practice of new leaders 
as they transition into their roles. They are not meant to fix 
everything, but to set a clear and bold direction while 
delivering near-term tangible results.
    The 100-Day Plan period ended in March, but the work 
continues to transform the way Tomah leaders operate, to change 
how Tomah treats their veteran patients, and to rebuild trust 
with veterans, employees, and the community.
    Thanks to this ambitious plan and the dedication of caring 
frontline staff, Tomah, once a symbol of the overuse of 
opioids, is actually on its way to becoming a model for change 
and best practices.
    Let me highlight some of the great work by Vicki and the 
staff.
    In April, Tomah completed more than 98 percent of their 
appointments with in 30 days. In fact, nearly 17,000 
appointments were completed in April. Of all of those, 217 were 
over 30 days from the day that the veteran wished to be seen.
    Their wait times are consistently among the best in all of 
the VA.
    For primary care, less than 3 days. Specialty care, less 
than 6 days. And, for mental health, a little more than 2 days.
    Vicki and the team are working to restore trust among 
veterans. She is opening lines of communication with our 
veterans by opening her door, meeting with countless veterans 
these past months.
    Other continuing efforts include developing an academic 
detailing team to review the medical center's most complex 
chronic pain patients and provide additional recommendations 
for their care.
    To support this initiative, more than 30 primary care and 
mental health providers attended academic detailing educational 
sessions in the month of March.
    She is also creating a veteran pain school to assess and 
customize alternative pain management strategies for veterans. 
Importantly, Tomah has reduced the number of veterans receiving 
opioids by nearly one fourth.
    Tomah partners with the Wisconsin State Prescription Drug 
Monitoring Program, a program designed to ensure veterans are 
not obtaining opioid medications from multiple providers.
    Another step forward is the effective use of VA's audit 
tool, which allows doctors to improve practice and safety by 
seeing all the medications veterans are taking on a single 
dashboard.
    Vicki has made overdose education and Naloxone rescue kits 
available to patients at risk of accidental or intentional 
overdose. Naloxone has proven effective in reversing an opioid 
overdose. Simply put, she is finding options, alternatives, and 
solutions other than just a bag of pills.
    Let me tell you about one of Tomah's best practices. 
Evidence shows that the best outcomes in pain management occur 
with a comprehensive approach across multiple disciplines with 
the patient as the central focus. This empowers the veteran to 
be an active participant in decision making regarding pain care 
options.
    Tomah developed the integrated pain university, which is 
strongly based on patient education and empowerment. This whole 
health perspective identifies and addresses biological, 
psychological, and social aspects of pain management in 
conjunction with assessment by the Patient Aligned Care Team 
and any necessary specialty consults.
    Additionally, veterans receive information through a 
variety of elective classes taught by their respective health 
care professionals, which include pain medications, pain and 
nutrition, pain and sleep, aroma therapy, mindfulness, the 
neuroscience of pain, introduction to movement, staying 
motivated, and spirituality.
    The result of these and other efforts. As of the second 
quarter of fiscal year (FY) 2016, just over 9 percent of 
veterans at Tomah are prescribed some form of opioid.
    Across the entire country, across all of the VA's 
population, that national rate is nearly 13 percent.
    Vicki and the team are also listening. They are listening 
to veterans, to the community, and to employees. Listening led 
to the development of the Tomah VAMC Veterans Experience 
Council and Strategic Partnership Committee. The Veterans 
Experience Council will help make sure that Tomah leaders have 
a clear understanding of how veterans perceive VA, while the 
Strategic Partnership Committee will work to strengthen and 
promote a unified approach to veteran care throughout the 
community.
    Vicki has hosted more than 15 employee listening sessions 
covering all work shifts at the Medical Center. These listening 
sessions are critical in getting a sense of how staff can 
better serve veterans while using input from these sessions to 
improve employee engagement, making sure employees are 
satisfied with their work environment. Monthly staff meetings, 
quarterly nurse town hall, and roundings with local union 
officers are all part of the larger efforts of our commitment 
to employees.
    As a result of these and many other actions, we are seeing 
Tomah's performance improve, as measured both internally and by 
veterans themselves.
    By understanding the challenges and taking ownership in the 
problems, Vicki and the leadership team are improving the 
organizational culture and climate, providing more oversight, 
effective oversight, of care delivery, and addressing problems 
and prescribing practices.
    While there is more work to be done, this strategic 
direction has led to a real positive change.
    Vicki is modeling effective leadership by taking ownership 
and accepting accountability of past mistakes in order to make 
tangible progressin caring for our Nation's veterans.
    Bob McDonald and I talk a lot about sustainable 
accountability. Making sure employees understand our mission, 
values, and strategy. It has accountability that results in 
positive veteran outcomes, not just in the very near term, but 
over the long term as well.
    And I believe that is what we are seeing here at Tomah.
    Across all of the VA, our work to change prescribing 
practices and develop alternative approaches to pain management 
is delivering steady progress. We have also developed a 
predictive model and a clinical decisions support tool to 
identify patients being treated with opioids, who may be at 
risk of suicide-related events or overdose.
    This tool for opioid risk mitigation estimates the 
likelihood of an overdose or suicide event in the next year 
providing patient-tailored recommendations for risk mitigation 
and nonopioid pain management options.
    Lessons learned have caused a greater engagement and 
improves lives.
    We are also getting unwanted drugs out of veterans hands. 
Removal of veterans unwanted and unneeded medications reduces 
the risk of diversion, as well as intentional or unintentional 
overdose or poisonings.
    As of May 1, approximately 27,000 pounds of unwanted and 
unneeded medication have been collected and destroyed in an 
environmentally responsible manner.
    The overuse and misuse of opioids is a national problem, 
not just a VA problem. What we are doing here at Tomah and 
across the VA is part of a broader national effort to fight 
opioid addiction and overprescribing of powerful drugs.
    Our hope is that VA's efforts here and elsewhere will 
become part of the national approach that will benefit not just 
veterans, but all Americans.
    We still have work to do.
    With your support and the support of many others, we will 
succeed. The needs of veterans cannot be secondary to other 
agendas. It is unacceptable to VA leadership and should be 
unacceptable to anyone claiming to care about our Nation's 
veterans.
    I need your help to change the dialogue and a perception of 
this facility in order to get the right people interested in 
these jobs.
    Mr. Chairman, I appreciate your Committee's support in 
identifying and resolving challenges here in Tomah. And, we 
look forward to your questions.
    Senator Johnson. Thank you, Mr. Gibson. Our next witness is 
Michael Missal. Mr. Missal is the Inspector General for the 
Department of Veterans Affairs.
    I had the privilege of going on the Senate floor and asking 
unanimous consent to have you confirmed. I know Senator Baldwin 
and members were calling for a firm Inspector General and we 
are glad we have one.
    Mr. Missal is accompanied by Dr. John Daigh, Assistant 
Inspector General for the Healthcare Inspections within the VA 
Office of Inspector General. Inspector General Missal.

  TESTIMONY OF THE HONORABLE MICHAEL J. MISSAL,\1\ INSPECTOR 
 GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY 
  DR. JOHN DAIGH, ASSISTANT INSPECTOR GENERAL FOR HEALTHCARE 
 INSPECTIONS, OFFICE OF THE INSPECTOR GENERAL, U.S. DEPARTMENT 
                      OF VETERANS AFFAIRS

    Mr. Missal. Thank you. Chairman Johnson, Senator Baldwin.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Missal appears in the Appendix on 
page 58.
---------------------------------------------------------------------------
    Chairman Johnson, Senator Baldwin, Congressman Kind and 
Congressman Walz, thank you for the opportunity to appear today 
regarding the Office of Inspector General's past inspections of 
the Tomah VA Medical Center and our work in the area of pain 
management and opioid use.
    I am accompanied by Dr. John Daigh, Assistant Inspector 
General for Healthcare Inspections. He is a retired Army 
Colonel and has spent over 25 years providing healthcare to 
soldiers.
    First, on a personal note. I want to thank all veterans for 
their great and selfless service to our Nation.
    In addition, I want to express my sympathies to the 
families of those impacted by events at Tomah. All of us at the 
OIG need to take these experiences and use them to improve VA's 
operations.
    Finally, as the son of a World War II veteran, I had a 
strong reminder of our mission's importance when I had the 
great honor of attending the wreath laying ceremony at 
Arlington National Cemetery yesterday.
    On May 2, 2016, I was sworn in as the Inspector General. 
Since then, I have immersed myself to understand the people, 
work and goals of our office. I have been impressed with the 
OIG staff, many of whom are veterans, and their focus on 
bringing about positive changes in the integrity, efficiency 
and effectiveness of VA operations. While my integration has 
gone very well, I know there is much more to learn.
    I strongly advocate three overriding principals for our 
office. First, we must maintain our independence in all of our 
work, including avoiding the mere appearance of any undue 
outside influence. Second, we must be as transparent as 
possible, while safeguarding the privacy of veterans, 
whistleblowers, and others. Third, we must produce work of the 
highest quality, making sure it is accurate, timely, fair, 
objective and thorough.
    During my first month, I have spent significant time 
reviewing our healthcare inspections of Tomah. I have also met 
with the Homeland Security staff on two occasions to ensure 
they have the necessary information about our work as it 
pertains to Tomah.
    My written statement contains a timeline of events related 
to the Tomah Administrative Closure and I will not repeat it 
here. The inspection was administratively closed given the 
totality of the facts identified at that time.
    Specifically, that the allegations could not be 
substantiated, the impact that disclosure of unsubstantiated 
allegations could have on an individual's reputation and 
privacy, and knowing our forthcoming 2014 national report would 
highlight many deficiency in VA providers' compliance with 
opioid prescribing guidelines.
    I would like to comment on the White Paper about the Tomah 
inspection that was issued by my office on June 4, 2015. I do 
not agree with its tone or the gratuitous attacks on the 
reputation of individuals mentioned in it. It does not meet the 
high standards expected of our office.
    We have learned important lessons from this experience, 
including increasing the transparency of our work that should 
help us better meet our mission going forward.
    The changes made should increase the confidence that 
veterans, Veterans Service Organizations (VSOs), Congress, and 
the public have in us.
    Subsequent to last year's hearing here, we released two 
additional inspections regarding Tomah. In June we issued a 
report with local and national recommendations focused on acute 
stroke treatment. And, in August we issued a report regarding 
the unexpected death of a patient during treatment at Tomah. 
This report had four recommendations.
    Notably we recommended that the facility ensure clinicians 
comply with VA policy regarding written informed consent when 
administering hazardous drugs.
    The issues associated with the use of opioids to treat 
chronic pain and other conditions are a serious concern, not 
just at Tomah, but throughout our Nation.
    We continue to focus on VA's opioid prescription practices, 
publishing two reports on the topics earlier this year. That 
work identified many of the same issues reported in our May 
2014, national review.
    We found VA was not following its own policies and 
procedures in six key areas, including follow-up evaluations of 
patients on take-home opioids, prescribing and dispensing of 
benzodiazepines concurrently with opioids, and routine and 
random urine drug tests prior to and during take-home opioid 
therapy.
    We note VA has taken actions to implement that report's 
recommendations, but they must monitor facility compliance with 
opioid prescription policies.
    Later this year we expect to publish a wide-ranging 
national review of VA's pain management services, substance use 
treatment programs, use of non-VA treatments, opioid 
prescribing practices, and access to State prescription drug 
monitoring programs.
    Yesterday our Nation paid tribute to the sacrifices of 
those who gave their lives in our defense. It is a valuable 
reminder for us at the OIG to rededicate ourselves to ensuring 
that our work is independent, accurate, timely, fair, objective 
and thorough.
    Dr. Daigh and I look forward to your questions.
    Senator Johnson. Thank you, Inspector General Missal.
    Mr. Gibson, let me start with you. When did the problems 
here at Tomah first hit your radar screen? When did you first 
hear about them? And, you have been in the VA how long?
    Mr. Gibson. I have been in VA for 2 years and 3 months--2 
years and 4 months--right around there.
    I think I am going to go from broad recollection, because I 
did not go back to check the record. I am going to say probably 
sometime around January.
    Senator Johnson. Ok. When the news story broke, basically?
    Mr. Gibson. Yes, that is correct.
    Senator Johnson. So, in your experience with the VA, what 
was--during that time frame, what was the attitude of the VA? 
The main Department with the Office of Inspector General?
    Mr. Gibson. I would tell you, coming into the organization, 
I have always viewed, whether it is called an IG or some other 
entity, an auditor, that having a working relationship, a 
constructive relationship, albeit recognizing their 
independence, is vital, because, at the end of the day, we are 
after the same thing.
    I have worked to try to create that kind of relationship. I 
always find it amusing when folks suggest that the IG has been 
management's lap dog, because, if you go look, they issue over 
300 reports a year, which means we are getting wire-bushed 
about six times a week, every single week, and you scan the 
array of IG reports and you will find that there is no 
pandering to VA interest there. It is a very strong and 
independent entity.
    Senator Johnson. This Committee, does a lot of work with 
different Inspectors General. We see kind of a spectrum, quite 
honestly.
    Mr. Gibson. I am sure you do.
    Senator Johnson. As Ranking Member of a Subcommittee of 
this Committee, we uncovered the corruption within the Office 
of Inspector General at the Department of Homeland Security and 
Charles Edwards basically moved on ahead of the posse, so have 
seen the lack of independence.
    Mr. Gibson. Yes.
    Senator Johnson. What I thought was quite shocking as we 
got involved in this situation, is that the Office of Inspector 
General had 140 reports on investigations and inspections that 
it buried, that it was covered up, it did not make public. Now, 
I have mentioned that to other Inspectors General and I asked 
them, how many reports have you not made public? And, they 
really look at me like I am from some other planet.
    I think I have had one Inspector General say, well, there 
was one we did not publish, because of concerns about national 
security.
    So, do you think it is appropriate that there are 140--now 
there is, by the way, another 70 percent reports on different 
wait time problems that apparently now the Office of Inspector 
General was starting to produce on a rolling basis, but that is 
a shocking number of reports on investigations and inspections 
from an independent transparent office that were not made 
public.
    What is your take on that?
    Mr. Gibson. Well, my take is that, in general, they should 
be made public. And, I think that is the stance that the IG has 
taken. There have been instances where this Office of Inspector 
General has identified things in the course of their 
investigation that were not related to what they were seeking 
to look into where they have come to me specifically to say, 
you need to know about this and where we have taken appropriate 
actions in the wake of that.
    That is the kind, I think, frankly, part of what you see 
here, and I was not here 4 years ago, so I cannot talk 
knowledgeably about what was or was not the environment and the 
practice. But I will tell you, over my two plus years here, 
that the IG has been willing to bring things to me, and I think 
it is a much more principled base view. I think some of this, 
we get wrapped up in the rules, and we get so wrapped up in the 
rules, we lose sight of the principles.
    And so, here is a case where I think, quite frankly, this 
is my view from the outside looking in, where we got focused on 
the rules. And, the rules basically said, this is what we are 
here to investigate, and we did step back and look more broadly 
at principles and I think the IG has demonstrated the 
willingness and the ability to do that in subsequent events. I 
do not know whether they learned from this particular instance 
or from other, but I think that is what we owe veterans.
    And, I am going to go back and say that, ahead of anything 
else, this is a leadership failure. There is lots of finger 
pointing and everything else. At the end of the day, we own 
this. VA leadership owns this. We had ample opportunity over a 
period of years to fix this. That was the leadership's 
responsibility.
    And, we failed to get it done.
    Senator Johnson. I appreciate that. Dr. Daigh, you were 
part of the inspection team for Tomah, correct?
    Dr. Daigh. That is correct.
    Senator Johnson. One of the things that come across in our 
report is the confusion over what is the standard for 
substantiating a claim? For example, in so many instances, this 
was not a he said/she said, which, again, I have been in 
business. I have had these employees situations where it is 
kind of difficult when it is he said/she said. This is a case 
with Dr. Houlihan where it was he said/they said. I mean, there 
was so much corroboration of the allegations.
    How did you come to the conclusion that so many of these 
charges were unsubstantiated? What is the standard?
    Dr. Daigh. Well, maybe what I could do is go through the 
allegations one by one and we can talk about them.
    Senator Johnson. Let us talk about, why we do not talk 
about the allegations of a climate of fear, a culture of fear 
within the--I mean, there was so many reports and it was so 
obvious that Dr. Houlihan, according to testimony, was a bully 
and created that and retaliated, and there were people fired as 
a result. And, Chris Kirkpatrick committed suicide after he was 
fired. I mean, there was so much accumulated evidence, how 
could that not be substantiated?
    Dr. Daigh. So, we did substantiate that there was an issue 
with the relationship between the Chief of Staff and the 
pharmacists, primarily. And, we transmitted that information to 
the Veterans Health Administration (VHA). It was not a 
surprise. And, the proof that we transmitted that, and that it 
was not a surprise is at the end our review. We sat down and 
talked with both the Director of Tomah and the Veterans 
Integrated Service Network (VISN) Director, and they told us at 
the time that we were outbriefing them, of the changes they had 
made so that the Chief of Staff no longer supervised the 
pharmacists.
    They were aware of problems in the pharmacy and were 
working to try to correct them. So, with respect to the 
relationship between the Chief of Staff and the pharmacists, 
our Administrative Closure lays it out clearly that that was an 
issue.
    It was not, in my view, the primary problem that was 
addressed at Tomah.
    The primary problem was the allegation that Tomah providers 
were providing narcotics outside of the standard of care and 
that narcotics were being distributed in such a way that the 
rules of law were being broken.
    We looked extensively to find out whether that was true or 
not.
    Medical experts reviewed many charts. We reviewed many 
emails of 17 providers at VA looking for evidence of a problem. 
Evidence of criminality.
    Our investigators went undercover looking for evidence of 
criminality.
    So, I am left with the problem of, there are allegations, 
and I just do not have the facts to support many of those 
allegations.
    Senator Johnson. I mean, most people reading our report 
will say there is a lot of substantiated evidence to support 
that charge.
    Just quick before I turn over to Senator Baldwin.
    On page 270, we have your signature on the Administrative 
Closure sheet. Every ounce of evidence that we can find shows 
that Administrative Closure occurred in August of 2014. I want 
everybody to take a look at page 270. It completely looks like 
this has been doctored from 8-12-14 to 3-12-14.
    Dr. Daigh. It has not been doctored.
    Senator Johnson. So what, what further evidence, other than 
this, what appears to be a doctored----
    Voice. Liar.
    Senator Johnson [continued]. Signature, what other evidence 
would indicate that you closed this out in March versus August?
    Dr. Daigh. So, when information flows, I would sign a 
document, as I signed this one. And, in the Administrative 
Closures they come to my desk. I sign them and I write a date 
on it.
    Senator Johnson. Is that normally how you write a three? 
With an eight kind of embodied within the three?
    Dr. Daigh. That is what I wrote.
    Senator Johnson. Is there any further evidence that this 
was actually administratively closed in March of 2014, because 
everything else shows that you administratively closed this in 
August?
    Dr. Daigh. No, I do not know what you are talking about. 
The actual date that I signed the report, it then goes into 
other systems, which are systems of record, and it is entered 
into what we call a different computer system, and it was 
closed at that time.
    Senator Johnson. I find this unbelievably puzzling and I do 
want to get to the bottom of this. Senator Baldwin.
    Senator Baldwin. Thank you. So, I want to kind of start 
where Senator Johnson left off with regard to this process on 
this Administrative Closure.
    The report, Committee report outlines a very long 
inspection, investigation. You used the words somewhat 
interchangeably.
    Now, the work product after the inspection, the visits, the 
interviews, etc., seems to have gone through a number of 
iterations prior to there being a decision to make this an 
Administrative Closure. I know that, and you will see this 
throughout the Committee report, frustrations expressed about 
documents that were requested from the Inspector General, but 
were not granted to the Committee.
    But we had an opportunity granted by the IG's office in the 

last couple of weeks to inspect the draft reports. Could not 
take notes--and I did not do it, but my staff went in to see 
them, and so the Committee has reviewed some of the drafts 
prepared during the Tomah investigation, and I was disturbed to 
learn, after I was briefed, that things that the IG staff was 
aware of did not make it into the final Administrative Closure.
    For example, one case study referenced in an IG draft 
report explained that Dr. Houlihan had increased one patient's 
dosage of oxycodone more than eight fold in one year. And, that 
there was not always a rationale noted in the chart. During the 
same time frame, this patient had nine refills of a Schedule II 
controlled substance dispensed more than a week early.
    Probably more disturbing, the case study explained, and I 
am paraphrasing, because there were not copies available, that 
Dr. Houlihan miscalculated the number of pills prescribed to 
the patient and that Dr. Houlihan made up for the shortage by 
refilling the prescription early.
    Can you explain to me why details of these case studies 
referenced in the draft report did not make it into the final 
Administrative Closure?
    Dr. Daigh. My instruction to the staff was, because the 
draft report did not substantiate what I thought were the 
significant allegations that we were looking at, I asked them 
then to write an Administrative Closure. So, the same people 
that wrote the draft report wrote the Administrative Closure. 
There were no instructions as to what to put in or what to put 
out.
    If you will take a look at the 140 Administrative Closures 
that we had done previously, and I will say that it was my 
understanding and our practice that if I took a hotline, I 
would either publish it to the web or I would note in the Semi-
Annual report (SAR) to the Congress that we had an 
Administrative Closure. So they were, in my view, made public 
there, although, albeit, not with very much detail. Some years 
there was a lot of detail, some years there was not, but I 
asked them to write an Administrative Closure. So they chose, 
for I do not know what reason, to shorten it up, and it was, 11 
pages for the Administrative Closure. Most of the 
Administrative Closures that we publish are one or two pages, 
so they were trying to put in the detail they thought was 
relevant.
    Senator Baldwin. Well, I mean, on that Administrative 
Closure, you did note that patients requested early refills, 
but the document does not state that Dr. Houlihan wrote in 
files that he miscalculated the prescriptions and made up for 
the shortages by refilling the prescriptions. And, to me, this 
tells a different story. There is also no mention that he did 
not always provide a rationale in the charts for substantially 
increasing already high prescriptions like the example I just 
mentioned.
    So we gathered, in March of 2015, this, the Senate Homeland 
Security and Governmental Affairs Committee, and you testified. 
You testified that staff at Tomah were at the outer boundary of 
acceptable prescribing practices. And, this statement seems to 
imply to me that there may have been some unusual practices 
happening at the Tomah facility and within the facility's 
leadership.
    So, is the example I just raised the type of thing that was 
on the outer boundary of acceptable prescribing practices or is 
it beyond that boundary.
    Dr. Daigh. I would say that our view was that, in summary, 
he was at the outer boundary. And, the facts that you described 
would be, in my view, probably over the outer boundary. But we 
thought that the totality of the care provided, was at the 
outer boundary.
    Senator Baldwin. Inspector General Missal, I know you are 
new to this position, but you have read this Committee report, 
and I guess I want to know your opinion on putting out a policy 
that outlines what the standard ought to be in your Agency for 
substantiating or unsubstantiating allegations, at least for 
cases like this where you think it might be a close call or 
right outside those boundaries?
    Mr. Missal. Yes. I have looked at that. I have had the 
opportunity to review the report. Standard of care is a 
complicated issue. For instance, when we are doing an 
investigation, we look to see if somebody did something wrong. 
The standard to me is preponderance of the evidence. Is it more 
likely than not that somebody did it?
    With respect to healthcare inspections, you are looking at 
the quality of care, which is a far more complicated area. And, 
it really depends on a variety of things of what you are 
looking at. For example, what the literature says, what experts 
may say, etc., but I understand the point. I know it was a 
significant issue and we intend to look very closely at that 
and to talk about standard of care and the standards that we 
are going to be using going forward, so we will be doing that.
    Senator Baldwin. Well, with the advantage of hindsight, 
this does not look all that complicated to me.
    Mr. Missal. We are going to look at that very closely.
    Senator Johnson. Thank you, Senator Baldwin.
    What is amazing is they had a pretty high standard for, 
substantiating a claim in their OIG report, but yet in the 
White Paper, they had no problem rushing out a report that 
literally threw the whistleblowers and these individuals under 
the bus. It is really quite remarkable.
    I also appreciate the fact that you were talking about the 
frustration this Committee has had in obtaining the 
information. I just want to refer everybody to page 324. This 
is what one of the documents looks like provided by the Office 
of Inspector General, who has not yet complied with our full 
subpoena. I mean, think about that. This Committee had to 
subpoena the Office of Inspector General to get the 
information. And now, 16 months later, well, it is really about 
a year later, because we issued the subpoena at the end of 
April, still has not been complied with, so, Mr. Missal, again, 
we look forward to working with you on that.
    I do want to welcome Representative Kind and Representative 
Walz from Minnesota, and we will not hold that against you. 
Congressman Kind.

             OPENING STATEMENT OF CONGRESSMAN KIND

    Mr. Kind. Thank you, Senator. I want to thank you too for 
yours and the Committee's invitation for me and Representative 
Walz to participate in today's hearing.
    Yesterday, as many of us were at Memorial Day commemoration 
events, and during it, it is a sober reminder of not only our 
obligation to honor our fallen heroes, but the unfinished work 
of making sure that our veterans, those who served our nation 
are receiving the care and the treatment that they have earned 
and that they deserve. And, that has always been my guiding 
star throughout this whole process, given the tragedy, given 
the mistakes that were made at Tomah, which, according to your 
testimony here today, has not been unusual in regards to the VA 
medical system throughout the nation. If we keep our focus on 
the veterans and making sure that that is our true guiding 
star, then hopefully we can bring some good out of a tragedy. 
And, I know that is exactly what has been motivating the 
Simcakoski family this whole time.
    I have been proud and honored to be able to work with each 
one of them when it comes to fixing the problems to ensure that 
no veteran in the future goes through what that family has 
done. Jason's wife Heather, and his parents, Linda and Marv, 
have been intimately involved in not only providing feedback on 
the legislation we have been working on to honor his legacy, 
the Jason Simcakoski Promise Act, but they have even taken the 
extra step of making phone calls to appropriate Committee 
Members, even to Speaker Ryan, about the importance and the 
urgency of getting this legislation done and implemented as 
quickly as possible.
    In fact, Heather and Linda and Heather's daughter Aniah 
were out just out in Washington a couple of weeks ago to make 
some last minute visits, but also to personally witness the 
passage of the Jason Simcakoski Promise Act unanimously on the 
House floor, and we look forward to working with this Committee 
and you Senators in order to ensure that this reaches the 
President's desk and get this done and implement it as quickly 
as possible.
    Heather asked today if I would be willing to read a short 
two-paragraph statement for the record and I ask unanimous 
consent to do so at this time.
    Senator Johnson. Sure.
    Mr. Kind. She writes, and I quote, ``It is encouraging to 
see the Congressional delegation working together in honor of 
Jason, to ensure no other families go through what we had to 
endure. We are proud of the progress made so far in passing 
legislation named after Jason. We look forward to working with 
the Congressional delegation to make sure the legislation 
becomes law.
    ``We are grateful for an opportunity to see everyone come 
together to turn such tragedy into something that has the 
potential to save so many lives in the future. As we can 
continue moving forward, we are committed to remaining focused 
on the bipartisan support for this legislation.''
    Clearly the job is not done yet, but I do want to commend 
Acting Director Vicki Brahm, for the progress that has been 
made at Tomah. This comes on the heels of the work that then 
Acting Director John Rohrer when he came in, and inherited the 
challenge that existed and what they are trying to build on 
right now--the community outreach, working with the staff on 
best practices, but especially listening to the families and to 
the veterans themselves, making sure that they have input and 
say in what is taking place there.
    I think it is important that we stay focused in that 
endeavor.
    But I also would be remiss if I did not mention the good 
work that has been done at Tomah. I have been somewhat 
surprised by the number of veterans who have gone out of their 
way to personally notify me at how happy they are with the care 
and treatment they have received at Tomah. Any my guess is this 
would be fairly consistent around the country too.
    So, although there were serious allegations and mistakes 
made, I do not think we should overlook a lot of the 
dedication, a lot of the professionalism, a lot of compassion 
that is taking place at places like Tomah each and every day, 
and sometimes, given the sensation of these stories and what 
the media tends to focus on, that gets lost in kind of the fog 
of everything that we are trying to accomplish.
    But, Mr. Missal, while we have you here, and we know you 
are new to the position, and it has been raised already by the 
Senators, we did have some communication problems with the IG's 
office when it comes to conducting the investigation, proper 
notification.
    I know that when I had received an anonymous letter back in 
September of 2011, I immediately forwarded that onto the OIG's 
office, asking them to look into it and conduct an 
investigation. Received notification that they were going to do 
that and that we be notified at the end of that investigation.
    Now, listen, I am a former special prosecutor and I have 
been involved in a lot of investigations myself. You do not 
know when you go into an investigation how long it is going to 
take, how complex it is going to be. You talk to one witness 
and suddenly 10 more names appear. I get all of that. But what 
was problematic to me and to the Committees of jurisdiction was 
the lack of notification when the IG's office administratively 
closed it with certain reforms and changes that had to be made 
and we were operating in the dark, because there was no 
notification again.
    And, I also want to commend Representative Walz who serves 
on the House Committee on Veterans' Affairs for the work that 
he has done. He has been a good partner through all of this, 
along with Gus Bilirakis, a real bipartisan effort, but we are 
only as good as the information that is given to us.
    And, Dr. Daigh, when the report did come out, and I later 
found out that we were not notified, I called you and others 
that were involved in the investigation into my office 
immediately to get clarification on what was taking place. To 
your credit, you guys owned up, that the ball had been dropped, 
notification was not given when the intent was--I know this was 
coming at the time of Phoenix and other news stories that were 
breaking at the time, but in light of all that, I introduced 
legislation, the Inspector General Transparency Act, which I am 
glad was included in the year-end budget last year, which now 
requires that notification.
    So, Mr. Missal, on that point specifically, is that going 
to help in your mind, as far as the lines of communication, 
keeping policy makers informed of what changes and reforms have 
to be made, so we can be working together and in tandem to make 
sure that this gets done?
    Mr. Missal. Yes, I think it will help, but hopefully we do 
not need legislation to become more transparent.
    My goal is to communicate better with the public, with 
Congress and with the Department on issues. There were a number 
of mistakes made by my office at the time and we agree that one 
of the mistakes was not keeping Congress better informed on 
this issue. And, I am going to work very hard to make sure that 
does not happen again.
    Mr. Kind. Mr. Gibson, I appreciate your testimony, written 
and your oral testimony today, about the need to continue on a 
more coordinated, integrated veteran-focused healthcare 
delivery system. I think a lot of ways--the VA system 
throughout the country has been good in driving that, that 
goal, that momentum in that direction, but, clearly, more work 
needs to be done.
    Mr. Gibson. Yes.
    Mr. Kind. Is there any other things that Congress needs to 
be working with the VA on right now to make sure that you are 
given the policy prescription, but also the tools and resources 
in order to get this accomplished?
    Mr. Gibson. I appreciate the request, and I appreciate your 
recognizing the good work that goes on every day. Because, you 
are right, it does not get reported. It does not diminish the 
challenges that we have, but it is part of the context. The 
short answer is yes. And, we have been working, really, with 
both of our authorizing committees on an array of legislative 
priorities that we have, many of which get at some of these 
very issues. I am thinking most immediately of the request to 
make all of our Medical Center Directors and Network Directors 
Title 38.
    Quite frankly, if I had that authority in my hip pocket 
right now, the lady sitting behind me would already be the 
Medical Center Director here. But I am probably going to get in 
trouble for committing a prohibited personnel practice for 
having said that, but, she is doing awesome work and she is the 
kind of person--and having the kind of ability to, to direct 
hire and a little flexibility around compensation would make 
that possible, among a large number of other priorities that 
you have identified. Thank you for asking, sir.
    Mr. Kind. Thank you.
    Senator Johnson. Congressman Walz.

             OPENING STATEMENT OF CONGRESSMAN WALZ

    Mr. Walz. Thank you Senator Johnson, for including me in 
this hearing and the past one.
    Thank you, Senator Baldwin and Congressman Kind, for all 
three of you, the work that you do.
    I am Tim Walz. I represent Minnesota's First Congressional 
District. It is just a little bit west of here across the river 
and then all the way out to South Dakota. And, that river may 
separate us on football loyalty, but it does not separate us as 
Americans.
    And, many of my constituents use this facility.
    Also, prior to being in Congress I spend 24 years as an 
artilleryman and retired as a Command Sergeant Major and spent 
the last 10 years on the House Veterans' Affairs Committee, so 
I have spent the last 35 years, not just talking about veterans 
issues, but being part of that.
    And, I can tell you this--that, as a member of Congress, 
the security of this nation and the care of our warriors is our 
number one priority. That is also the number one priority of 
all of you sitting out there and every constituent in my 
District and Ron's District and across Wisconsin and Minnesota. 
It is also the number one priority of these folks sitting up 
here.
    And, you just do not get in this and leave. For example, 
Mr. Gibson, some of you do not know, my capacity of working 
with him prior to his current position was, he ran the United 
Service Organizations (USO), a fabulous organization that cares 
for our warriors, which he did with grace, skill, 
effectiveness, and I think for all of us trying to find 
solutions to the best care possible is what we are here for, so 
I appreciate all of you coming out on a day like this.
    And, to the family, you heard it. And, I think that is the 
thing that always most strikes me. In the midst of heart-
wrenching tragedy that I will not even attempt to understand, a 
family seeking justice, which they deserve, and we should 
deliver, but also transferring that into solutions to make sure 
no other family goes through it too, whether they meet them or 
not. And, that is a very powerful call to action for us. So, I 
look at it as, our responsibility is to get them the justice, 
find out what went wrong, find out who is responsible and hold 
them accountable, but simultaneously making sure that the 
changes that are being made do not happen.
    And, for some of you to think on this is, there really is 
nothing new under the sun. I think about this, and the folks up 
here, and Ron and I have talked about this and have worked 
together on.
    The first two things that I was able to do when I got to 
Congress would actually put into law and effected was first 
increasing the budget for the VA Inspector General, which at 
that time was incredibly low and you simply did not have enough 
people to go out. We would send in a request, and you would 
say, I do not have people to cover this and we could not find 
those eyes on it.
    And, secondly was passing step pain management on opioid 
reduction. In 2007 people were already thinking about that. Not 
just me, but folks up here and folks that understood this were 
trying to implement that. And, I guess for me, we made a good 
effort, and I think the VA and Mr. Gibson are right. This is an 
issue that is systemic to our entire culture. And, it is a huge 
problem. Now you hear lots of people talking about it. That is 
great, but there are solutions out there. We need to implement 
them and move them forward.
    And, I know that the bill that I passed went from 2009 to 
2014. We were only able to implement 31 percent of it by the 
time it expired in terms of doing this. And, these are best 
practices that are out there.
    So, I think today in the time that we are going to have 
here today, I am going to attempt to try to focus on what has 
changed at Tomah. And, trust me on this. Dr. Houlihan or anyone 
else involved in this, justice needs to be served and we will 
find that. Senator Johnson will continue to do that and Senator 
Baldwin.
    As a member of the House Veterans' Affairs Committee, I 
want to know what you have done to make a difference. What 
happens with my veterans from Houston County who come over to 
Tomah now and what has changed?
    And, with my remaining time I am going to start on a line 
of questioning on this is, and, Mr. Gibson, maybe you can help 
me with this. How do I know things are better at Tomah? How do 
I know, if someone asked me, is it better at Tomah or is it the 
same thing that happened when the reputation that, that started 
this was there?
    Mr. Gibson. I think some of the activities that I described 
earlier, Vicki has been engaging in; the open door with 
veterans, the outreach into the community, and looking for ways 
where we bring the community together to help support our 
veterans.
    And, one of the things that we started doing recently, 
because access is such a critical issue for us, is we started, 
at our kiosks, asking the one very simple question, how 
satisfied were you that you got today's appointment when you 
wanted it. At Tomah the answer is 93 percent satisfied or 
completely satisfied.
    They are doing so many things so well. You can look at the 
sale data.
    Many of you may not realize VA leads the country, perhaps 
the world, in reducing healthcare associated infections. 
Healthcare associated infections--second leading cause of death 
in 
America--more than automobile accidents and breast cancer 
combined.
    And when, and external studies, when looked, who was, who 
was doing this better than any other organization? It was not 
the Cleveland Clinic. It was not Kaiser Permanente. It was not 
Geisinger. It was VA.
    Mr. Walz. Not even Mayo.
    Mr. Gibson. Guess who? Guess who leads VA? Tomah, in 
minimizing healthcare associated infections.
    I will tell you, the number one area where they have work 
to do is in employee satisfaction and employee engagement. And, 
that is the culture problem. And, that is why leadership 
matters so much.
    So, veterans are telling us, you are hearing from veterans 
that are saying--I have heard from veterans here. And, I will 
tell you, my classmate was a patient here in the Community 
Living Center (CLC) for 23 years. And, the family in his 
obituary said the staff here made them feel like they were part 
of their family.
    That is what is happening with so many of the Wisconsinites 
that are working right here, caring for our veterans, are they 
doing the right thing, but we did not have the right leadership 
in place. And, I think, I think we have a good clue----
    Mr. Walz. We need to give them the tools because----
    Mr. Gibson. Yes, we do.
    Mr. Walz. We owe them nothing less. You hear that.
    Mr. Gibson. Yes.
    Mr. Walz. But, and equally important as holding 
accountable, and if it is firing, or whatever needs to be done 
to those people, we need to have the ability, as you said, and 
I am with you on the Title 38. We need to be able to hire the 
best and possible, because we cannot fire away to a fix, but we 
can simultaneously get rid of the bad and bring in the good.
    Mr. Gibson. You got it.
    Mr. Walz. And, I yield back.
    Mr. Gibson. You got it.
    Senator Johnson. Thank you, Congressman Walz.
    Let me continue on that vein about accountability.
    In 2015 I introduced the Ensuring Veterans Safety Through 
Accountability Act and I testified with Senator Baldwin when 
she introduced the Jason Simcakoski--I always forget the full 
name.
    Senator Baldwin. Opioid Safety Act.
    Senator Johnson. Opioid Safety Act at the Veterans' Affairs 
Committee. I was more than disappointed when the 
representatives from the VA testified against the 
Accountability Act.
    Now, fortunately, a similar provision introduced by Marco 
Rubio, which I cosponsored, was passed by the VA Committee, but 
having been in business for 30 some years, I mean, I understand 
that probably the most corrosive thing to any organization is 
not being able to hold the bad actors accountable. And, yet 
here you have the representatives of VA saying, nah, we do not 
want that authority to hold people accountable.
    I mean, that is at the heart. I agree with you. I think all 
of us here agree. As we tour around and talk to the doctors and 
nurses, and as I said in my opening statement, they do an 
extraordinary job. They are really concerned, but unless we 
really have the ability to hold people accountable, that is 
what causes these types of tragedies, so is that something that 
the VA will now embrace? The ability to actually discipline and 
terminate and hold people accountable through the VA system.
    Mr. Gibson. I would say the answer is an unequivocal yes.
    Senator Johnson. Good. We will move on.
    Mr. Gibson. Well, that has been part of my own personal 
obligation as a leader since I first got to VA. I am the guy 
that takes action on senior leaders in the department. I am the 
guy that issued the removal on DeSanctis. And, I am the guy 
that looks at other instances of particular notoriety to ensure 
that we are taking the appropriate action.
    Senator Johnson. Good. But we want to give you that 
authority, because you have to have it.
    Another piece of legislation I introduced was the Dr. Chris 
Kirkpatrick--let me give you the full title of that one as 
well: The Christopher Kirkpatrick Whistleblower Protection Act. 
And, this was really prompted by a Committee hearing we had 
where Sean Kirkpatrick testified before our Committee, and one 
thing that I have been literally shocked by, again, coming from 
the private sector, even though we have all these whistleblower 
protection laws on the books for a hundred years, the level of 
retaliation against those people that have the courage to come 
forward, like Dr. Noelle Johnson, like Ryan Honl, like Chris 
Kirkpatrick, is jaw dropping.
    So, again, I hope that the VA will embrace and help support 
the passage of that piece of legislation to give those 
whistleblowers the protection they really need.
    And, by the way, I would announce again that my 
Committee has set up the whistleblower hotline. It is just 
whistleblower@ronjohnson.senate.gov. People are using that. 
And, I think it is also an important step that is required, so 
that whistleblowers within the VA--and, by the way, the highest 
level of retaliation, according to the Office of Special 
Counsel (OSC), is within the Veterans Administration, which is 
a real problem.
    So, again, will you support the Christopher Kirkpatrick 
Whistleblower Protection Act?
    Mr. Gibson. I do not know what is in the Act and I also do 
not know what is in the Accountability legislation you referred 
to earlier.
    But what I will tell you is that I personally, as the 
Acting Secretary, met with Carolyn Lerner, the Special Counsel 
of the United States. I committed to VA becoming certified, the 
first large Federal department that became certified as a 
whistleblower protecting organization. I have publicly 
recognized and, and presented awards to whistleblowers. I meet 
with whistleblowers in every location where I go visit. When I 
came to this location last year, I met with Ryan Honl. I do 
that. Coming out of the private sector, I understand that your 
most valuable source of information on how to do things better 
are your frontline employees.
    The last thing you want are people that are afraid to raise 
their hand, so everything we are doing as an organization has 
to do with creating that kind of culture.
    A little bit along the lines of what Mike said earlier, I 
do not need a law to tell me to do that. That is back to just 
good leadership. Not necessarily from me, but from people 
across the Department.
    Senator Johnson. I appreciate that.
    Dr. Daigh, as I am going through the Committee's report. 
And, you see that the first hotline notice, really, is about 
March 2011. And, for whatever reason, it did not rise to the 
level. And, then in August 2011, partly because of 
Representative Kind's inquiry, it all of a sudden became a 
Congressional hotline or Congressional inquiry, gained a little 
steam and got the notice, but it took until 2014 to complete 
this inspection, investigation, and then issue some kind of 
report.
    There is an awful lot of activity and I think the first 
site visit was in 2012, and not a whole lot happened in 2013 
into whatever date it actually was closed. What was happening 
during that point in time?
    Dr. Daigh. Well, let me first set the record straight on 
the issue of the date at the bottom of the report. That date is 
accurate. And, if you will look at the e-mails which transmit 
the pdf of the report I signed, you will find that those dates 
are consistent with the date I signed.
    Senator Johnson. OK, good. Great. I appreciate that.
    Dr. Daigh. That is absolutely the truth. And, I believe 
that data may be in your hands now. I am not absolutely sure 
how many of the thousands of records we gave you, you have.
    The problem with this Tomah allegation was, we got a letter 
very early on, that laid out a whole series of cases which 
alleged that there was horrible care provided. And, 
unfortunately, I received many more allegations than I have the 
resources to investigate or inspect. So, with that letter, we 
read it. I did not have the resources at the date that came in, 
and so I sent it to VHA. I usually send it to one management 
level above, so it would go the VISN. And, the VISN wrote us 
back a letter with each of the cases outlying how the quality 
of care has been appropriate. So, we read that letter. And, we 
said, OK, this makes sense. We will say that, we will close 
this at this point in time.
    As part of the Combined Assessment Program (CAP) process, 
we have an employee survey where we ask employees what their 
view of the world is with respect to quality of care at a 
facility. And, we did a CAP about that time and a number of 
Tomah employees indicated that there were concerns about 
medication abuse at Tomah. We had that fact.
    We got a letter from Congressman Kind, saying there was an 
issue, so we said OK. We need to go out to Tomah and figure out 
what the real story is. And so, that launched our hotline 
review.
    I sent a team out there, as you note, and we made calls 
before. We got all the data we could ahead of time. We went out 
there. And, the allegations continued to increase. I think the 
Administrative Closure lists 32 or 33 different allegations.
    So, as the allegations increase, you go down more and more 
tracks. And, as we would go down a track, unfortunately we got 
a lot of dead ends. People would say, a certain transaction had 
occurred at a certain place. We could not find any data for 
that. We could not find evidence for that.
    So, we decided then that what we needed to do was to pull 
all the emails for employees that worked there for a certain 
period of time, so you have to stop and say, ``OK let us go get 
the emails.'' We had an email pull. It was insufficient the 
first time. Then we had to go actually to their computers and 
pull the email off their computers, and get that back. You have 
to read that email. We were in continuous conversation with the 
DEA, trying to understand where they were or did they have any 
issues with this?
    I then met with our agents and they investigated it, the 
investigators. They agreed to go on-site. So, they went on site 
and did work. So, it took a long time, if you have a relatively 
small number of people and you have allegations that explode, 
to run down each of these tracks.
    Senator Johnson. And, I appreciate that, and yes, the VA, 
when they undertook their own investigation, together with this 
Committee, in just a couple of months pretty well substantiated 
the charge and started holding people accountable, so.
    Dr. Daigh. I think, for me, the important question is 
whether or not VA was aware as we were doing our work of what 
we were finding and were they aware that there were issues at 
Tomah? And, I believe that they were at the local level, the 
VISN level, and at the Veterans Affairs Central Office (VACO), 
aware that there were issues at Tomah that needed to be 
addressed and that we were in communication with them. Not 
every fact was presented to them until we were able to assemble 
the facts and put them out there, and lay them out for everyone 
to see clearly.
    Senator Johnson. I would argue that the responsibility of 
the Inspector General is to make that information public and 
also make sure that something is done about it. And, that did 
not happen.
    I am out of time here. Senator Baldwin.
    Senator Baldwin. On the issue of accountability, I have a 
questions for you, Mr. Gibson.
    Dr. Houlihan was fired from the VA. And, at the time that 
he was fired, I wrote to the VA to ensure that veterans would 
not ultimately be referred to his practice outside the VA 
through the Veterans Choice Program.
    Subsequently, through public reports, his license was 
suspended by the State of Wisconsin. And, I received a letter 
back from the VA indicating that he would not be eligible to 
serve veterans under the Choice Program because his license was 
suspended.
    You may or may not be aware, again, through public 
reporting it appears that an Administrative Law Judge (ALJ) has 
reinstated his license during the pendency of proceedings 
before this State.
    And so, I want to, first of all, get assurances from you 
that in light of that new development, that Dr. Houlihan would 
not be getting referrals of veterans through the Veterans 
Choice Program.
    Mr. Gibson. Absolutely not.
    Senator Baldwin. And----
    Senator Johnson. Senator Baldwin, if I can briefly 
interrupt. That is an incredibly important point you are 
making. That Administrative Law Judge is citing the White 
Paper, so Inspector General Missal, would you repudiate that so 
that that can no longer be used by the Administrative Law 
Judge? That White Paper?
    Mr. Missal. Yes. My office took the White Paper off its 
website, so to me that means it no longer is a document of the 
Inspector General's Office.
    Senator Johnson. Thank you. Senator Baldwin.
    Senator Baldwin. So, this correspondence between me and the 
VA has highlighted for me that nothing in the VA Choice 
legislation explicitly requires that somebody who is fired or 
suspended from the VA for cause related to their service, to 
our nation's veterans, there is nothing that explicitly 
addresses this in the law. And so, I feel like this is a 
dangerous loophole that we currently have.
    I have recently introduced bipartisan legislation that just 
passed the Senate, although it has not made it all the way 
through the legislative process. That legislation requires the 
VA Secretary to block the healthcare provider from 
participating in community programs if that provider was fired 
or suspended from the VA, violated his or her medical license, 
had a Department certification revoked, or otherwise broke the 
law.
    Secretary Gibson, are there steps that the VA can take 
right now to ensure that this loophole is not being exploited 
to taken advantage of by other providers other than the case 
that we are talking about today?
    Mr. Gibson. I have not discussed the matters specifically 
with the folks that are working here in the community, but I 
will do so. There is no reason why we cannot implement a policy 
that accomplishes the same thing without the need for 
legislation.
    Senator Baldwin. During our Chairman's opening statement, 
he drew our attention to portions of the Committee report 
discussing the concern that two of the witnesses during the 
inspection were impaired, possibly by drugs or alcohol. It was 
a suspicion. There is a lot of discussion in the Committee 
report on this.
    I think disturbing was that the only two follow-up actions 
were a doctor emailed the VA OIG's General Counsel wanted to 
discuss a concern regarding possibly an impaired interviewee, 
or interviewees, and subsequently, and off-the-record 
discussion with the Tomah VA's Director at the time, Mario 
DeSanctis.
    There is no clear record of whether that tip was followed 
up on or not.
    My question is, will the VA Office of Inspector General 
adopt new policies or procedures so that if this happen in a 
future case, and, of course, we hope it never does, that the IG 
suspects that a witness employed by the VA is under the 
influence of a controlled substance that there is a procedure 
that will be followed that would provide greater accountability 
and safety for our Nation's veterans?
    I would like to hear both of you on that, but, this was 
first noticed by the team doing the inspection, and so, I want 
to hear what the Inspector General has to say about procedures 
if this should ever happen again. And, then I would like to 
hear from you, Deputy Secretary Gibson.
    Mr. Gibson. I would love to share my two cents worth, yes, 
ma'am.
    Mr. Missal. With respect to my view on that, if I ever see 
a situation where I think somebody, particularly somebody 
providing healthcare to veterans, may be in a situation where 
they are impaired in one way, I would immediately make sure 
appropriate people within VHA or above that were aware of that 
and to follow up and to make sure that that situation was 
resolved to our satisfaction as quickly as possible.
    Senator Baldwin. And, in this particular case, do you have 
any knowledge that the Committee does not about whether 
anything was followed up on by Director DeSanctis?
    Mr. Missal. I do not have any more information.
    Mr. Gibson. I am going to tell you, based upon the first 
time I ever heard of this was reading it in the report. First 
time ever. We are right back to leadership. That is what this 
is about. This is about delivering safe care to veterans. And, 
the failure of leadership that happened here was the failure on 
the part of the Medical Center Director to take appropriate 
action.
    And, everything that I mentioned earlier, I issued the 
removal on the Medical Center Director. I reviewed hundreds and 
hundreds of pages of evidence. And, I will tell you, not doing 
something about this would be very consistent with the pattern 
of behavior that I saw there. It was a failure of leadership. 
It should not have happened. Period.
    The principles here, you said, put the veteran at the 
center of everything that you are doing, and that is exactly 
what we are trying to do. And, understanding--making leadership 
in the organization understand the sense of urgency with which 
they must act when something has been presented to them that 
suggests, that the safety of the veteran, the care of the 
veteran, may be at risk, that is an urgent situation. You have 
to act and you have to act timely and promptly. That is what 
these folks have been doing.
    There was an instance that happened--these folks, and I am 
not going to--I will not get into the great details, but here 
is the timeline. They became aware on November 19, 2015, that 
there was misconduct. They launched a Fact Finding the next 
day, November 20, 2015. The Fact Finding was completed on 
December 7 and the proposed removal was issued on December 8. 
That is the kind of timely action and follow-up. That is what 
good leaders do. And, that is what we have to ensure we have in 
place all across this Department.
    Senator Johnson. I could not agree more.
    Mr. Gibson. We do not need a watchdog to tell us how to do 
our job. Important to have a good watchdog, but we do not need 
one to tell us how to do our job.
    Senator Johnson. Congressman Kind.
    Mr. Kind. Than you, Senator.
    Mr. Gibson, let me stay with you, because, clearly, one of 
the problems we had at Tomah was chain of command. We had a 
Chief of Staff, in this case Dr. Houlihan, who was also 
prescribing medication. And, getting back to the team or 
coordinated approach to proper healthcare delivery, there was a 
culture of intimidation----
    Mr. Gibson. Yes.
    Mr. Kind [continuing]. That was created by Dr. Houlihan 
that made it almost impossible for someone with a dissenting 
view or dissenting opinion to come forward in order to change a 
certain treatment regimen.
    Mr. Gibson. Yes.
    Mr. Kind. Has that been fixed now? Not just in Tomah, but 
throughout the VA Medical System?
    Mr. Gibson. I know it has been fixed here in Tomah. I think 
the issues that has been raised here prompts a review across 
our organization to ensure that we have appropriate separation 
of authority here.
    Very early on, in fact, at the very beginning of the 
Medical Center Director's tenure, the issue of separating the 
reporting relationship for pharmacy was raised. The Medical 
Center Director refused to do that, until, I am going to say, 
roughly a year and a half later, when he finally got a new 
Associate Director in place. We had problems in construction 
with VA and, and the Executive Director responsible for that 
area was encouraged to leave, and he did leave.
    I accepted direct responsibility for construction and 
facilities management until such time as we got the leadership 
in place. That is precisely the kind of action that should have 
been taken here.
    Mr. Kind. That is the thing that probably made me the 
angriest, the information coming out, and probably for more 
most people in this room, was that culture of intimidation.
    Mr. Gibson. Yes.
    Mr. Kind. The bullying that was taking place. Good people 
trying to do the right thing, keeping the focus on the veterans 
were cut off. And, one instance led to a suicide. Other 
instances led to firing or people leaving their positions 
because of this culture that was created. I think it is just 
essential that we fix that throughout the entire system or we 
are going to have another hearing somewhere else in this 
country, I am afraid, talking about the same set of facts.
    Mr. Gibson. The day you and I were here in Tomah, last 
year, together, was the day that Houlihan was placed on 
administrative leave.
    Mr. Kind. I remember that.
    Mr. Gibson. He had been removed from clinical duties, but 
it became evident to me that he was still exerting undue 
influence on other providers in the organization. That was the 
day he was removed.
    Mr. Kind. Back to my original question--what more can 
Congress be doing working with you? I think in your written 
testimony, you said we have to adequately fund the OSC to make 
sure that there are resources to hire additional investigators. 
Do you still have that opinion?
    Mr. Gibson. I do. We work very closely and very 
collaboratively with the Office of Special Counsel. I would say 
to my brethren next to me here that there is probably an 
opportunity for the Office of Special Counsel and our IG to 
work more collaboratively together. Sometimes things have 
gotten in the way of that. But between our investigation 
resources, their investigative resources, and the Office of 
Special Counsel's investigative resources, I think there was an 
opportunity for us to do better by taxpayers and better by 
veterans both.
    Mr. Kind. I would be happy to follow up with you in 
regards----
    Mr. Gibson. Yes.
    Mr. Kind [continuing]. To funding levels and that, but--and 
I know the VA here in Tomah are also exploring more 
alternatives and complimentary forms of medical treatment----
    Mr. Gibson. Yes.
    Mr. Kind [continuing]. Just not loading the vets up on a 
cocktail of prescription drugs and expecting that to solve all 
the problems, but there is also a danger of overreacting. And, 
I have some feedback from veterans that it is a little more 
difficult for them to get the prescription meds, the opioids 
that they need for proper pain management. I know it is a 
difficult balance, but how well are we doing on that front.
    Mr. Gibson. Dr. West.
    Dr. West. Thank you for that question, and you bring up a 
very important point that you cannot overreact, right. I mean, 
I am a physician that still treats patients every week, in my 
own clinic, and you know, I kind of see it every week.
    Forever, the medical system as a whole, including VA and 
our academic centers, was moving forward prescribing pills. We 
found out that was wrong, and that that was actually killing 
people.
    Now we are turning a big aircraft carrier around, and the 
way we are doing it is through exactly what you mentioned, 
complimentary and alternative medicines, and there are other 
medicines to treat pain. There are not just opiates. There are 
neuromodulating agents, new agents coming out all the time.
    So, as a clinician, you have to be very sensitive to the 
patient and the individual case and really work through the 
patient's--I mean, this is all a veteran-centric work-through, 
and it takes a long time. You need things like this. This is a 
brilliant thing that they have come up with at Tomah to support 
frontline physicians in decisionmaking for patients, education 
for patients, and other treatments for patients that they can 
use for their pain.
    Mr. Kind. I would also encourage the VA to continue the 
efforts to provide an avenue or a line of communication for the 
family members themselves. I still think they are the best line 
of defense in all of this. They are going to know what is 
working and what is not with the loved one and their family, so 
making sure we foster that receptive environment for them.
    And, finally, Mr. Gibson, we have to get the message to the 
Directors of all the VA Medical Centers that they have to be as 
candid and truthful and honest with us, because many of us are 
visiting these campuses all the time. Check in on the veterans. 
Find out what is working, what is not working. And, I am at 
Tomah. I am up in the Cities. I try to get down to Madison too. 
And, I am always asking, what do I need to be aware of? Are 
there any problems here that I need to be aware of that we can 
work with you on?
    And, that did not happen, unfortunately, under Director 
DeSanctis's leadership. And, I was on campus. I was looking him 
in the eyes. What do I need to know? What is going on? Is there 
any problems? And, I later found out that just 2 months, 2 
months before I had been on campus one time, the IG was there, 
with the conclusion of the report with recommendations and 
changes that they were already moving forward on. And, I asked 
them and they did not breathe of word of it. And, it is just so 
frustrating, because if you lose that trust, and then something 
like this blows up, there is a lot of preventable error and a 
lot that we could accomplish, so we need to communicate with 
the leadership of our medical centers. They have to be up front 
and honest with us policymakers for us to make the changes that 
are necessary.
    Mr. Gibson. One of the things that we have been doing under 
Leaders Developing Leaders, the Secretary and I have personally 
met with the 600 top leaders of the entire Department, and one 
of the messages that we deliver is the message that you just 
spoke. It is the importance of getting news, whether it be good 
news or bad news. This is a 180 degree change for this 
organization. First of all, folks--they were not talking to 
members of Congress or to the media under any circumstance. 
What we are trying to do is to get them to talk, both when 
there is good news or when there is bad news, let us get it out 
on the table, own the problem, start tackling it, and get it 
fixed. I mean, that is how you earn trust back.
    Mr. Kind. I again commend Acting Director Brahm, because 
the open policy that she has had, it has been a sea change, and 
I am sure we are going to see that continue in the future.
    Mr. Gibson. Yes, sir.
    Senator Johnson. Congressman Walz.
    Mr. Walz. Thank you, Senator. I am going to continue down 
this kind of same line. And, it is about improvement, about 
working towards that, and you have heard it, culture of fear, 
and Senator Johnson rightfully expressed, and I am grateful for 
him, on protection of whistleblowers, of making sure, folks. 
And, I think that is an unfortunate name we give people. If you 
look it up, the synonyms are not positive on this. These are 
ethical employees trying to improve the care for veterans, and 
that is how they need to be referred to and that is how they 
should be treated.
    And, Deputy Secretary Gibson and I have both privately and 
publicly discussed this issue. And, this is frustrating amongst 
all of you out there and my constituents. Nothing makes me more 
boiling mad than when you are saying you know someone did 
something, and then you see they are put on administrative 
leave with pay, and you are thinking, I would have gotten fired 
at my job on that. And, all of us up here--in 5 months, all of 
us are up for that. We get a performance review, and that is 
good, up or down on how it works. There is that sense of 
frustration, but it is also balancing, and you have done--we 
have talked through this.
    Due process is important to our system of rule of law. That 
is due process for the employee and due process for the veteran 
and their family of trying to strike that balance.
    And, I think as you work with--Mr. Kind is right about 
this. It is the transparency. It is restoring the trust of the 
veteran and their family so that know they are going to get the 
best care, but they trust that it is going to work for them. 
So, when you hear Mr. Gibson talk about this, this is no small 
matter. When you hear Title 38 and some of these terms or 
whatever, this part of the authority he is talking about. Laws 
that both the Senate and the House passed to allow them to work 
with their special executive service folks. These are the top-
ranked administrators. Those are the things we are trying to 
get at.
    And, I am not going--and it is not the appropriate place. I 
think it is an appropriate debate, but the idea of employee due 
process, sometimes this idea that you should be able to walk 
in, point a finger and say, you are gone, for any reason, I do 
not think any of us want to live under that. And, I do not 
think any of us want to get rid of the good employees who are 
there. So, what I worry about is, we go gung ho to say, just 
clean the dang place out and fire all these. You have a food 
service worker who has been stripped of their right to have 
someone represent them, bring an allegation forward against bad 
management, and they do not have anyone to stand for them, and 
they are gone. And, the bad management still sits there.
    So, Secretary Gibson, your point on this is you do not need 
a law to do a lot of these things. What you need is an ethical 
compass and the moral responsibility to care for our veterans, 
which I believe we are starting to get there, but what we are 
hearing from up here is, what can we do to ensure that the 
public believes that? Believes that we are not protecting bad 
employees? Believe we are not protecting and giving rights that 
no one else in society would have for bad employees to continue 
to draw a paycheck? Does the Title 38 and some of these tools--
because I can tell you now, if you think it takes a long time 
to fire somebody, try and hire them at the VA. It takes longer.
    You have fresh-faced graduates, psychiatrists, wanting to 
serve this nation's veterans and they wait 9 months to even 
hear back if they are going to get a job. These people are like 
Sasquatch. If you find them, take a picture. Because there is 
none of them. There is none of them.
    And, again, how can we compete if they can go to Mayo 
Clinic or Cleveland Clinic and make five times more?
    Now, I know these people want to serve, but there has to be 
a fairness, so I am just asking you, Mr. Secretary, how do we 
strike this balance between appeasing the public's right for 
justice and getting rid of bad actors, because I deal with 
this.
    I am a school teacher too. And, I know people always say, 
oh, you cannot get rid of a bad school teacher. You know who 
wants to get rid of a bad school teacher more than anybody? A 
good school teacher teaching next door to them.
    Do you know who wants to get rid of a bad VA employee? A 
good VA employee.
    So, how would describe what we can do to ensure you have 
those tools?
    Mr. Gibson. I think first of all, the Title 38 provision 
around senior executives is precisely the right place to go to 
give us both the authority that we need on hiring as well as 
the authority that we need from a disciplinary standpoint.
    I freely admit there are instances where I start wading 
into a particular case, and I ask out loud, who is the advocate 
for the veteran in all of this, because there are lots of 
advocates for the employee. Who is the advocate for the 
veteran? And, I step up and fill that particular void.
    We have to ensure that we are restoring balance there and I 
would tell you, one of the most powerful things that any member 
can do--we all know that there are a lot of good thing going on 
at VA. We all know that. And, when there are opportunities to--
I am not saying, ``do not talk about the bad things,'' because 
there are bad things that we have to do, as well, Just tell the 
whole picture. Yes, we have to fix this. We have to fix this, 
but did you know they are doing this? They are doing this?
    Because the real tragedy comes when veterans who need to 
come to VA for help or for care do not, because of what they 
have been reading in the media and they stay away. That is the 
tragedy. You look at some of the suicide numbers and the 
statistics, and I think we are close to coming out with some 
refined statistics there, but, what we have seen consistently 
when we have looked, is that the preponderant number of 
suicides that veterans commit, each day are veterans that are 
not in the VA Healthcare System.
    And, you look at--the old number has been 17 of the 22 are 
veterans that are not receiving care at VA. We want those 
veterans into the VA Healthcare System if there is any way, 
shape or form for us to get them.
    There were things that we do--Gavin and I have been having 
this conversation because of some of the transformational work 
that he is doing. If we sat here and spent 30 minutes and 
talked about all of the things that VA does around mental 
healthcare, you would not realize. There is no healthcare 
organization in America, perhaps even in the world, that does 
the things, that has the capability that VA has. 550,000 
completed mental health outpatient appointments every single 
month. I mean, all of the ancillary support services that we 
alluded to earlier.
    Mr. Walz. I would argue with you on that. I think this is a 
very important point you are bringing up and this is why that 
simultaneous----
    Mr. Gibson. Thank you very much.
    Mr. Walz [continuing]. Accountability with improvement, if 
I could, Senator Johnson, just end with this, that we as a 
Nation need to not talk about those 22. We do not need to set 
expectations that this is an outcome that is going to happen. 
We have to talk about names and individuals, so when we are 
talking about the mistake here, it is Jason and his family.
    Mr. Gibson. Yes.
    Mr. Walz. What we are going to produce in the future is 
that individual and I think that attitude----
    Mr. Gibson. Yes.
    Mr. Walz [continuing]. Takes us in a better direction.
    Mr. Gibson. Yes.
    Voice. Thank you, sir.
    Senator Johnson. Thank you, Congressman Walz.
    I want to be respectful of everybody's time here. Another 
round of questions would definitely eat into that time, so I 
certainly encourage the Members of the Committee here and the 
Congressmen to certainly submit their questions for the record. 
I am sure we all have additional questions.
    I want to thank our witnesses, but I particularly want to 
thank the families that have suffered this tragedy and the 
whistleblowers for coming forward and having the courage to 
make this public. I know it is not all that easy, but this is 
what transparency is all about. It is what really does produce 
the kind of accountability that, and justice that really is 
deserved here.
    So, with that--I know I have the magic words here 
somewhere. I have them.
    The hearing record will remain open for 15 days until June 
15, at 5:00 p.m. for the submission of statements and questions 
for the record.
    This hearing is adjourned.
    [Whereupon, at 11:49 a.m., the Committee was adjourned.]

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