The Arizona Republic Channel 12 news
written by Dennis Wagner, AZ Central
Wednesday July 9, 2014
WASHINGTON -- Department of Veterans Affairs whistle-blowers took turns ripping their own agency during a congressional hearing Tuesday, not only for failing America's veterans and falsifying appointment records, but for retaliating against employees who try to expose safety and ethics violations.
Among those testifying before the House Committee on Veterans' Affairs was Dr. Katherine Mitchell, a physician at the Phoenix VA Health Care System, who told the committee some patients died because of medical care breakdowns. By trying to stand up for veterans, Mitchell added, she became the target of sham investigations, smear campaigns, job transfers and other reprisals.
Whistle-blowers and some committee members said the VA culture places the interests of administrators above care for veterans and ignores or harasses employees who speak out. Mitchell said the VA system and leadership are so dysfunctional that employees have no faith they can safely identify flaws.
"As much as you love the veterans, the administration wears you down," she said, "and you begin to question your own professional abilities."
"Something's got to change," added Scott Davis, an Atlanta VA program specialist who said he was subjected to harassment after raising concerns about delayed care for veterans and falsified records. "…I don't believe the VA can police itself."
Rep. Tim Walz, D-Minn., reacted angrily to the employee accounts. "This is bullying. That's what it amounts to," he said. "This is about people and accountability."
Rep. Jeff Miller, R-Fla., the committee chairman, said he is planning legislation to protect VA staffers from reprisal while Congress is considering measures that would make it easier to fire managers for abuse and other misconduct.
"None of these whistle-blowers lost sight of the initial mission of the VA — the mission to serve veterans," Miller added.
In written testimony submitted for the hearing, the director of the federal Office of Special Counsel said the VA has consistently dealt with internal criticism and complaints by acknowledging problems in management or practices while claiming the errors were "harmless" because they did not affect patient care.
Special Counsel Carolyn Lerner and her deputy, Eric Bachman, said that tactic — used especially by the VA's Office of the Medical Inspector — "hides the severity of systemic and long-standing problems, and has prevented the VA from taking the steps necessary to improve quality of care for veterans."
The testimony refers to scores of whistle-blowers nationwide who have been victimized by retribution, with 76 instances now under investigation.
"It is clear that the workplace culture in many VA facilities is hostile to whistle-blowers and actively discourages them from coming forward with what is often critical information," says the written testimony. "The number of cases increases daily."
Earlier Tuesday, in apparent anticipation of that testimony, VA Secretary Sloan Gibson announced that the OMI is being completely overhauled. "Given recent revelations by the Office of Special Counsel," he said in a news release, "it is clear that we need to restructure the Office of Medical Inspector to create a strong internal audit function which will ensure issues of care quality and patient safety remain at the forefront."
He said a new director will be appointed to replace Dr. John Pierce, who retired as Veterans Health Administration medical inspector June 30, and all whistle-blower complaints will be diverted to the Office of Inspector General. Gibson also reiterated previous declarations that VA employees are encouraged to report wrongdoing, and he will not tolerate intimidation or retaliation.
Dr. James Tuchschmidt, the VHA's acting principal deputy undersecretary, told committee members the department is "a broken system," and he was "sickened" by revelations.
"We failed the trust that America has placed in us to fulfill our mission," he added. "I apologize to every one of our employees who feels their voice has been silenced or their passion has been stifled."
Tuchschmidt told committee members in a written statement the VA is dedicated to core values contained in a motto — "ICARE" — which stands for integrity, commitment, advocacy, respect and excellence.
He said the VA relies on feedback from employees, including criticism, to uphold that standard.
"We are deeply concerned and distressed about the allegations that employees who sought to report deficiencies were either ignored, or worse, intimidated into silence. Let me be clear: VA will not tolerate an environment where intimidation or suppression of reports occur."
The Office of Special Counsel's written submission listed examples of systemic breakdown.
At VA health-care clinics in Fort Collins, Colo., according to the testimony, hundreds of patients were not notified that their appointments had been canceled and not rescheduled. Staffers who objected to this violation of VA policy allegedly were transferred to Wyoming. Meanwhile, the OMI said it "could not substantiate that the failure to properly train staff resulted in a danger to public health and safety."
Special counsel's written testimony said the medical inspector's conclusion is unsupportable, and disproved by similar practices in Phoenix that the VA Office of Inspector General said "negatively impacted the quality of care at the facility."
Another example involved concerns raised by a psychiatrist at the VA medical center in Brockton, Mass., that veterans with mental- health issues were not being evaluated or treated appropriately. One resident patient with 100 percent psychiatric disability showed only a single note on his treatment chart over eight years, yet the OMI said the negligent practices were "harmless error" and patient rights were not violated.
Mitchell, the Phoenix VA physician, testified that she has been subjected to a campaign of retaliation for raising concerns about the endangerment of patients in an overcrowded Emergency Department, a dramatic increase in suicides and other problems. She said her confidential complaint to the Office of Inspector General was leaked to her supervisors.
In retaliation, she said VA administrators targeted her with false accusations, investigations, written discipline and job transfer.
On whether the VA is salvageable, Mitchell stressed that there are thousands of dedicated employees hoping the national scandal will bring change. "You have an entire group of people who are ready for a revolution. And they want this," she said.
Dr. Jose Mathews, former chief of psychiatry at the VA medical center in St. Louis, testified that he was dismissed from that post after trying to improve patient access to mental-health care. Mathews said psychiatrists were spending only 3.5 hours daily with patients during their 8-hour shifts, causing veterans to face long delays and turn-downs. He said 60 percent of the veterans who had sought out help did not even request follow-up appointments.
Scott Davis, a program specialist at the VA Health Eligibility Center in Atlanta, said applications for care were shredded at a time when 600,000 enrollment forms were backlogged. He said his whistle-blower complaint to the White House was leaked to his administrators, after which his work records were altered and he was placed on involuntary leave.
"This goes to the heart of the question as to whether or not the VA should be able to police itself," he said.
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