>> yes, by the providers. basically the provider side they that they would no longer practice this in this area and

they were responsive to that. so now it is a certain amount of perception. and it also took a lot of experience for the providers for those who as a group spoke up and said this is not right. so i do think that this is appropriate. and i think a lot of times resources are placed in areas where there are too many resources and things. so again, it involves a solution >> very quickly. >> to quickly outcome i was trying to institute a position with what is being provided. so we had those two accurate measures, we can know which facility we are putting end, 15 hours or whatever, and the answer exists with more

resources. and this includes the psychiatrist that i was monitoring and so there is a solution there that has more efficiency and it's not just more resources. it. >> thank you very much. i appreciate it. >> sir, you are recognized for five minutes. >> thank you, mr. chairman. i am grateful to all of you as well. it's interesting. mr. davis coming you said something i can relate to. but i have been here 18 months as well. a typical pattern of how this investigation is working out to get the health care that we promised them when they fall for liberty and freedom. so typically a panel comes in and the reference desk. and it tells us unbelievably shocking stories, back to your comment, that are so shocking and disappointing and disappointing to me representing

veterans of our district. and there's nothing celebratory about it. and especially we need to commissar mentions a good future. and representative walden alluded to this as well. you will walk out of here there have been dozens of be a panelist are going to get us to answers, either that you are not telling the truth we don't have other questions to answer and that's going to happen again tonight and if it doesn't happen tonight, i will be shocked. but there are dozens and dozens of high-ranking members and specifically doctor mitchell, this has kind of been in

phoenix, the phoenix facility has been part of this reaction time. one of the things that has floored me is the lack of urgency on the part of the va that there is a five alarm fire and no one is rushing to put it out. i'm thinking that if i was in an among the phoenix va, and if i was responsible for any of this stuff from the minute that this hit the fan nationally i would be trying to get us out doubletime and make sure that my facility is the standard and that we have reset the record and we are an example for the rest of the country. in the three months of this has been part of it, the american people so they will not tolerate this and this committee says that we will not tolerate this either. we will drill this down to where we can provide the best health care of our veterans. but doctor mitchell, have you sent anything in phoenix that says, wow, what a turnaround? people have been fired, there's a ton of accountability and the

people demanding accountability. have you seen that in phoenix in a. >> the turnaround that i have seen has to do with scheduling. because the backlogs have been reduced. i put in a consult and we got a phone call during my appointment and they have certainly done tremendous work in the veterans process. but the problem is they only fix the problem in the media and they haven't fixed the patient care problem although they are certainly working on that in the psychiatry department. so there are administrators they are the refused addresses that was directly impeding care for those patients in the emergency room and there was a meeting or five or six full-time positions we're part of the chain of command and he said flat out that we will not investigate this against doctor mitchell. >> we had the inspector general here a couple of weeks ago who said that the issue of ruling

out corruption is not going to stopcoming it is still actively going on in your corroborating that's actually going on against you. until somebody does a prison and people are fired and that there's actual tangible action being taken and that includes the veterans for health care and in third, your colleagues that you work with as well feel like your backs are covered. how long do you see if it took a national urgency, but it took a resilience on the part of the chairmen chairman and the ranking member actually go after this issue to try to reset it. even if we keep pressure up, even if a new secretary comes in, if we don't root out the corruption, how long do you see that it will take to turn this around if we keep up the same amount of pressure? >> i am not sure i'm in the best position to judge that. but the media paid attention to the scheduling issues and i

think all of a sudden that that is completed within 10 minutes. they need to pay attention to the lack of ethics. >> absolutely. >> i would like to say that i think that we have to do two things. we do need a separate group and one a new secretary comes in, he or she will have to deal with the health care issue first. it will probably not have time to become the chief of police for the va and make the health care reforms. so you're going to need some assistance with this operating authority only acting for a period of years until you get the va under control. so the next thing we have to look at his performance standard for leadership. unlike those who work at medical facilities, they may have some legitimate researchers for their challenges. and our in our organization, the primary function is to enroll the veterans and health care and

that is not just about the politics of the law but the va having a public affairs division here and a national veteran outreach here and it helps us with the communication outfit and that was sent down to atlanta for the sole purpose of a senior executive at a performance goal and had nothing to do with anything else. so what you need this agency to look at us? we have 600,000 and that rivals the number of people who roll in the va in a given year. so imagine a years worth of applications sitting in a pending status. put this in context of talking about a bank. 600,000 deposits go in on monday and we never hear about them for another year or two. so do you think the walls of the bank would still be standing here today? and yet the men and women who

sacrificed his country have to deal with us. and not because we don't have the resources. the focus on the insurance program and marketing materials for delta dental and metlife, yet we need to let people know if you had a pending application in these years, contact these numbers. the same that we put in getting the bonuses would attaching ourselves to a high-profile projects. so the same tension into the veterans. so if nothing else, make sure that we move to a system that has more data integrity and this includes the people that sit on these panels to sign off on information that they turn into congress. this way when they come back they cannot say that the report was done by someone else. that is the only way, to hold them accountable and do it in public and do it when the cameras are on.

>> thank you, mr. chairman. >> sir, you are recognized for five minutes thank you, mr. chairman. doctor, what is the relationship between ucla and the l.a. va hospital? >> like many of our institutions we have an affiliation agreement and a institution and a member of them have joint appointments with both of these within the university and also with the va. so i ask because this is a very egregious case and i shared my colleagues comments and it was a case ultimately against ucla board of regents. >> that is correct. >> so the settlement was with this and not with the va? >> well, it is a complicated

case in with my case we both satisfactorily agreed to part ways. but if you have noticed, there is tremendous overlap in a federal component two. >> so here is my question. trying to distinguish this. the incident he referred to was the june 2006 party of one of these parties. so was it strictly ucla party? or was it also the va institutional involved in our? >> at a particular party of there were a number of members who were employed as physicians at the va. a component of that was directly

related to that investigation occurred at the va. >> the facts of the case led to a settlement with the board of regents in california, do they also support a claim against the va and is it a habit you from filing some kind of legal action against the va? or was it specific ucla and not the va? >> i cannot comment on the state component of this. >> here is my question. because it is a significant case. the facts solely lead you to litigation against ucla and at what is the prohibits somebody in your position from seeking redress from the va? >> it allows me to seek this from the va and there is a federal component. >> but your settlement is on the stateside? >> yes. >> are you familiar with this

program? >> it's something that i have seen and has been highlighted by my local va hospital is a program that every bacs from the cost of meals staff to others, if they see something that interferes with the delivery of patient care at any level, it is an imagery, if you will, that any employee has the ability to stop operations immediately out of concern for something they might see. it has been adopted in a number of facilities and none of you are aware of this? remapped i certainly am not. [laughter] >> i will be honest with you. it was promoted to me as an effort by the va to encourage every employee to step up and

say that there is a problem. but each of you have already supported a whistle blower capacity and yet have no knowledge of the program that says perhaps that is not as promoted as internally as somewhat just say has been. >> i would say during this long process, i find that very distinguished. >> thank you, mr. chairman. i yield back. >> thank you, members. i like to go head to the next panel, unless someone has a burning question that they would like to ask. thank you very much the witnesses. we do all appreciate the courage it took to come here tonight. we will be watching and rest assured if any of you contact us, we will all jump to protect you from any further retaliation and we thank you for being here

tonight. [applause] [applause] >> members, we are not going to take a break, but we are going to continue on with the next panel. [applause] [inaudible conversations] [inaudible conversations] >> members, okay, we are going

to call our second panel to the witness table. our second panel we will hear from carolyn lerner, special counsel. accompanied by eric bachmann, of the deputy special counsel for litigation from the va and we will hear from the acting principal deputy undersecretary and he is accompanied by the deputy medical inspector for national assessment of the medical inspector office. if you would, please rise again before you get too comfortable. please raise your right hand. do you solemnly swell under penalty of perjury, what he swears the whole truth and

nothing but the truth? >> okay, thank you so much. please go ahead with the first panel. your complete written statements will be made a part of the record. you are now recognized for five minutes. >> thank you, chairman miller, ranking member, members of the committee. thank you for the opportunity to testify today about the u.s. office of special counsel and our ongoing work of the department of veterans affairs. i'm joined today by eric bachmann, who is supervising our efforts to protect the va employees from retaliation. i would like to acknowledge the many employees here who have been working tirelessly with all of our va cases and there are too many to identify by name, but several are here with us this evening. i see been tonight will focus on three areas, first, the special

counsel and whistleblower disclosure cases. second, an overview of the current caseload and there, some encouraging signs of progress. we are an independent prosecutorial agency with jurisdiction with over 2 million federal employees and we have a staff of about 120 and the lowest budget of any federal law enforcement agency. we provide a safe channel for employees to disclose this government wrongdoing and if it is not, then we send it to the head of the agency who is in turn sending a report asked me. it was within this statutory framework that we received and are still receiving dozens of disclosures from employees across the country. the office also protects federal

practices, especially retaliation and in these cases we conduct to determine if retaliation occurred. turning first to the whistle lower disclosures, we have found that rather than using the valuable information provided as an early warning system, the va often minimizes problems. his approach has allowed issues to fester and grow. the numerous cases before the agency we see a pattern where the va has an office of medical inspector that admits to serious deficiencies in patient care yet implausibly denies any impact veterans health. the impact of this denial has been to hide many issues that have recently come to light. my written testimony provides several examples of this

approach and i want to highlight one egregious example of outpatient neglect and a long-term health care facility in massachusetts. specifically the report substantiated allegations that two veterans with severe psychiatric conditions waited seven and eight years to get mental health treatment. despite the findings, they denied that this had any negative impact on patient care. this conclusion is indicative of many other cases we have reported on. turning now, we have received scores of complaints for this and we currently have 67 active investigations into complaints from those who reported health and safety concerns. these complaints come from 28 states and 45 separate facilities, and the number increases daily.

since june 1 we have received 25 new retaliation complaints we are taking several steps to resolve the complaints and we have reallocated staff resources and we now have this to take process for the cases. in an effort to work constructively with the va, but my staff and i have met with many va officials, including the active secretary. i think it's her important to note the encouraging signs and there appears to be a willingness to listen to concerns raised by whistleblowers come act on them appropriately, and ensure that employees are protected from speaking out. when i met recently with acting secretary gibson, he committed to meritorious whistleblower commitments on an expedited basis. it will avoid the need for

lengthy investigations and help whistleblowers who have suffered retaliation get back on their feet quickly. it will also send a powerful message to other va employees that if they have the courage to report wrongdoing, the va will take action to protect them from retaliation and in conclusion, i want to applaud the courageous employees who are speaking out and these problems would not have come to light up for the information that they provide it. we look forward to working with the whistleblowers and with the va to find solutions to these ongoing problems and we look forward to answering any permission in turn questions at the va may have. >> thank you. doctor, you are now recognized for five minutes. >> thank you, good evening. chairman miller, ranking member, i come here tonight with my

credibility in question and there is no doubt about that. and i have some prepared remarks, but i would rather speak my mind. we failed in the trust that america has placed in us to fulfill our mission. patients have clearly waited too long with the care they have earned and i would agree that it took a whistleblower in a crisis and just focus on correcting those deficiencies. as i sat and listened to the first panel, quite rightly i was very disheartened with the staff

feel that they cannot fix problems that affect safety and the quality in our business integrity. i think that this is unacceptable and the acting secretary has made it clear that it is unacceptable. he sent a memo on june 13 indicating that that kind of behavior was unacceptable and we would not tolerate a retaliation. and so the stories i heard tonight clearly depict, in my mind, a broken system. and i have to believe and i have to hope that these things are exceptions and that they are not the rule. i know that there are many good employees in this organization who work tirelessly on behalf of veterans. there are many managers and executives to do the same.

there is someone out there who is quiet and he tries and who cannot make any effort into his goes away. those, unfortunately, the risks in our system and the deficiencies that are not fixed or bad. i apologize to everyone of our employees who feel their voice has been silenced and that there passion has been stifled. that is not acceptable and it is certainly not what i stand. quite frankly, i am past being upset and mad and angry about this. i am very disillusioned and sickened by all of this. and i cannot believe that i'm at a point in the organization where we are in a place that we worked so hard for to make it a great place.

and i left private mess and come work and i did that because i thought there was no more greater devotion than what i am doing. i did not come to work for a mediocre health care system but for one of the best health care systems in the country and i believe that the system can be the best system in the country once again. the problems that we have can be fixed and we went to one of the greatest transformations in the health care industry in the 1990s to become what i think was a greek system. and i have hope and confidence that we can do that again. mr. chairman, that concludes my remarks and i promise to i will do my best to answer questions. >> thank you for your comments.

and there are a lot of things that we need to cover. i was looking over this where they described an issue of the montgomery va were in fact we are writing accurate notes were a patient was confirmed to have copied and pasted pulmonologist notes to 1241 separate record and yet astonishingly he still worked for the va. can you explain how this can be? >> i don't want to go into a detailed for a number of reasons. there are ongoing investigations and a number of areas around the country by other entities and

there are potential issues around privacy and employees and patients here and we would view that are discussing that and i'm happy to do this. >> it's better for you but not better for this committee. >> i understand. >> we haven't developed this with any patient names. do you accept the fact that it says that they found where he pulmonologist did in fact do this? >> absolutely, i do not dispute this. >> so how in the world can this person still be employed at the va? >> as i said, i don't feel like i can really go into the details. however, i would say this.

and i think that we very much are interested in the quality of care with the va and the documentation is an important part of that. it is a common practice to take store all information and prior note and that doesn't change. but we don't copy and paste material from old records into new record is evidence of a current encounter with a patient. we would not tolerate that. we would not support that in the organization and that would be a part of inpatient care. >> ma'am, could you comment on what is going on? you may not share the same fear that the doctor made clear tonight or discuss something that may be a source of a va investigation. >> the theme is that we do look

at this as medical inspector. it confirms the allegations and then says that it's not a problem. so here the whistleblowers said that this is happening as a doctor surgeon who discovered that another physician was cutting and copy and paste patient records. including information for the surgeon to have, very important information for the surgeon have before they operate. and they substantiated that it was over 1200 patient records that evolved. the problem is that they put that position on a review plan and there is a specific name for it. it is fppe. while he was on the review, he was still cutting and pasting

and instead of them taking disciplinary action against a physician, they ended the fppe and as far as we know no serious disciplinary action was taken. so this fits the problem and the pattern that we are concerned about where allegations are confirmed. no harm is found to patient health and no corrective action is taken against wrongdoers. so that is really what i think needs to be fixed. >> who's luckier? doctor or the veterans who didn't get harmed by the egregious incident but the doctor, in fact, that he perpetrated on the patients. >> i cannot answer that question. but i do think that again the cutting and pasting of information misrepresents things

and would not be acceptable and would not be acceptable to us. i'm happy to discuss those details. there is an issue of harm and when they do the briefing and put out the reports and say that they found no harm, i have looked at some of these cases clearly. while there might not be evidence that someone was actually harmed in the process, that doesn't mean that we as agency would say that what happened is appropriate. i believe that those are different things in terms of the work that they did and we would not disclose what was actually harmed by that. but i want to reiterate that i do not believe that i personally interpret that and i don't think

her agency does either as necessarily condoning appropriate behavior. >> i would submit to you before i yield, this person is still employed by the department of veterans affairs and it does give the signal that it is an appropriate thing to do. >> i understand. >> sir? >> thank you very much, mr. chairman. a press release today says the acting secretary spends some restructuring in order to create a strong internal audit function that will ensure that issues of care, quality, and patient safety remains in the forefront. would you believe is the primary mission that it should be? >> it was set up as a quality

improvement process within the organization. and i think it is clear with respect to these cases they were done prior to this in a different way and we took over the quality of those and everyone agreed that at the request of this. and today i think that we realize that we need a different function within the organization this includes an internal all the control function that has been proposed. i can tell you today that the calls are going together and they are not taking new cases in this interim period. so all the issues, whether they are from this area or the oig or whistleblowers, they are now

being handled by a team of people at the department level that report directly to the secretary. citing that the organization is trying desperately to address the issues with respect to doing these investigations and the secretary has made it clear that not only will we expedite those investigations, but where appropriate we will expeditiously take a disciplinary action to hold people accountable. >> how many more employees of the department plan to add for this internal audit function? >> i do not believe at this time that the plans for that -- i i, in fact, don't have an answer to that question. >> man, does this press release by the department today, vowing

to restructure this issue you have raised time and again regarding va responses to complaints? >> that is a tough question to answer because we don't really know what the restructuring is going to look like. but i am encouraged by the va's sort of new response to this issue including by the active secretary and other leaders. i am an optimist and i believe that it is very possible to make improvements and solve this problem. and so i don't know the answer to your question but definitely willing to talk. >> how will they ensure that the recommendations and the result

of the investigations undertaken are acted upon? >> well, we have, for a long time, we have taken the recommendations of the findings and we have talked about how we have developed plans to make corrective actions. and i think that one of the things that we need to do going forward in this new process is clearly to tighten up those various steps of the process from discovery and investigation and action planning and accountability in a much tighter way. up until now they have been distributed over different silos of the organization. and so in any system like that, that is prone for things to fall through the cracks and etc. so part of the process is really

starting to tighten things up and also draw a clear line through them. >> following up on the chairman's point, how we achieve real accountability? >> i think that this itself, i don't know that it would ultimately be doing this work, but it will not be responsible for the accountability part. that is a management function of buyers its own set of activities to be able to do the fact-finding and say that this is an appropriate disciplinary process that needs to happen swiftly and systematically and also with fairness. >> thank you. my questions to

doctor mitchell and her responses at the veterans health and safety was compromised because the warnings as a whistleblower were not heeded even to the point of patients dying according to what she said. as thanks for her efforts she was tallied against it to make it even worse. so how can we strengthen whistleblower statutes are already on the booo blowers like doctor mitchell in the future? >> the whistleblower protection enhancement act has all the elements that are necessary to protect whistleblowers everywhere. it has to be enforced and people need to feel comfortable coming forward. the employer needs to create a

welcoming environment for whistleblowers and welcome change as well that the whistleblowers recommend and not minimize it. the agency enforces this and i think it is a good actor and i think the structure is in place now for whistleblowers to be protected and i think that robust enforcement is very important and i'm not positive what changes i would recommend making to the act to provide this protection. >> well, if it's not working as well as it is intended to work, and he just said that needs to be better enforced, what has to change the terms of the culture of the va to prevent these problems in the future? >> one step that can happen is that the va can become certified

under this section and it is a pretty simple program that we help to implement and i have gotten a commitment from secretary gibson to have them become certified under the program and its things that require more training and having posters put up in the facilities and having a link to my agency's website with pretty simple steps in a very good step for the va to take. i think another important step is for them to actually take expedited actions once retaliation cases are before us and if we are trying to work with them to resolve them and not let them go through a prolonged investigation in getting believe quickly, sending a positive message and it would put some meat on the bones of

the promised not to retaliate. so i'm very hopeful that that would happen and if it does, i think that that would be a positive step. there are other things that agencies do and they have a problem with culture of retaliation and many agencies, one that comes to mind is the air force where we got serious complaints about retaliation and misconduct happening. we heard repeatedly about the culture there being very bad. once the air force decided to take steps to send a strong message to its employees, we got reports back that things were much better and i don't think this is an insurmountable problem. the because the va is so big, it will require a lot of effort to

train supervisors at the regional level as to how important it is not to retaliate and value the information we are getting from the whistle lowers. >> there is legislation that the house has passed, making it easier to fire a certain number of people with the top 400 or so people in the va. so that would send a very powerful signal, even if it's just the threat of not being available. >> that is possible. i haven't reviewed that legislation. i don't feel comfortable commenting on that. but i don't think it requires this. what you are saying is not minimal disciplinary action, but i would like to see at least some disciplinary action being taken. in some cases it probably requires termination. but i think again there is a structure in place that would provide for that type of disciplinary action and we just haven't seen a lot of it. as we are not sure if it is

necessary rather than enforcing the law as it exists today. >> thank you very much,nqueue, . >> thank you. >> are you saying that the current civil service protections are not so onerous press we will to impose discipline and dismissal of in this case copying and pasting medical records? >> you can be terminated for misconduct under the federal civil service laws. there is a current framework for doing that. >> whatever reason, it is just not happening. can you speculate as to why it is not? is it because we are not adequately trained?

it's quite extraordinary for college. so it points to our management here in this instance. >> we have one case that he has taken disciplinary action in retaliation case. it is not impossible to do it at all, there just has to be willingness to do this. but we have seen for the most part in our cases is that people are not really disciplined, or if they are, it's a mild discipline. what is going on with the va in terms of why they are not doing that, i can only speculate. but it is certainly possible and we have seen it done. >> i'm just curious. this case of this particular position, the copying and pasting, and generally heard positive reviews by some

doctors. some people tell me that it is not -- but it's not incredibly user-friendly. we could find relevant data which is difficult. one doctor i spoke to is retired from retired private practice. and he evaluates records for the purposes of determining whether people are eligible for this disability. he reviews a lot of records and he says that he will get a record from the va that will be like a phone book. and this includes other record systems as well and he has to go through pages and pages to be able to get the relevant information. so is there truth to this, and is part of the reason because this doctor thought that he could did away with this, that there is one ability with the

system? >> our patients tend to have multiple complex diseases and a lot of visits in the organization. including the average agent. and i think that computerized patient record system, without going into specifics, i can talk a little bit about what is a common practice so that i am seeing a patient and night but this into the record the patient's problem was, a list of things that are wrong with them, the medical history about when they had surgery or when they are hospitalized in the past, those facts do not change. so it is common practice on paper look at the chart and rewrite the things on a new note or an electronic record system to copy that and paste it. so if someone is not careful, they may capture more than what they intend to end inadvertently places in a new note. i am actually not defending what

happened in this situation, but rather explain a common practice with what could happen. i want to say couple of things. and we have many elements of whistleblower certification including training for a long time. we have had some discussions about that. and so it's important that we continue because we want to do that. and so accountability, we heard so much tonight about culture. you can change structure and processes and people. in the end it is about leadership and it is about accountability in the organization.

that is the commitment that the secretary has made and the commitment that i am making tonight. and i think one of the biggest issues that i have heard tonight was that there are people who felt they suffered while the process was being resolved. i would like to make a commitment tonight and i will give you my cell phone number. you can call me and i will do whatever i can to intervene the moment that you know so that those employees do not suffer adverse consequences while you do your investigations. >> thank you. >> you're the second person who has given me the cell phone number for this very reason. i am encouraged. >> mr. chairman, my time has expired. >> he didn't say he would answer his cell phone. [laughter] >> sir, you're recognized for five minutes. >> mr. vice chairman, you're recognized for five minutes. >> thank you, mr. chairman.

>> doctor, how many employments -- excuse me, employees have been reprimanded or terminated which negatively affects the health care industry through the va. >> i cannot give you a number tonight, sir. what we have, in some of these cases cited and looked at those action plans and where there is administrative action recommended. we have taken administrative action. >> you cannot give me a rough estimate? >> i can take it to the record and we can get that to you. >> how many employees have been placed on the ministry of we've or terminated for actively retaliating whistleblowers?

>> again, i would have to take that further. >> thank you. >> how many whistleblowers have been placed on administrative leave and reprimanded or terminated to expose misconduct within the department? can you give me a rough estimate? >> i do not have that information. but i can tell you that we have to range from 67 whistleblowers that are active in our agency. i'm going to turn to my deputy, mr. bockman, and see if he can add to that. >> in these three areas, those who have come forward recently, that we have been able to get disciplinary action against them. that includes when they come forward or hit with a 14 day

were seven-day suspension. we have contacted the va and persuaded them while they conduct the investigation. that is one role that we are able to play in all of this and i would be happy to go back and check records to see if we have exact numbers for you in terms of the administrative leave. >> would you say that there are more whistleblowers being reprimanded as opposed to those who have received misconduct and negligence? >> if what you are asking is do they come to us, do they suffer adverse consequences -- >> more so than maybe someone who is committing negligence or malpractice. >> unfortunately, i do not know the goings on.

>> can anyone on the panel answer the question? >> no, i don't think i can. >> i would like to get that information as soon as possible. >> when cases are referred to ose, what disciplinary action is taken? anyone? >> sure, one of the things we look for when we get the agency's report of investigation is what disciplinary action, if any, is taken. most of the cases we have reviewed, there has not been disciplinary action taken and i cannot give you exact numbers, but i can tell you that it is the exception and not the rule. >> one last question. sir, what consequences for those who provide false information, what do they face?

>> i don't know that i can answer that question specifically. but when we do believe that disciplinary action needs to be taken, there is a set of criteria that depend upon the egregiousness. >> can you give me a hypothetical case? >> i'm not i am not sure that i can make up a hypothetical case, but there is a table of penalties that exists. and that is judged by what has happened before because the it intention of disciplinary action is not to be in punitive, but to try to change the behavior of the employee were refilled it we cannot change that behavior, it's a hopeless situation anonymously separation is what has to happen then. they usually that is the end result of a series of processes to remediate. >> so if they give us

information -- that would be criminal imax. >> i would think. >> thank you very much, i yield back. >> i would like to have that information as soon as possible. >> we will get you what we can. >> you're recognized for five minutes. >> thank you, mr. chair. >> ma'am, you spoke about the whistleblower program and certification being a good first step. so why is this an optional one, and why isn't nonmandatory? >> it is now mandatory. recently the president issued an order requiring agencies to go through that certification process and their plans for doing so are supposed to be hosted by june of this year. so i don't know why was initially made a voluntary program. but we made this in the early '90s and unfortunately a lot

of agencies have been certified. >> to the va compiler that by the deadline of june? or are they saying that they will go through the steps for the certification? >> i do not know if this has been posted. i was told last week by the acting secretary that they would be doing so very soon. so i'm going to train a follow-up. >> our agency will help them become certified and i signed a little certificate so i will know the minute that they reach that milestone. >> very good. and we heard from our panelists earlier today, those whose identities were compromised in the process of working with the ig and you heard the testimony. so can you give me an idea of what your office does and what about the ig's office?

what steps are taken to ensure production of the whistleblower? >> yes. if someone comes to us with the disclosure committee have the option of remaining anonymous. if they they choose not to, we referred to the agency. so we don't do independent investigations for disclosures once we make a finding of a substantial likelihood, we then send it to the agency or investigation. and then we review the agency's investigation for this and reported to those in congress. so, the first step in keeping information confidential, the second is when the we remind them of the need to protect and

they have to protect that person from retaliation. and so in order to do this full investigation sometimes, sometimes we have to speak to the whistleblower and one problem that we found is that often with the investigations it doesn't actually talk very early and sometimes they don't even interview them. and that is a problem of themselves because this is a subject matter expert in the have to speak to them or get the full picture. so it's very hard to do an investigation without disclosing identity. >> part of the certification program, will it help with enforcement? in terms of the protection piece? >> program in itself does not

directly involve enforcement. but by making sure that when someone does come forward that it is part of this and i do think it will have a derivative of fact asserting a purpose. >> thank you. >> doctor, i understand you're relatively new to this position. >> yes, i am. >> inure formally lift the transformation efforts. >> yes smacks i presume that that means that as part of the va's transformation? so i'm just curious to know how you thought you were doing. ..

to hold people accountable. you can't say i didn't know those rules anymore. so that program has the potential to have a pretty positive impact. >> i think the chairman. i think as you know there's this

thing very important it's called trust. you said the va was great. and a lot of good people tomorrow are going to get up and go to work and take the very best care of patients they can. how can we lose trust anything they say when we have panel after panel explained these agree just things that have occurred and let me give you an example it is almost impossible to make a politician speechless but the va has done that. when you have to severely ill veterans a second veteran was admitted to the facility in 2000 through the chronic mental-health issues yet first comprehensive psychiatric evaluation didn't occur until

2011. how in the world in a healthcarh care system in america could that have been anywhere? and let me go on. no modifications occur until 2011 when another doctor mack came along and reevaluated this veteran. despite these findings, they would not acknowledge the confirmed neglect of residence in the facility had any impact on patient care the typical answer is a harmless era approach completed in the field but in some areas that are in could have been better taken care of not like a word for each years, but the omi doesn't feel the rights were violated. how in the world with a straight face can you do that. that is someone that is dishonest. and me when i have a consultant

and i've been to the operating room thousands of times i've got to know what they are telling me is truthful and i can promise you this. if that has occurred in my practice, they would have been fired on the spot. if they found out in the hospital where i practiced for over 30 years they would have been fired on the spot. and what we are hearing is that the people, the whistleblowers that bring this up as mr. bilirakis said suffer more consequences than the people that actually did the egregious act. i don't understand that at all. can you and lighted me a little bit? >> quite frankly i am speechless. i am appalled. i don't know what else to say. we may have some comments about the process, but i can tell you that i don't think that any of us think that is acceptable for

a patient to be in one of our facilities for eight years and did not have a major psychiatric exam acceptance of one's. >> it is comprehension to me that not one but two veterans have read the facility. and i know you said this a moment ago, but we bring information up here if someone knowingly lies to them you are out of here today but don't go by your fired into right now there doesn't appear that they are doing that as we tap dance around all these things. my time is about also. basically how can you -- and i know that you are new in this position under the damage that you have done to this physician and others whose career have

been damaged by this. what do you do to repair their reputations? >> i don't know the answer to that. in some cases the damage clearly has been done. i don't know. but we do over some people in apology and we need to figure out how we can make people who whole. the most important thing is that we have to go forward. i can't undo the past, but i can do something to change -- >> i appreciate that. and i feel very badly for the people that are going to go to work tomorrow. you are doing a good job working hard. it had something done for him the va you have a reasonable expectation when you are in the

hospital that people being honest i handed off cases that we would turn over the duty and cuba tincuba to take the beeperw it is a cell phone you expected your partner to tell you the truth because people's lives depended on it. this isn't a game that we are playing. people's lives are at stake. >> you're recognized for five minutes. >> i appreciate what the secretary is doing with the restructuring and coming up with a strong internal audit system. however i must express that i am skeptical about how that is going to work. we have the whistleblower protection act but it's not enforced. my concern burst of office we have heard so much testimony in thandthe committee about a cultf secrecy and culture of

retaliation, and retaliation is a huge deterrent to hearing the complaints. so my first question is to you we heard there's been retaliation against employees. i encountered there is retaliation against patients who might feel they have a complaint against a facility. are you aware of any retaliation against patients or veteran's? >> i think that's a really important question. i'm not aware of any retaliation in part because my agency jurisdiction is for employees to come forward with retaliation complaints or disclosures of waste, fraud, abuse or health safety problems. someone could come to us if they thought that a patient was being retaliated against. i don't think that we've got any of those cases. people do come to my agency with disclosures about poor patient

care where they complain about patients not getting appropriate treatment and that retaliated against themselves for having made those complaints. but in terms of patients, we probably wouldn't get those. >> is very hot line to be a patients can call if they have a complaint about the facility? >> i don't know the answer to that. there are a number of mechanisms to patients have to give feedback. they complain quite frankly to the patient advocate system. that is a real human being sitting at each facility that they can go to. what we are seeing here is a pattern but it stays within the facility. it never goes outside of that. let me throw out an idea. i'm a former prosecutor and have a difficult time getting people to report child abuse and neglect and elder abuse until we

established a hotline where the reports could be anonymous but there would be an investigation. there is no possibility of retaliation anyway, anywhere because of those reports. even if they turned out to be false. and i just don't see how we are going to get to the root of this without something like that. in the options of veterans have, that patients can call the oig hotline today. >> but who knows how to do that? we look at this very hard.

one of the things we are looking at today the department of defense had a program that they call i see. it is an interactive bang on their website to go right on the website and provide feedback, finally complaint can see that you did a great job and it goes to the top of the command chain. they bring it over to the va to be able to put it on our website. right now we are in discussions about what is the mechanism. it means to be high and the

organization. i yield back the balance of my time mr. chairman. with the whistleblower case load whistleblowers can you tell us what the congres congress can dp alleviate the amount of time on the activities that you can continue to take care of the needs of the va whistleblowers? i want to start by noting that the committee has been particularly supportive as the staff and the oversight investigation subcommittee for their work on this issue and their work with our agency we consider it to be a real partnership and we are very grateful for this committee's support. we have received a number of

referrals from this committee and we appreciate your confidence and ability to work with the employees that your office refers. so that's one thing. it's already happening. we are doing everything that we possibly can. we've set up a priority system and we free allocated staff to handle the va employee claims. but as the numbers increase its a very hard to keep up. we were at capacity before. in the retaliation cases now it exceeds 130, and the number as i mentioned continues to increase pretty much daily. we are an agency that has 120 employees more or less. we have jurisdiction for the statute for the reemployment

rights act and we are working now on a demonstration for the committee provided to us. we also handle disclosures over 1200 as year and this will be a record with the va disclosures and we also handle prohibited personnel practices, so we are stretched pretty thin. >> please continue to let us know what we can do. some whistleblowers have provided some limited patient information such is allowed through special channels through what they proceed.

with the privacy violations what can we do about this? how do we get the va to stop the charges of the privacy violations when the whistleblowers go through the proper steps to this? >> i am aware of one instance where that happened. the employee in my opinion an appropriately was put on administrative leave while the investigation is being done. over concerns that the person to patient information and data violate hippa. the leadership now knows that people have the right to have information and can share that information with congress and it isn't a violation.

we need to do a better job of making sure that people across the organization understand this issue clearly and i wish i could say that it would never happen again. that would certainly be our intention to make sure that people are more aware and more cautious about what they do. >> we will continue to try to put that message out. i yield back. >> thank you very much mr. chairman and in all of you for coming this evening. i wanted to ask in the private sector they have a process of quality assurance committee because the quality assurance committee where information that is shared in reviewing the cases with that kennedy is typically by statute protected from the medical malpractice lawsuit.

and as an attorney i want to get to the bottom of whether part of the behavior that we are hearing about tonight and throughout the testimony from the whistleblowers has to do with the va trying to protect the agency from medical malpractice lawsuits and if that's the case, is there something that we could do such of early this is something i worked on at the state level many, many years ago in the statute that protected the quality assurance so that you can have a quality improvement process going forward without all this behavior covering their backs and blaming people that are bringing these issues forward. can you comment on that? >> i think we have quite frankly adequate protections in place

for quality assurance documents that are covered statutorily. i don't -- i can't say. we are in organization of 300,000 people. i don't know what everybody thinks when they go out and do something. but i can tell you that i don't -- i would be surprised if they concerned about the release of quality information is part of what might be a motivating some of the concerns and the recovery behavior about the whistleblowers. i think that clearly managing those situations is difficult for the local management. i think that we need clearly to do a better job of informing and educating. i was appalled by the stories i heard tonight. we as an organization should tolerate that. i don't think that you should let us tolerate that.

>> on another issue entirely, another level of shock for me was the information in the record that we have about the doctor and the very clear pattern, disturbing pattern of racial prejudice. can you tell me in the organization first up hell does that exist in this day and age and second coming is there some way to cope with that and make sure that that's not -- in this day and age honestly with the progress that we have made in our country and in all aspects of diversity, gender, race, religion, ethnic backgrounds i

can't imagine with this many employees that we would even begin to be tolerated the type of behavior. it's in the other slide and it is even more important and it's astounding that it happened at the ucla medical school among the highly educated professionals. i don't get it. i just don't get it. again in an organization with 300,000 people where people do stupid things and we can't always control that. >> would there be a procedure -- would there be any kind of protocol or process if that was reported up the chain? >> absolutely. and in my 20 somethin twentysoms i can tell you i think that this

organization has been for a long time one of the most inclusive and supportive of the diversity organizations. we train people in the workplace for asthma issues. we have programs to support cultural diversity and cultural competency. i'm just astounded quite frankly and quite frankly i learned about three of the whistleblowers first time reading about it in the paper. i think that we need to do a better job of making sure that people can communicate their concerns. there are a lot of avenues. they have the process.

they can come to you all. but my dismay is they don't feel like they can come to us within the organization because that's where it has to start. if we really want an organization that is dedicated to the safety and the quality and integrity it has to start with our employees being engaged on the front line into taking a meaningfuand taking ameaningfule they can fix those things within their sphere of influence. if we can't do that -- >> as far as i'm concerned there are people that their position over this. >> thank you for letting me go over. you are recognized for five minutes. >> thank you mr. chairman. doctor mitchell in the previous panel talked about the peer

review process. have you seen anything like that in your investigations? >> we have seen that in some of our investigations and we are taking a very close look at those when we see them. those types of investigations can be difficult to prove sometimes that we are seeing that as an emerging trend, and it's something that we are focusing on and making sure that we are gathering all the evidence that we can to see exactly why it was a peer review undertaken. >> are you aware of this program that was started called the stop the line safety initiative that we talked about are you aware of the program? >> i am not sure i know exactly what program you're talking about because there are -- stop

the line is part of the clean technology process. there are many -- >> as i understand it was a way to encourage them to step forward when you have something going on that i think we would expect. >> many of our facilities have implemented an as part of our national patient safety program, we have a stop the line timeout process so any employee, and this is true in the procedure based area any employee who feels like something isn't right before something is about to happen to the patient can call a timeout, stop the line and say i disagree with that. it could be the doctor doctor, e nurse caught the housekeeper in the operating room because they feel something isn't right and the line stops until it is a result so that is a part of our national patient safety. >> does the va keep track of how

many times the initiative is invoked? >> not to my knowledge. >> are reports collected? >> is part of the business process. >> i was aware of this incident where we have a report on the anesthesia within the va along the country i into formal communication to the va with the stop the line initiative regarding the policy that would change how surgical care was delivered into the chiefs of communication was sent to the va secretary and the undersecretary for health and the principal deputy undersecretary for health october 1. >> that would be the former. >> about despite being told otherwise by the va officials they haven't received a

response. >> i can't comment i'm happy to take that back and find out. >> we were briefed they did get a response and then subsequent we were told they didn't so i would like to know what the response is and can you please geget back to the? >> i have no idea but i will get a response for you and for them if they didn't get one. >> do you know how often they get a letter for more than 60 of the department heads? >> i don't. >> would that be worth a response? >> it would seem atypical, yes. >> those are the things you are having to explain and actually we appreciate your apology to veterans in the country.

>> is a huge problem that we are trying to deal with severe emotion and it's hard for us to even sit here without going what is going on and how do we fix this and you are in the same boat. we need a dramatic change we hope this will make a dramatic change because i looked at the va for 20 years and i -- the comments that you made earlier about these being isolated incidents but it's not isolated. i went to the meeting in the va and there's a whole mess of them telling me this. it's a systemic problem and we need to deal with it.

>> i appreciate your sentiments. >> you are recognized for five minutes. >> thank you mr. chairman and all of you for being here. i agree and that so often is the case i concur. it may be something. it doesn't appear people have come to grips with. that's how i feel and how my veterans feel. a generation of good work has been raised and i think you understand that. very very difficult because this is about care and getting the trust and getting them in the system and working on things like seamless transitions and making sure blinded veterans are there and all the things we worked on. for 24 years prior in the data from trying to prove to be a good actor on this one but the question i have is that again what's going to change. what is your definition of unacceptable?

>> the bottom line from the time i went to medical school until today has the patient gotten what he or she believed they needed and it has to be quality, it has to be safe and effective. to me that's the bottom line. >> as we try to find what the fix is we are going to sit here and i agree we have to diagnose first before we can find the treatment. but we have to move forward on how to get it fixed. today the letter comes out of the office of the medical inspector and it's clear that the acting secretary made it clear that as i told the work force intimidation and retaliation against whistleblowers or any employee who makes a suggestion or reports with maybe the violation absolutely unacceptable was it not unacceptable to the secretary? was there any way that you copy and oppression that it was acceptable then but not now?

what changed today? >> what changed today is we do have new leadership. the acting secretary has stepped up. he is hel out in the field goino medical centers. he has in fact pulled the process of the whistleblower investigations to the level that he can personally supervise it. his engagement is phenomenal. one of the complaints about how the va works is that there is a belief that they can outlive people. they are going to outlive mr. gibson and the and they migk in november is coming around. he will be gone. i have to tell you and this pains me more than anything this breach of faith and i sat up here for eight years and i am the staunchest supporter but i will be the hardest critic i've listened to this today and it floors me that i don't believe with one fiber of my being that you are going to get that right

and it's disturbing which makes me then come back and say if i were you sitting there asking what are you going to do about it that's what i'm asking for. i want us to take this back. i want us to pull this back and and know that the data is true. so i ask you is there a way to do this? is there a way to have the third-party validation to have that accountability? we can be the most accountable because we have to stand in front of the voters that are the constituents every two years. they are never going to see my veterans ever. so how do we restructure this and are we trying to fix a broken system beyond repair on trying to fix this? >> i said before i'm an optimist. >> i supervised a high school lunchroom. >> and you're very brave as well. i am the ultimate optimist and i have been shaken by this, so that's why i asked you what proof is there? to her reputation is on the line

if you say that it's going to be fixed by this. >> my job is to shed light because that is the best disinfectant on a broken system and the whistleblowers are shedding light on where the problems are. the next step is to actually see some action. what we have heard in the last several weeks from the leadership ivy league is encouraging. >> i asked what is the problem with the rochester va and you said your right you deserve an answer right away. so here i said i am off the reservation on this one. why has there not been an answer on that one? a member of congress was told they would get an answer about what is wrong with the local da in the place i spent much time with my veterans and i haven't gotten an answer. >> i'm not here to defend the va. i've had a pretty ringing indictment of what has been going on. but i think that there are steps

that can be take in expediting the review of the whistleblower complaints when people believe they are being retaliated against if we can get that review in place and the whistleblowers can see quick action that sends a very powerful message not just to the individuals involved but the facilities there is disciplinary action when someone retaliates against someone we need to have actions that back up the positive words and -- >> you think we can get them. >> i'm going to do my best to follow up on the promises made to me. we are continuing to do oversight. that's our job. i'm happy to come back and report what actions we have actually seen taken. but one of the problems i think has been that we have gotten the

warnings from the whistleblowers about where the problems are that they have been sort of hitting from the va leadership because they've been saying no harm, no foul. there's no violation here or regulation that's been violated. whatever replaces it will have the same issue. there are certain steps that can be taken. whatever the entity is that it's investigating, there needs to number one has a review triggered whenever there is a finding of a problem it has to go higher. i think the second thing is there has to be the look to see whether the actual harm has occurred because what we are -- what we have been seeing is yes the allegations are true but there is no harm but they don't look to see whether they have been harmed or not. in the case they only looked at

the three patients to psychiatrists reported on. the psychiatrist said this is a widespread problem for both a facility that the only looked at those three patients into good and look to see if there was a more widespread problem. >> i am beyond my time. thank you researcher in. i apologize. >> you are recognized for five minutes. >> i would like to g to give testimony that we heard in the first question would be for the doctor. in the testimony doctor matthews stated that when you repeatedly brought up the problems with doctors only doing three and a half hours work during any workday the consistent explanation he received his the va. for the doctors there were only a portion of the time they are being paid for? >> that isn't a common practice. that is an expectation. i think --

>> can you tell me how you know whether that is true or not? >> writing there was a briefing on capacity and the organization -- >> they said the data was no good. the second question is reference to mr. davis and if you could shed some light on this but you indicated that folks from your association met with white house deputy chief of staff ron neighbors and secretary gibson. were you in those meetings? >> i was. >> i would like to ask because he does know he believes the deputy chief of staff of the white house leaked his complaint. did you know about this possibility and what the penalties might be for doing such an action?

>> by meeting it didn't focus on this matter. i don't know anything about it quite frankly. my guess -- and i'm just guessing he was trying to intervene to help and not leak someone's name in a vindictive kind of way. >> this goes to the highest level. the allegation is the folks at the highest level that we were relying on were violating their own law. how do you inform the employees about the rights? >> we have trained employees that have taken the system so there's online training available to all employees in a supervisory training -- >> is it mandatory? >> yes. >> how often do they take the

training? >> i believe it is annually. >> and you will certify everyone takes this training >> we do track it and the system. >> if you can provide evidence to that as well. >> following up a few more things. in the fiscal year 2013 the director of the va healthcare system received an 8,985-dollar bonus. based on the testimony from the doctor tonight including the continued retaliation will there be any effort to rescind her bonus? >> i can't comment. i don't know. >> let me ask you about another one then. the director in the phoenix va healthcare system to director susan bowers received an 8,985-dollar bonus in fiscal year 2013 as well.

would there be any efforts to rescind bonus? >> typically we have performance awards that are tied to the performance evaluation, the performance evaluation was done based upon the knowledge at the time that that was completed and we don't really believe we have the authority to go back once those are done and change the prior performance evaluation. >> and thoroughly in the testimony to folks about him receiving 8,052-dollar bonus from the member service they received a bonus of over $7,600. we wouldn't normally go back and change valuations once they are completed. >> zero in on the patient records that were also tied. how many records do you have to falsify to be fired as an

employee? >> i would hope you don't have to falsify any. >> apparently that wasn't enough. >> one would be unacceptable. >> i can't comment on the specifics of the case. >> but you said it's one end you verified to put up 41 times and they are still working serving veterans when they falsified the data and your response is they started to keep their job. >> i would be happy to arrange a time to share that with you. >> i would be happy to hear that. but what i think the public needs to know is are you really serious about that? with the 130 complaints still continuing to be investigated. >> the va has come and briefed our staff and said that the va believes they have up to one

year to be able to apply the bonus back. is it your testimony that even though the fraud was committed that a bonus is still something that individuals should receive based on the information that was known at the time? >> you are getting out of my swim lane. i don't know the technical answer to the question. but i am happy to go back and get that for you. >> it's called fraud and it is it legal. -- illegal. >> i want to continue the line of questioning about montgomery and highlight some of what was included in her testimony that in 2012 a whistleblower that was the insurgent was first alerted to the misconduct by an

anesthesiologist during the veterans alternative so that is the danger to the threat and potentially a bad outcome for the better in. we don't have the right information for the anesthesiologist in this case. a whistleblower reports are to the alabama va management in 2012 to put him at work or on disk e. valuation and during that evaluation, he cuts and pastes information onto the veteran's medical records. then the review determines that they engage as others have said in the 1241 separate patient records. so a couple things. you keep saying you can't

comment on this but it defies common sense and what all of us would expect from anyone that you would say this person will be fired. i don't know why ms. lerner can tell us all these details and this is now public record and you can't tell us -- you can't tell the people in alabama more importantly the veterans what's happening. and also, if we are talking about creating a culture of accountability, what does it say to the surgeon who is a whistleblower -- what does it say to the anesthesiologist at this pulmonologist is still working on this and you have the courage to take the risk to stand up and alert your superiors to malpractice or malfeasance in the va. the signal that you send to everybody tonight is don't take that risk. we aren't going to do anything.

the sun couldn't be more glaring than that documented by ms. lerner. is there anything that you can say? what will it cost you were the va or the federal government to go out on a limb and say he or she shouldn't be working for us. >> as i said earlier there are reasons i feel i cannot come into details here. there are still active investigations going on to a lot of these issues by the oig. there are -- if i put enough details out there somebody can make connections. these are complicated issues. >> i don't know how it's complicated. >> let me ask this complicated question. in the testimony related in the case, you say that they requested and have not yet received information to determine if the 1241 instances

of copy and paste resulted in the adverse patient outcomes. when did they request that? >> i don't know the exact date >> more than a week or a month? >> yes i'm quite sure. i still don't understand why you can't answer the questions about why this pulmonologist is still working but certainly you can answer the question about responding to the request to understand how this has affected the patient outcomes i don't know where the response is that i can find out why the response hasn't been received. i can say to you that i think that it is our intention. i am committed in the job i'm now acted to try to address these issues.

>> i'm not convinced that you're going to do it and i don't know you so you can't take this personally but it's been reflected in the testimony from almost every representative as i've been here which hasn't been a long time but long enough to know that we have a major problem with accountability and performance and i'm not convinced we are going to be able to turn around. everything would wind up beautifully by the previous panel about the kind of problems and for how long it existed and what is needed to change this and then we hear from the va the non- answer that sends the message to us and every employee that you don't take this seriously. you can see that you are appalled and outraged and disappointed and that's been said before but what we need now is this is what we have done. this is what we are currently doing.

this is what we will do and i haven't heard that tonight. quickly mr. chairman previous hand when we alerted to him to these outrageous problems with 36% of the veterans not being able to obtain one, huge growth discrepancies between what we are reporting and what we finally learned the audit was the truth. the response was let's not get into the assigning blame. in other words let's not hold anybody accountable, what's there not be consequences. let's not change anything we are doing. >> i have to register the deep profound disappointment you've heard from so many others today. and i would ask the acting secretary to change the culture now and change the responses we are getting.

it appears the same tactics are occurring and numerous medical centers across the country this would seem to indicate that there is a universal policy in place against whistleblowers that is well known among all of the supervisors throughout the country. do you have an explanation to this? >> i don't belief there is any policy collusion to suppress the whistleblowers among the top leadership in the organization. in fact secretary gibson says we intend to do something about that. the message has gone out to everybody in that june 13 letter that there are consequences for retaliation. we have to go through a process

when those complaints come in i think of investigating them so that we treat people fairly and we know both sides of the story and we have the facts before we take action. but i think the organization, the secretary speaks for the organization and i think that commitment is there and i have to take him at his word. it's clear to me tonight from all the comments here and all of you we have an enormous problem and we are a huge organization. it isn't going to change overnight. we are all inpatient but it's going to take some time to fix some of these fundamental issues. it's good to start with leadership and we have a new acting undersecretary. and i hope the new principal deputy undersecretary. and i hope that the organization that's the kind of change we need in the organization to get

back on the right track. >> you've been a part of the leadership for quite some time. how long have you been a part of the leadership -- >> over 20 years. >> and you testified tonight that this is the first time that you have become aware of the problems that were brought forward by the whistleblowers tonight isn't it correct that was your previous testimony? >> i learned about these whistleblowers by reading them in the paper, yes. >> 720 years -- here's the problem you've been in the leadership with the va and you've been in the leadership for 20 years and you're just totally oblivious to what is occurring around you and all of the problems and it wasn't until it's become a national story that's now you're suddenly aware and i think that's -- that speaks to the culture of the problem that if not for the

whistleblowers who have come forward, we would never be aware of the magnitude of the problems that exist today because the leadership or the lack thereof never brought these issues forward. are you a header in your self? >> no i'm not. >> i've got to tell you if the military action for this is i don't think that you can read starving troops to the town hall i have to tell you that if the new secretary confirmed by the senate and i believe he will pass folks like you and senior leadership he is sending a message to us that he's not serious about change. i yield back. >> you are recognized for five minutes. >> thank you mr. chairman. i would like to go back to what i mentioned earlier and that is my concern about the new las vegas hospital.

they came and spoke with me at my invitation and talk about the problems there and the lack of leadership and manipulation of schedules and those that work for the va directly versus those that are contracted from the private sector who get special treatment and i just don't want them to get in trouble because of my initiating the invitation to learn more about what was going on earlier, so i would ask you if you can't provide it here you can let me know if they are among those cases that have been filed if anything has come out of las vegas. >> i can't speak to any of the specifics but we haven't received any complaints from the las vegas facility. >> i'm glad to hear that. i would also like to ask you -- we heard mr. davis was saying different things are comfortable for different people. some go to the press.

some are lawyers and some go to a veterans advocacy groups and some go to their members of congress. well, i think a lot of them come to me. this is our biggest constituent kind of service that we do in the district with veterans. if someone that works at the hospital, some doctor or somebody that works out there feels like they want to be a whistleblower and they come to me tell me what practical advice i give them. here's what you should do. here's how you are protected and who you call into the form you fill out. what advice do i give them? >> this is the number one priority in our office right now. we are throwing everything we have at this. we've dedicated over half of our program staff to dealing with these whistleblower retaliation complaints into so that would be the first step and went we get in contact with them we can find

out what their issues are in it for some reason we are unable to help we can point them in the wrong direction. >> and they would come to you here in washington and not in nevada. >> thank you mr. chairman. i yield back. >> thank you mr. chairman and i will be brief. i would like to note for the record the conversation is important. it was presented at my local hospital something that was the end all and be all for accountability to step up and make a comment and yet we have for whistleblowers with the courage to come forward but haven't heard of the program and it's not a question other than just i recognize the importance of the program and it hasn't penetrated to the level that at least was presented to me during my meeting.

it's an important question and i'm going to give you the rest of the time to answer. you've apologized tonight and you've spoken of accountability and you've passed your cell phone number and you impressed me by publishing and referring to the crisis of integrity. i noticed as a member of congresnew member ofcongress wee in the tone under the acting secretary and i will say that for the witness who two weeks ago said the system was dishonest which i think was a different responsibility but by and large i think we have seen a change in the tone. you've been with the va for more than 20 years. here is the softball. have you noticed a change in the past six or eight weeks as a result? how we got here is a question do

you believe that we are entering the leadership regardless of who steps into the position and the time is yours on that one. >> i think there are many places around the system that are phenomenal have the care that exists in the private sector. we have places that have outstanding access. i agree with you absolutely we have a crisis of integrity. how we restore that is going to be a slow and painful process. the clinical issues i think our biggest issue is that we do not have a uniform systematic approach to these things and so we have pockets of excellence and places that are not performing so well. the amount of activity in the weeks that i've been in this job

and have had the opportunity to be aware of these problems has been outstanding. the secretaries out there, we are sending teams into the facilities and i think we have sent the teams now three or four times to help them and ask them what do they need a. i practiced as a clinician in the intensive care unit. i practiced there. i knew what was going on in my facility. i've walked the halls. my values i wore on my short sleeves and people knew where i stood on issues around integrity, around bringing problems forward, around people coming together. there was no doubt in my mind about what it took to make sure the patient wa patient was the d

be-all of what we took care of and that's why we were all there and if you were not there for that purpose and you better takr take a hike. that was clear to everybody. i spent many nights sitting in bed wondering what i could have done differently. but i personally could have done differently. when i have raised my hand. could i have pushed back harder. could i not have known that i would have known many sleepless nights. not just at the undersecretary level tha that although we don'o the service chief. i have a lot of people in this organization that wil that was o the plate and i'm confident that we are going to bring people into the organization today to help solve those problems.

the long-term plan of intended actions in the target date that would determine what actions take against the va managers with reprisals. measuring the effectiveness of such actions as a periodic survey of employees and designing and implementing a system for tracking overall whistleblower complaints. in addition, we recommend the va analyzed the data periodically to ascertain whether additional steps are needed to ensure that of reprisal is not tolerated.

we have five legislative days to extend remarks and include any extraneous materials without objection. i want to thank both panels of witnesses and the audience for joining us at tonight's critical hearing on the importance of whistleblowers and effective oversight investigations and one last question. is ms. helmand still on the payroll tax >> i can't answer that question. >> does she work under your purview? >> many layers down. >> but you don't know if she is on the payroll? >> i would have to get that for the record. >> with the outcome of the hearing is adjourned. [inaudible conversations]

this was the fourth nighttime oversight hearings of time -- so far this summer. it's an unusual practice for the staffers are hinting it could become the norm. the navy times writes the staffers are already planning more late hearings for the office congressional research recess. we've been asking for your comments about the hearing on facebook.com/c-span. kenneth writes as the u.s. army veteran i'm not happy at all with the recent stories about the va. finger-pointing and negative remarks are not going to fix this mess. it's about time somebody stands ustandup to the federal governmd its corruption. a comment from paula think these people for all of their courage and willingness to put themselves at risk by telling the truth. and the las