VA First, Veteran Second: The Biden-Harris Legacy

1[House Hearing, 119 Congress]2[From the U.S. Government Publishing Office]34                       VA FIRST, VETERAN SECOND:5                        THE BIDEN-HARRIS LEGACY67=======================================================================89                                HEARING1011                               before the1213              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS1415                                 of the1617                     COMMITTEE ON VETERANS' AFFAIRS1819                     U.S. HOUSE OF REPRESENTATIVES2021                    ONE HUNDRED NINETEENTH CONGRESS2223                             FIRST SESSION2425                               __________2627                       THURSDAY, FEBRUARY 6, 20252829                               __________3031                            Serial No. 119-33233                               __________3435       Printed for the use of the Committee on Veterans' Affairs3637    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]3839                    Available via http://govinfo.gov4041                                   _______4243                 U.S. GOVERNMENT PUBLISHING OFFICE444559-613                   WASHINGTON : 20254647                     COMMITTEE ON VETERANS' AFFAIRS4849                     MIKE BOST, Illinois, Chairman5051AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking52    American Samoa, Vice-Chairwoman      Member53JACK BERGMAN, Michigan               JULIA BROWNLEY, California54NANCY MACE, South Carolina           CHRIS PAPPAS, New Hampshire55MARIANNETTE MILLER-MEEKS, Iowa       SHEILA CHERFILUS-MCCORMICK,56GREGORY F. MURPHY, North Carolina        Florida57DERRICK VAN ORDEN, Wisconsin         MORGAN MCGARVEY, Kentucky58MORGAN LUTTRELL, Texas               DELIA RAMIREZ, Illinois59JUAN CISCOMANI, Arizona              NIKKI BUDZINSKI, Illinois60KEITH SELF, Texas                    TIMOTHY M. KENNEDY, New York61JEN KIGGANS, Virginia                MAXINE DEXTER, Oregon62ABE HAMADEH, Arizona                 HERB CONAWAY, New Jersey63KIMBERLYN KING-HINDS, Northern       KELLY MORRISON, Minnesota64    Mariana Islands65TOM BARRETT, Michigan6667                       Jon Clark, Staff Director68                  Matt Reel, Democratic Staff Director6970              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS7172                   JEN KIGGANS, Virginia, Chairwoman7374AUMUA AMATA COLEMAN RADEWAGEN,       DELIA RAMIREZ, Illinois, Ranking75    American Samoa                       Member76JUAN CISCOMANI, Arizona              TIMOTHY M. KENNEDY, New York77KEITH SELF, Texas                    HERB CONAWAY, New Jersey7879Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public80hearing records of the Committee on Veterans' Affairs are also81published in electronic form. The printed hearing record remains the82official version. Because electronic submissions are used to prepare83both printed and electronic versions of the hearing record, the process84of converting between various electronic formats may introduce85unintentional errors or omissions. Such occurrences are inherent in the86current publication process and should diminish as the process is87further refined.8889                         C  O  N  T  E  N  T  S9091                              ----------9293                       THURSDAY, FEBRUARY 6, 20259495                                                                   Page9697                           OPENING STATEMENTS9899The Honorable Jen Kiggans, Chairwoman............................     1100The Honorable Delia Ramirez, Ranking Member......................     2101The Honorable Mark Takano, Ranking Member, Full Committee........     5102103                               WITNESSES104105Mr. Ted Radway, Acting Assistant Secretary, Office of106  Accountability and Whistleblower Protection, U.S. Department of107  Veterans Affairs...............................................     7108109        Accompanied by:110111    Ms. Tracey Therit, Chief Human Capital Officer, Office of112        Human Resources and Administration, Security, and113        Preparedness, Veterans Health Administration, U.S.114        Department of Veterans Affairs115116    Dr. Mark Upton, Deputy to the Deputy Under Secretary for117        Health, Veterans Health Administration, U.S. Department118        of Veterans Affairs119120Mr. David Case, Acting Inspector General/Deputy Inspector121  General, U.S. Department of Veterans Affairs, Office of the122  Inspector General..............................................     9123124Mr. Donald Sherman, Executive Director and Chief Counsel,125  Citizens for Responsibility and Ethics in Washington...........    11126127                                APPENDIX128                    Prepared Statements Of Witnesses129130Mr. Ted Radway Prepared Statement................................    29131Mr. David Case Prepared Statement................................    31132Mr. Donald Sherman Prepared Statement............................    38133134                       Statements For The Record135136Government Accountability Project Prepared Statement.............    45137American Federation of Government Employees, AFL-CIO Prepared138  Statement......................................................    46139Disabled American Veterans Prepared Statement....................    50140Concerned Veterans for America Prepared Statement................    56141142                       VA FIRST, VETERAN SECOND:143                        THE BIDEN-HARRIS LEGACY144145                              ----------146147                       THURSDAY, FEBRUARY 6, 2025148149             Subcommittee on Oversight and150                            Investigations,151                    Committee on Veterans' Affairs,152                             U.S. House of Representatives,153                                                   Washington, D.C.154    The subcommittee met, pursuant to notice, at 2:03 p.m., in155room 360, Cannon House Office Building, Hon. Jennifer A.156Kiggans [chairwoman of the subcommittee] presiding.157    Present: Representatives Kiggans, Ciscomani, Self, Ramirez,158Kennedy, and Conaway.159160          OPENING STATEMENT OF JEN KIGGANS, CHAIRWOMAN161162    Ms. Kiggans. Good afternoon, everyone. The subcommittee163will come to order.164    I would like to welcome everyone to the first hearing of165the Subcommittee on Oversight and Investigations of the 119th166Congress. While not new to the committee, all of our members167other than myself are new to the subcommittee.168    I am confident that we will continue to work in a169bipartisan manner to hold the VA to its mission of providing170world-class care for our veterans.171    Additionally, I would like to congratulate Mr. Doug Collins172on his confirmation to serve as the VA Secretary. I look173forward to working with him this Congress.174    Last Congress, we uncovered countless instances where the175VA failed to hold bad employees accountable and ultimately let176veterans down. Time after time, career government employees177were protected at the expense of veterans. Protecting bad178employees from the consequences of failing the veterans they179serve is unacceptable, especially at the cost of the taxpayer180dollar.181    Veterans should always be at the forefront of VA's mind182when they make decisions. Unfortunately, too many times183bureaucracy is put first and veterans come in second. I do184believe that 99 percent of VA employees are dedicated and185hardworking public servants that in many cases want to serve186their fellow veterans while still working in a productive,187accountable workplace.188    Over the past few years, whistleblowers continue to189describe situations where VA leaders face little discipline190despite investigations substantiating the allegations against191them.192    It takes an incredible amount of strength and fortitude to193come forward to blow the whistle on wrongdoing in the VA. I194want to take a moment to thank the whistleblowers who have195courageously come forward to the VA and to Congress to bring196attention to these problems. Your bravery is one of the reasons197we were able to do our oversight work in Congress.198    In Buffalo, one veteran with cancer did not receive care199for 10 weeks because the leadership at the facility failed to200connect him with the care he needed. This committee sent201multiple questions regarding ongoing investigations or202disciplinary actions for this failure in care, and our203questions went unanswered.204    In my own district, the poor management at the Hampton VA205Medical Center caused the facility to be left with one206anesthesiologist to serve every patient. Despite VA taking207action, I have heard continued allegations about the quality of208care issues at Hampton. To date, I have still not received209clear indication that the VA fully investigated the local210leaders at this facility. As a former provider and nurse211practitioner, these stories are heartbreaking. Our patients212deserve better.213    Unfortunately, this is not an isolated issue. Even more214shocking, there have been instances where the VA promoted215leaders even after they were found to have engaged in216misconduct. This is why Chairman Bost, along with every217Republican on this committee, reintroduced the Restore VA218Accountability Act of 2025.219    This legislation makes clear that bad VA employees need to220be held accountable to ensure that the best Federal employees221are serving veterans. Congress needs to solidify this good222government measure.223    This legislation will address many of the concerns and224challenges that we will hear from our witnesses during today's225hearing. As a provider myself, I know that leaders at local226hospitals play a critical role in ensuring patient safety. They227are responsible for creating a positive work environment that228allows nurses and doctors to care for the patients they serve,229and at the VA that is veterans. If the leaders are not holding230themselves to a high standard, then they do not need to be in231leadership. It is that simple.232    As someone with experience working with the VA in veteran233care, I know firsthand the bulk of VA employees do good work234and provide safe patient care for our veterans. This work is235valuable to our Nation, and these employees deserve safe and236sanitary working conditions. The American people have given us237a mandate to make sure their government works for them, not238poor-performing career government employees, and the VA is no239different.240    It should go without saying that veterans have earned a241system that serves them well. I am looking forward to working242with the Trump administration to course-correct the mistakes243from the previous 4 years. I look forward to hearing from our244witnesses today about how the VA will hold its employees245accountable to the mission. By restoring accountability at the246VA, we will ensure that the VA puts veterans first.247    I now recognize Ranking Member Ramirez for her opening248comments.249250       OPENING STATEMENT OF DELIA RAMIREZ, RANKING MEMBER251252    Ms. Ramirez. Thank you, Chair Kiggans. I look forward to253working with you on the Oversight and Investigations254Subcommittee as its ranking member.255    I believe we, as members of this committee, have an256obligation and a shared responsibility to ensure that the VA is257succeeding in its mission to provide veterans world-class258healthcare and benefits that they have not just earned but that259they deserve.260    The title of this hearing and the Republican majority's261approach to this topic makes it clear to me that not everyone262in this room takes that responsibility seriously. It is clear263the intent of the majority is to undermine the VA and its264mission by vilifying and persecuting an important asset, the265hundreds of thousands of public servants who show up to work266every single day to serve our veterans.267    Let us keep in mind that a third of VA employees are268veterans themselves. The end goal of their vilification is the269privatization of the VA for the profit of Trump's billionaire270bosses. I want to suggest a more appropriate title. Perhaps271this should be more like Unaccountable Billionaires First,272Veterans Last: The Musk-Trump agenda.273    In the 18 days that Trump has been in office, he has gone274on a chaotic rampage to make the Federal Government a hostile275workplace for its employees, for its three million employees.276Trump wants to either fill those positions with Make America277Great Again (MAGA) operatives and loyalists or outsource278contracts for his billionaire bosses who were lined up right in279the front row at the inauguration.280    Folks, that does not feel like it is about our veterans. It281is not about accountability. It is about profit. Trump is not282even hiding that. On January 31st, he sat in the Oval Office283after sending Federal employees a buyout email identical to the284unelected, unaccountable President Musk, who sent to his former285Twitter employees and said, quote, ``It is our dream to have286everybody, almost, working in the private sector.''287    Trump and Musk are the definition of horrible bosses, and288they are using the bad boss playbook to push public servants289out of their jobs. For those VA employees listening, look, I290want to say this to you: I know you have figured this out291yourselves, but do not take deceptive offers. Stay in the fight292with us. We need you. Our veterans need you.293    What Musk and Trump are doing to the Federal workforce294through various executive orders (EO), Office of Management and295Budget (OMB) memoranda, and tweets is demeaning, it is296shameful, and it is threatening. Their actions are going to297have dangerous impacts for our veterans, because within hours298of being back in the office Trump ordered an across-the-board299hiring freeze at Federal agencies. After the outpour of300confusion, of concern, and Trump-inflicted chaos VA employees301experienced, Trump eventually gave in to the onslaught of302pressure from Democrats and exempted some VA healthcare303positions from the freeze.304    Let me be clear. Despite our advocacy and pressure, there305are still thousands of vacancies for jobs at the VA that will306go unfilled. These jobs are mission-critical claims processors,307disability examiners, maintenance workers, environmental308management technicians, food service workers, just to name a309few.310    The VA cannot deliver the benefits our veterans have earned311and deserve without these people. Patient safety cannot be312compromised, because we know what is going to happen. Veterans313are going to suffer. That is the whole point, right? That is314exactly what Trump and Vance want. They want to cripple VA so315they can sell it off piece by piece to the highest bidder.316    The greedy billionaires sitting in awe in the front row at317Trump's inauguration stand to turn their billions into318trillions at the expense of Federal workforce, everyday319working-class American taxpayers, and ultimately veterans.320    I want to make myself very clear. I take our oversight321responsibility very seriously, and in my role as the ranking322member extremely seriously.323    Since I joined this committee, there have been several324investigations into employee wrongdoing that came to our325attention, and they were alarming. We heard hearings last326Congress that touched on issues at the VA Central Office,327Hampton, Loma Linda, eastern Colorado, Buffalo and Mountain328Home.329    In each of those cases, the Inspector General (IG) and VA330identified wrongdoing, rooted it out and disciplined the331employees in accordance with the law.332    It is a misrepresentation of the law to say that VA does333not have adequate legal authority under Title V to hold334employees accountable. VA disciplined employees under Title V335every single day. I have no problem with holding employees336accountable, and I implore the VA to do so to ensure veterans337are receiving the best care and benefits they deserve.338    What I am not going to be standing for is an excuse of my339colleagues across the aisle as they complicitly work with the340Trump administration to abuse their power, subversion of due341process rights afforded to Federal employees and the342deconstruction of the services and programs that provide343veterans the benefits they have earned and they deserve.344    Look, if you want to have real conversations about345accountability at the VA, let us have it. I am at the table346ready to talk, and I know that my colleagues are as well.347    Let us talk about ensuring that veterans get the benefits348they promise. Let us talk about improving training for HR and349supervisors. Let us talk about breaking down reporting silos350for employees to disclose misconduct when they actually see it.351Let us talk about our expectations for leadership when issues352arise at a facility. Let us talk about ensuring VA staff work353in an environment that empowers them to put veteran safety354first.355    When we have a President who removes over a dozen356Inspectors General charged with being independent arbiters of357truth and transparency in government in the middle of the358night, I find it hard to believe that this is the party that is359truly interested in making the VA more accountable for360veterans.361    With that, I want to introduce our minority witness today,362Mr. Donald Sherman, who is going to be joining us from Citizens363for Responsibility and Ethics in Washington, or CREW. CREW's364ethos is Americans deserve a democracy that is ethical,365accountable, and open. I could not agree more. If there is an366expert on government accountability out there, it is you, Mr.367Sherman.368    Thank you for being here. I look forward to your testimony.369    With that, Chairman, I yield back.370    Ms. Kiggans. The chair now recognizes Ranking Member Takano371for 5 minutes for any remarks.372373    OPENING STATEMENT OF MARK TAKANO, RANKING MEMBER, FULL374                           COMMITTEE375376    Mr. Takano. Thank you, Chair Kiggans, for this courtesy.377    Let us talk about accountability at the VA. If my majority378colleagues want to use this committee's time to take a look379back at the Biden-Harris administration, I offer to take us380back a bit further. I appreciate the opportunity to do a381history lesson for those who may be unfamiliar or who have382forgotten how Trump and his lackeys sabotaged the VA from383within during his first administration by sowing fear and384hostility in its workforce. He is following that same playbook385now that he has regained power, and it is clear that Trump is386on a witch hunt against VA employees.387    Just earlier this week, he sent Elon Musk's entourage to388the VA Central Office to do who knows what. Trump has allowed389Musk's team of teenage interns to access, collect, and poke390around the private information of American citizens at391Treasury, some of which includes veterans' data. I am deeply392concerned that they are doing the same at VA.393    Veterans are at very real risk, and we demand answers.394Unelected bureaucrats and billionaires now have access to395hordes of private data, but are not being held to any of the396same privacy standards we ask of VA employees or partners. That397does not sound very accountable to me, but perhaps this is all398part of the Republicans' plan for VA.399    As I have explained many times, a key step of the400Republican VA death spiral is an erosion of veteran trust in401the VA workforce. That is the purpose of this hearing today. My402colleagues are painting a distorted picture of the past to make403sure--to make their case as to why Congress needs to rush404past--rush to pass their incredibly flawed and unconstitutional405Restore VA Accountability Act of 2025.406    Let me tell you why their case fails. This is their third407bite at the apple, of the apple to attempt to make--and I say408to attempt to make--it easier for VA to fire employees. I say409``attempt'' with emphasis, because when the Republicans tried410this in 2014 and 2017, they failed egregiously, and veterans411and taxpayers were left holding the bag.412    The 2014 Veterans Access, Choice, and Accountability413(CHOICE) Act included expedited authorities to remove VA senior414leaders or demote them to a lower position. Employees who were415removed or demoted using that authority challenged the law's416constitutionality in court. The Department of Justice417ultimately declined to defend the law from those challenges,418and VA ceased using the law to discipline employees.419    Now, I want to be clear that I did, in fact, vote in favor420of CHOICE and the VA Accountability and Whistleblower421Protection Act of 2017. We were still dealing with the fallout422of the Phoenix wait time scandal, and at the time these bills423seemed like they would help VA weather that crisis.424    However, hindsight is 20/20 and I learned a valuable425lesson, not to trust Trump with power. Instead of using the4262017 law to improve VA, Trump and his corrupt allies weaponized427the bill to intimidate employees who were perceived to be428unloyal to Trump and to remove employees without due process.429    During Trump's first go-round at VA, his team set up the430Office of Accountability and Whistleblower Protection,431otherwise known as OAWP, as required in the 2017 law. They then432used that office to retaliate against the whistleblowers they433were supposed to protect. I wish I was making this up, but it434is well-documented truth.435    The Inspector General and other watchdog organizations,436like the Project on Government Oversight and Government437Accountability Project, helped bring this malfeasance to light.438Ultimately, however, during the Biden-Harris administration,439OAWP was able to turn things around and become a respected440organization we regularly relied on to investigate and441recommend discipline for employee misconduct.442    The death knell for the 2017 law came when the Court443scrutinized its implementation and VA ultimately quit444disciplining employees under its so-called Section 714445authorities to avoid further litigation.446    As a reminder, this is exactly what happened with the 2014447law. Settlements from the use of the 2017 law resulted in 140448million taxpayer dollars being paid out to former employees. If449that is not a failure for veterans, I do not know what is.450    The Restore VA Accountability Act of 2025 is just more of451the same. It is essentially a codification of Trump's various452executive orders to give his political appointees sharpened453tools to exact swift justice on VA employees for perceived454disloyalty or insubordination. They want to make it as easy as455possible to fire VA employees without cause. It is that simple.456    Restore is opposed to--is opposed by nearly every major457labor union. VA has testified time and time again that they do458not need the authorities in Restore to hold employees459accountable for misconduct, nor will Restore speed up the460disciplinary process, contrary to what my colleagues believe.461    Hampton, Loma Linda, eastern Colorado, Buffalo and now Ann462Arbor all present issues that warrant our attention so that we463can help VA improve patient safety and veteran464dissatisfaction--veteran satisfaction at those facilities.465    Let me be absolutely clear. The Restore VA Accountability466Act will not fix those issues. The Restore Act is not going to467hire more people to process referrals. It is not going to bring468in more qualified executive leadership. It is not going to469improve patient outcomes. What Restore will be is an empty470promise to veterans and a tool used to harm the Federal471employees that serve them.472    I know that Ranking Member Ramirez and I are committed to473work to ensure VA is an accountable organization that holds its474employees to the highest standards for our veterans. Let us475come back together and explore opportunities for476bipartisanship.477    I yield back.478    Ms. Kiggans. Thank you.479    Before the chair introduces the witness from our first480panel, I just think there is a time and place for partisan481politics, and I really wish it was not in this committee. I482think it is really important for us to continue to focus on the483issues at hand, rooting out misconduct and ensuring the VA484effectively holds those accountable who allow it. That should485not be partisan. I have said it before and I will say it again.486Partisan games have no place when veterans' care is on the487line.488    With that, I would like to recognize the witnesses on our489first panel. Testifying before us today, we have Mr. Ted490Radway, the Acting Assistant Secretary of the Office of491Accountability and Whistleblower Protection.492    We have Ms. Tracey Therit, the Chief Human Capital Officer,493Office of Human Resources and Administration, Security, and494Preparedness.495    We have Dr. Mark Upton, Deputy to the Deputy Under496Secretary for Veterans Health Administration (VHA).497    Then we have Mr. David Case, the Acting Inspector General498of the Inspector General.499    We also have with us Mr. Donald Sherman, executive director500and chief counsel of Citizens for Responsibility and Ethics in501Washington.502    If the witnesses could please stand and raise their hand,503and we will swear you in.504    [Witnesses sworn.]505    Ms. Kiggans. You may be seated.506    Let the record reflect that the witnesses answered in the507affirmative.508    Mr. Radway, you are now recognized for 5 minutes to provide509VA's testimony.510511                    STATEMENT OF TED RADWAY512513    Mr. Radway. Good afternoon, Chairwoman Kiggans, Ranking514Member Ramirez, Ranking Member Takano, distinguished members of515the subcommittee. Thank you for inviting us today to discuss516the VA's efforts to improve accountability within the517Department.518    Joining me is Ms. Tracey Therit, Chief Human Capital519Officer in VA's Office of Human Resources and Administration/520Operations, Security, and Preparedness; and Dr. Mark Upton,521Deputy to the Deputy Under Secretary for Health.522    VA is committed to providing veterans with the care and523benefits they have earned through service to our country. Our524veterans and their families, caregivers, and survivors deserve525nothing less. We and the more than 450,000 VA employees are526devoted to the sacred duty and work diligently daily to fulfill527this mission.528    Sometimes, even with the best intentions, VA recognizes529that the performance and action of some employees and leaders530fall short of expectations and what our veterans deserve. When531that happens, holding employees accountable is integral to532effective management and we take that responsibility seriously.533In today's hearing, we welcome the opportunity to discuss our534improvements to strengthen our accountability.535    The Office of Accountability and Whistleblower Protection536promotes and improves individual and organizational537accountability across VA in numerous ways.538    First, we investigate allegations against senior leaders539involving misconduct and poor performance and allegations540against all supervisors involving retaliation against541whistleblowers. Our highly skilled professional investigators542and analysts work hand in hand with our attorneys, who ensure543that investigations are properly scoped, within our544jurisdiction, all relevant issues and potential misconduct are545identified and the conclusions and recommendations are legally546supportable and appropriate.547    We issue reports with recommendations for disciplinary548actions, but we do not carry out those actions. Instead, our549report is issued to the appropriate management official with550authority to propose and/or carry out those actions. If our551recommendations are not taken, we report that, along with the552deciding official's reasoning, to Congress.553    OAWP employees have led a remarkable turnaround in554productivity, success, and impact on individual accountability.555From Fiscal Year `21 to `24, the number of incoming complaints556increased by over 60 percent to 3,305 complaints. This shows VA557employees' trust in OAWP's ability to resolve complaints fairly558and efficiently.559    Despite the rapid increase in case volume, OAWP's efforts560have dramatically reduced the time it takes to close a case.561From Fiscal Year `21 to `24, we reduced the time it takes to562close a complex case by over 75 percent.563    In addition, we have seen a jump in acceptance by564management of our recommendations. In Fiscal Year `21,565management took some action or the employee retired or resigned566in only 64 percent of our disciplinary recommendations. In567Fiscal Year `23, that number jumped to 100 percent; and in568Fiscal Year `24, we doubled the number of recommendations we569issued and management took some action or the employee retired570or resigned in all but three cases, or 92 percent.571    We also issue nondisciplinary recommendations for relief572for the whistleblower, training, or policy modifications.573Management regularly takes these recommendations between 96 and574100 percent of the time.575    OAWP also drives organizational accountability. By statute,576we provide advice, reports, and recommendations to the577Secretary on all matters relating to accountability. In the578past two years, this included providing the Secretary with579eight reports on the VA's efforts to support veterans with580military sexual trauma (MST). Half of the 32 recommendations581have been implemented to date, driving greater organizational582accountability and a better experience for our veterans with583MST.584    OAWP also launches climate reviews that give leadership585insight into the whistleblower reporting environment and make586recommendations to improve the reporting culture to drive587greater accountability and whistleblower protection.588    In 2019, VHA began a transformational modernization. The589transformation into a high-reliability organization, or HRO,590was central to this effort. An HRO is an organization that591experiences fewer than anticipated accidents or events of harm592despite operating in highly complex, high-risk environments593where even small errors can lead to tragic results.594    The Department empowers all staff to lead continuous595process improvements, and we strive to create an environment596where employees feel safe to report harm or near misses. We are597committed to continuing to build on the great strides we have598made in improving safety and quality of care.599    As VHA advances toward HRO maturity, leaders are applying600an organization-wide commitment to zero harm by developing an601even stronger safety culture, featuring empowered frontline602teams supported by engaged leadership within a climate of trust603and continuous improvement.604    The Office of Medical Inspector (OMI) is responsible for605assessing the quality of VA healthcare through investigations606of VA facilities. OMI issues comprehensive reports of its607healthcare investigations, including recommendations for608corrective action and/or improvements to the quality of609veterans' healthcare. While it does make referrals to OAWP, OMI610generally does not make specific recommendations related to611discipline. Instead, it focuses on oversight and improvement in612veterans' healthcare.613    VA is proud of its large dedicated workforce who work hard614to carry out VA's great mission every day. The Department is615committed to and engages in continuous improvement of616accountability to assess how to help identify and effect617cultural improvements within the VA, hold employees618accountable, and continue to work to protect whistleblowers.619    Thank you, and we look forward to responding to any620questions you may have.621622    [The Prepared Statement Of Ted Radway Appears In The623Appendix]624625    Ms. Kiggans. Thank you, Mr. Radway.626    Mr. Case, you are now recognized for 5 minutes to provide627your testimony.628629                    STATEMENT OF DAVID CASE630631    Mr. Case. Thank you, Chairwoman Kiggans, Ranking Member632Ramirez, and members of the subcommittee. I appreciate this633opportunity to discuss how the Office of Inspector General's634(OIG) work enhances VA's accountability.635    The OIG shares your goal of putting veterans first, and we636do that by conducting effective independent oversight of VA so637it can better serve veterans, their families, survivors and638caregivers.639    In fiscal 2024, our office released more than 300 oversight640publications with over 1,100 recommendations to VA. We made641nearly 250 arrests and secured 179 convictions. We had a642monetary impact of more than $6.5 billion in addition to the643invaluable work of our healthcare inspectors, who enhance644patient care and safety.645    These efforts to improve benefits and services for veterans646and their families would not be possible without the funding647and support we receive from Congress. The engagement of648Veterans Service Organizations (VSO)s and other stakeholders649has also been crucial to our success. In addition, we have a650strong collaborative relationship with Government651Accountability Office (GAO). We coordinate our efforts with652them to promote more consequential oversight.653    In my written testimony, I lay out the five principles that654the OIG has determined are foundational to accountability and655provide examples of each.656    First, there must be strong governance and clarity of roles657and responsibilities. We have found tension between the VA658office with its policy and oversight functions and the leaders659in the field who are not accountable to those offices. In other660cases, staff do not fully understand their roles and661responsibilities due, in part, to outdated or conflicting662guidance. Several of our healthcare inspections identified663facilities where leaders did not act on known issues, resulting664in greater risk to patients or delays in veterans receiving665care.666    Second, there must be adequate and qualified staff to carry667out clear duties. VA faces staff vacancies in key occupations,668especially within VHA. These longstanding shortages make it669challenging for VA to carry out some programs and functions.670When implementing new programs, staff often must navigate671rapidly changing guidance for processing VA benefits. The672resulting confusion can affect the amount of money and services673veterans receive.674    Third, VA needs updated IT system and effective business675processes. VA is modernizing significant systems critical to676its operations. We have been proactively overseeing VA's677implementation of these systems, including publishing 22678reports on the transformation of VA's electronic health record679(EHR) system alone. Our work has identified poor planning,680billions of dollars in unanticipated cost, patient safety681issues, low user acceptance and gaps in functionalities, making682it difficult for personnel to efficiently do their jobs.683    Fourth, effective quality assurance and monitoring is684essential. VA often lacks controls to consistently ensure685quality standards are met. Breakdowns in routine monitoring and686workarounds undermine efforts to identify and fix problems as687well as make certain the eligible veterans and their families688receive timely services and benefits.689    Last, consistent and effective leadership is critical.690Engaged and dedicated leadership fosters open communication,691efficiency, and accountability among all staff.692    These five themes are routinely highlighted in OIG reports.693Although report findings and recommendations are often directed694to a single facility, system, or program, they serve as a695roadmap to help prevent or correct similar problems in other696facilities or offices.697    We recognize that VA is working to build a stronger sense698of accountability. We routinely observe personnel committed to699providing the highest quality care, benefits, and services to700veterans and their families despite obstacles.701    The OIG will continue to provide practical and meaningful702recommendations to help VA remove these obstacles to serve703veterans first, address fraud and other crimes, as well as704waste and improve efficiency.705    Finally, I want to thank Congress for passing the Elizabeth706Dole Act, which includes a requirement that all new VA707employees receive training on how to report and cooperate with708the OIG.709    Chairwoman Kiggans and members of the subcommittee, this710concludes my statement. I look forward to answering any711questions you may have.712713    [The Prepared Statement Of David Case Appears In The714Appendix]715716    Ms. Kiggans. Thank you, Mr. Case.717    Mr. Sherman, you are now recognized for 5 minutes to718provide your testimony.719720                  STATEMENT OF DONALD SHERMAN721722    Mr. Sherman. Chairwoman Kiggans, Ranking Member Ramirez,723and members of the committee, thank you for the opportunity to724testify before you today.725    The Department of Veterans Affairs' mission to provide for726the care, benefits, and support of veterans is the fulfillment727of a promise that our Nation made and must continue to honor to728those who have protected our Nation in the Armed Services.729    My own family includes veterans who served in combat, and730my grandfather proudly worked at the VA in his hometown of731Tuskegee, Alabama. I thank our Nation's veterans and military732families for their service and sacrifice for our country.733    In order to meet its critical mandate, the VA plays many734roles, including administering pensions, insurance and home735loans for veterans, providing survivor support for veterans'736families, and running the Veterans Health Administration, the737largest integrated healthcare network in the United States.738    The VA cannot falter in this mission. Yet, managing such739complex systems is a daunting task. The VA has experienced740challenges across both Democratic and Republican741administrations that demand robust, independent oversight.742    It is certainly reasonable to look backward at the Biden743administration's stewardship of the VA and acknowledge areas of744success and challenge. That is why it would have been useful to745have former VA IG Michael Missal in attendance here today.746    During his tenure, Mr. Missal's leadership of OIG garnered747bipartisan praise, and he released numerous reports critical of748VA officials during both President Trump's and President749Biden's terms in office.750    In 2024 alone, IG Missal's team published more than 300751reports with over 1,100 recommendations to help the VA improve752the lives of veterans, with a monetary impact on at least $6753billion in taxpayer funds.754    Under Mr. Missal's leadership, VA OIG pushed the agency to755address deficiencies in its assessment of suicide risk,756healthcare failures at facilities like the Hampton VA Medical757Center, as well as longstanding management challenges.758    Despite that staggering impact, President Trump fired Mr.759Missal last month, along with more than a dozen other760Inspectors General. That is not normal. In fact, these firings761were illegal. Provisions of the bipartisan Securing Inspector762General Independence Act require the President to provide763Congress with 30 days' notice and an explanation before firing764an IG. President Trump did neither.765    Although it is beyond my expertise to opine on VA's766mission-specific operations, independent oversight is essential767for the agency to better support our Nation's veterans.768    President Trump's firing of IGs, including Mr. Missal, was769unethical, and our veterans will be among the many communities770harmed as a result of these and other authoritarian actions.771    These attacks include President Trump's gutting of the772nonpartisan Civil Service. Veterans make up roughly 6 percent773of the American working-age population, but nearly a third of774the Federal workforce. Efforts to fire, suspend, and demote775civil servants across agencies disproportionately impacts776veterans. President Trump's hiring freeze on many components of777the VA likewise undermines the agency's work to meet the needs778of veterans and military families.779    In January, my organization filed a lawsuit to force780President Trump's billionaire-led Department of Government781Efficiency (DOGE) to stop operating in the shadows and to the782exclusion of veterans and other stakeholders.783    The administration has also terminated programs aimed at784meeting the unique experiences of diverse veterans. Having an785independent permanent IG here today would be valuable to assess786the impact of these policies and opine on reforms that this787committee is interested in pursuing. That is why CREW has788pressed for IG vacancies to be filled and for independent789oversight under both Presidents Trump and Biden.790    The VA OIG vacancy is especially concerning, given the791corruption scandals at VA during the first Trump792administration, including President Trump allowing cronies to793help run the agency from Mar-a-Lago. OIG's investigation of794Secretary Shulkin's lavish taxpayer-funded travel helped to795lead to his removal in 2018.796    In closing, President Trump's ouster of Mr. Missal suggests797that even his successor could be fired on a political whim.798That fact does nothing to help the VA better serve veterans and799military families, address the longstanding challenges the VA800has faced across administrations or prevent the corruption that801plagued the VA during the first Trump term.802    If this committee is serious about oversight of the VA,803then I would expect Members of both parties to vocally oppose804President Trump's illegal attack on IGs and the Civil Service.805    Thank you. I welcome your questions.806807    [The Prepared Statement Of Donald Sherman Appears In The808Appendix]809810    Ms. Kiggans. Thank you, Mr. Sherman.811    We will now move to questions, and I yield myself 5812minutes. Just before that, in accordance with committee rule8135(e), I ask unanimous consent that Representative Moylan from814Guam be permitted to participate in today's subcommittee815hearing.816    Without objection, so ordered.817    Mr. Case, the VA Inspector General has published three818different reports about concerns with the clinical care819veterans receive at the Hampton VA in my district. Each report820highlights the importance of having quality assurance processes821in place. If these are not in place, patients bear the822consequences.823    Can you tell me your opinion about why it is important for824leaders to have quality measures in place for patient care, and825can you also give us some examples of these quality measures?826    Mr. Case. Chairwoman Kiggans, we have published those827reports, and the whole goal is to put the veteran first there.828Quality assurance and important quality measures have to be in829place. Adherence to defined processes and objective assessments830of basic patient safety activities is critical.831    Leaders must be proactive in monitoring compliance and832tracking and trending compliance. They then have to intervene,833modify, or enhance resources in real time to keep patients834safe. If they see problems, then there is constant monitoring.835    An example from Hampton, is there were ineffective836monitoring of the processes to address substandard care by a837surgeon. By doing that, you allow a surgeon to stay in place838who is believed to be not operating at the highest level or839even at an acceptable level. By monitoring those processes,840paying attention, demanding accountability, you ensure safety841and patient safety.842    Ms. Kiggans. The IG also published a report that showed843severe mismanagement in veterans' oncology care, resulting in844serious delays, which is unacceptable.845    How can leaders be proactive in their oversight and846involvement in patient care? You talked about hands-on and just847managing that care, but can you give me specific examples? Is848this reviewing charts? Is this periodic reviews with small849groups? Just a little more specific.850    Mr. Case. Yes. As a general matter, trust is critical851between leaders and staff, but verification of performance and852adherence to policy and standards is absolutely necessary. The853stakes are too high, and the data is too readily available to854assume patients are getting the care they need, especially855those at high risk.856    The best example that comes to mind is in Buffalo, where857there was--the chief of oncology, the staff oncologist were858demanding that a patient get an appointment scheduled in the859community. The response from others was: we are taking care of860it. We will get it done. It was not getting done.861    That is an instance where you can trust, but you have to862verify. You have to intervene and make sure that that patient863is getting the care he needs, especially incumbent upon864facility management, the staff oncologist and the oncologist.865    Ms. Kiggans. Which takes manpower and then also people who866are very thorough and attention to detail in doing this. A867follow up for their jobs, which I can appreciate. Thank you,868Mr. Case.869    Mr. Radway, from your experience in the last 4 years, what870has OAWP identified as repeat areas of concern across the VA in871patient care?872    Mr. Radway. We have not, Congresswoman, really focused on873patient care issues per se. We have really looked more at874misconduct.875    We have seen several cases where there was a failure to876oversee providers who were alleged to have committed misconduct877in terms of patient care and improperly treated patients. Then878we will look at the activities of those senior leaders who879failed to oversee their providers, their chiefs of surgery,880things like that.881    Ms. Kiggans. The office--and Mr. Radway again--the Office882of Medical Inspector is responsible for assessing VA's quality883of care. How do the recommendations made in the OMI reports884work to mitigate repeated errors in the care provided in the885VA?886    Mr. Radway. Dr. Upton, do you want to----887    Dr. Upton. I would be happy to take that, Madam Chairwoman.888    The OMI recommendations come to both the leaders of the889facilities as well as to our senior leaders in VHA. They, as890was mentioned earlier, look at important quality and safety891issues within our system, often charged by the Under Secretary892for Health or others.893    We--the OMI specifically makes sure that those894recommendations are followed through, and we take them very895seriously as part of our commitment to quality.896    Ms. Kiggans. You follow up at each facility individually?897    Dr. Upton. We review them as leaders, as the senior898leadership team. They also work with each facility, because899many of these are very facility-specific. We certainly try to900take lessons learned across the system as well.901    Ms. Kiggans. Very good. Thank you.902    Let us see. Then we will now--I want to--we will now move903to questions from the ranking member.904    Ranking Member Ramirez, you are recognized for 5 minutes.905    Ms. Ramirez. Thank you, Chairwoman.906    I want to just thank all of you for being here again. I907really appreciate your testimonies and having an opportunity to908read through them.909    I want to do a little quick level-setting exercise with910some of the witnesses here today, because we are I know a911little bit in a time crunch. I want to go down the row with912three of you and ask you each to answer a question.913    Ms. Therit, in your work, do you put veterans or VA first?914    Ms. Therit. Congresswoman Ramirez, yes.915    Ms. Ramirez. Veterans?916    Ms. Therit. Veterans first.917    Ms. Ramirez. Mr. Radway, in your work, do you put veterans918or VA first?919    Mr. Radway. Veterans.920    Ms. Ramirez. Dr. Upton, you are a provider who cares for921veterans. Do you put veterans first or VA?922    Dr. Upton. Veterans first every time.923    Ms. Ramirez. Thank you. I want to make sure that the record924shows that it is crystal clear that these public servants925before us put veterans first. I believe them.926    We relied on each of you during the last 4 years to ensure927the VA continued its journey to becoming an accountable928institution that prioritizes patient safety, and I just want to929thank you for your service.930    Now, Ms. Therit, I appreciated VA's testimony that you931provided regarding actions taken to hold employees accountable932for misconduct. I want to ask you a couple follow-up questions.933    How frequently does the VA use its authority under Title V934to remove employees?935    Ms. Therit. Congresswoman Ramirez, last Fiscal Year we used936our authority under Title V and the Accountability Act, because937we use both of the authorities. We use 713 in the938Accountability Act for our senior leaders and the Chapter 43939and Chapter 75 authorities in Title V.940    There were over 5,000 actions that we took to remove, to941suspend, or to demote employees who engaged in poor performance942or misconduct. That number mirrors about the same number that943were taken the first year after the Accountability Act was944passed.945    Ms. Ramirez. Pretty frequently.946    How recently have you used Title V authority? When was the947last time?948    Ms. Therit. We use the authorities that we have on a daily949basis.950    Ms. Ramirez. Got it. I am looking at a chart right now that951compares year over year the total number of adverse actions952taken by the VA. It says that for year 2024, there were 5,875953adverse actions. You just mentioned that. In year 2024, the VA954would have been using Title V authorities for adverse actions,955as you mentioned, correct?956    Just to follow up, the chart says that in 2018, `19, `20,957`21 and `22, the VA had 5,952, 5,653, 5,694, 4,673 and 4,068958adverse actions, respectively.959    During that period, which authority or authorities for960adverse actions would the VA have been using?961    Ms. Therit. Prior to Fiscal Year 2023, we were using a962combination of Accountability Act, Chapters 713 and 714963authorities in addition to our Title V authorities.964    I would say that we are always using all of our965authorities, whether under Title 38 or Title V, to ensure our966Title 38 and our Title V workforce are being held accountable.967    Ms. Ramirez. Got it. VA uses Title V at the same or higher968rates for adverse actions than they did with the authorities in969the 2017 Accountability law, correct?970    Ms. Therit. Correct. We have a track record of legally971defensible actions under Title V, because they have been before972the Merit Systems Protection Board, they have been before third973parties. Any time we take an action, we want to make sure that974that employee does not come back if we remove them, if they are975suspended that suspension is upheld.976    We try and look at the case law to make sure that the977actions that we are taking are legally defensible and that we978will not have to reinstate bad actors who should not be at the979VA serving veterans.980    Ms. Ramirez. That sounds efficient.981    Ms. Therit, my understanding is that you sit on Council982with other agency chief human capital officers. Is that983correct? Yes?984    Ms. Therit. Yes, ma'am.985    Ms. Ramirez. I have another follow up. Are there other986Federal agencies that also employee physicians, nurses, and987housekeepers, like the VA?988    Ms. Therit. There are. The Department of Health and Human989Services. The Department of----990    Ms. Ramirez. Let me ask you, though. I have a couple991seconds left here.992    Do those agencies also use Title V to discipline employees?993    Ms. Therit. They do.994    Ms. Ramirez. Ms. Therit, can you describe an instance when995you could not remove an employee under Title V?996    Ms. Therit. If there are instances when an employee cannot997be removed under Title V or Title 38, it is typically, as Mr.998Radway had alluded to, because of a lack of evidence, you know,999an inability to support the level of discipline that is being1000proposed.1001    Rarely is it the authority that is limiting it as opposed1002to the substance of the investigation or the prior conduct or1003performance of that individual.1004    Ms. Ramirez. Thank you, Ms. Therit.1005    Just a quick question to Mr. Sherman. Thank you for being1006here again. How would you describe the first 20 days of the1007Trump's second administration in the last 10 seconds? Hard, I1008know.1009    Mr. Sherman. Lawless, evasive, chaotic. You know, I think1010if the President was serious about oversight of the VA in1011particular, he would not have fired the IG and he would not1012have sent minions from DOGE to root around there.1013    Ms. Ramirez. Thank you, Mr. Sherman.1014    I yield back.1015    Mr. Self. [Presiding.] Thank you. I recognize myself for 51016minutes.1017    First of all, I want to thank you for being here. I want to1018assure you that you are not stage props. The hysteria and the1019hyperbole that you have heard today will not stop this1020committee from conducting reasonable oversight, which is our1021duty.1022    Mr. Case, your testimony, particularly your written1023testimony, is pretty damning. I will just quote a few sentences1024from it. ``Accountability, components of accountability1025identified by the OIG are often lacking within VA programs and1026operations.'' You listed the five, gave a very detailed.1027    ``The OIG regularly identifies instances of misconduct,1028broken systems, confusing and conflicting governing policies or1029guidance, and inefficiencies or missteps in implementing1030programs.'' Further, you say, ``Misconduct, failures to take1031appropriate action, and persistent problems are often the1032result of VA personnel or contractors not understanding their1033roles or responsibilities. In other cases, they understand1034their duties, simply do not or cannot fulfill them. This may be1035due in part to outdated policies and procedures, conflicting1036guidance, lack of clear decision-making--often by those best1037positioned to act lacking the authority to do so,'' and you go1038on.1039    Everything that I just read is a leadership issue. I will1040tell you that during my first term in Congress on this1041committee, we spent an inordinate amount of time on countless1042scandals throughout the VA, normally at the leadership level.1043    In the past 2 years under the Biden administration, we have1044been made aware of many cases, not executing their jobs,1045employees not executing their jobs. This subcommittee sent over104680 letters--80 letters--to try to uncover why that is. I can1047only compare it to a dumpster fire in a windstorm. If you think1048it cannot get any worse, it blows up again.1049    Mr. Case, I want to go to you first. Have you found1050Veterans Integrated Service Network (VISN) directors exercise1051inconsistent oversight--and this is leading to another1052question--leading to major disparities in quality of care and1053leadership across the VISNs?1054    Mr. Case. We have found disparity in oversight by VISN1055directors, largely attributable, we see often, in the fact they1056do not have clear definitions of what their responsibilities1057are and what their duties are. This is not just VISN directors.1058It goes to all leadership, mental health directors at the VISN1059level.1060    Once the responsibilities and duties are clarified, then I1061think they will be in a position to move forward.1062    Mr. Self. Do you attribute this to lack of leadership at1063the VA leadership level to a Secretary administrative level, or1064is it they have too much autonomy at the VISN director level?1065Again, leading to another question.1066    Mr. Case. Yes. How the VA got itself in the situation is1067probably a long story. Autonomy can work if there is1068standardization of duties at the highest level, at the VISN1069level, and those duties are clear. As it exists right now,1070there is not that clarity for VISN leaders to act on their1071duties.1072    Mr. Self. Okay. Let me go to the EHR, because--and I1073realize it probably is not in the core mission of this hearing.1074Is it not true, from the OIG perspective, that we cannot get to1075a clear EHR solution because of the customization at the VISN1076level? Is that a true statement or not?1077    Mr. Case. That could be part of it, and it is probably part1078of it. There are many reasons, though, why EHR is in the state1079it is in at the present time.1080    Mr. Self. The ethics violations. We covered, oh, probably1081all the way from sexual to the bonuses, those scandals that I1082referred to, to what would you owe that?1083    Mr. Case. That depends on the instance that we are trying1084to address. Sometimes it is personal malfeasance. It boils down1085to that. Other times, malfeasance is allowed to go on. It just1086varies, and it is individualized. That is why our reports are1087very specific, focused, and practical.1088    Mr. Self. In the last couple of seconds, Mr. Radway, do you1089track instances where VISN leadership intervenes--no. Do you1090identify cases where interference allows people to be1091transferred as opposed to held accountable? Quickly.1092    Mr. Radway. We do not track whether people are transferred.1093We just track whether the VISN leaders, if they are the1094deciding official, implement the recommendation for discipline1095or not.1096    Mr. Self. Okay. Thank you. I yield back and recognize Mr.1097Conaway.1098    Mr. Conaway. Thank you.1099    Mr. Self. Dr. Conaway. I apologize.1100    Mr. Conaway. Well, thank you for that. I appreciate that.1101Thank you, Mr. Chairman.1102    Thank you, lady and gentlemen, for presenting yourself to1103us today. Hopefully we, working together, can bring about the1104necessary improvements to ensure that the VA meets the demands1105of the American people and certainly the desires of our veteran1106community to receive first-rate service at the VA.1107    I would like to follow up, however, on a question that was1108just raised about ethics and to raise a concern about the1109President's actions upon--in office with respect to EOs.1110    My notes say here that among the recisions that the1111President made changed the ethics commitments by executive1112branch personnel and others with respect to gifts and the like.1113    Have any recent changes in the administration impacted the1114ethics rules governing the highest reaches in the VA? That is1115either for Mr. Case or Mr. Sherman. I will help out that way.1116    Mr. Sherman. Well, I think when President Trump came in, he1117rescinded the ethics pledge for appointees in the government,1118and significantly weakened those rules, making it easier for1119appointees to accept gifts and to move back and forth between1120the private sector and the public sector.1121    Certainly, I would be concerned about conflicts of1122interest, you know, undermining the efficacy of service that1123the American people, including our veterans, get from their1124government.1125    Mr. Case. From the IG perspective, we will look at issues1126that are raised to us, and we will investigate those and do1127reports. We do investigate those, but we do not address broad1128policy issues, and we do not address in a significant way what1129is the result of those policy issues until we have specific1130requests to go and look at specific instances. That is1131basically are people meeting standards. That is how we operate1132in doing our reports.1133    Mr. Conaway. I thank you for that. I just have to say that1134these ethics rules are intended to ensure that the vendors who1135work for the VA, you know, public money is being spent there.1136If someone is getting gifts or not behaving appropriately with1137respect to awarding contracts and overseeing those because of1138gifts, then we are going to see waste and we are going to see,1139as we have seen, unfortunately, throughout the VA, serious1140problems with implementing the systems for everything from1141getting appointments, the Electronic Medical Record (EMR) which1142you just mentioned, and many other things in the reports that1143we have gotten that have looked at cost overruns and the1144inability to get these critical systems implemented and online.1145    Mr. Radway, again, thank you for being here. Can you1146describe how the OAWP improved the quality of investigative1147work over the last 4 years during the Biden-Harris1148administration, and have improvements been made, not been made?1149    You noted here that there are a number of investigations1150under the current authorities that have led to more than 5,0001151people being removed from their jobs for various infractions.1152    Can you describe the--how the OAWP process has worked with1153respect to quality of investigations?1154    Mr. Radway. Sure, Congressman. A lot of it has to do with1155hiring the right people. I hired skilled 1810 administrative1156investigators who--many of whom are retired military or retired1157law enforcement and are on their second career.1158    We instituted standard operating procedures, based on the1159Council of the Inspectors General on Integrity and Efficiency1160Investigative Standards, and we modelled those standards for1161our investigation. We have given our folks training, and we1162established the Investigative Attorneys Division, which ensures1163that our reports are legally sufficient and our recommendations1164are legally supportable.1165    Mr. Conaway. That is all I have.1166    Mr. Sherman, can you talk about the--regarding the1167reinstatement of Schedule F by the current administration, how1168will this executive order create a VA that is more prone to1169corruption versus one that prioritizes accountability and the1170well-being and care of veterans?1171    Mr. Sherman. Well, certainly weakening Civil Service1172protections makes it easier to fire government workers,1173nonpartisan government workers, when they report misconduct by1174the political leadership of the agency.1175    It makes it less likely that people will report misconduct,1176and it makes it more likely that the Civil Service is subject1177to partisan pressure, which is exactly what we do not want our1178veterans to experience when they come to the government for1179help.1180    Mr. Conaway. Well, with the time I have, I just want to say1181that we need a professionalized Civil Service and not people1182who are amateurs coming in there on political appointments that1183are not accountable to their mission but, rather, to the1184appointing authority.1185    Thank you, Mr. Chairman.1186    Mr. Self. I recognize Mr. Ciscomani.1187    Mr. Ciscomani. Thank you, Mr. Chairman.1188    Our ultimate duty here on the committee is to ensure1189veterans come first and not senior executive bureaucrats. It is1190one thing to be able to say that and then another to act on1191that.1192    Arizona is, sadly, the epicenter of what can go wrong when1193oversight is not taken seriously, as we saw in 2014. It was1194referred to that earlier today as well.1195    While we seek to ensure the VA is effective, we also have1196worked to create great public, private, and VSO partnership1197programs to fill the void in the community in Arizona as a1198result of what happened.1199    One example is the Be Connected program that for years has1200partnered with VA to ensure veterans are able to access the1201resources and benefits they have earned. While ensuring these1202partnerships continue, I want to make sure recent events in1203Arizona, such as a veteran passing away in the parking lot of1204the Phoenix Medical Center or a physician improperly1205administering care to veterans cease to occur.1206    Now, when we--Mr. Radway and Mr. Case, this will be going1207to you on the issue and the topic of the senior executive staff1208improper bonus pay.1209    Last Congress, it was discovered--and in this area I would1210like you to please provide some insight as well as getting into1211the OIG's work.1212    Last Congress, it was discovered Senior Executive Service1213(SES) pay bonuses were paid despite the purpose of these1214dollars being allocated for frontline healthcare workers who1215are day in and day out serving our veterans.1216    What is the VA doing to, one, regain trust; two, ensure1217this does not happen again; and, three, how do you plan to1218continue oversight of work with the new administration, given1219its Presidential memo regarding additional accountability for1220SES employees?1221    Mr. Radway. Congressman, in response to the IG report on1222critical skills incentives, or CSIs, our office was tasked with1223conducting an investigation into that episode, issued a 165-1224page report to the Secretary with recommendations for1225disciplinary and nondisciplinary action, including policies and1226procedures that would prevent that from reoccurring.1227    Most of our recommendations to date have been implemented.1228We have not seen any issues of reoccurrence brought to our1229attention, but if they were we would certainly investigate1230those, as appropriate.1231    Mr. Case. We have received a response to our1232recommendations, asking that they have been closed, from the VA1233That came on January 10th. The closure of recommendations and1234whether the VA has met the action plans they put forward is not1235a binary process. It is not a yes or no process.1236    Oftentimes it requires a discussion with VA as to what they1237have done, have they done enough, and see what their response1238is. We are analyzing those right now. From our perspective, I1239think some of those could probably be closed, but I think1240others are going to require this ongoing discussion as to what1241has been done and is it sufficient to meet the action plan of1242the recommendations.1243    Mr. Ciscomani. What about my last part of the question1244regarding the new administration giving the Presidential memo1245regarding additional accountability for SES employees? How does1246that play into what you just explained?1247    Mr. Case. Yes. When we do our work, we hold VA to1248standards, and those standards could include legislation,1249regulation, VA policies, clinical policies. Whatever it is that1250we are trying to investigate we hold them to standards, and if1251they come up short on those standards, then that would be part1252of our report, our findings, and we will make recommendations1253and then follow up to see if the action plans are implemented1254in the way that meets those recommendations. This would be part1255of that process, sir.1256    Mr. Ciscomani. We are running out of time here, but just1257moving on, one of the major concerns is the number of times I1258have seen individuals resign while under investigation as well1259in an attempt to avoid accountability to their actions or for1260actions of those they oversee as well. That happened1261repeatedly. It was mentioned by the chairman in terms of how1262many of those we saw in this committee.1263    How does this impact accountability and the investigation1264processes?1265    Mr. Radway. It does happen, sir. It does not impact the1266investigation itself. We are continuing to close out our1267investigation. I am going to defer to Ms. Therit to speak about1268the consequences of that.1269    Ms. Therit. Congressman Ciscomani, two things that I would1270offer. One is we do have authority under 5 USC 3322 to annotate1271personnel records when someone resigns under an investigation.1272I will tell you that authority is very limited to certain1273circumstances, and we cannot use it broadly.1274    I know later this month we have a legislative hearing, and1275we are looking forward to sharing some views that we have on1276more things that we can do to approve accountability at the VA.1277    Mr. Ciscomani. I am interested in participating and helping1278in any way on that.1279    Mr. Chairman, I think that whenever someone saves1280themselves from any consequences by resigning, that is an1281accountability problem.1282    Thank you.1283    Mr. Self. Mr. Kennedy.1284    Mr. Kennedy. Thank you. Thank you all for your testimony.1285Thanks for your service to our great country.1286    Dr. Upton, I understand that you have been involved in1287improving the care in the community program of the Buffalo1288Medical Center. Are you fully read into the OIG report and what1289was found in that report and what has been recommended for the1290Buffalo VA Medical Center in the fall?1291    Dr. Upton. Thank you, Congressman.1292    As a healthcare provider myself, this was mentioned1293earlier, as well as some of the works nationally, we need to1294make sure that when veterans are referred for care, that it1295happens timely and in a high quality way. Certainly that was1296the challenge, you know, the significant concern we heard in1297Buffalo.1298    I will say when that concern came to us, our under1299secretary for health very swiftly pulled a team of experts1300together from various disciplines to go to Buffalo directly, as1301you know, sir, and really look at all aspects of the issue1302there, from process to education to staffing to ensuring the1303right reviews are occurring of leadership as well.1304    Mr. Kennedy. You are familiar?1305    Dr. Upton. I am very familiar, yes.1306    Mr. Kennedy. Excellent. Well, thank you.1307    The under secretary came up at my invitation, and we had a1308very productive meeting with the leadership of the staff at1309that hospital, and one of the issues that came up was a lack of1310staffing.1311    Through what you have read in the OIG report and in order1312to achieve the OIG recommendations, do you believe that it is1313important that the staff is hired to a level that is necessary1314to provide the service to our veterans?1315    Dr. Upton. I do, Congressman.1316    Mr. Kennedy. The VA is currently under a hiring freeze, is1317it not?1318    Dr. Upton. We are complying with the, you know, orders from1319the administration, but we have received a number of exceptions1320for important critical roles within the healthcare delivery1321system.1322    Mr. Kennedy. What is the VA doing to get more hires at the1323Buffalo VA specifically to help the veterans get the care that1324they need?1325    Dr. Upton. I know that the current leadership at the1326Buffalo VA, as well as the VISN, are taking that very1327seriously, and I would be happy to follow up with you directly,1328Congressman, on the specific hiring in various key areas there.1329    Mr. Kennedy. Well, it is important that the hiring is up to1330a level that the hospital and the system functions.1331    When the fork in the road email went out, there was a1332department of VA memo that stated that there were approximately13331,900 plus jobs that were rescinded and 716 job postings that1334were removed from USAJobs. Those are positions that are1335effectively providing service to our veterans, are they not?1336    Dr. Upton. We are absolutely committed to hiring all the1337key positions we need, Congressman, and were able to repost a1338large number of those.1339    Mr. Kennedy. I understand what you are saying, but I would1340like to know precisely how. Buffalo VA is indicative of what is1341happening around the country. If there is a hiring freeze in1342place, and what we are hearing, not only in my district but1343across the country, is that there are individuals that are1344being put on performance improvement plans, there are people1345that are on probation that are being cut without explanation,1346and are those positions being hired?1347    It sounds to me and others that we are hearing from, again,1348my constituents that we are blowing a hole in the staffing1349levels at not only the Buffalo VA and the Buffalo network, VA1350network, but across the country.1351    Can you speak to that?1352    Dr. Upton. I will say that we are absolutely committed to1353hiring key staff, and I agree with you, Congressman. It is so1354important that we bring the staff in to serve veterans. The1355specifics of Buffalo in the network I would be happy to follow1356up with you with, but I certainly understand your concern.1357    Mr. Kennedy. How can we be confident that the VA network1358across the country is being staffed appropriately when, in1359fact, there have been jobs that have been rescinded, offers1360that have been rescinded, and postings that have been removed,1361thousands of jobs and postings, and, you know, there are1362reports of individuals, again, being put on performance1363improvement plans that ultimately we know is the first step1364toward termination, and individuals that are currently in a1365probationary hiring period that are being terminated without1366cause?1367    Dr. Upton. I will say we are going to stay laser focused as1368a health administration to hire all the employees that we can1369and follow all accordant directives and guidance, but we are1370laser focused on bringing the critical healthcare workers we1371need, Congressman.1372    Mr. Kennedy. I would like you to, please, provide in1373writing to this committee, this subcommittee a hiring chart of1374exactly what is happening, where the hirings are, where the1375staffing levels are open, and all of which have transpired1376since the fork in the road memo went out.1377    I yield back. Thank you.1378    Mr. Self. Mr. Moylan.1379    Mr. Moylan. Thank you, Chairman Self and Ranking Member1380Ramirez. I would like to thank the subcommittee for the1381opportunity to speak on behalf of the veterans of Guam who have1382been some of the most dedicated and selfless members of our1383Nation's armed forces.1384    Now, despite Guam having the highest enlistment rate per1385capita in the United States and one of the highest1386concentrations of veterans, our island has consistently been1387left behind when it comes to access to resources and benefits1388they deserve from the VA under the previous administration.1389    There is an ongoing discrepancy between the number of1390veterans reported by the government of Guam and those1391recognized by the VA. This is likely due to the VA's reliance1392on the number of veterans registered without considering the1393need for increased outreach and support to those who have not1394been connected to the system.1395    We know that our veterans in Guam have sacrificed so much1396in service to this Nation. It is our responsibility to ensure1397that they are not left behind simply because they live in1398geographically isolated territory.1399    The failure of the VA to provide adequate staffing,1400oversight, and resources for Guam's veterans under the previous1401administration is a situation that demands immediate1402correction.1403    Today's hearing is a crucial step in ensuring that the1404brave men and women of Guam who have served our country are no1405longer neglected. We must take action to provide the support1406and services they have earned.1407    For my first question, Dr. Upton, Guam currently falls1408under the VA Pacific Island's healthcare system which services1409the largest geographic region in the country. How does VHA1410determine resources, allocations for its facilities and the1411territories which face unique challenges in accessing Federal1412resources and services?1413    Dr. Upton. Thank you, Congressman.1414    I want to echo how important it is that we serve the1415veterans of Guam and appreciate their service. As you1416mentioned, Guam is part of that particular VISN network, and we1417look at the veteran population, the services they need, the1418location of various facilities, as well as in VA and in the1419community.1420    I would be happy, Congressman, to sit down with you and1421that VISN leadership to talk about the needs in Guam from the1422healthcare perspective. I know that, you know, it sounds like1423we can do better. They need support, and I would be happy to1424work with you.1425    Mr. Moylan. The next question will be for Mr. Radway. How1426much oversight exists when issues arise in Guam and the other1427territories? How often are visits conducted, and how does the1428VA address these matters?1429    Mr. Radway. I can only speak to oversight of the senior1430leaders. I do not have numbers for you on how many1431investigations we have had in Guam. I can certainly get those1432numbers for you, Congressman. If we receive allegations, we1433would treat those just the same and investigate them just as we1434would any other VISN or facility.1435    Mr. Moylan. All right. Thank you.1436    Last question. Ms. Therit, a consistent issue brought forth1437by my constituents is how does the VA decide where staffing is1438needed? How is the annual review conducted to determine if1439staffing needs to be increased?1440    Ms. Therit. Congressman Moylan, thank you for that1441question.1442    In terms of the staffing resources and models that the1443Veterans Health Administration uses, those are assessed on an1444ongoing basis. We publish data on a recurring basis. On a1445monthly basis, we publish a public-facing report that looks at1446staffing levels. Then on a quarterly basis, we report it on the1447Mission Act 505 section with respect to our vacancies and our1448staffing levels.1449    Where those staffing levels need to be adjusted, I think as1450Dr. Upton mentioned, that local leadership will work with their1451VISN leadership to make sure that they are getting the1452resources and the budget and the allocations that they need to1453ensure that the services are being provided in a timely and1454high quality manner. Those assessments are ongoing.1455    If there are any circumstances that you want to discuss1456specifically in your area, I am glad to take a closer look at1457that with the VHA HR team.1458    Mr. Moylan. I appreciate your time and you all coming and1459testifying before the subcommittee. I thank you very much.1460    Mr. Chairman, thank you.1461    Mr. Self. Thank you.1462    I want to thank the witnesses for coming today for your1463candor, for your willingness to come, and to the VA for1464providing the witnesses, the expert that they have.1465    We need to ensure the VA has good governance. Veterans are1466getting the quality care that they deserve and they have1467earned, to quote several members from this side. Absolutely,1468that is imperative. That starts with ensuring that all1469employees are held accountable. Leadership culture matters.1470    Restoring accountability remains a top priority of this1471committee, and I am speaking for the chairwoman. We all look1472forward to continuing to ensure that VA remains committed to1473this goal. We all look forward to the leadership of Secretary1474Collins, and I believe that we will see a dramatic difference1475    Ranking Member Ramirez, closing comments.1476    Ms. Ramirez. Thank you, chairman.1477    I also want to echo the sentiments from the chairman now.1478We are really incredibly thankful for you to be here today.1479    This committee is going to be incredibly important over the1480next few weeks, over the next few years. We have to make sure1481that we use oversight and we use every authority in our power1482to ensure that we put our veterans first, that we ask hard1483questions, that we make sure that in everything we do, we are1484centering veterans and their families.1485    For many years, I got to shelter them. I fed them. I helped1486them find jobs. It is the work that I have done from a very1487young age--I know I look young, but that was almost 20 years1488ago.1489    I want to say that as I am thinking about and transitioning1490out of this hearing today, I am concerned that at no point1491during this hearing today we mentioned on this side--we1492certainly heard it from Mr. Sherman--but we did not address the1493removal of the VA's inspector general, Mike Missal.1494    Let me just say despite the fact that in this last1495Congress, Republicans relied on his testimony 22 times--let me1496repeat that. Republicans relied on his testimony 22 times. I1497have not heard anyone talk about his removal, and it does not1498surprise me, but it does not make it right.1499    I have said it once and I will say it again. Accountability1500for Members of Congress has to be one of our priorities.1501    The President made it very clear when he removed over a1502dozen qualified inspector generals, including the VA's former1503inspector general, Missal. From our own records, we can agree1504that Mr. Missal's work was apolitical. He did his job and held1505the VA to standards that ensured veterans were treated with1506dignity and got the care they earned.1507    Not once did my colleagues raise concerns or question Mr.1508Missal's integrity as they relied on his testimony. In fact,1509they thanked him for his transparency. They thanked him for his1510directness when discussing issues he and his staff uncovered at1511the VA. Yet now my Republican colleagues are silent, following1512their marching orders.1513    For a group of people fixated on qualifications, it seems1514like the only qualification that now matters is loyalty to the1515President or Musk.1516    Let us be real here. We cannot have an honest conversation1517about accountability at the VA without addressing Mr. Missal's1518removal, and that is why I want to make sure, Mr. Case, that1519you know and you hear this from me I am deeply concerned about1520reports that Elon Musk and his teenage intern team who are not1521government employees, at least I am not aware that they are,1522were at the VA central office earlier this week.1523    Look, I do not think they have legal authority to direct1524the people and the resources of the VA, and they do not have1525authority to access the VA data. This feels like an abuse of1526power.1527    I am going to be officially requesting the inspector1528general to initiate an investigation into this and report back1529to Congress as to whether Musk or his team were or are1530currently working at the VA, who they are meeting with, who is1531being discussed, what veteran data is being assessed, and1532whether that access is lawfully.1533    That is the responsibility that we have here, oversight and1534accountability. I look forward to working with you.1535    Mr. Chairman, I yield back.1536    Mr. Self. Thank you, ranking member, and thank everyone for1537being here, and the audience included.1538    I ask unanimous consent that all members shall have 51539legislative days in which to revise and extend their remarks1540and include any extraneous material.1541    Hearing no objection, so ordered.1542    This hearing is now adjourned.1543    [Whereupon, at 3:18 p.m., the subcommittee was adjourned.]15441545?15461547=======================================================================15481549                         A  P  P  E  N  D  I  X15501551=======================================================================15521553                    Prepared Statements of Witnesses15541555                              ----------15561557                    Prepared Statement of Ted Radway15581559    Good afternoon, Chairwoman Kiggans, Ranking Member Ramirez, and1560distinguished Members of the Subcommittee. Thank you for inviting us1561today to discuss the VA's efforts to improve accountability within the1562Department. Joining me today is Ms. Tracey Therit, Chief Human Capital1563Officer in VA's Office of Human Resources and Administration/1564Operations, Security, and Preparedness, and Dr. Mark Upton, Deputy to1565the Deputy Under Secretary for Health.1566    VA is committed to providing Veterans with the care and benefits1567they have earned through service to our country. Our Veterans and their1568families, caregivers, and survivors deserve nothing less. We and the1569more than 450,000 VA employees are devoted to this sacred duty and work1570diligently daily to fulfill this mission. Sometimes, even with the best1571intentions, the VA recognizes that the performance and actions of some1572VA employees, including some leaders, fall short of what we expect and1573what our Veterans deserve. When that happens, holding employees1574accountable is integral to effective, efficient management, and we take1575that responsibility seriously.1576    We look forward to working with the House and Senate Veterans1577Affairs Committees to strengthen our accountability policy, processes,1578procedures, training, and systems. Accountability starts long before we1579propose disciplinary actions; thus, VA continues to strengthen its1580employee relations, which supports its ability to hold employees1581accountable promptly and appropriately. In today's hearing, we welcome1582the opportunity to discuss our improvements to strengthen our1583accountability.15841585Office of Accountability and Whistleblower Protection15861587    The Office of Accountability and Whistleblower Protection (OAWP)1588actively promotes and improves individual and organizational1589accountability across VA. We do this in several ways. While OAWP is1590most well-known for its investigations of senior leader misconduct and1591poor performance and of supervisor retaliation against whistleblowers,1592as the Office has matured, we have taken substantial steps to implement1593and operationalize the non-investigatory parts of our statute to help1594drive accountability in different ways.1595    First, we investigate allegations against VA senior leaders1596involving misconduct and poor performance; we also investigate1597allegations against all VA supervisors involving retaliation against1598whistleblowers who have made a protected disclosure. OAWP conducts1599these investigations using highly skilled professional 1810-series1600investigators under standard operating procedures modeled in part on1601the Council of the Inspectors General on Integrity and Efficiency1602Quality Standards for Investigations. The Investigations Division works1603hand-in-hand with our Investigative Attorneys Division (IAD), formed in16042022, which gives us complete independence from the VA's Office of1605General Counsel in conducting our investigations. The attorneys ensure1606investigations are properly scoped and within our statutory1607jurisdiction, all relevant issues and potential misconduct are1608identified, and the investigative conclusions and recommendations are1609legally supportable and appropriate.1610    After investigating allegations of senior leader misconduct and/or1611poor performance or whistleblower retaliation by a supervisor, OAWP1612issues a report that includes the allegations, background information,1613factual findings, conclusions, and recommendations for disciplinary1614actions where appropriate. OAWP does not carry out those disciplinary1615actions. Instead, our report is issued to the appropriate VA official1616with the authority to propose and/or carry out those actions. If OAWP's1617recommended actions are not taken, or not taken within 60 days, OAWP1618reports the decision not to take the recommended action, along with the1619deciding official's reasoning, to the House and Senate Veterans Affairs1620committees.1621    Our work training our investigators, standardizing procedures, and1622forming the Investigative Attorneys Division has led to a remarkable1623turnaround in OAWP's productivity, success, and impact on individual1624accountability. For example, in fiscal year (FY) 2021, management took1625some action, or the employee retired or resigned, on only 64% of our1626disciplinary recommendations. In FY23, that number increased to 100%.1627In FY24, we issued a record number of recommendations, and management1628has taken some action, or the employee retired or resigned in all but1629three (3) cases, or 92%. We may also issue non-disciplinary1630recommendations for relief or corrective action for the whistleblower,1631training, or policy modifications. Since FY21, management has1632consistently taken those non-disciplinary recommendations between 96%1633and 100% of the time.1634    The growth in investigative work quality and the resulting1635recommendations occurred while the volume of complaints coming to OAWP1636has increased yearly. The number of complaints increased by over 60%1637from FY21 to FY24 and 22% from FY23 to FY24 alone, to 3,305 complaints1638in FY24. This shows VA employees' trust in OAWP's ability to resolve1639complaints fairly and efficiently. A majority of complaints come in1640through our redesigned, user-friendly online portal, which allows1641whistleblowers to file reports anonymously and still track their1642complaints.1643    Despite the rapid increase in case volume, OAWP's efforts have1644dramatically reduced the time it takes us to close a case. In FY21, it1645took an average of 496 days to close a case that resulted in a written1646report of investigation. By contrast, in FY24, it only took an average1647of 122 days, a greater than 75% reduction in time to close a case. By1648comparison, according to its recent public filing, the Office of1649Special Counsel (OSC) closes 87% of its prohibited personnel cases in1650240 days or less.\1\1651---------------------------------------------------------------------------1652    \1\ Office of Special Counsel, Performance and Accountability1653Report for Fiscal Year 2024, January 7, 2025, at p. 29 (https://1654osc.gov/Documents/Resources/Statutory%20Reports%20and%20Notices/1655Performance%20and%20Accountability%20Reports%20(PAR/1656Performance%20Reports/1657FY%202024%20Performance%20and%20Accountability%20Report.pdf).1658---------------------------------------------------------------------------1659    By statute, OAWP also receives whistleblower disclosures that do1660not fall within its direct investigatory authority; for example,1661violations of law, rule or regulation, or gross mismanagement by a non-1662senior leader are referred to the appropriate VA organization to1663address potential problems and concerns. OAWP maintains oversight of1664those referrals, ensuring the investigations meet procedural1665requirements.1666    OAWP's success in fostering more significant reporting of1667wrongdoing and completing fair investigations promptly, resulting in1668recommendations that are acted on by VA management, drives greater1669individual accountability across the VA.1670    Beyond carrying out investigations, we also drive organizational1671accountability. By statute, OAWP provides advice, reports, and1672recommendations to the Secretary on all matters relating to1673accountability. In the past two years, this included providing the1674Secretary with eight reports on the VA's organization and efforts1675surrounding how we interact with and provide care to Veterans with1676Military Sexual Trauma, or MST. The eight reports contained 321677recommendations for VHA, VBA, and VA, all of which were concurred with,1678and more than half have already been implemented, with the rest1679scheduled for implementation in FY25 - driving greater organizational1680accountability and, more importantly, a better experience for our1681Veterans with MST. OAWP is also executing its statutory authority to1682confirm and review VA's implementation of recommendations from Office1683of Inspector General (OIG), Government Accountability Office (GAO), and1684the Office of the Medical Inspector (OMI), partnering with VA and those1685other oversight entities to identify repeated areas of concern,1686determine if VA is still implementing the closed recommendation, and1687identify any root cause solutions that might be scalable across the1688enterprise, thus identifying best practices to drive greater1689accountability and better service for our Veterans.1690    OAWP also launched Climate Reviews, on-site evaluations that1691include interviews and focus groups in addition to an anonymous all-1692employee survey that gives leadership insight into the whistleblower1693reporting environment at their facility and makes recommendations to1694improve that reporting culture to drive greater accountability and1695whistleblower protection.1696    OAWP also dramatically increased the data trend analyses it1697performs under its statute. It now shares that data, for example, with1698VISN leadership so they can identify and address any potentially1699problematic trends.1700    Finally, OAWP has expanded its training on whistleblower rights and1701protections, not just providing the bi-annual Training Management1702System (TMS) recorded training to all employees and annual TMS1703supervisor training but also providing live, in-person, or TEAMS1704training to a number of Administrations, VACO offices, VISN leadership1705teams, and individual facilities that have all reached out and1706requested we provide additional training. In FY24, OAWP provided1707approximately 226 of these supplemental training sessions.17081709VHA as a High-Reliability Organization (HRO)17101711    In 2019, the Veterans Health Administration (VHA) began a1712transformational modernization. Our transformation into a High-1713Reliability Organization (HRO) was central to this modernization. An1714HRO is an organization that experiences fewer than anticipated1715accidents or events of harm despite operating in highly complex, high-1716risk environments where even small errors can lead to tragic results.1717The Department empowers all staff to lead continuous process1718improvements within their workspaces. We created an environment where1719employees feel safe to report harm or near misses. This framework1720requires our leaders to focus on the why, not the who, when errors1721occur.1722    The work to become an HRO not only unleashed the incredible talent1723and commitment within our system to do great things but also underpins1724our efforts to strengthen the trust of Veterans and the American people1725in VA. We are committed to continuing to build on the great strides we1726made in improving safety and quality of care. In the most recent CMS1727Overall Hospital Quality Star Ratings, more than 58% of VA hospitals1728included received 4-or 5-star ratings compared to 40% of non-VA1729hospitals.\2\ As Veterans Integrated Service Networks (VISNs) and VA1730Medical Centers (VAMCs) advance toward HRO maturity, leaders are1731applying an organization-wide commitment to Zero Harm by developing an1732even stronger safety culture featuring empowered, collaborative1733frontline teams supported by engaged leadership within a climate of1734trust and continuous improvement.1735---------------------------------------------------------------------------1736    \2\ https://www.Medicare.gov/care-compare/17371738---------------------------------------------------------------------------1739Office of Medical Inspector (OMI)17401741    The Office of Medical Inspector (OMI) is responsible for assessing1742the quality of VA health care through investigations of VA facilities1743Nationwide. OMI investigations are initiated after receiving1744allegations and/or disclosures, including those referred by Veterans,1745VA employees and leadership, OAWP, OIG, Office of General Counsel, and1746Congress. Once a concern is identified, the Under Secretary for Health1747directs OMI to assemble and lead a team to initiate an investigation.1748OMI issues comprehensive reports of the health care investigations that1749generally include the allegations investigated, necessary background1750information, factual findings, conclusions, and actionable1751recommendations for corrective action and/or improvements to the1752quality of Veterans' health care.1753    When OMI uncovers evidence of potential misconduct or poor1754performance by a senior leader during one of its investigations, it1755refers the allegations and/or evidence to OAWP for investigation of the1756alleged misconduct and/or poor performance. OMI generally does not make1757specific recommendations related to discipline. Instead, it focuses on1758oversight and improvement of Veterans' health care.17591760Conclusion17611762    VA is proud of its large, dedicated workforce, who work hard to1763carry out VA's great mission every day. The Department engages in1764continuous improvement of accountability to assess how to help identify1765and affect cultural improvements within the VA, hold employees1766accountable, and continue to work to protect whistleblowers. VA is1767committed to holding employees accountable, including taking1768disciplinary actions when necessary, and still celebrates VA's many1769accomplishments. Chairwoman Kiggans, Ranking Member Ramirez, and1770distinguished Members of the Subcommittee, we look forward to1771responding to any questions you may have.1772                                 ______17731774                    Prepared Statement of David Case17751776    Chairwoman Kiggans, Ranking Member Ramirez, and subcommittee1777members, thank you for the opportunity to discuss the efforts of the1778Office of Inspector General (OIG) to enhance VA's accountability and1779aid in its continuous improvement. The OIG's mission is to serve1780veterans and the public by conducting meaningful independent oversight1781of VA's services, programs, and operations. OIG staff execute this1782mission by conducting accurate, fair, and impactful audits, reviews,1783healthcare inspections, and investigations across the nation. For1784fiscal year (FY) 2024, the OIG produced 316 oversight publications with17851,106 recommendations to VA for corrective action. Our personnel made1786nearly 250 arrests, fielded more than 34,000 contacts to our hotline,1787and testified before congressional committees on 14 occasions, as well1788as conducted nearly 200 briefings to members of Congress and their1789staff. Our work has resulted in a monetary impact of more than $6.81790billion for that 12-month period. This would not have been possible1791without the funding and other support we receive from Congress. We are1792also grateful to the veterans service organizations from whom we1793regularly solicit concerns and the many VA personnel and other1794stakeholders who bring to our attention a wide range of problems with1795VA programs and operations.1796    Integral to every OIG effort is intense scrutiny of the1797effectiveness of leadership and the quality management of VA operations1798that makes the most efficient use of taxpayer dollars. In a department1799the size of VA, with the nation's largest integrated public healthcare1800system, an aging infrastructure, and massive information technology1801(IT) modernization efforts, the OIG must remain vigilant to all risks1802to veterans, their families, and survivors. This requires the use of1803sophisticated data analytics and modeling; being responsive to hotline1804contacts and other allegations of misconduct; and rigorous and1805continuous oversight. OIG staff monitor programs and operations for1806breakdowns in processes; noncompliance with mandates; failures to1807provide quality health care; and deficiencies in the delivery of1808benefits and services. In addition, the OIG advances accountability by1809conducting an expansive range of administrative and criminal1810investigations that include, fraud, waste, and abuse of authority.1811    OIG leaders have testified before this subcommittee and other1812congressional committees many times in the past about enhancing1813accountability at VA.\1\ There are several recurring themes and1814deficiencies that remain unchanged. These key elements of1815accountability are routinely identified by OIG staff and shared with VA1816leaders across the enterprise to encourage positive change and1817efficiencies within their respective programs and operations. OIG1818recommendations that focus on even a single medical facility or1819benefits process are often a road map for other facilities and offices1820across VA to help prevent or correct similar problems that have gone1821undetected or unaddressed.1822---------------------------------------------------------------------------1823    \1\  Recent OIG testimony to Congress can be accessed here.1824---------------------------------------------------------------------------1825    This testimony focuses on five components of accountability1826identified by the OIG as often lacking within VA programs and1827operations, and highlights several illustrative oversight reports:18281829        1. Strong governance and clarity of roles and responsibilities18301831        2. Adequate and qualified staffing to carry out those duties18321833        3. Updated IT systems and effectual business processes to1834        support quality healthcare delivery, accurate and timely1835        benefits, and efficient operations18361837        4. Effective quality assurance and monitoring to detect and1838        resolve issues18391840        5. Leadership that fosters responsibility for actions and1841        continuous improvement18421843    The OIG appreciates the work VA personnel--the vast majority of1844whom work under challenging conditions and are committed to continuous1845improvement--do every day on behalf of veterans. Despite these efforts,1846the OIG regularly identifies instances of misconduct, broken systems,1847confusing and conflicting governing policies or guidance, and1848inefficiencies or missteps in implementing programs. Given the1849importance of VA's mission, every individual at VA should feel a1850responsibility to identify and report risks and any resulting problems,1851and then take action to address the underlying causes and mitigate the1852chances for future occurrences. To underscore the need for personnel to1853report potential crimes and issues that put veterans, VA employees, and1854resources at risk, the Senator Elizabeth Dole 21st Century Veterans1855Healthcare and Benefits Improvement Act recently codified the1856requirement that all new VA employees receive training on how to report1857and cooperate with OIG staff.\2\ Ensuring employees and leaders1858understand their duty to report and remediate problems is meant to1859foster a culture of accountability across VA.1860---------------------------------------------------------------------------1861    \2\ Senator Elizabeth Dole 21st Century Veterans Healthcare and1862Benefits Improvement Act, Pub. L. No. 118-210 Sec.  501.18631864---------------------------------------------------------------------------1865STRONG GOVERNANCE AND CLARITY OF ROLES AND RESPONSIBILITIES18661867    Misconduct, failures to take appropriate action, and persistent1868problems are often the result of VA personnel or contractors not1869understanding their roles and responsibilities. In other cases, they1870understand their duties, but simply do not or cannot fulfill them. This1871may be due in part to outdated policies and procedures, conflicting1872guidance, or a lack of clear decision-making--often with those best1873positioned to act lacking the authority to do so. Offices in1874administrations can be responsible for developing policy, but not for1875implementing or overseeing it. For example, financial officers in1876different administrations within VA do not report to the VA chief1877financial officer.1878    Two recent OIG reports serve as examples of how leaders did not act1879on known issues, resulting in delays in patients receiving health care.1880Last fall, the OIG published the results of a healthcare inspection1881regarding community care consult (referral) appointment scheduling1882practices. It examined delays for patients with serious health1883conditions who received community care through referrals from the VA1884Western New York Healthcare System in Buffalo.\3\ The OIG found the1885system's community care staff did not timely schedule patients'1886radiation therapy and neurosurgery appointments, which resulted in1887delays in providing care and, in some cases, caused or increased the1888risk of patient harm. In particular, had there not been the delay in1889scheduling, and eventual cancellation of community care radiation1890therapy to treat a patient's cancer-related pain, efforts could have1891been made to alleviate that pain and improve the quality of life in the1892patient's final months. The Buffalo healthcare system and its community1893care leaders did not resolve the scheduling delays, despite advocacy by1894care providers and staff. The OIG found healthcare system leaders1895relied on inaccurate assurances from their community care managers that1896urgent, high-risk patient care consults were reviewed and prioritized,1897even as they received ongoing alerts about care concerns regarding1898those patients. The healthcare system and community care leaders'1899inactions were inconsistent with VA's stated commitment to the1900principles and values of high reliability organizations, as they failed1901to consistently focus on patients, get to the root causes of concerns,1902and predict and eliminate risks before causing patient harm. The OIG1903made two recommendations to the Veterans Integrated Service Network1904(VISN) director related to the healthcare system leaders' response to1905patient concerns and oversight of community care; and two1906recommendations to the Buffalo system's director related to1907establishing community care policies aligned with Veterans Health1908Administration (VHA) standards, as well as the disclosure of an adverse1909event (which has now been completed).\4\1910---------------------------------------------------------------------------1911    \3\ VA OIG, Leaders Failed to Address Community Care Consult Delays1912Despite Staff's Advocacy Efforts at VA Western New York Healthcare1913System in Buffalo, September 27, 2024.1914    \4\ VA has 18 VISNs across the nation--a regional network of care1915in which each VISN oversees VHA local healthcare facilities in their1916assigned area. An adverse event disclosure happens when a healthcare1917provider informs a patient or their family when a medical error or1918unexpected complication occurs during treatment that resulted in harm.1919---------------------------------------------------------------------------1920    Following an OIG analysis of VHA data, our healthcare inspectors1921reviewed the VA Loma Linda (California) Healthcare System's high use of1922community care providers for primary care, the impact, and system1923leaders' related oversight of VA outpatient clinics.\5\ The OIG found1924that a new contractor responsible for the healthcare system's five non-1925VHA-operated community-based outpatient clinics experienced challenges1926staffing them. As a result, system leaders paused enrollment of new1927patients at all five of these clinics. VHA-operated clinics were unable1928to absorb the additional patients leading to an increase in the1929system's use of community care providers for primary care. Further, the1930system's community care office was not able to timely process the1931consults and schedule community appointments. The OIG did not identify1932any patients who experienced poor outcomes as a result. However, the1933lack of a formal oversight structure for non-VHA-operated clinics,1934turnover in the system's leadership positions, and the new contractor1935together created a vulnerability in the management of primary care1936services provided at the system's clinics. The OIG's three1937recommendations to the system director are unimplemented at this time.1938They focus on monitoring primary care staffing and panel sizes (the1939number of patients assigned), timeliness of community care consult1940processing, and oversight of all the system's clinics.1941---------------------------------------------------------------------------1942    \5\ VA OIG, Increased Utilization of Primary Care in the Community1943by the VA Loma Linda Healthcare System in California, April 23, 202419441945---------------------------------------------------------------------------1946ADEQUATE AND QUALIFIED STAFFING TO CARRY OUT DUTIES19471948    Historically, VA has faced high vacancy rates across its programs1949and operations, especially within VHA. Shortages of qualified personnel1950in key positions have made it difficult for VA to carry out its goals1951and functions. Having the right people in the right positions committed1952to doing the right thing is essential to building workforce1953accountability, as is instilling that sense of responsibility in new1954hires.1955    As for persistent shortages, VA is not alone. Medical systems1956across the country are facing challenges in finding and retaining1957qualified personnel. The OIG is required by law to annually identify1958clinical and nonclinical VHA occupations with the largest staffing1959shortages within each VHA medical center.\6\ The FY 2024 review, the196011th and most recent that the OIG has conducted, found that 137 of 1391961surveyed VHA facilities reported at least one severe occupational1962staffing shortage.\7\ The total number of their reported severe1963shortages was 2,959, a 5% decrease from FY 2023, when facilities1964reported 3,118 total shortage occupations. Every year since 2014, the1965medical officer and nurse occupations have been identified as severe1966shortages, with the designations of medical officer as a severe1967occupational shortage generally decreasing since FY 2018. Following1968staffing increases in FYs 2022 and 2023, the nurse occupation was1969reported as a shortage by fewer facilities in FY 2024. Psychology was1970the most frequently reported clinical severe occupational staffing1971shortage in FY 2024, by 61% of facilities (85 of 139). Facilities also1972reported custodial worker and medical support assistance as the most1973frequent nonclinical shortage occupations, the same as for FYs 2022 and19742023.1975---------------------------------------------------------------------------1976    \6\ VA Choice and Quality Employment Act, Pub. L. No. 115-46, 1311977Stat. 958 (2017).1978    \7\ VA OIG, OIG Determination of Veterans Health Administration's1979Occupational Staffing Shortages Fiscal Year 2024, August 7, 2024.1980---------------------------------------------------------------------------1981    An OIG review published last week highlights the impacts of1982insufficient staffing and hiring delays at the Joseph Maxwell Cleland1983Atlanta VA Medical Center's contact center for appointment scheduling.1984Callers experienced long hold times that led to abandoned phone1985calls.\8\ Significantly, the facility's leaders were not attentive to1986concerning call center performance metrics, such as wait times and1987abandonment rates. The report also identified that the VISN had not1988been using available data to determine if its own call center was1989properly staffed.1990---------------------------------------------------------------------------1991    \8\  VA OIG, Atlanta Call Center Staffing and Operational1992Challenges Provide Lessons for the New VISN 7 Clinical Contact Center,1993January 30, 2025. The three recommendations to the VISN director and1994the recommendation to the facility director are not yet implemented.1995The OIG will begin to follow up with VBA for progress on the1996recommendation's implementation on or about May 1, 2025. At quarterly1997intervals commencing 90 calendar days from the date of the report's1998issuance, the OIG sends a follow-up request to the VA office overseeing1999corrective action asking for an implementation status report. The OIG2000follow-up staff provides VA with 30 calendar days to respond. Nothing2001precludes VA from providing interim progress reports.2002---------------------------------------------------------------------------2003    In addition to addressing staffing shortages, VA should also ensure2004its existing personnel are equipped and prepared to do their jobs. The2005OIG has published numerous reviews over the last few years that2006examined whether staff at the Veterans Benefits Administration (VBA)2007were sufficiently trained for their duties.\9\ For example, VBA uses2008the VA Schedule for Rating Disabilities (the rating schedule) to2009determine monthly compensation to eligible veterans for service-2010connected disabilities based on documented medical severity. In 2021,2011updates were made to the rating schedule for the musculoskeletal body2012system. The OIG performed a review to assess the effectiveness of VBA's2013implementation of the rating schedule changes for hip and knee2014replacements. The report on the review's findings, published in2015February 2024, found an estimated 38% of claims had an improper payment2016during the review period.\10\ VBA paid an estimated $3.3 million in2017total improper payments for hip and knee replacement claims during that2018same period--including both underpayments and overpayments for these2019claims.VBA concurred with the OIG's four recommendations.\11\ VBA has2020since provided sufficient documentation for the OIG to close its2021recommendations to supplement training on the rating schedule updates,2022including how to apply the changes to help ensure claims processors'2023comprehension.2024---------------------------------------------------------------------------2025    \9\  See, e.g., VA OIG, Rating Schedule Updates for Hip and Knee2026Replacement Benefits Were Not Consistently Applied, February 21, 2024;2027VA OIG, VBA Needs to Improve Accuracy of Decisions for Total Disability2028Based on Individual Unemployability, July 17, 2024; VA OIG, Veterans2029Are Still Being Required to Attend Unwarranted Medical Reexaminations2030for Disability Benefits, March 16, 2023; VA OIG, VBA Could Improve the2031Accuracy and Completeness of Medical Opinion Requests for Veterans'2032Disability Benefits Claims, September 7, 2022.2033    \10\ VA OIG, Rating Schedule Updates for Hip and Knee Replacement2034Benefits Were Not Consistently Applied, February 21, 2024. The OIG team2035reviewed a random sample of 112 in-scope claims from a universe of2036about 3,200 claims for convalescence for hip or knee replacements or2037resurfacing, received and decided from February 7, 2021, through August203831, 2022.2039    \11\ There were two other recommendations that address issues2040unrelated to quality assurance and training.2041---------------------------------------------------------------------------2042    The importance of a well-trained workforce to implementing VA's2043major initiatives cannot be overstated. Signed into law in August 2022,2044the PACT Act dramatically expanded access to VA health care and2045benefits for millions of veterans exposed to toxic substances.\12\ The2046OIG assessed whether VBA staff processed PACT Act claims for2047presumptive disabilities in accordance with applicable laws and2048procedures before denying them--recognizing the potential impact on2049eligible veterans if claims were improperly denied. The OIG review team2050found errors resulting in unnecessary payments for examinations and2051medical opinions, as well as underpayments to veterans. A VBA leader2052told the OIG team that some claims processors said that information2053came at them quickly and there were too many changes. They further2054stated the implementation of PACT Act legislation was very challenging,2055but VBA did the best it could given the circumstances. In an interview,2056the former Compensation Service quality assurance rating review chief2057stated PACT Act guidance changed repeatedly after the initial rollout.2058Further, the chief stated VBA hired many new employees to process the2059most complex claims, which, combined with the changing guidance, may2060have caused confusion when regional office staff were working these2061claims and resulted in errors. VBA concurred with the OIG's two2062recommendations to update the claims processing manual to clarify when2063examinations and medical opinions are needed and to continue to develop2064tools to aid claims processors in determining when they are needed and2065to evaluate their effectiveness. The OIG has issued other reports on2066implementation of the PACT Act and will continue to monitor VA's2067implementation of the legislation.\13\2068---------------------------------------------------------------------------2069    \12\ Sergeant First Class Heath Robinson Honoring our Promise to2070Address Comprehensive Toxics (PACT) Act of 2022, Pub. L. No. 117-168.2071    \13\ VA OIG, VBA Provided Accurate Training on Processing PACT Act2072Claims but Did Not Fully Evaluate Its Effectiveness, January 15, 2025;2073VA OIG, Staff Incorrectly Processed Claims When Denying Veterans'2074Benefits for Presumptive Disabilities Under the PACT Act, December 3,20752024.20762077EFFECTIVE IT SYSTEMS AND BUSINESS PROCESSES TO SUPPORT QUALITY HEALTH2078---------------------------------------------------------------------------2079CARE, ACCURATE AND TIMELY BENEFITS, AND EFFICIENT OPERATIONS20802081    VA is modernizing numerous significant systems that are critical to2082its operations. However, as detailed in multiple proactive reports, the2083OIG identified breakdowns with upgrading or replacing key systems that2084support patient care, supply management, benefits to veterans and their2085families, and the stewardship of taxpayer dollars. VA's process for2086replacing crucial IT systems faces significant ongoing challenges.2087These have typically included weaknesses in planning, insufficient2088stakeholder engagement, failures to promptly fix known issues, and2089program management or coordination deficiencies. The results have been2090long delays, billions of dollars in over-budget costs, low user2091acceptance, and gaps in functionalities that make it more difficult for2092VA personnel to do their jobs. In some cases, the modernization efforts2093have put patients, beneficiaries, and resources at greater risk for2094harm or loss. The OIG understands the tremendous complexity of these2095efforts and continues to provide recommendations that are as practical2096and actionable as possible to support VA personnel working to ensure2097patient safety and to deliver benefits and services to eligible2098veterans, their families, caregivers, and survivors.2099    The Electronic Health Record Modernization (EHRM) program is2100probably the largest contract in VA history and critical to continued2101patient safety and care at VHA. Since April 2020, the OIG has released210222 oversight publications on VA's rollout of its electronic health2103record system that identify critical missteps and lack of2104remediation.\14\ Of the 93 recommendations issued to date, 32 have not2105yet been implemented--with eight open for more than three years. The2106open recommendations include VA minimizing the number of required2107mitigation strategies healthcare providers must use when the system2108goes live, determining whether veterans' appointments are being2109scheduled correctly, and addressing unresolved issues that could hinder2110the system from resolving major performance incidents and outages.2111Unless VA more effectively manages all affected offices and2112contractors, IT solutions will continue to be delayed, more cost2113overruns will occur, and the risk to patients and VA operations will2114increase.2115---------------------------------------------------------------------------2116    \14\ OIG reports may be found on the website at All Reports. A list2117of EHRM reports can be found by searching on the key word ``EHRM''.2118---------------------------------------------------------------------------2119    Although VA lifted the June 2022 EHRM rollout pause, users of the2120new system continue to raise issues that the system hinders the2121delivery of prompt, high-quality patient care. Moreover, VA has not2122adequately addressed open OIG recommendations focused on the need to2123develop a reliable, high-quality schedule for future rollouts, in2124addition to the many other open EHRM recommendations. The effects on2125staff, workload, and the risks for errors are also concerning. In March21262024, the OIG reported that an error in the system led Columbus (Ohio)2127facility staff to not complete the minimum scheduling efforts following2128a missed appointment for a patient who later died by drug overdose.\15\2129The OIG team determined that for sites using the new electronic health2130record system, VHA required fewer patient contact attempts following2131missed mental health appointments. Essential to implementing and2132budgeting this multibillion-dollar effort, VA needs a high-quality,2133reliable, integrated master schedule to ensure all tasks are properly2134accounted for and fully completed. A 2022 OIG audit found, however,2135that this foundational master schedule had significant weaknesses,2136including missing tasks, no baseline schedule, and no risk analyses,2137meaning VA cannot offer reliable assurances on timelines and costs.\16\2138That schedule has still not been completed at this time. The OIG will2139continue to conduct oversight on VA's plan to begin deployment2140operations next year in Michigan.2141---------------------------------------------------------------------------2142    \15\ VA OIG, Scheduling Error of the New Electronic Health Record2143and Inadequate Mental Health Care at the VA Central Ohio Healthcare2144System in Columbus Contributed to a Patient Death, March 21, 2024.2145    \16\ VA OIG, The Electronic Health Record Modernization Program Did2146Not Fully Meet the Standards for a High-Quality, Reliable Schedule,2147April 25, 2022.2148---------------------------------------------------------------------------2149    VA's delivery of education benefits to veterans is also tied to a2150new IT system. In 2024, the OIG reported on VBA's delays and increased2151costs in transitioning to the Digital GI Bill platform.\17\ Unclear2152contract requirements and unrealistic expectations led to delays. In2153addition, the project's integrated master schedule was not updated2154consistently due to the lack of an overall schedule that tracked2155external dependencies. Poor communication between VBA and the2156contractor contributed to critical scheduling failures that caused2157delays and increased costs. VBA later renegotiated the original2158contract, more than doubling the cost to $932 million. The OIG made2159three recommendations, all as yet unimplemented, to the then under2160secretary for benefits to increase the chances of successful2161implementation under the new contract through improved monitoring,2162regular communication with the contractor to ensure a consistent and2163updated master schedule, and strategies to address critical path2164failures.2165---------------------------------------------------------------------------2166    \17\ VA OIG, VBA Needs to Improve Oversight of the Digital GI Bill2167Platform, August 28, 2024.2168---------------------------------------------------------------------------2169    There are many other IT modernization efforts that are also2170interdependent and have had significant stalls, setbacks, or stops.2171These include financial and supply chain management--also the subject2172of myriad OIG oversight reports.21732174EFFECTIVE QUALITY ASSURANCE AND MONITORING TO DETECT AND RESOLVE ISSUES21752176    VA often lacks controls that adequately and consistently ensure2177quality standards are met. Breakdowns in routine monitoring and the2178continual use of work-arounds undermine efforts to provide timely,2179high-quality services and benefits to eligible veterans and their2180families. Ineffective quality assurance and monitoring relate not just2181to systems and processes, but to personnel as well--particularly in2182areas such as personnel suitability programs, credentialing,2183privileging, and monitoring of healthcare professionals entrusted with2184veterans' care.\18\2185---------------------------------------------------------------------------2186    \18\ In March 2018, the OIG reported on deficiencies within the VHA2187personnel suitability program, concluding that neither VA nor VHA2188effectively governed the background investigation process to ensure2189requirements were met at medical facilities nationwide. VA OIG, Audit2190of the Personnel Suitability Program, March 26, 2018. In September21912023, the OIG reported on similar deficiencies during a follow-up audit2192of VHA's personnel suitability program. VA OIG, VA's Governance of Its2193Personnel Suitability Program for Medical Facilities Continues to Need2194Improvement, September 21, 2023. These prior audits identified issues2195that could affect the entire VA enterprise, prompting the OIG to audit2196the background investigation process for VBA and the National Cemetery2197Administration staff and determine whether investigation actions were2198completed on time and recorded reliably. The OIG determined there were2199problems at every step of the process, making four recommendations, all2200still open, to the under secretaries of benefits and memorial affairs.2201VA OIG, VBA's and NCA's Personnel Suitability Programs Need Improved2202Governance, September 30, 2024.2203---------------------------------------------------------------------------2204    In September 2024, the OIG testified to this subcommittee and its2205full committee about issues at the Hampton VA Medical Center in2206Virginia.\19\ For each of the last three years (2022-2024), the OIG2207published healthcare inspections of the Hampton facility that2208substantiated concerns related to clinical care.\20\ In the most recent22092024 report, there were unaddressed clinical care concerns involving2210the facility's then assistant chief of surgery.\21\ The facility2211leaders at the time mishandled the processes for professional practice2212evaluations of surgeons, the surgical service's quality management, and2213institutional disclosures to patients or their representatives of an2214adverse event that resulted in harm. Facility leaders made numerous2215errors when determining whether changes were needed to the assistant2216chief of surgery's clinical privileges.\22\ Leaders also did not report2217the assistant chief to the state licensing board. Failing to report2218providers may result in medical facilities within and outside of VHA2219hiring providers who do not meet generally accepted standards of2220clinical practice. These leaders also lacked a basic understanding of2221the quality assurance processes that support the delivery of safe2222health care. These three reports collectively uncovered issues with2223care coordination, communication, quality of care, administrative and2224clinical oversight, quality assurance, and overall employee engagement.2225The identified deficiencies contributed to increased risks to patient2226safety and adverse outcomes.2227---------------------------------------------------------------------------2228    \19\ VA OIG, Statement of Inspector General Michael J. Missal2229before the House Committee on Veterans' Affairs, September 10, 2024; VA2230OIG, Statement of Jennifer Baptiste, MD, before the House Committee on2231Veterans Affairs, September 24, 2024.2232    \20\ VA OIG, Multiple Failures in Test Results Follow-up for a2233Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center2234in Virginia, June 28, 2022 (multiple healthcare providers did not2235appropriately manage abnormal test results for this patient and staff2236and leaders did not initiate or submit patient safety reports or peer2237reviews); VA OIG, Delay in Diagnosis and Treatment for a Patient with a2238New Lung Mass at the Hampton VA Medical Center in Virginia, September223929, 2023 (facility leaders were unaware until the OIG inspection and2240the facility lacked oncology care controls due to missing/ineffective2241cancer committee, tumor board, and cancer registry); VA OIG, Mismanaged2242Surgical Privileging Actions and Deficient Surgical Service Quality2243Management Processes at the Hampton VA Medical Center in Virginia, July224423, 2024.2245    \21\ VA OIG, Mismanaged Surgical Privileging Actions and Deficient2246Surgical Service Quality Management Processes at the Hampton VA Medical2247Center in Virginia, July 23, 2024.2248    \22\  Clinical privileging is defined as the process by which a VA2249facility authorizes a physician to independently (i.e., without2250supervision or restriction) provide healthcare services on a facility-2251specific basis. Clinical privileges are based on the individual's2252clinical competence as determined by peer references, professional2253experience, health status, education, training, and licensure.2254---------------------------------------------------------------------------2255    In their oversight work, what OIG healthcare inspectors find most2256troubling is when facility managers and leaders are either unaware of2257personnel and patient concerns or do not ensure the required quality2258management processes are carried out that would detect and correct2259them. High reliability organization principles foster a culture of2260``collective mindfulness,'' in which all staff look for and report2261small problems or unsafe conditions before they pose a substantial2262risk. If leaders are not aware of concerning singular events or more2263systemic challenges, they cannot ensure the appropriate steps are taken2264to safeguard patients. Implementing quality improvements to address2265specific patient safety issues requires open and honest communication2266from, and among, staff at every level of a facility.22672268LEADERSHIP THAT FOSTERS RESPONSIBILITY FOR ACTIONS AND CONTINUOUS2269IMPROVEMENT22702271    The OIG published a report that was featured in congressional2272hearings and the national media on senior executives in VA's central2273office being improperly awarded $10.8 million in critical skills2274incentives authorized by the PACT Act. It uncovered weaknesses in VA's2275governance, leadership, and accountability, with excessive deference to2276both VHA and VBA leaders by individuals responsible for providing2277necessary checks and balances.\23\ The PACT Act authorized VA to award2278critical skill incentives to only those staff who possessed a high-2279demand skill or skill that is at a shortage. As detailed in OIG2280testimony before this committee in June, officials at multiple levels2281across VA did not ensure their actions met the requirements and intent2282of the law and did not successfully escalate concerns to then Secretary2283McDonough.\24\ VA concurred with the OIG findings that the awards were2284inconsistent with the PACT Act and VA policy and that VA's internal2285controls were ineffective to prevent the improper awards. The OIG2286continues to monitor VA's progress in implementing these2287recommendations until sufficient evidence is provided to enable2288closure.2289---------------------------------------------------------------------------2290    \23\ VA OIG, VA Improperly Awarded $10.8 Million in Incentives to2291Central Office Senior Executives, May 9, 2024.2292    \24\ VA OIG, Statement of Inspector General Michael J. Missal2293before the House Committee on Veterans' Affairs, June 4, 2024.2294---------------------------------------------------------------------------2295    Other oversight work has revealed that VA leaders at every level2296often do not get the information they need to make effective decisions.2297Some also do not take necessary and prompt action, while others2298struggle to create a workplace in which every employee feels they can2299and should report problems. The frequent turnover in key positions or2300the long-term use of acting positions exacerbates these challenges.2301    In 2024, the OIG released three reports on the VA medical facility2302in Aurora, Colorado, also describing the kind of accountability2303failures that every facility leader should be vigilant in preventing.2304The OIG's first report found that key senior leaders created an2305environment in which a significant number of clinical and2306administrative service and section leaders and frontline staff felt2307intimidated, deeply disrespected, and dismissed.\25\ For example, staff2308feared that speaking up or offering a difference of opinion to the Peer2309Review Committee would result in reprisal. In a second report, an OIG2310team substantiated that leaders' actions to change the facility's2311intensive care unit from an open to a closed model (affecting which2312providers had patient care responsibility) were made without adequate2313planning and input from relevant leaders and staff.\26\ These problems2314were allowed to persist because VISN leaders did not fulfill their own2315required oversight of the medical center.\27\ The third report found2316that telemetry medical instrument technicians were not properly2317monitoring patients and that staff did not properly enter a Joint2318Patient Safety Report following a patient's death.\28\2319---------------------------------------------------------------------------2320    \25\  VA OIG, Leaders at the VA Eastern Colorado Health Care System2321in Aurora Created an Environment That Undermined the Culture of Safety,2322June 24, 2024. One of seven recommendations has been closed.2323    \26\ VA OIG, Extended Pause in Cardiac Surgeries and Leaders'2324Inadequate Planning of Intensive Care Unit Change and Negative Impact2325on Resident Education at the VA Eastern Colorado Health Care System in2326Aurora, June 24, 2024. All recommendations remain open.2327    \27\ VA administers healthcare services through a nationwide2328network of 18 regional systems referred to as Veterans Integrated2329Service Networks that oversee the medical facilities in their2330designated area.2331    \28\ VA OIG, Failures by Telemetry Medical Instrument Technicians2332and Leaders' Response at the VA Eastern Colorado Health Care System in2333Aurora, August 13, 2024. Five of the six recommendations remain open.2334---------------------------------------------------------------------------2335    As to work that is forthcoming that illustrates the OIG's2336commitment to enhancing VA accountability, OIG teams are finishing work2337on the conditions and contributing factors to the FY 2024 supplemental2338request by VBA and the multibillion dollar shortfall in VHA's budget2339for FY 2025.\29\ In accordance with the governing statute, the OIG will2340publish these reviews before March 19, 2025.\30\ VA's ability to2341accurately forecast its administration and staff office budgets, and2342then properly execute appropriated funds, is dependent on adhering to2343the foundational elements of accountability.2344---------------------------------------------------------------------------2345    \29\  According to the budget submission dated March 2024, VHA2346initially estimated needing about $149.5 billion to care for patients2347in fiscal year (FY) 2025. However, by July 2024, VHA estimated that it2348would need an additional $12 billion in FY 2025 for medical care. By2349November, that request was modified to $6.6 billion.2350    \30\ The Veterans Benefits Continuity and Accountability2351Supplemental Appropriations Act, 2024, Pub. L. No. 118-92 Sec.  104.23522353---------------------------------------------------------------------------2354CONCLUSION23552356    The OIG has experienced that the overwhelming number of VA leaders2357and personnel are committed to serving veterans, their families, and2358caregivers, as well as answering the call for assistance from their2359local communities in times of crisis. They often have to navigate2360obstacles and overcome challenges to make certain that patients receive2361prompt high-quality care and that veterans and other eligible2362beneficiaries receive the compensation and services they are owed.2363Unfortunately, the OIG has found that VA has struggled with the2364foundations of accountability, including strong governance and clarity2365of roles and responsibilities; adequate and qualified staffing; updated2366IT systems and effectual business processes; effective quality2367assurance and monitoring; and leadership that fosters responsibility2368for actions and continuous improvement. The OIG strongly encourages VA2369personnel at every level to lead by example and escalate matters that2370put veterans' health and welfare at risk, undermine VA's services and2371operations, or waste taxpayer dollars.2372    Chairwoman Kiggans, Ranking Member Ramirez, and members of the2373Subcommittee, this concludes my statement. The OIG looks forward to2374working with you and this Congress to advance VA's delivery of care and2375services to veterans, their families, and caregivers. I would be happy2376to answer any questions you may have.2377                                 ______23782379                  Prepared Statement of Donald Sherman23802381    Chairwoman Kiggans, Ranking Member Ramirez, and members of the2382Subcommittee, thank you for the opportunity to testify regarding2383accountability at the U.S. Department of Veterans Affairs (VA).2384    The Department of Veterans Affairs is a large agency with a2385similarly large and important mission. The care, benefits and support2386veterans receive through the VA is the fulfillment of a promise that2387our nation makes, and must continue to make, to those who serve and2388protect our country. My family includes veterans who served in World2389War II, the Korean War and in the Marines as well as the Army. My2390grandfather proudly worked for many years at the VA in his hometown of2391Tuskegee, Alabama, made famous by the Tuskegee Airman. On behalf of2392myself and my organization, Citizens for Responsibility and Ethics in2393Washington (CREW), I thank our nation's veterans and military families2394for their service and sacrifice for our country.2395    In order to meet its critical mission, the VA plays many roles. It2396is one of the largest federal agencies in the government with functions2397including administering pensions, insurance and home loans for2398veterans, providing survivor support for veterans' families and running2399the Veterans Health Administration, the largest integrated healthcare2400network in the United States. It is incumbent upon Congress and the2401president to ensure that the VA does not falter in fulfilling its2402mission. It is equally important to acknowledge that managing such2403complex systems is a daunting task. It is therefore perhaps2404unsurprising that the VA has experienced challenges across multiple2405administrations, Republican and Democratic. The inherent risks and2406challenges associated with operating a large agency make ensuring2407robust oversight and accountability absolutely critical.2408    As the members of this Committee know well, the VA's Office of2409Inspector General (OIG) has consistently played a key role in providing2410oversight to help the VA fulfill its mission and to ferret out waste,2411fraud and abuse in the agency. For decades under both Republican and2412Democratic administrations, the OIG has issued numerous reports and2413recommendations to improve the VA's operations, including 189 open VA2414OIG reports in 2020 during the final year of President Trump's first2415term and 197 open VA OIG reports in 2016 during the final year of2416President Obama's administration.\1\2417---------------------------------------------------------------------------2418    \1\ Department of Veterans Affairs Office of Inspector General,2419Semiannual Report to Congress Issue 76 (Apr. 1, 2016 to Sept. 30,24202016), https://www.vaoig.gov/sites/default/files/document/2023-08/2421VAOIG-SAR-2016-2.pdf; Department of Veterans Affairs Office of2422Inspector General, Semiannual Report to Congress Issue 84 (Apr. 1, 20202423to Sept. 30, 2020), https://www.vaoig.gov/sites/default/files/document/24242023-08/vaoig-sar-2020-2.pdf).2425---------------------------------------------------------------------------2426    Inspector General (IG) Michael Missal led VA OIG for more than2427eight years.\2\ Mr. Missal was confirmed by the Senate in April 20162428after being favorably voted out of the Republican led Senate Veterans'2429Affairs Committee and unanimously voted out of the Republican led2430Senate Homeland Security and Governmental Affairs Committee.\3\ Mr.2431Missal's confirmation was ``urge[d]'' by Chairman Ron Johnson so that2432the VA OIG could have ``permanent, independent leadership.'' \4\ The2433Chairman of the House Veterans' Affairs Committee at the time, Rep.2434Jeff Miller, expressed relief at Mr. Missal's confirmation, saying that2435he was ``glad'' that the Senate ``finally confirmed a permanent''2436IG.\5\2437---------------------------------------------------------------------------2438    \2\ Council of the Inspectors General on Integrity and Efficiency2439(CIGIE), Inspector General Historical Data (July 25, 2017) https://2440www.ignet.gov/sites/default/files/files/IG%20History%20(PAS)%20-%207-244125-17.pdf; Department of Veterans Affairs, Staff Biographies: Inspector2442General Michael J. Missal (last accessed Feb. 4, 2025) https://2443department.va.gov/staff-biographies/michael-j-missal/.2444    \3\ PN897, 114th Cong. (2016), https://www.Congress.gov/nomination/2445114th-congress/897; Council of the Inspectors General on Integrity and2446Efficiency (CIGIE), Inspector General Historical Data, (July 25, 2017)2447https://www.ignet.gov/sites/default/files/files/2448IG%20History%20(PAS)%20-%207-25-17.pdf; Department of Veterans Affairs,2449Staff Biographies: Inspector General Michael J. Missal (last accessed2450Feb. 4, 2025) https://department.va.gov/staff-biographies/michael-j-2451missal/.2452    \4\ Press Release, Senate HSGAC, Johnson, Committee Unanimously2453Approve Michael Missal For VA Inspector General, Jan. 21, 2016 https://2454www.hsgac.senate.gov/media/reps/johnson-committee-unanimously approve-2455michael-missal-for-va-inspector-general/.2456    \5\ Press Release, House Veterans' Affairs Committee, Miller2457Statement on Senate Confirmation of VA Inspector General, Apr. 20,24582016, https://veterans.house.gov/news/2459documentsingle.aspx?DocumentID=876.2460---------------------------------------------------------------------------2461    In fiscal year 2024 alone, former VA Inspector General Missal's2462office issued ``a total of 316 reports and 1,106 recommendations'' and2463made a monetary impact of nearly $6.8 billion amounting to ``a return2464on investment of $28:1'' for every dollar spent on the inspector2465general's oversight.\6\ And those savings still pale in comparison to2466the extraordinary work that VA OIG did to address veteran suicides and2467improve health outcomes for veterans and military families throughout2468the many years of Mr. Missal's leadership of the office.\7\ That impact2469is priceless. Inspector General Missal's leadership of OIG garnered2470bipartisan approval for independent and vigorous oversight of the2471agency across the Obama, Trump and Biden administrations.\8\ As the2472Military Times noted, Mr. Missal released numerous reports critical of2473VA officials during President Trump's first term as well as President2474Biden's term in office.\9\2475---------------------------------------------------------------------------2476    \6\ Department of Veterans Affairs Office of Inspector General,2477Semiannual Report to Congress Issue 92 (Apr. 1, 2024 to Sept. 30, 20242478https://www.vaoig.gov/sites/default/files/document/2024-11/2479semiannual_report_to_congress_issue_92.pdf.2480    \7\ Department of Veteran Office of Inspector General, September24812024 Highlights (Sept. 24, 2024) https://www.vaoig.gov/sites/default/2482files/document/2024-10/monthly_highlights_september_2024.pdf.2483    \8\ See e.g., @SenatorTester, X (Feb. 16, 2022, 5:47 PM), https://2484x.com/SenatorTester/status/1494081013940641793; Press Release, Boozman,2485Hassan Introduce Bipartisan Legislation Requiring Mandatory2486Whistleblower Training for VA Employees, Office of Senator John Boozman2487(July 23, 2021) https://www.boozman.senate.gov/public/index.cfm/2021/7/2488boozman-hassan-introduce-bipartisan-legislation-requiring-mandatory-2489whistleblower-training-for-va-employees; @SenCapito, X (July 31, 2020,24901:32 PM), https://x.com/SenCapito/status/1289252668695748609; and Press2491Release, Inspector General to Investigate Reports of ``Wait Lists'' at2492Colorado VA Facility, Senate HSGAC (Oct. 16, 2020), https://2493www.hsgac.senate.gov/media/reps/inspector-general-to-investigate-2494reports-of-wait-lists-at-colorado-v a-facility/.2495    \9\ Leo Shane III, VA, DOD oversight questioned after Trump2496inspector general firings, Military Times (Jan. 27, 2025), https://2497www.militarytimes.com/news/pentagon-congress/2025/01/27/va-dod-2498oversight-questioned-after-trump-inspector-general-firings/.2499---------------------------------------------------------------------------2500    Despite that staggering impact, Mr. Missal is not here today to2501testify about his oversight of the VA OIG during President Biden's2502tenure because President Trump unceremoniously fired him last month2503along with more than a dozen other independent agency inspectors2504general.\10\ The firing of IG Missal came just days after Chairman of2505the Senate Committee on Veterans' Affairs Jerry Moran stated: ``We work2506closely with the inspector general at VA... I find him valuable both to2507me and to this committee, and he should be valuable to the Department2508of Veterans Affairs.'' \11\2509---------------------------------------------------------------------------2510    \10\ Id.2511    \11\ Id.2512---------------------------------------------------------------------------2513    Although it is beyond my expertise to opine on the state of VA's2514mission-specific operations, the mere existence of these reports2515highlights the value of robust oversight to ensure accountability at2516the VA. Without the work of the inspector general and the cooperation2517of past administrations, the waste, fraud, abuse and operational2518challenges identified in some of these reports and recommendations may2519never have come to light. And the efforts that administrations have2520taken to implement and correct these recommendations to better support2521our nation's veterans and military families likely would never have2522been possible. That includes efforts to address over 266,000 reports of2523potential wrongdoing, waste, abuse or inefficiencies received through2524the VA OIG hotline over the last eight fiscal years covering the Trump2525and Biden administrations.\12\ During the first Trump and Biden2526administrations combined, the VA OIG's work resulted in cost savings2527with an estimated total monetary impact of over $40 billion.\13\2528---------------------------------------------------------------------------2529    \12\ These figures were calculated by CREW using reports available2530at ``All Reports,'' Department of Veterans Affairs Office of Inspector2531General, https://www.vaoig.gov/reports/all.2532    \13\ Id.2533---------------------------------------------------------------------------2534    Inspectors general are critical to improving government agencies'2535efficiency in serving the American public and investigating fraud. In2536the nearly 50 years since the first inspector general positions were2537established, these officials have provided critical independent2538oversight that improved the integrity of our government. Crucially,2539inspector general terms were not designed to be tied to that of the2540president, because they provide oversight and accountability regardless2541of political party or who sits in the Oval Office. I am proud to have2542worked cooperatively with inspectors general and their staff during my2543tenure in the House, Senate and executive branch. At a time when there2544is a low global trust in government, the role of inspectors general is2545more important than ever to rebuild and strengthen that public2546trust.\14\ Under both Presidents Trump and Biden, CREW has consistently2547pressed for Inspector General vacancies to be filled and advocated for2548strong independent oversight of federal departments and agencies.\15\2549---------------------------------------------------------------------------2550    \14\ OECD Survey on Drivers of Trust in Public Institutions - 20242551Results: Building Trust in a Complex Policy Environment, OECD, July 12,25522024, https://doi.org/10.1787/9a20554b-en.2553    \15\  President Biden should fill vacant inspector general and2554ethics roles, CREW (Aug. 7, 2024), https://www.citizensforethics.org/2555legal-action/letters/president-biden-should-fill-vacant-inspector-2556general-an d-ethics-roles/; Donald K. Sherman, 12 Federal agencies2557still do not have permanent inspectors general, CREW (Sept. 23, 2020,2558https://www.citizensforethics.org/reports-investigations/crew-2559investigations/12-inspector-general-vacancies/.2560---------------------------------------------------------------------------2561    During President Trump's first term, my organization identified at2562least 25 actions taken by him to undermine the inspector general2563community, including firing two permanent IGs, removing three acting2564IGs without any clear justification and appointing four IGs to dual2565roles thus limiting their ability operate independently - a critical2566aspect of the IG role.\16\ During his first term, President Trump also2567suggested that he would prevent the Special Inspector General for2568Pandemic Recovery from communicating with Congress about administration2569misconduct and obstruction, thus attempting to stifle Congress'2570constitutional oversight role.\17\ These attempts to politicize IG2571offices undermined their independence, thus hindering their ability to2572identify waste, fraud and abuse. They were rightfully condemned by2573lawmakers on both sides of the aisle.\18\2574---------------------------------------------------------------------------2575    \16\ Donald K. Sherman, Trump's war on watchdogs and what Congress2576can do about it, Citizens for Responsibility and Ethics In Washington2577(June 15, 2020), https://www.citizensforethics.org/reports-2578investigations/crew-reports/trumps-war-on-watchdogs-and-what-congress-2579can-do-about-it/.2580    \17\  Charlie Savage, Trump Suggests He Can Gag Inspector General2581for Stimulus Bailout Program, The New York Times (Mar. 27, 2020),2582https://www.nytimes.com/2020/03/27/us/trump-signing-statement-2583coronavirus.html.2584    \18\ Press Release, Grassley Leads Bipartisan Call to Safeguard2585Inspector General Independence Following ICIG Removal (Apr. 8,25862020),https://www.grassley.senate.gov/news/news-releases/grassley-2587leads-bipartisan-call-safeguard-inspector-general-independence-2588following; Alexander Bolton and Laura Kelly, Senate Republicans demand2589answers from Trump on IG firing, The Hill (May 18, 2020), https://2590thehill.com/homenews/senate/498425-senate-republicans-demand-answers-2591from-trump-on-ig-firing/.2592---------------------------------------------------------------------------2593    Also critical to the mission of providing excellent care for our2594nation's veterans is the support of a strong, well-trained and2595experienced civil service to carry out the important mission of the2596department. Supporting veterans through the implementation of federal2597programs requires agencies to be staffed by individuals with a thorough2598understanding of statutory and regulatory schemes, institutional2599knowledge of the history of the programs, familiarity with relevant2600stakeholders inside and outside government, and substantial technical2601expertise. That is what the career civil service provides. Sometimes2602lost in the discussion about the civil service is that veterans make up260330% of the federal civilian workforce,\19\ 53% of whom are2604disabled.\20\ Attacks on the federal civil service is an attack on2605veterans. Right now, veteran unemployment stands at 2.8%, but that2606number could rise with efforts to weaken civil service protections and2607reduce the size of the federal workforce.\21\2608---------------------------------------------------------------------------2609    \19\ Office of Personnel Management, Employment of Veterans in the2610Federal Executive Branch (Fiscal Year 2021), https://www.opm.gov/2611fedshirevets/hiring-officials/ved-fy21.pdf.2612    \20\ Id.2613    \21\ Department of Labor, Veteran Unemployment Rates (Jan. 10,26142025), https://www.dol.gov/agencies/vets/latest-numbers.2615---------------------------------------------------------------------------2616    Our merit-based system is critical to the government's ability to2617continue operating effectively, and is thus crucial to the protection2618of the health and welfare of America's veterans. The merit-based civil2619service system was created to replace its predecessor, the spoils2620system, under which, politicians would put in place political cronies2621\22\ who often lacked the knowledge or expertise to fulfill their jobs2622in positions of power.2623---------------------------------------------------------------------------2624    \22\ See ``Spoils System,'' Encyclopedia.com; Machine Politics,2625PBS, https://www.pbs.org/wgbh/americanexperience/features/presidents-2626unity-garfield/; Gabe Lezra and Diamond Brown, FAQ: The conservative2627attack on the merit-based civil service, CREW (Jan. 25, 2024), https://2628www.citizensforethics.org/news/analysis/faq-the-conservative-attack-on-2629the-merit-based-civil-service/.2630---------------------------------------------------------------------------2631    The first Trump administration sought to upend the merit-based2632civil service by implementing an executive order referred to as2633``Schedule F,'' which would have stripped employment protections away2634from thousands of career civil servants. Had Schedule F not been2635rescinded, independent civil servants could have been replaced with2636political loyalists who likely would have prioritized blind obedience2637over following the law, leading to a government more prone to2638corruption.2639    During President Trump's first term in office, the VA was2640specifically targeted by efforts to upend the civil service. In 2017,2641President Trump signed the VA Accountability and Whistleblower2642Protection Act into law.\23\ Although the bill was ostensibly aimed at2643making it easier to remove government managers, in actuality the law2644was used to target low-level workers and retaliate against2645whistleblowers.\24\ Between June 2017 (the month the bill was passed)2646and March 2018, 1,700 low level VA employees were removed from their2647positions, including housekeepers and food service workers, many of2648whom may have been veterans themselves.\25\ An investigation by2649ProPublica found that whistleblowers and people who had filed2650discrimination complaints were among those fired. In 2018, the VA OIG2651reported significant staff shortages in the Veterans Health2652Administration, with high staff turnover being one of the top causes of2653the shortages.\26\ These firings were so egregious that the VA paid2654roughly $134 million to the 1,700 former VA employees who had been2655wrongfully fired as part of a settlement it reached with the American2656Federation of Government Employees.\27\ Yet, despite this successful2657legal challenge, the Trump administration and its allies indicated that2658the VA's system should be replicated across all federal agencies.\28\2659---------------------------------------------------------------------------2660    \23\ S. 1094, 115th Cong. (2017), https://www.Congress.gov/bill/2661115th-congress/senate-bill/1094.2662    \24\ Jasper Craven, At the VA, a Law Meant to Discipline Executives2663is Being Used to Fire Low-Level Workers, The Nation (May 10,26642018),https://www.thenation.com/article/archive/at-the-va-a-law-meant-2665to-discipline-executives-is-being-used-to-fi re-low-level-workers/;2666Department of Veterans Affairs Office of Inspector General, Failures2667Implementing Aspects of the VA Accountability and Whistleblower2668Protection Act of 2017 (Oct. 24, 2019), https://www.vaoig.gov/sites/2669default/files/reports/2019-10/VAOIG-18-04968-249.pdf .2670    \25\ Jory Heckman, VA reinstated 100 employees fired under widely2671challenged law, paid $134M to hundreds more, Federal News Network (Oct.267229, 2024),https://Federalnewsnetwork.com/workforce/2024/10/va-2673reinstated-100-employees-fired-under-widely challenged-law-paid-134m-2674to-hundreds-more/; Isaac Arnsdorf, The Trump Administration's Campaign2675to Weaken Civil Service Ramps Up at the VA, ProPublica (Mar. 12,26762018),https://www.propublica.org/article/veterans-affairs-the-trump-2677administration-campaign-to-weaken-civil-service-ramps-up; Craven, Supra2678note 24.2679    \26\  Department of Veterans Affairs Office of Inspector General,2680OIG Determination of Veterans Health Administration's Occupational2681Staffing Shortages (FY2018), https://www.vaoig.gov/sites/default/files/2682reports/2018-06/VAOIG-18-01693-196.pdf.2683    \27\ Heckman, supra note 25.2684    \28\ Arnsdorf, supra note 25.2685---------------------------------------------------------------------------2686    As unprecedented, damaging, and in some cases illegal, as President2687Trump's actions were toward inspectors general and the civil service2688during his first term, what we have seen unfold in recent days is on an2689entirely different scale. If these attacks continue, they will harm all2690Americans, including our veterans.2691    On the day President Trump was sworn in, he signed a series of2692executive orders, including one essentially reinstating Schedule F.\29\2693In a separate executive order, President Trump implemented an immediate2694and broad hiring freeze across the government,\30\ reportedly causing2695chaos for certain vacancies at the VA.\31\ VA employees and applicants2696rightfully questioned the impact of the hiring freeze on vital care and2697services provided by the VA.\32\2698---------------------------------------------------------------------------2699    \29\  Office of Personnel Management, Memorandum from Acting2700Director Charles Ezell to Heads and Acting Heads of Departments and2701Agencies on Guidance on Implementing President Trump's Executive Order,2702Restoring Accountability To Policy-Influencing Positions Within the2703Federal Workforce (Jan. 27, 2025), https://www.opm.gov/policy-data-2704oversight/latest-memos/guidance-on-implementing-president-trump-s-2705executive-order-titled-restoring-accountability-to-policy-influencing-2706positions-within-the-federal-workforce.pdf2707    \30\ The White House, Executive Order entitled Hiring Freeze (Jan.270820, 2025), https://www.whitehouse.gov/presidential-actions/2025/01/2709hiring-freeze/.2710    \31\ Jory Heckman, VA reinstates job offers to health care hires,2711but some still in limbo amid hiring freeze, Federal News Network (Jan.271227, 2025),https://federalnewsnetwork.com/veterans-affairs/2025/01/va-2713reinstates-job-offers-to-health-care-hires-but-some-still-in-limbo-2714amid-hiring-freeze/.2715    \32\  Id.2716---------------------------------------------------------------------------2717    President Trump's broadside attack against the government hasn't2718been limited to hiring - his administration is also taking aim at2719across the board government funding, including funding for programs2720that are designed to protect and support our veterans. Last week, the2721Acting Director of the Office of Management and Budget issued a2722memorandum, requiring every federal agency to pause ``all activities2723related to obligation or disbursement of all Federal financial2724assistance, and other relevant agency activities that may be implicated2725by [President Trump's] executive orders.'' \33\ According to reports,272644 separate financial assistance programs related to veterans were2727temporarily suspended while the department reviewed them to see if they2728were in compliance with OMB's funding freeze.\34\ Although they were2729exempted from the freeze after they were reviewed, those included2730veterans' suicide prevention, homelessness, job training and nursing2731home support programs.\35\ The memo, which was halted by two federal2732court judges who heard legal challenges to the rule, was later2733rescinded by the administration. In one of the judicial opinions, a2734federal district court judge wrote, ``For many, the harms caused by the2735freeze are non-speculative, impending, and potentially catastrophic.''2736\36\2737---------------------------------------------------------------------------2738    \33\ Memorandum from Matthew Vaeth to Heads of Executive2739Departments and Agencies, Office of Management and Budget (Jan. 27,27402025),https://www.documentcloud.org/documents/25506361-omb-memo-on-2741Federal-aid-freeze/.2742    \34\ Leo Shane III, VA benefits won't be halted under White House2743funding freeze order, Military Times (Jan. 29, 2025), https://2744www.militarytimes.com/news/pentagon-congress/2025/01/29/va-benefits-2745wont-be-halted-under-white-house-funding-freeze-order/.2746    \35\ Id.2747    \36\ Lindsay Whitehurst, Judge in nation's capital extends block on2748Trump administration federal funding freeze, AP News (Feb. 3,27492025),https://apnews.com/article/trump-federal-grants-loans-funding-2750freeze-court-1bc457d8e333dd8a8f374572ea33 927c.2751---------------------------------------------------------------------------2752    President Trump's actions aimed at the civil service have produced,2753and will continue to cause, untold ripple effects across departments2754and agencies which will likely lead to complications, waste and2755opportunities for abuse. That is why oversight and accountability is2756needed now more than ever. Yet, within his first week in office,2757President Trump fired inspectors general and members of their staffs2758across 17 different federal agencies, including VA Inspector General2759Missal, who members of Congress from both sides of the aisle have2760lauded for his oversight work during both Democratic and Republican2761administrations.\37\2762---------------------------------------------------------------------------2763    \37\ Campaign Legal Center., The Significance of Firing Inspectors2764General: Explained (Jan.31, 2025) https://campaignlegal.org/update/2765significance-firing-inspectors-general-explained; Leo Shane III, VA,2766DOD oversight questioned after Trump inspector general firings,2767Military Times (Jan. 27, 2025), https://www.militarytimes.com/news/2768pentagon-congress/2025/01/27/va-dod-oversight-questioned-after-trump-2769inspector-general-firings/; Fired Inspectors General Raise Alarms as2770Trump Administration Moves to Finalize Purge, The New York Times (Jan.277127, 2025),https://www.nytimes.com/2025/01/27/us/politics/trump-2772inspectors-general-fired.html); See e.g., VA, DOD oversight questioned2773after Trump inspector general firings, Military Times (Jan. 27, 2025)2774https://www.militarytimes.com/news/pentagon-congress/2025/01/27/va-dod-2775oversight-questioned-after-trump-inspector-general-firings/; See e.g.,2776House Committee on Veterans Affairs Minority, Press Release: Ranking2777Member Takano's Statement on Trump's Late-Night Purge of 12 Inspectors2778General (Jan. 25. 2025), https://democrats-veterans.house.gov/news/2779press-releases/ranking-member-takanos-statement-on-trumps-late-night-2780purge-of-12-inspectors-general.2781---------------------------------------------------------------------------2782    President Trump defended the firing of the inspectors general,2783saying that ``it's a very common thing to do.'' \38\ That is not the2784truth. The only precedent for such a mass firing of IGs by an incoming2785president after the passage of the Inspectors General Act of 1978 was2786the firing of 15 IGs by President Ronald Reagan in 1981 - an act met by2787strong disfavor, which was only eased when President Reagan renominated2788several of the removed IGs.\39\2789---------------------------------------------------------------------------2790    \38\ Manu Raju, Alayna Treene, Morgan Rimmer and Annie Grayer,2791Trump fires inspectors general from more than a dozen federal agencies,2792CNN (Jan. 25, 2025),https://www.cnn.com/2025/01/25/politics/trump-2793fires-inspectors-general/index.html.2794    \39\ Congressional Research Service, Removal of Inspectors General:2795Rules, Practice, and Considerations for Congress (Updated January 25,27962025) https://crsreports.congress.gov/product/pdf/IF/IF11546.2797---------------------------------------------------------------------------2798    As Hannibal Ware, the Chairperson of the Council of the Inspectors2799General on Integrity and Efficiency, publicly acknowledged, ``IGs are2800not immune from removal. However, the law must be followed to protect2801independent government oversight for America.'' \40\ Within the last 202802years, Congress has passed two laws with bipartisan support to prevent2803the precise type of action President Trump just took.\41\ The Inspector2804General Reform Act of 2008, which established a requirement that2805Congress be notified in writing no later than 30 days before removal or2806transfer of an IG,\42\ and the Securing Inspector General Independence2807Act of 2022, provisions of which became law as part of the James M.2808Inhofe National Defense Authorization Act for Fiscal Year 2023, added a2809requirement that Congress be given a detailed account of the2810justification for the removal of an inspector general and the inspector2811general remain in place for 30 days while Congress considers that2812justification.\43\2813---------------------------------------------------------------------------2814    \40\ Council of the Inspectors General on Integrity and Efficiency2815(CIGIE), Statement from Hon. Hannibal Ware, Chairperson of the Council2816of the Inspectors General on Integrity and Efficiency (Jan. 25, 2025)2817https://www.ignet.gov/sites/default/files/files/CIGIE%20Statement%20--2818%201_25_2025.pdf2819    \41\ Roll Call 661 for Bill Number: H.R. 928 Inspector General2820Reform Act of 2008 (Sept. 27, 2008) https://clerk.house.gov/Votes/28212008661 ; Cosponsors Securing Inspector General Independence Act of28222021 https://www.congress.gov/bill/117th-congress/senate-bill/587/2823cosponsors.2824    \42\ Public Law No: 110-409 (Oct. 14, 2008).2825    \43\  Public Law No: 117-263 (Dec. 23, 2022).2826---------------------------------------------------------------------------2827    The firings of the IGs by President Trump were made all the more2828concerning because President Trump failed to follow the law and provide2829the legally required 30-day notice and case-specific reasons for2830removal, as Chairman Chuck Grassley and Ranking Member Dick Durbin of2831the Senate Judiciary Committee recently noted in a letter to President2832Trump.\44\ The fact that these inspectors general appear to have been2833fired without cause suggests that they may have been fired to stifle2834oversight of the new administration and raises questions about whether2835the next inspector general will be a partisan loyalist or simply fired2836on the president's political whim. Will anyone filling these posts2837actually conduct robust oversight? How can a federal employee stripped2838of their employment protections by Trump's executive orders feel2839comfortable going to a potential Trump loyalist hand-picked to serve as2840IG to blow the whistle on waste, fraud or abuse? These are important2841questions that I urge Congress to address.2842---------------------------------------------------------------------------2843    \44\ Letter from Senate Judiciary Chairman Chuck Grassley and2844Ranking Member Dick Durbin to President Donald J. Trump (Jan. 28,28452025),https://www.judiciary.senate.gov/press/rep/releases/grassley-2846durbin-seek-presidential-explanation-for-ig-dismissals (citing Pub. L.2847117-263 The ``President ``shall'' communicate to Congress in writing 302848days before removing or transferring an IG from office the2849``substantive rationale, including detailed and case-specific reasons''2850for the removal or transfer).2851---------------------------------------------------------------------------2852    It is critical that the VA has a permanent IG that has the2853expertise and institutional knowledge to provide continuity in the2854oversight work directed at addressing critical long-term challenges at2855the Department. For instance, the VA Office of Inspector General under2856Missal, conducted in-depth work reviewing healthcare staffing2857shortages, patient safety concerns, inadequate clinical care, as well2858as veterans' suicide risk and prevention.\45\ It is important for2859veterans and military families that IG oversight in these areas2860continues unabated. Although VA Deputy IG David Case has been made2861acting IG, having an acting IG is a far cry from having a properly2862vetted and Senate-confirmed official serving in that role. As Senator2863Grassley has noted, permanent IGs are critical because ``[e]ven the2864best acting Inspector General lacks the standing to make lasting2865changes needed to improve his or her office.'' \46\ Moreover, an acting2866IG may not have the experience necessary, nor feel adequately2867empowered, to take sensitive and problematic issues to the Secretary or2868Congress as Inspector General Missal did when he confronted then-VA2869Secretary David Shulkin, in 2018, with allegations of the Secretary's2870own unethical conduct, including the improper acceptance of gifts and2871the misuse of agency resources.\47\ Or like Mr. Missal's office did in2872May 2024 when it issued a report finding that the Biden VA erroneously2873awarded $10.8 million in recruitment and retention bonuses to senior2874executives, leading to an effort by then-Secretary McDonough to recoup2875those funds.\48\2876---------------------------------------------------------------------------2877    \45\ See e.g., Department of Veterans Affairs Office of Inspector2878General, Deficiencies in Inpatient Mental Health Suicide Risk2879Assessment, Mental Health Treatment Coordinator Processes, and2880Discharge Care Coordination (Dec. 18, 2024),https://www.vaoig.gov/2881reports/national-healthcare-review/deficiencies-inpatient-mental-2882health-suicide-risk-assessment; Department of Veterans Affairs Office2883of Inspector General, Inadequate Staff Training and Lack of Oversight2884Contribute to the Veterans Health Administration's Suicide Risk2885Screening and Evaluation Deficiencies (Dec. 18, 2024), https://2886www.vaoig.gov/reports/national-healthcare-review/inadequate-staff-2887training-and-lack-oversight-contribute-veterans; Department of Veterans2888Affairs Office of Inspector General, Mismanaged Surgical Privileging2889Actions and Deficient Surgical Service Quality Management Processes at2890the Hampton VA Medical Center in Virginia (July 23, 2024),https://2891www.vaoig.gov/reports/hotline-healthcare-inspection/mismanaged-2892surgical-privileging-actions-and-deficient.2893    \46\ Andrew Ackerman,Maloney Named Interim SEC Inspector General,2894Wall Street Journal (Jan. 27 2012), https://www.wsj.com/articles/2895SB10001424052970204573704577187443078314650.2896    \47\ Department of Veterans Affairs Office of Inspector General,2897Administrative Investigation - VA Secretary and Delegation Travel to2898Europe (Feb. 14, 2018),https://www.vaoig.gov/sites/default/files/2899reports/2018-02/VAOIG-17-05909-106.pdf.2900    \48\ Department of Veterans Affairs Office of Inspector General, VA2901Improperly Awarded $10.8 Million in Incentives to Central Office Senior2902Executives (May 9, 2024), https://www.vaoig.gov/reports/administrative-2903investigation/va-improperly-awarded-108-million-incentives-central-2904office; Eric Katz, Lawmakers blast VA over executive bonus scandal, but2905secretary declines to offer any heads, Government Executive (June 4,29062024), https://www.govexec.com/pay-benefits/2024/06/lawmakers-blast-va-2907over-executive-bonus-scandal-secretary-declines-offer-any-heads/2908397095/.2909---------------------------------------------------------------------------2910    To an administration that claims to value monetary efficiency in2911government, I would argue that firing inspectors general actually2912hinders efficiency and results in monetary waste. Mr. Missal's ouster2913certainly did not benefit any veterans or military families. Instead,2914attacking the IG and the civil service does a disservice to veterans2915and makes the VA more susceptible to waste, fraud and abuse.2916    Thank you. I am happy to answer your questions on ways to foster2917accountability at the VA and ensure our veterans and military families2918can get the help, care and support they deserve.29192920                       Statements for the Record29212922                              ----------29232924        Prepared Statement of Government Accountability Project29252926    MR. CHAIRMAN:2927    Thank you for the opportunity to submit written testimony on the2928Department of Veterans Affairs (VA)'s Office of Accountability and2929Whistleblower Protection (OAWP). I serve as Legal Director of the2930Government Accountability Project (GAP), a non-profit, non-partisan2931whistleblower support and advocacy organization. I hope this testimony2932will provide additional context for matters not considered in the2933February 6 hearing. summarizes issues Government Accountability Project2934previously testified on four times in the previous hearings by this2935Committee.2936    GAP has engaged in aggressive oversight of whistleblower rights at2937the Department of Veterans Affairs (DVA) during the last two2938administrations. When I first testified in 2019, 10 DVA whistleblowers2939were 40% of my 25-client reprisal docket. The worst offender was the2940agency's whistleblower protection office, the Office of Accountability2941and Whistleblower Protection. During the Biden administration, the new2942OAWP chief resolved all the OAWP reprisal cases in an even-handed2943manner, and administratively instituted significant reforms that this2944Committee unanimously sought to institutionalize in the H.R. 8510, the2945Strengthening Whistleblower Protection at the Department of Veterans2946Affairs Act. At the end of this testimony, we recommend that this2947committee try again to codify the key reforms it approved previously.29482949                  HISTORY OF WHISTLEBLOWER RETALIATION29502951    The DVA long has been the Executive branch's worst agency with2952respect to whistleblower retaliation. GAP's 40% rate of DVA2953whistleblowers compared to the rest of the government is consistent2954with that of the U.S. Office of Special Counsel. To illustrate from our2955clients, misconduct that whistleblowers were retaliated against for2956exposing included----29572958      gross mismanagement that led to multi-year waiting lists2959for patients who needed immediate care for life threatening conditions;29602961      lying to patients that they would receive timely care2962while concealing the secret waiting lists;29632964      sabotaging corrective action for waiting lists through2965unqualified, buddy system contracts;29662967      breakdown of the suicide prevention program;29682969      breakdown of the program to treat spinal cord injuries;2970and29712972      bribery that led to contamination of the water supply at2973a facility.29742975    These examples are representative of a DVA pattern of betraying its2976mission to promote its own self-interest. It was encouraging, however,2977that whistleblower reprisal complaints to GAP dropped sharply during2978the last Administration.29792980       THE OFFICE OF ACCOUNTABILITY AND WHISTLEBLOWER PROTECTION29812982    The OAWP had a disastrous birth, with GAP receiving more2983whistleblowing disclosures and retaliation complaints from its staff2984than the rest of the Department. The Office was not producing results,2985as all the cases summarized above sought and failed to receive help. In2986particular, OAWP employees blew the whistle on mission breakdowns such2987as----29882989      gagging its own employees despite being a whistleblower2990protection agency;29912992      lacking enforcement authority due to veto authority for2993the agency General Counsel to veto actions;29942995      canceling its effective mentoring mediations program; and29962997      canceling counseling services that had assisted over29981,000 DVA employees.29993000    Again, we were encouraged that the recent OAWP chief, Mary Donohue,3001had significant success turning the agency around. All the3002whistleblower retaliation complaints were resolved on fair terms. OAWP3003obtained its own counsel. The mentoring and counseling programs were3004restored.3005    While the progress was welcome, our organization and others have3006advocated that the improved practices be institutionalized through3007statutory requirements. We recommend that any further remedial3008legislation include the following:30093010    1. Independent Counsel for OAWP:3011    By statute, OAWP must have independent legal counsel free from VA3012Officer of General Counsel (OGC) oversight. While OAWP attorneys now3013exercise significant autonomy, OGC retains control over disciplinary3014decisions. True structural independence must be codified.30153016    2. Transfer of Investigative Authority to the Office of Special3017Counsel (OSC):3018    OAWP lacks enforcement power. Unlike OSC, it cannot litigate to3019enforce corrective action. Instead, it can only make recommendations VA3020officials routinely ignore. If OAWP retains investigative authority,3021Congress must grant it enforcement power to ensure real consequences3022for retaliation.30233024    3. Protection Against Retaliatory Licensing Board Referrals:3025    DVA officials often circumvent whistleblower protections by3026referring employees to state licensing boards, effectively blocklisting3027them from their profession. This practice must be explicitly prohibited3028to prevent career-ending retaliation.30293030    4. Increased Transparency in OAWP Oversight:3031    OAWP has improved its public reporting, but gaps remain. Unlike3032OSC, OAWP does not disclose its assessments of agency corrective3033actions. Congress should require parity with OSC's transparency3034standards, ensuring full oversight and public accountability.30353036    5. Mandatory Whistleblower Navigators:3037    An early administration eliminated whistleblower counseling3038services, leaving employees to navigate a complex system alone. OAWP3039has reinstated a navigator function, but Congress should codify this as3040a permanent, mandatory service.30413042    6. Institutionalized Alternative Dispute Resolution (ADR):3043    A prior OAWP mediation program successfully resolved whistleblower3044disputes without litigation. However, this initiative was discontinued.3045Congress should restore and mandate a no-fault ADR program to provide3046an alternative to prolonged legal battles.30473048    7. Tracking and Reporting Compliance with Recommendations:3049    OAWP claims that 95% of its recommendations are accepted, but there3050is no data on whether they are implemented. Agencies frequently accept3051recommendations without acting on them. Congress should require annual3052reports on compliance and enforcement actions.3053    These reforms are necessary to ensure that OAWP serves its intended3054purpose: protecting whistleblowers and upholding accountability at the3055VA. While recent leadership changes have improved the agency's3056responsiveness, structural safeguards are essential to prevent3057regression.3058    Government Accountability Project remains committed to supporting3059these efforts and is on call however we can be helpful. Thank you for3060your time and attention to this matter.3061                                 ______30623063Prepared Statement of American Federation of Government Employees, AFL-3064                                  CIO30653066    Chairman Kiggans, Ranking Member Ramirez, and Members of the3067Subcommittee:3068    The American Federation of Government Employees, AFL-CIO (AFGE) and3069its National Veterans Affairs Council (NVAC) appreciate the opportunity3070to submit a statement for the record on today's hearing titled ``VA3071First, Veteran Second: The Biden-Harris Legacy.'' AFGE represents more3072than 750,000 federal and District of Columbia government employees,3073310,000 of whom are proud, dedicated Department of Veterans Affairs3074(VA) employees. These include front-line providers at the Veterans3075Health Administration (VHA) who provide exemplary specialized medical3076and mental health care to veterans, the Veterans Benefits3077Administration (VBA) workforce responsible for the processing veterans'3078claims, the Board of Veterans' Appeals (Board) employees who shepherd3079veterans' appeals, and the National Cemetery Administration Employees3080(NCA) who honor the memory of the nation's fallen veterans every day.3081    With this firsthand and front-line perspective, we offer our3082observations on the problems the Department of Veterans Affairs3083Accountability and Whistleblower Protection Act of 2017 has caused3084front-line VA Employees. Specially, AFGE has long objected to the VA's3085use of 38 U.S.C. 714 (Sec. 714) of the law and how it has harmed3086hardworking and dedicated employees. Additionally, through this3087experience AFGE is also aware of the failure of VA leadership to hold3088managers accountable under other provisions of the law. AFGE has3089supported efforts to amend the law to restore fairness to VA employees3090and encourages the committee to restore basic fairness to the VA3091workforce.30923093Background30943095    Public Law 115-41, the Department of Veterans Affairs3096Accountability and Whistleblower Protection Act (Accountability Act or3097Act), was signed into law on June 23, 2017. At the time of its passage,3098supporters claimed the Act was intended to simplify and expedite the3099disciplinary process at VA so that it could better hold bad employees3100accountable. The Act is divided into two parts, Title I, which3101established the Office of Accountability and Whistleblower Protections3102(OAWP) and Title II, which governs Accountability and Adverse Actions3103for Senior Executives, VA Employees, and Supervisors disciplinary3104procedures. Within Title II, the bill enacted 38 U.S.C. Sec. 714 which3105changed the following disciplinary procedures for bargaining unit3106employees (38 U.S.C. Sec. 713 is for managers):31073108      Required management to make a final decision within 153109business days of proposing an adverse action (i.e., suspension of more3110than 14 days, demotion, or removal);31113112      Reduced the time period for an employee to respond to3113proposed adverse action to 7 business days;31143115      Reduced the time period for an employee to appeal the3116final adverse action;31173118      Lowered the standard of proof necessary to sustain an3119adverse action before a third party, such as arbitrators and the Merit3120Systems Protection Board (MSPB), from preponderance of the evidence to3121substantial evidence;31223123      Prevented third part adjudicators from mitigating the3124penalties assigned by VA.31253126Oversight31273128    Since the Act's enactment, there has been robust oversight over the3129Act's implementation, and its effect on the workforce in multiple3130venues:31313132        Congressional Oversight31333134    The House Veterans' Affairs Committee held an oversight hearing in3135July 2018 before the Committee on Veterans' Affairs entitled ``The VA3136Accountability and Whistleblower Protection Act: One Year Later.'' \1\3137The committee's goal was to address problems caused by the VA's3138implementation of the Act. In his opening statement, then-Ranking3139Member Mark Takano addressed the VA's penchant to use the Act to3140disproportionately discipline rank and file employees as opposed to3141supervisors and other management officials stating: \2\3142---------------------------------------------------------------------------3143    \1\ The VA Accountability and Whistleblower Protection Act: One3144Year Later: Before the H. Comm. On Veterans Affairs, 115th Congr.3145(2018), https://republicans-veterans.house.gov/calendar/3146eventsingle.aspx?EventID=2212.3147    \2\  The VA Accountability and Whistleblower Protection Act: One3148Year Later: Before the H. Comm. On Veterans Affairs, 115th Congr.3149(2018) (statement of Mark Takano, ranking member), https://republicans-3150veterans.house.gov/calendar/eventsingle.aspx?EventID=2212.31513152        ``[Of] the 1,086 removals during the first five months of 2018,3153        the majority of those fired were housekeeping aides...I also3154        find it hard to believe that there are large numbers of3155        housekeeping aides whose performance is so poor that it cannot3156        be addressed. If that is truly the case, then it stands to3157        reason that there are also management issues behind their poor3158        performance. But of those 1,096 removals, only fifteen were3159        supervisors which is less than 1.4%. Firing rank and file3160        employees does nothing to resolve persistent management3161        issues.'' He continued ``it is not possible to fire your way to3162---------------------------------------------------------------------------3163        excellence.''31643165    AFGE also testified at this hearing citing how the law3166disproportionately harmed lower paid federal workers and not the3167managers who supervised them, and also further explained many of the3168structural problems with the law that continue to exist today.\3\ AFGE3169has also commented on the Accountability Act and Whistleblower at other3170House Veterans' Affairs Committee hearings including before this3171subcommittee on May 19, 2021 at hearing titled ``Protecting3172Whistleblowers and Promoting Accountability: is VA Making Progress?''3173\4\ citing the problems with the current law and the need to pass3174reforms. AFGE also submitted a statement for the record before this3175subcommittee on March 9, 2023 discussing the problems with the 20173176accountability statute at a hearing titled ``Accountability at VA:3177Leadership Decisions Impacting its Employees and Veterans.''3178---------------------------------------------------------------------------3179    \3\ The VA Accountability and Whistleblower Protection Act: One3180Year Later: Before the H. Comm. On Veterans Affairs, 115th Congr.3181(2018) (statement of AFGE National President J. David Cox). https://3182docs.house.gov/Committee/Calendar/ByEvent.aspx?EventID=108516.3183    \4\ Protecting Whistleblowers and Promoting Accountability: is VA3184Making Progress? Before the H. Comm. On Veterans Affairs Subcommittee3185on Oversight and Investigations, 117th Congr. (2021) (AFGE Statement3186for the Record).31873188---------------------------------------------------------------------------3189        Inspector General Investigation31903191    In response to requests for an investigation from multiple3192legislators, the Office of Inspector General (OIG) highlighted VA's3193failure to properly implement the portion of the Act pertaining to3194whistleblower protection. The OIG issued a report, which explained,3195``in many instances, [OAWP] focused only on finding evidence sufficient3196to substantiate the allegations without attempting to find exculpatory3197or contradictory evidence.''3198    Further, while VA front-line employees were being disciplined more3199often and more harshly under section 202 of the Accountability Act, the3200OIG report found that VA ``struggled with implementing the Act's3201authority to hold executives accountable.'' OIG explained that despite3202statements from then-Secretary Shulkin, as of May 22, 2019, VA had only3203removed one covered executive employee under 38 U.S.C. 713, which3204addresses discipline for senior executives. Further, of thirty-five3205cases involving executives, VA mitigated the discipline of thirty-two.3206    The OIG investigation revealed unlawful whistleblower retaliation3207by OAWP itself, noting that after an OAWP employee made a whistleblower3208complaint, Executive Director O'Rourke instructed a subordinate to3209remove the employee. Finally, the OIG found that the VA did not comply3210with reporting and training requirements of the Act and failed to3211adequately report to Congress regarding the outcomes of disciplinary3212actions.32133214        Freedom of Information Act32153216    In an attempt to learn more about the VA's use of its authorities3217under the Accountability Act, on May 31, 2022, AFGE submitted a Freedom3218of Information Act (FOIA) Request to the VA. This request asked the VA3219to share, without violating the privacy of employees, the VA's use of3220Section 204 of the Veterans Affairs Accountability and Whistleblower3221Protection Act of 2017, 38 U.S.C. Sec. 721, which authorizes the3222Secretary to issue an order, under certain circumstances, directing an3223employee to repay an award or bonus paid to the employee. This request3224covered the period from June 23, 2017, through May 31, 2022. In3225response to the AFGE's request, the VA responded on June 2, 2022, and3226stated that ``This is a recently enacted VA policy and there are no3227responsive records.'' This is evidence that the VA has not utilized all3228of the tools at its disposal to hold employees accountable, and that3229the VA does not need additional tools for accountability.32303231Challenges in Federal Court32323233    Since the enactment of the Accountability Act, the certain parts of3234the law have been challenged in federal courts, relating to the3235restrictions on the MSPB or third party adjudicators to mitigate a3236penalty. In Sayers v. Dep't of Veterans Affairs, the U.S. Court of3237Appeals for the Federal Circuit (Federal Circuit or Court) determined3238that, contrary to VA's contentions, the MSPB was permitted to review3239the penalty as well as the facts of a case under Sec. 714. The Court3240explained that ``[d]eciding that an employee stole a paper clip is not3241the same as deciding that the theft of a paper clip warranted the3242employee's removal.'' It is clear that prior to Sayers, the Agency3243promoted a limited review and harshly disciplined employees under3244Sec. 714, often for similarly trivial acts.3245    The perceived inability to mitigate led judges to affirm decisions3246where even a single charge was proven by substantial evidence. Where3247the harshest available penalty, removal, was used liberally, this led3248to a loss of employee resources for the smallest of infractions. VA's3249rush to remove employees was clear in performance cases as well. As3250Administrative Judges believed they could not mitigate penalties,3251employees were removed for easily remedied performance failures.3252    Another key element of the law examined by the courts is the3253elimination of the preponderance of the evidence standard, and the3254implementation of the new substantial evidence standard. In Rodriguez3255v. Dep't of Veterans Affairs, the Court held that the ``preponderance3256of the evidence, rather than substantial evidence was the correct3257standard for management to apply at the administrative level in conduct3258cases under [Sec. ]714.'' \5\ The Court explained that when determining3259whether conduct justified discipline under Sec. 714, preponderance of3260the evidence was the correct evidentiary burden, and the MSPB's3261standard of review should be substantial evidence. Consequently, the3262Court found that VA had applied the wrong evidentiary standard in its3263Sec. 714 conduct cases. The Court held in August 2021 that VA and MSPB3264must apply the Douglas Factors in deciding and reviewing the imposed3265penalty.\6\3266---------------------------------------------------------------------------3267    \5\ Ariel Rodriguez v. Department of Veterans Affairs, 8 F.4th 12903268(Fed. Cir.) (2021).3269    \6\ Stephen Connor v. Department of Veterans Affairs, 8 F.4th 13193270(Fed. Cir.) (2021).3271---------------------------------------------------------------------------3272    By subjecting management's decisions to additional scrutiny, the3273Court demonstrated VA's overreach in its use of the Accountability Act.3274The use of Sec. 714 has proven to have had its greatest impact on3275lower-level employees, compounding a staffing crisis while doing little3276to address systemic problems such as inadequate training and hostile3277managers. Thus, while the reviewing arbitrators, Administrative Law3278Judges, and Federal Circuit Judges have done much to curtail VA's broad3279interpretation of the law, the law itself must be amended if it is to3280accomplish its stated goal of improving systemic flaws in the Agency.3281    Furthermore, in the recent case Richardson v. Department of3282Veterans Affairs, the MSPB further limited the applicability of the3283law.\7\ In Richardson, the MSPB ruled that an employee appointed under328438 U.S.C 7401(3), a ``hybrid'' Title 38/Title 5 employee, could not be3285terminated under Sec. 714 as the text of 38 U.S.C. 7403(f)(3) dictated3286its reliance on ``the procedures'' of chapter 75 of Title 5.\8\3287---------------------------------------------------------------------------3288    \7\ Richardson v. Department of Veterans Affairs, Docket No. AT-32890714-21-0109-I-1 (MSPB) (2023).3290    \8\ Id.3291---------------------------------------------------------------------------3292    As a result of these and other legal rulings and determinations,3293the VA announced on March 5, 2023, that the VA will prospectively3294``cease using the provisions of 38 U.S.C. Sec.  714 to propose new3295adverse actions against employees of the Department of Veterans Affairs3296(VA), effective April 3, 2023.''3297    In the remaining 21 months of the Biden Administration, the VA3298reverted to using standard and well understood Title 5 discipline for3299employees covered by Sec. 714, which provided discipline, including3300removal for VA employees, while simultaneously guarding the civil3301service protections of the dedicated VA workforce.33023303Suggested Reforms33043305    Irrespective of the possibility that future VA Secretaries could3306reverse the Secretary's determination to cease using Sec. 714, AFGE3307recommends two legislative changes to the Accountability Act:33083309        Restore the Standard of Review to Preponderance of Evidence33103311    38 U.S.C. Sec.  714 established by the Accountability Act mandates3312that the MSPB uphold management's decision to remove, demote, or3313suspend an employee if the decision is supported by substantial3314evidence. While not defined in the law, management guidance defined3315substantial evidence as ``relevant evidence that a reasonable person,3316considering the record as a whole, might accept as adequate to support3317a conclusion, even though other reasonable persons might disagree, or3318evidence that a reasonable mind would accept as adequate to support a3319conclusion.''3320    Prior to the implementation of Sec. 714, discipline based on3321unacceptable performance was considered under Chapter 43. Disciplinary3322actions to promote the efficiency of the service were considered under3323Chapter 75 of Title 5 of the United States Code. Under those chapters,3324a disciplinary action was upheld where substantial evidence3325demonstrated that the unacceptable performance took place under Chapter332643, and where a preponderance of the evidence demonstrated that the3327misconduct or performance took place under Chapter 75. The difference3328in the burdens of proof aligned with the differences in penalties, as3329Chapter 43 actions led to attempts to improve that performance whereas3330harsher penalties, to include immediate removal, were available for3331misconduct under Chapter 75.3332    As discussed in Rodriguez v. Dep't of Veterans Affairs, VA3333improperly read Sec. 714 to mean that its burden of proof in justifying3334discipline was lowered to the substantial evidence standard. The3335Federal Circuit disagreed with the Agency's position, finding that the3336Agency conflated burden of proof and standard of review. Consequently,3337the Court found that the VA still had to meet the preponderance of the3338evidence burden of proof in its decision to discipline for conduct.3339    Rodriguez clarified the difference between the burden of proof3340required of management, a preponderance of the evidence for conduct3341cases, and the standard of review by the MSPB, changed to substantial3342evidence under Sec. 714. Even a proper reading of Sec. 714, however,3343puts reviewers in a position they often have little choice but to3344rubber stamp VA's harsh penalties. Changing the standard of review to3345the preponderance of the evidence is necessary to ensure that VA3346reassumes the burden of proving that the claimed action occurred. Where3347an employee's job is on the line, VA's decisions should be held to a3348higher degree of scrutiny.33493350        Restore the Authority to Mitigate Unreasonable Penalties33513352    Connor v. Department of Veterans Affairs, spoke to the issue of3353mitigation. In that case, on appeal, the MSPB sustained only one of the335427 charges against the employee. On appeal to the Federal Circuit, the3355Agency argued it need not consider the Douglas Factors in Sec. 7143356proceedings.\9\3357---------------------------------------------------------------------------3358    \9\ Stephen Connor v. Department of Veterans Affairs, 8 F.4th 13193359(Fed. Cir.) (2021).3360---------------------------------------------------------------------------3361    Under current statute established by Sec. 714, the law provides3362that where the Agency's decision is supported by substantial evidence,3363the MSPB or an arbitrator may not mitigate the penalty. Thus, the MSPB3364or an arbitrator could only reverse an Agency decision it determined3365was unreasonable. MSPB had an extremely high rate of affirming Agency3366decisions even before the enactment of the Accountability Act. MSPB's3367affirmance rate of VA decisions was 83.7%, of the years recorded since,33682019 was the highest rate of affirmance at 89.44%. Few cases were3369mitigated prior to 2017, however, mitigation was available to reviewing3370entities, saving the time of sending back a case, causing needless3371delay.3372    The Accountability Act was promoted as enabling management to3373streamline the disciplinary process. VA's failure to use the right3374evidentiary standard and MSPB's inability to mitigate discipline caused3375many disciplinary cases to be returned to the Agency for time-consuming3376work and increased the time it took to process discipline.3377    AFGE strongly supports restoring the standard of review applicable3378to the Agency to the preponderance of the evidence and restoring the3379ability of reviewing bodies to mitigate penalties under Sec. 714. Such3380changes would ensure fair determinations and streamline the3381disciplinary process.3382    Both of these recommendations would be enacted by passing H.R. 932,3383the bi-partisan ``Protecting VA Employees Act.''33843385Conclusion33863387    AFGE thanks the House Veterans' Affairs Committee for the3388opportunity to submit a Statement for the Record for today's hearing.3389AFGE stands ready to work with the committee and the VA to address the3390workforce issues currently facing the department and find solutions3391that will enable VA employees to better serve our nation's veterans.3392                                 ______33933394            Prepared Statement of Disabled American Veterans33953396    Chairman Bost, Ranking Member Takano and Members of the Committee:3397    Thank you for inviting DAV (Disabled American Veterans) to submit3398testimony for the record of this legislative hearing. As you know, DAV3399is a congressionally chartered and Department of Veterans Affairs (VA)3400accredited veterans service organization. We provide meaningful claims3401support free of charge to more than 1 million veterans, family members,3402caregivers and survivors. We are pleased to provide our views on the3403bills under consideration by the Committee.34043405          H.R. 472, the Restore VA Accountability Act of 202534063407    DAV has consistently advocated for a culture of accountability3408within the VA, where VA employees are held to the highest standards of3409performance and conduct. We applaud the committee for its efforts to3410address longstanding issues within the VA and to ensure that federal3411employees are responsible for their actions. We concur that bad3412employees must be held accountable to ensure that the best federal3413employees are serving veterans; however, accountability must include3414due process principles, protecting the rights of employees, including3415veterans, who make up nearly 30% of VA's workforce.3416    H.R. 472, the Restore VA Accountability Act of 2025, makes several3417changes to the due process of appeals for employees at the VA. The Act3418would allow for expedited disciplinary actions for certain categories3419of VA employees based on substantial evidence of misconduct or poor3420performance. Specifically, the bill would remove the Performance3421Improvement Plan (PIP) requirement and the appellant's review by the3422Merit Systems Protection Board (MSPB).3423    Although the goal of the Restore VA Accountability Act is to3424increase accountability by streamlining the disciplinary process and3425ensuring that VA employees who do not meet performance standards or3426engage in misconduct can be held accountable more swiftly and3427effectively, DAV asks the committee to give careful consideration to3428our concerns, which may have an indirect impact on the high quality of3429care and benefits services provided to veterans.3430    DAV's major concern is the exclusion of the MSPB from the appeals3431process for federal employees. The MSPB has historically served as an3432independent and impartial body that reviews agency decisions and3433safeguards employees from arbitrary or unjust actions. By removing the3434MSPB from the appeals process, we risk depriving employees of a crucial3435avenue for redress and oversight.3436    Additionally, DAV has concerns with provisions that eliminate the3437necessity for PIPs before any disciplinary measures are taken. PIPs3438provide employees with a fair opportunity to address and correct3439performance issues before facing more severe consequences. Eliminating3440this critical step could lead to unjust disciplinary actions.3441    DAV wholeheartedly supports the Committee's commitment to3442accountability within the VA. However, striking a balance between3443holding civil servants accountable for their performance while3444maintaining the VA as an employer of choice for the best and brightest3445to ensure veterans receive the best care and timely services remains3446our priority.3447    We firmly believe that due process must not be compromised in3448pursuit of these goals, which has been reiterated within DAV's3449Resolution No. 138 that notes any bill enacted by Congress should3450include standards by which accountability can be measured while3451ensuring due process and fairness for VA employees subject to such3452standards.34533454                 H.R. 740, Veterans' ACCESS Act of 202534553456    The VA health care system is vital to millions of service-disabled3457veterans, offering comprehensive primary care and specialized programs3458tailored to their unique needs. While community care should be3459available as a supplement when the VA cannot provide timely,3460accessible, or high-quality care, it should not replace the VA's3461primary role in delivering and coordinating integrated care for3462enrolled veterans. The lack of expansion in the VA's capacity to meet3463the increasing demand for care has led to an over-reliance on external3464providers. The growing reliance on community care in recent years3465presents significant challenges to this comprehensive, evidence-based3466care model.3467    The VA MISSION Act of 2018 (P.L. 115-182) introduced a new process3468for integrating community care with the VA's hospital care, medical3469care, and extended care services, ensuring veterans receive the highest3470standards of care regardless of limitations within the VA health care3471system. The legislation aimed to expand access to non-VA care when3472necessary while strengthening the VA direct care system to meet the3473growing needs of enrolled veterans.3474    The Act established the Veterans Community Care Program (VCCP),3475setting wait time and travel distance standards. The goal was to ensure3476the VA maintained overall responsibility for veterans' care by3477coordinating their treatment and requiring community providers to meet3478the same quality standards as VA providers. Unfortunately, the VA has3479yet to implement the intended quality standards for non-VA providers or3480establish a robust care coordination program for veterans receiving3481both VA and community care.3482    The Act also included provisions to enhance the VA's internal3483capacity by improving the recruitment, hiring, and retention of3484qualified clinicians and addressing the longstanding neglect of the3485VA's aging health care infrastructure. Without sufficient3486infrastructure and capacity to meet the rising needs of veterans, the3487VA has turned increasingly to community care, which has seen more rapid3488growth than VA services. Despite significant increases in the VA's3489workforce over the past six years, the Department's health care3490infrastructure remains critically under-funded.3491    H.R. 740, the Veterans' Assuring Critical Care Expansions to3492Support Servicemembers (ACCESS) Act of 2025, aims to improve the3493provision of care and services under the VCCP and enhance veterans'3494health care with defined eligibility standards, mandatory notification3495of eligibility and denial of requests, consideration of veterans' care3496preferences, and extension of claim submission deadlines. It also seeks3497to streamline specialized mental health treatment programs with a3498standardized eligibility process and make improvements to the Mental3499Health Residential Rehabilitation Treatment Program (RRTP). The3500legislation also includes provisions to establish an interactive online3501self-service module for care, change requirements for the Center for3502Care and Payment Innovation (CCPI), and mandate pilot programs and3503reports to ensure effective implementation.3504    The ACCESS Act stands to bring substantial changes to the VCCP,3505potentially impacting the VA's mission of delivering timely, high-3506quality, veteran-focused health care and services to enrolled veterans.3507As we move forward with proposed program changes, we believe that it is3508essential to appropriately balance the role community care plays in the3509VA's provision of specialized health care and support to our nation's3510ill and injured veterans.3511    The Independent Budget for fiscal year 2026-2027--coauthored by the3512DAV, Veterans of Foreign Wars and Paralyzed Veterans of America, calls3513on Congress to ensure that VA remains the primary provider and3514coordinator of care for veterans and that community care is available3515and accessible to veterans as needed to support and supplement VA care.3516With this background and context, DAV offers the following comments and3517recommendations regarding H.R. 740.35183519Section 101: Codification of Requirements for Eligibility Standards for3520Access to Community Care from the Department of Veterans Affairs35213522    Section 101 of the bill would codify the minimum access standards3523for community care from the VA including all extended care services,3524except for nursing home care and mandate the VA to review these3525standards with an expanded stakeholder group and report to Congress3526triennially. Provisions in this section would prohibit telehealth3527appointments from fulfilling access standards if an in-person VA3528appointment is unavailable within the standards. It would also require3529that canceled VA appointments restart the wait time calculation from3530the original request date, and any deviations in wait time or distance3531agreed upon by a veteran and their provider must be documented and3532provided to the veteran and apply to all VA care and patients, whether3533new or established.3534    DAV has no concerns with codifying the eligibility standards for3535access to community care from VHA, while emphasizing the need for3536thorough and periodic reviews of these standards. However, we strongly3537recommend amending the provision that the Secretary shall not take into3538consideration the availability of telehealth appointments from the3539Department when determining whether the VA is able to furnish such care3540or services. We believe that a telehealth appointment should be3541considered as an option if agreeable with a veteran. Additionally, if a3542veteran is eligible and opts for an in-person community care3543appointment because VA only had a telehealth appointment available,3544that appointment in the community should be for an in-person3545appointment only. Telehealth services would have already been offered3546or provided by the VA under Section 105 of this act, which requires the3547VA to discuss telehealth with veterans as an option for care, both in3548the VA health care system and in the community, if telehealth is3549available, appropriate, and acceptable to the veteran.3550    We endorse the mandate in this section of the bill to document3551medical records and make them accessible to veterans through digital3552platforms such as VA.gov, email, and mobile text, except where veterans3553specifically request them and lack digital access.35543555Section 102: Requirement that Secretary Notify Veterans of Eligibility3556for Care under Veterans Community Care Program35573558    Section 102 mandates the VA to promptly notify veterans of their3559eligibility for community care. To ensure clarity, we propose that the3560two-day notification requirement includes digital methods, as3561traditional mail may not meet the deadline. We recommend expeditious3562deployment of the External Provider Scheduling (EPS) system within the3563Community Care Network (CCN) to facilitate real-time scheduling when3564the VA cannot provide direct care or meet access standards, thereby3565enhancing more timely and effective communication and care coordination3566for veterans.35673568Section 103: Consideration of Veteran Preference for Care, Continuity3569of Care, and Need for Caregiver or Attendant35703571    Section 103 of the Veterans ACCESS Act would require the VA to3572consider various factors when determining if it is in the best medical3573interest of a veteran to seek care in the community. These factors3574include the veteran's preference for when, where, and how to receive3575care, continuity of care, and the veteran's need or desire for a3576caregiver or attendant to accompany them.3577    We have concerns with the definition of veterans' preference for3578where, when, and how to seek hospital care, medical care, or extended3579care services. While we want the veteran's preference to be considered3580when determining the best option for care, the best medical interest3581including the distance to care, the frequency of care, and the3582availability of appointments, should be the primary factors considered,3583as provided in the MISSION Act.35843585Section 104: Notification of Denial of Request for Care under Veterans3586Community Care Program35873588    Section 104 mandates that if the VA denies a veteran's request for3589community care, it must provide the veteran with the reason for the3590denial and instructions for appealing the decision through the Veterans3591Health Administration's clinical appeals process. DAV has no concerns3592with this section. In fact, our benefits advocates stand ready to3593assist any veteran with filing a clinical appeal.35943595Section 106: Extension of Deadline for Submittal of Claims by3596Healthcare Entities and Providers under Prompt Payment Standard35973598    Section 106 extends the deadline for health care entities and3599providers to submit claims for reimbursement for community care3600services from the current 180 days to up to one year after service,3601aligning with industry standards.3602    DAV has no concerns with this section, as it provides a more3603flexible timeframe for providers without compromising the timely3604processing of claims or the quality of care for veterans.36053606Section 202: Standardized Process to Determine Eligibility of Covered3607Veterans for Participation in Certain Mental Health Treatment Programs36083609    Section 202 would require the VA to establish a standardized3610screening process to determine, based on clinical needs, whether a3611covered veteran satisfies criteria for priority admission to a covered3612residential rehabilitation treatment program (RRTP). As part of the3613evaluation process a veteran must be screened and admitted into a3614program within 48 hours if determined eligible for RRTP. Either a3615veteran or relevant health care provider can make the request for3616admission into a treatment program if they meet criteria for priority3617admission.3618    We recommend that the language in this section be amended to3619require that a VA clinician make the determination if the veteran meets3620the eligibility criteria for priority admission within 48 hours of the3621request.3622    We appreciate the provision in this section of the bill that3623requires non-department RRTP facilities to be properly licensed by a3624state and accredited by the Commission on Accreditation of3625Rehabilitation Facilities (CARF) or the Joint Commission.36263627Section 203: Improvements to Department of Veterans Affairs Mental3628Health Residential Rehabilitation Treatment Program36293630    We appreciate that Section 203 includes requirements for the VA to3631develop a process for assessing the quality of specialized RRTP care3632delivered by both VA and non-VA providers, including the use of3633evidence-based treatments, cultural competency, clinical outcomes and3634oversight, and referral of billing practices.3635    The VA is advancing efforts to give veterans faster and simpler3636access to its mental health RRTPs, which provide around-the-clock3637support for substance use disorders, posttraumatic stress disorder,3638depression, and other mental health conditions common among veterans.3639Over 27,000 veterans were treated at VA RRTPs in fiscal year 2024, and3640we urge the department to increase its bed capacity to expand these3641critical services.3642    The VA's national RRTP conference in September 2024 underscored the3643high priority the VA is giving to fostering more timely access for3644veterans who need these programs. The VA is focused on implementing a3645new centralized screening process for each region. However, there are3646still limits to timely access to these specialized services, and we3647want to ensure veterans do not have barriers to accessing this life-3648changing care. Accountability and oversight are paramount to ensure3649facilities meet the quality of care standards, include veteran-centric3650programming, and demonstrate effective patient outcomes.36513652Section 301: Plan on Establishment of Interactive, Online Self-Service3653Module for Care36543655    Section 301 mandates the VA to create an interactive, online self-3656service module to help veterans schedule appointments, track referrals,3657appeal care denials, and receive reminders for both VA and community3658care appointments.3659    DAV is supportive of this effort but suggests that alternative3660methods and adequate support be provided to bridge the digital divide3661and guarantee equitable access to care for all veterans, including3662those living in rural and remote communities.36633664    Section 302: Modification of Requirements for the Center for3665Innovation for Care and Payment of the Department of Veterans Affairs3666and Requirement for Pilot Program36673668    Section 302 would require the VA to establish and report to3669Congress on a three-year pilot program allowing enrolled veterans to3670access outpatient mental health and/or substance use services through3671community care network providers without referral or pre-authorization.3672This pilot program would be conducted in areas with varying degrees of3673urbanization, locations with high rates of veteran suicide, overdose3674deaths, calls to the Veterans Crisis Line, and long wait times for VA3675mental health and substance use disorder services. The VA would also be3676required to develop a care coordination plan with appropriate oversight3677and patient safety plans to monitor and support veterans participating3678in the pilot.3679    The bill requires development of robust metrics and measures to3680track and oversee the program's implementation, patient safety, and3681patient outcomes. Annual reports would be required to the Committee on3682Veterans' Affairs, detailing the number of participating veterans and3683health care providers, program effectiveness, costs, and other relevant3684matters.3685    We appreciate the intent behind the proposed pilot program aimed at3686improving access to outpatient mental health and substance use services3687for veterans. However, we have significant concerns about the bill's3688lack of a requirement for clinical authorization for such care from the3689VA.3690    While we fully support the goal of enhancing access to critical3691mental health and substance use services, the absence of a clinical3692authorization requirement raises serious questions about the quality3693and coordination of care. Clinical authorization is a key element in3694ensuring that veterans receive appropriate, evidence-based treatment3695that is tailored to their individual needs. Without this oversight,3696there is a risk of fragmented care, potential overuse or misuse of3697services, and the potential for insufficient monitoring of treatment3698outcomes.3699    The VA has a comprehensive understanding of veterans' unique health3700care needs and a robust system for coordinating care across the system.3701By bypassing clinical authorization, the bill may undermine the VA's3702ability to properly manage and oversee the delivery of care3703effectively. This could result in inconsistent treatment plans, gaps in3704care continuity, and ultimately, negative impacts on veterans' health3705outcomes.3706    We recommend that the bill be amended to include a requirement for3707clinical authorization from the VA for all services provided under the3708pilot program. This would ensure that veterans receive high-quality,3709veteran-centric, coordinated care that aligns with best practices and3710leverages the VA's expertise in managing veterans' health care and3711these specialized services. Incorporating this requirement will3712strengthen the program's effectiveness and safeguard the well-being of3713our veterans.3714    In conclusion, while we understand and support the intent of the3715pilot program, we urge the Committee to address the critical concern of3716clinical authorization. Ensuring that the VA retains a central role in3717authorizing and coordinating care will enhance the program's success3718and better serve our nation's veterans. We appreciate the opportunity3719to submit this statement and welcome further discussion on this3720important matter.37213722          H.R. 1041, the Veterans 2nd Amendment Protection Act37233724                                  and37253726Discussion draft to prohibit the VA Secretary from transmitting certain3727      information to the Department of Justice for the NICS list.37283729    The federal Gun Control Act of 1968, as amended, prohibits certain3730classes of persons from purchasing or possessing firearms and3731ammunition. One of the classes of prohibited persons are those who have3732been ``adjudicated as a mental defective.'' A person may be3733``adjudicated as a mental defective'' if a court, board, or commission3734finds that they are a danger to themselves or others.3735    Under the provisions of the Brady Handgun Violence Prevention Act3736of 1993, the Federal Bureau of Investigation (FBI) administers the3737National Instant Criminal Background Check System (NICS) that allows3738federally licensed firearms dealers to perform a required background3739check on potential buyers to ensure they are not prohibited from3740purchasing firearms and ammunition.3741    Historically, it has been the VA's policy to submit the names of3742all beneficiaries determined to be incompetent to the Attorney General3743for inclusion in NICS. However, incompetency within VA regulatory3744provisions (38 C.F.R. 3.353) defines a mentally incompetent person as3745someone who because of injury or disease lacks the mental capacity to3746contract or to manage his or her own affairs, including disbursement of3747funds without limitations. It does not address the requirement of a3748finding that they are a danger to themselves and others.3749    On March 15, 2024, VA announced that through the remainder of3750fiscal year 2024, VA would only report to the FBI NICS in instances3751when VA was aware that a mentally incompetent beneficiary had been3752found by a judicial authority to be a danger to themselves or others.3753While VA implemented this change and updated its electronic reporting,3754on March 11, 2024, VA stopped all weekly reporting to the NICS of3755mentally incompetent beneficiaries.3756    These bills focus on two main provisions that are essential to3757protecting veterans from unjust stigmatization and the loss of their3758Second Amendment rights without proper due process:37593760      The VA Secretary must notify the Attorney General that3761the basis for transmitting personally identifiable information of a3762beneficiary to the Department of Justice (DOJ) for use by NICS does not3763apply, or no longer applies, if such transmittal was solely based on a3764determination to pay benefits to a fiduciary.37653766      The VA Secretary shall not treat a person as having been3767adjudicated as a mental defective solely on the basis of requiring a3768fiduciary.37693770    Additionally, the draft bill would require notification of lack of3771basis for the VA to have transmitted a veteran's information to the DOJ3772on or after November 30, 1993, for placement on the NICS solely on the3773basis of a determination by the VA to pay benefits to a fiduciary.3774    DAV supports these bills, to ensure that veterans are not unfairly3775stigmatized or deprived of their Second Amendment rights based on VA3776determinations without judicial oversight. Our veterans have dedicated3777their lives to defending the freedoms we hold dear, and it is our3778responsibility to safeguard their constitutional rights in return.37793780   Discussion Draft, Student Veteran Benefit Restoration Act of 202537813782    Veterans have selflessly served our country, and it is our duty to3783ensure they receive the benefits they have earned. Unfortunately, some3784educational institutions have taken advantage of veterans, defrauding3785them of their well-deserved educational assistance.3786    This draft bill, the Student Veteran Benefit Restoration Act of37872025, would restore educational entitlements of those veterans who have3788fallen victim to fraudulent practices and would not be charged against3789their benefit entitlements. This includes periods when the institution3790was not approved or engaged in fraudulent activities. Additionally,3791educational institutions found guilty of fraud would be required to3792repay the VA Secretary any funds received fraudulently. This ensures3793that the burden of fraud is placed on the institutions rather than the3794veteran.3795    DAV supports this draft bill based on DAV Resolution No. 238, which3796calls for legislation that reduces and removes barriers to a service-3797disabled veteran continuing their education. We must ensure that we are3798protecting veterans and their hard-earned education benefits from fraud3799and deceptive acts.3800    Mr. Chairman, this concludes DAV's statement for the record.3801                                 ______38023803          Prepared Statement of Concerned Veterans for America38043805    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]38063807                                 [all]