Government and Regulations

The VA is working to implement Government Accountability Office (GAO) recommendations on improving efficiency and reporting of health care providers, according to Carolyn Clancy, MD, deputy under secretary for organizational excellence at the VHA. Dr. Clancy told members of the House Committee on Veterans’ Affairs that the “VA concurred with GAO’s recommendations and is already working to complete them.”

In July 2017, the GAO issued the report “Improvements Needed in Data and Monitoring of Clinical Productivity and Efficiency.” The report found that “VA’s productivity metrics and efficiency models may not provide complete and accurate information on provider productivity and VAMC efficiency.” Based on its findings, the GAO recommended that the “VA develop a policy requiring VAMCs to monitor and improve clinical inefficiency through a standard process, such as establishing performance standards based on VA’s efficiency models, and develop remediation plans for addressing clinical inefficiencies.” The GAO also made 4 specific recommendations:

1. Expand existing productivity metrics to track the productivity of all providers of care to veterans, including contract physicians and some advanced practice providers;
2. Ensure the accuracy of underlying staffing and workload data by, training all providers on coding clinical procedures;
3. Create a policy for all VAMCs to monitor and improve clinical efficiency by establishing performance standards based on VA’s efficiency models and developing a remediation plan for addressing clinical inefficiency; and
4. Establish an ongoing process to systematically review VAMCs and ensure that VAMCs and VISNs are implementing those plans and addressing low clinical productivity and inefficiency.

In her testimony, Dr. Clancy took pains to reassure the House committee that she agreed with the GAO recommendations. “VA appreciates our colleagues at GAO’s efforts and the efforts of others to improve clinical efficiency and productivity,” she told the panel. “Mr. Chairman, I am proud of the health care our employees provide to our nation’s veterans. Together with Congress, I look forward to making sure that VA will be a good steward of taxpayer dollars while providing this care in a productive and efficient manner.”

Dr. Clancy explained to the Committee that the VA will expand the use of some of its measures, such as the Specialty Productivity-Access Report and Quadrant (SPARQ) tool. In addition, Dr. Clancy pledged that the VA would take up training in clinical coding for health care providers as well as an effort to improve the efficiency of specialty providers. “We have also undertaken a comprehensive education and communication plan about the specialty physician productivity and staffing standards,” she told the committee. “Our specialty physicians are committed to demonstrating and improving specialty productivity and access.”

In addition, Dr. Clancy insisted that plans to improve clinical efficiency must be developed at each VAMC and that remediation plans would be tracked at both the facility and VISN. The central office will “review the progress VAMCs are making on the remediation plans for addressing low clinical productivity twice a year with the VISN,” she said. The expected completion date for this will be March 2018.

The VA is working to implement Government Accountability Office (GAO) recommendations on improving efficiency and reporting of health care providers, according to Carolyn Clancy, MD, deputy under secretary for organizational excellence at the VHA. Dr. Clancy told members of the House Committee on Veterans’ Affairs that the “VA concurred with GAO’s recommendations and is already working to complete them.”

In July 2017, the GAO issued the report “Improvements Needed in Data and Monitoring of Clinical Productivity and Efficiency.” The report found that “VA’s productivity metrics and efficiency models may not provide complete and accurate information on provider productivity and VAMC efficiency.” Based on its findings, the GAO recommended that the “VA develop a policy requiring VAMCs to monitor and improve clinical inefficiency through a standard process, such as establishing performance standards based on VA’s efficiency models, and develop remediation plans for addressing clinical inefficiencies.” The GAO also made 4 specific recommendations:

1. Expand existing productivity metrics to track the productivity of all providers of care to veterans, including contract physicians and some advanced practice providers;
2. Ensure the accuracy of underlying staffing and workload data by, training all providers on coding clinical procedures;
3. Create a policy for all VAMCs to monitor and improve clinical efficiency by establishing performance standards based on VA’s efficiency models and developing a remediation plan for addressing clinical inefficiency; and
4. Establish an ongoing process to systematically review VAMCs and ensure that VAMCs and VISNs are implementing those plans and addressing low clinical productivity and inefficiency.

In her testimony, Dr. Clancy took pains to reassure the House committee that she agreed with the GAO recommendations. “VA appreciates our colleagues at GAO’s efforts and the efforts of others to improve clinical efficiency and productivity,” she told the panel. “Mr. Chairman, I am proud of the health care our employees provide to our nation’s veterans. Together with Congress, I look forward to making sure that VA will be a good steward of taxpayer dollars while providing this care in a productive and efficient manner.”

Dr. Clancy explained to the Committee that the VA will expand the use of some of its measures, such as the Specialty Productivity-Access Report and Quadrant (SPARQ) tool. In addition, Dr. Clancy pledged that the VA would take up training in clinical coding for health care providers as well as an effort to improve the efficiency of specialty providers. “We have also undertaken a comprehensive education and communication plan about the specialty physician productivity and staffing standards,” she told the committee. “Our specialty physicians are committed to demonstrating and improving specialty productivity and access.”

In addition, Dr. Clancy insisted that plans to improve clinical efficiency must be developed at each VAMC and that remediation plans would be tracked at both the facility and VISN. The central office will “review the progress VAMCs are making on the remediation plans for addressing low clinical productivity twice a year with the VISN,” she said. The expected completion date for this will be March 2018.

The VA is working to implement Government Accountability Office (GAO) recommendations on improving efficiency and reporting of health care providers, according to Carolyn Clancy, MD, deputy under secretary for organizational excellence at the VHA. Dr. Clancy told members of the House Committee on Veterans’ Affairs that the “VA concurred with GAO’s recommendations and is already working to complete them.”

In July 2017, the GAO issued the report “Improvements Needed in Data and Monitoring of Clinical Productivity and Efficiency.” The report found that “VA’s productivity metrics and efficiency models may not provide complete and accurate information on provider productivity and VAMC efficiency.” Based on its findings, the GAO recommended that the “VA develop a policy requiring VAMCs to monitor and improve clinical inefficiency through a standard process, such as establishing performance standards based on VA’s efficiency models, and develop remediation plans for addressing clinical inefficiencies.” The GAO also made 4 specific recommendations:

1. Expand existing productivity metrics to track the productivity of all providers of care to veterans, including contract physicians and some advanced practice providers;
2. Ensure the accuracy of underlying staffing and workload data by, training all providers on coding clinical procedures;
3. Create a policy for all VAMCs to monitor and improve clinical efficiency by establishing performance standards based on VA’s efficiency models and developing a remediation plan for addressing clinical inefficiency; and
4. Establish an ongoing process to systematically review VAMCs and ensure that VAMCs and VISNs are implementing those plans and addressing low clinical productivity and inefficiency.

In her testimony, Dr. Clancy took pains to reassure the House committee that she agreed with the GAO recommendations. “VA appreciates our colleagues at GAO’s efforts and the efforts of others to improve clinical efficiency and productivity,” she told the panel. “Mr. Chairman, I am proud of the health care our employees provide to our nation’s veterans. Together with Congress, I look forward to making sure that VA will be a good steward of taxpayer dollars while providing this care in a productive and efficient manner.”

Dr. Clancy explained to the Committee that the VA will expand the use of some of its measures, such as the Specialty Productivity-Access Report and Quadrant (SPARQ) tool. In addition, Dr. Clancy pledged that the VA would take up training in clinical coding for health care providers as well as an effort to improve the efficiency of specialty providers. “We have also undertaken a comprehensive education and communication plan about the specialty physician productivity and staffing standards,” she told the committee. “Our specialty physicians are committed to demonstrating and improving specialty productivity and access.”

In addition, Dr. Clancy insisted that plans to improve clinical efficiency must be developed at each VAMC and that remediation plans would be tracked at both the facility and VISN. The central office will “review the progress VAMCs are making on the remediation plans for addressing low clinical productivity twice a year with the VISN,” she said. The expected completion date for this will be March 2018.

The proposed 2018 budget is raising alarm among Native Americans, according to an article in Voanews.com, the news website of Voice of America. The budget would drastically cut or eliminate agencies and programs that provide critical services to about 2.2 million Native Americans and Alaska Natives. The proposed cuts include the following:

• > $300 million from the Bureau of Indian Affairs
• 31.4% from the Environmental Protection Agency
• 18% from HHS, which houses IHS
• 13.5% from the Department of Education
• 13.2% from Housing and Urban Development

The proposed budget also would eliminate programs such as the Low Income Home Energy Assistance Program (LIHEAP). In 2016, 150 tribal groups and > 43,000 Native households received LIHEAP funds. In Alaska, the Essential Air Service, often the only route to health care in remote areas, also is slated to be cut.

Mark Trahant, journalist, academic, and member of the Shoshone-Bannock tribes, pointed out that “In Indian Country, more than half of all Indian kids who go through Indian Health Service have their insurance through Medicaid. Thirteen percent of Medicaid is Indian care.”

Fawn Sharp, president of the Affiliated Tribes of Northwest Indians, called the proposed cuts “illogical and unreasonable.” They are “cutting into the bone and fail to recognize very real and critically important needs,” she said at a tribal conference.

Lawmakers from states with large Native American populations, including Tom Udall (D-NM), vice chairman of the Senate Committee on Indian Affairs, and Tom Cole (R-OK) a member of the Chickasaw Nation, are speaking against the proposals. Cole says the budget shows the administration “doesn’t care very much about Indian health care.”

However, Trahant notes that releasing the budget is only the first step in a potentially long process, and says it is now up to Congress to rework it.

The proposed 2018 budget is raising alarm among Native Americans, according to an article in Voanews.com, the news website of Voice of America. The budget would drastically cut or eliminate agencies and programs that provide critical services to about 2.2 million Native Americans and Alaska Natives. The proposed cuts include the following:

• > $300 million from the Bureau of Indian Affairs
• 31.4% from the Environmental Protection Agency
• 18% from HHS, which houses IHS
• 13.5% from the Department of Education
• 13.2% from Housing and Urban Development

The proposed budget also would eliminate programs such as the Low Income Home Energy Assistance Program (LIHEAP). In 2016, 150 tribal groups and > 43,000 Native households received LIHEAP funds. In Alaska, the Essential Air Service, often the only route to health care in remote areas, also is slated to be cut.

Mark Trahant, journalist, academic, and member of the Shoshone-Bannock tribes, pointed out that “In Indian Country, more than half of all Indian kids who go through Indian Health Service have their insurance through Medicaid. Thirteen percent of Medicaid is Indian care.”

Fawn Sharp, president of the Affiliated Tribes of Northwest Indians, called the proposed cuts “illogical and unreasonable.” They are “cutting into the bone and fail to recognize very real and critically important needs,” she said at a tribal conference.

Lawmakers from states with large Native American populations, including Tom Udall (D-NM), vice chairman of the Senate Committee on Indian Affairs, and Tom Cole (R-OK) a member of the Chickasaw Nation, are speaking against the proposals. Cole says the budget shows the administration “doesn’t care very much about Indian health care.”

However, Trahant notes that releasing the budget is only the first step in a potentially long process, and says it is now up to Congress to rework it.

The proposed 2018 budget is raising alarm among Native Americans, according to an article in Voanews.com, the news website of Voice of America. The budget would drastically cut or eliminate agencies and programs that provide critical services to about 2.2 million Native Americans and Alaska Natives. The proposed cuts include the following:

• > $300 million from the Bureau of Indian Affairs
• 31.4% from the Environmental Protection Agency
• 18% from HHS, which houses IHS
• 13.5% from the Department of Education
• 13.2% from Housing and Urban Development

The proposed budget also would eliminate programs such as the Low Income Home Energy Assistance Program (LIHEAP). In 2016, 150 tribal groups and > 43,000 Native households received LIHEAP funds. In Alaska, the Essential Air Service, often the only route to health care in remote areas, also is slated to be cut.

Mark Trahant, journalist, academic, and member of the Shoshone-Bannock tribes, pointed out that “In Indian Country, more than half of all Indian kids who go through Indian Health Service have their insurance through Medicaid. Thirteen percent of Medicaid is Indian care.”

Fawn Sharp, president of the Affiliated Tribes of Northwest Indians, called the proposed cuts “illogical and unreasonable.” They are “cutting into the bone and fail to recognize very real and critically important needs,” she said at a tribal conference.

Lawmakers from states with large Native American populations, including Tom Udall (D-NM), vice chairman of the Senate Committee on Indian Affairs, and Tom Cole (R-OK) a member of the Chickasaw Nation, are speaking against the proposals. Cole says the budget shows the administration “doesn’t care very much about Indian health care.”

However, Trahant notes that releasing the budget is only the first step in a potentially long process, and says it is now up to Congress to rework it.

Whistleblowers report illegalities, improprieties, or injustices. They step forward wittingly or unwittingly to report perceived wrongdoing. But when a whistleblower takes on powerful and entrenched systems or people, retribution and retaliation often ensue, endangering their career and reputation. These negative consequences can have longterm impacts on the lives of those who believed they were acting in the public interest especially when patient care or public safety was at risk.

The following account is based on personal and professional experiences, conversations with more than a dozen other whistleblowers at the DoD, VA, several other organizations, and a literature review. This documentation of those informal peer conversations, combined with the research, is meant to provide insight into the experiences of a whistleblower and the need for peer support so that employees can remain resilient.

Adverse Whistleblower Experiences

Most employees do not set out to be whistleblowers. The process begins when the whistleblower perceives wrongdoing or harm that is being committed in their workplace. At a health care organization, whistleblowing often is focused on individual or organizational illegal or unethical activities, such as funding or contracting fraud, corruption, theft, discrimination, sexual harassment, public health safety or security violations, persistent medical errors, nepotism, or other violations of workplace rules and regulations. VA employees who experience, witness, or discover wrongdoing may choose to disclose their concerns to a supervisor, senior leader, the Office of the Inspector General (OIG), Human Resources or Equal Employment Opportunity (EEO) Office, Employee Assistance Program (EAP), Office of Special Counsel (OSC), Congress, or to a news organization.

According to the 2013 National Business Ethics Survey, more than 6 million American workers who reported misconduct experienced some form of retaliation.^1,2 Retribution can manifest in various overt or covert ways, ranging from outright retaliation and further discrimination to other forms of marginalization. For example, a VA physician alleged that he was detailed to an empty office with no patients after reporting patient wait list mismanagement at his hospital. Other whistleblowers report having misconduct charges levied against them, demotions or loss of position, obstruction from promotion, poor performance evaluations, details to more minor assignments, relocation to more meager office space, or pressure to resign or retire.³

Whistleblowers are rarely rewarded for reporting misconduct within their organization. The Joint Commission describes barriers to reporting sentinel events by medical professionals fearing humiliation, litigation, peer pressure, and oversight investigations if they identify medical errors.⁴

Once allegations are made, the information often is conveyed to a supervisor or leader. For example, some whistleblowers who have reported a hostile work environment to the DoD EAP have noted that the EAP representative contacted the whistleblower’s manager to mediate the situation. This process can take months or years to resolve. In those instances, the managers are rarely relocated. The whistleblower usually is the one forced to move or take another job, which is not always consistent with their job description, and in turn, may impact their performance rating and opportunities for promotion.

Often, OIG and OSC investigations at the VA and other federal agencies can take as long as 2 years. During that time the whistleblower may remain in a lesser or unwanted position or leave the agency. However, even when OIG substantiates claims of wrongdoing, the agency can make recommendations only to leadership, which may or may not be enacted. Whistleblowers report having to submit Freedom of Information Act requests to learn of the outcome of an OIG investigation when leadership chooses to ignore the recommendation.

Civilian government employees are undervalued by society in general, and the negative stereotypes of lazy, shiftless workers abound, even though many civil servants work to protect the nation’s health, welfare, and safety. Civil servants are familiar with derogatory expressions, such as “bureaucratic bean-counter,” and “good enough for government work.” Even President Trump stated that he would come to Washington, DC, and “drain the swamp.” Yet civil servants can go years without a cost of living increase, a promotion, or a bonus but still be asked to perform additional duties or work long hours to the sacrifice of a work/life balance.

In the Federal Employee Viewpoints Survey and other employee environmental climate scans, high levels of workforce stress often are related to the number of grievances filed, the level of morale, the rates of absenteeism and retention, recruitment shortages, and lost productivity.⁵  Success in toxic environments usually is based on trying to maintain a “go along to get along” status quo, which means looking the other way when contracts are fraudulently awarded or employee discrimination occurs. If leadership is antagonistic to reform, then identifying wrongdoing may come at significant personal risk.

Retaliatory Practices

Once a whistleblower has stepped forward, retaliatory practices may follow. There are tangible legal, financial, social, emotional, and physical tolls to whistleblowing. “Be in for a penny. Be in for a pound,” an OIG official advised one whistleblower. Once a disclosure is made, the process may become arduous for the whistleblower and require individual resilience to face adversity.

Keeping in mind that OIG, EEO, EAP, and OSC are government agencies that investigate, police, and monitor the system, they do not represent the civil servants who document and identify much of the evidence of wrongdoing on their own. Most civil service employees are not subject matter experts on the U.S. legal code that outlines prohibited personal practices or the Federal Acquisition Regulation.

The Notification and Federal Employee Antidiscrimination and Retaliation (NO FEAR) Act authorized in 2002 (U.S. Code § 2301) is designed to inform and protect those who file grievances or disclosures, but operationalizing those protections can be overwhelming and confusing. If a whistleblower wants advice, he or she must retain legal counsel often at a substantial personal cost. Whistleblowers report spending from $10,000 to more than $100,000 in legal fees for a 1- to 2-year investigation.

These legal fees may force whistleblowers to use family finances or borrow money while hoping for justice along with remuneration in the end. In some cases, the financial impact is compounded when the whistleblower has been demoted, denied a promotion, or fired. For medical professionals, the impact might result in the loss of hospital privileges, professional credentials, or state licensure. The loss of income also can lead to loss of health insurance. The legal and financial burdens impact marriages, spousal job options, retirement, and other family choices (eg, vacations, children’s schools, and caregiving obligations).

During investigations, social status and the reputation of the whistleblower are often impugned. For example, whistleblowers are sometimes depicted as snitches, moles, spies, or tattletales and may be categorized as paranoid, disloyal, or disgruntled by leadership. Rarely are whistleblowers labeled protectors, patriots, or heroes, despite the few high profile cases that come to light, such as Karen Silkwood, Erin Brockovich, or Frank Serpico.

More often, whistleblowers’ reputations, especially in civil sectors, are damaged through acts of discrimination, such as bullying; mobbing (asking other employees to monitor and report on the activities of the whistleblower); ostracizing the employee from the team; devaluing the contributions or the performance of the whistleblower; blackballing from other jobs or opportunities; doublebinding with difficult tasks to complete; gaslighting by calling into question the memory of the whistleblower, the reality of the accusation, or its scope; and marginalization. Accusations of misusing funds, inaccurately recording time and attendance, and disputing their judgement are all tactics used to socially isolate and harass whistleblowers into dropping their case or leaving the organization.³

Furthermore, this level of ostracism has documented impact on the psychological and physical well-being of the employee and negative consequences to the overall functioning of the organization.⁶ Consequences, such as physical violence and property damage at the time of termination and at other betrayals have occurred.^3,7 Other whistleblowers have reported being threatened in person or on social media, harassed, and assaulted, especially in the military.

Whistleblowers, similar to others who are bullied in the workplace often described feelings such as fear, depression, anxiety, loneliness, and humiliation.⁸ These feelings can lead to whistleblowers needing treatment for substance abuse, depression, anxiety, posttraumatic stress disorder (PTSD) and suicidal ideation.⁹ Multiple studies on depression and PTSD show a correlation to increased morbidity and mortality.¹⁰ However, whistleblowing retaliation is not clearly established as a traumatic stressor in relation to PTSD.¹¹

Insomnia and other sleep disturbances are not uncommon among whistleblowers who also note they have resorted to smoking, overeating, alcohol misuse, or medication to manage their distress. Health consequences also include migraines, muscle tension, gastrointestinal conditions, increased blood pressure, and cardiovascular disease.¹²

Peer Support Models

Studies of peer-to-peer programs for veterans, law enforcement officers, widows, cancer patients, disaster victims, and others bound by survivorship suggest that peer groups can be an effective means of support, even though the model may vary or be adapted to a specific population. In general, peer support is centered on a common experience, shared credibility, confidentiality, and trust. The approach is meant to provide nonjudgmental support that assists with decision making and resilience and provides comfort and hope. Most peer support or mentorship models require some level of peer counselor screening, competency training on an intervention model, supervision, monitoring, and case management by a more senior or credentialed mental health professional.¹³

The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) recognized that health care systems that support civil servants, military members, and veterans can benefit from partnerships with internal (eg, human resources, unions, or dedicated EAP) or external (eg, nonprofit and service organizations) employee peer support programs. The DCoE noted that peer networks facilitate referrals to medical care when threats of suicide or harm to others exists, offer additional case management support, and assist professionals in understanding the patient experience.¹³

Peer support offered at VA hospitals is conducted by peers who are supervised by mental health clinic staff (usually social workers).¹⁴ Law enforcement EAP is another example of peer support within an organization to augment mental health and resilience among officers who have experienced first-responder trauma.

External peer support resources can be accessed through partnerships or referrals. For example, the Tragedy Assistance Program for Survivors (TAPS) relies on survivors of military deaths to support each other through bereavement. Although the DoD offers casualty assistance and mental health care to grieving families, the level of peer support differs from TAPS.¹⁵ In another example, Castellano documented the benefits of a reciprocal peer support model implemented across 10 peer-based call center programs that manage high risk-populations.¹⁶ Core training was consistent across all programs, and mental health professionals supervised call center peer support providers. This peer/clinician collaboration enhances the overall community mental health efforts.

Temple University documented the patient care benefits for behavioral health services that augmented treatment with evidence-based peer support interventions.¹⁷ The researchers found that hospitals that used a peer model improved patient outcomes as demonstrated by fewer hospitalizations, increased life satisfaction and enhanced coping skills, increased medication adherence, and reduced substance abuse or suicidal ideation. Additionally, the peer providers themselves experienced positive health benefits based on their ability to help others, improved their own self-efficacy and gained social and economic growth based on their employment satisfaction.¹⁷

Peer Support Interventions

Peer support interventions have been effective with various populations and may be effective for whistleblowers as well. Since whistleblowing tends to involve legal processes that call for privacy and the confidentiality of all parties, whistleblowers experience isolation and alienation. Other whistleblowers can better understand the retaliation, discrimination, and isolation that results. In some instances, whistleblowers discovered years later that other employees had similar experiences. An organized, structured program dedicated to peer support can help employees within a health care system or EAP manage the impacts of identifying wrongdoing.¹⁸ Peers may be able to break down this isolation and help establish a new network of support for those involved in whistleblowing cases. Restoring a sense of purpose, meaning, and belonging in the workplace is of significant value for the whistleblower.¹⁹ Peers can mentor a whistleblower through the investigative process and help determine next steps. Peers can address building, maintaining, and sustaining resilience to overcome adversity.

Peers who already have experienced their own legal, financial, social, emotional, and physical risks and have developed the necessary resiliency skills to survive make ideal peer counselors.²⁰ These peers have faced similar challenges but have perservered.²¹

Although peer counselors cannot replace an attorney or mental health provider, they can provide background information on the roles and functions of EEO, EAP, OIG, OSC, and the MSPB and how to navigate those systems. Peers can assist whistleblowers in preparing testimony before congressional hearings or for press interviews. Peer supporters also can encourage whistleblowers to seek care for mental and physical health care and to remain adherent to treatment regimens. They case manage a team effort to enable the whistleblower to overcome the adversity of retaliation.

Creating A New Normal

After the Civil War, the False Claims Act, known as the Lincoln Law, served to protect federal reconstruction activities in the South from individuals who attempted to defraud the federal government.²² Today, most Americans are familiar with WikiLeaks. For generations, whistleblowers have exposed wrongdoing in order to protect or reform governmen programs. Whistleblowers have exposed graft and corruption at the highest levels and in daily operations. They have fought for diversity and inclusion and a workplace free of sexual harassment and assault. They have protected taxpayer dollars from waste, fraud, and abuse.

Despite the personal sacrifices often required, most whistleblowers’ spirits are bolstered by the positive outcomes that their disclosures may produce. However, whistleblowers need compassionate and competent assistance throughout the process. Peers can foster the resilience needed to survive the adversarial nature of the whistleblowing process. Therefore, whistleblowers need to be viewed in a new light that involves advocacy, transparency, and peer support so that positive outcomes in government can be realized for all Americans.

Whistleblowers report illegalities, improprieties, or injustices. They step forward wittingly or unwittingly to report perceived wrongdoing. But when a whistleblower takes on powerful and entrenched systems or people, retribution and retaliation often ensue, endangering their career and reputation. These negative consequences can have longterm impacts on the lives of those who believed they were acting in the public interest especially when patient care or public safety was at risk.

The following account is based on personal and professional experiences, conversations with more than a dozen other whistleblowers at the DoD, VA, several other organizations, and a literature review. This documentation of those informal peer conversations, combined with the research, is meant to provide insight into the experiences of a whistleblower and the need for peer support so that employees can remain resilient.

Adverse Whistleblower Experiences

Most employees do not set out to be whistleblowers. The process begins when the whistleblower perceives wrongdoing or harm that is being committed in their workplace. At a health care organization, whistleblowing often is focused on individual or organizational illegal or unethical activities, such as funding or contracting fraud, corruption, theft, discrimination, sexual harassment, public health safety or security violations, persistent medical errors, nepotism, or other violations of workplace rules and regulations. VA employees who experience, witness, or discover wrongdoing may choose to disclose their concerns to a supervisor, senior leader, the Office of the Inspector General (OIG), Human Resources or Equal Employment Opportunity (EEO) Office, Employee Assistance Program (EAP), Office of Special Counsel (OSC), Congress, or to a news organization.

According to the 2013 National Business Ethics Survey, more than 6 million American workers who reported misconduct experienced some form of retaliation.^1,2 Retribution can manifest in various overt or covert ways, ranging from outright retaliation and further discrimination to other forms of marginalization. For example, a VA physician alleged that he was detailed to an empty office with no patients after reporting patient wait list mismanagement at his hospital. Other whistleblowers report having misconduct charges levied against them, demotions or loss of position, obstruction from promotion, poor performance evaluations, details to more minor assignments, relocation to more meager office space, or pressure to resign or retire.³

Whistleblowers are rarely rewarded for reporting misconduct within their organization. The Joint Commission describes barriers to reporting sentinel events by medical professionals fearing humiliation, litigation, peer pressure, and oversight investigations if they identify medical errors.⁴

Once allegations are made, the information often is conveyed to a supervisor or leader. For example, some whistleblowers who have reported a hostile work environment to the DoD EAP have noted that the EAP representative contacted the whistleblower’s manager to mediate the situation. This process can take months or years to resolve. In those instances, the managers are rarely relocated. The whistleblower usually is the one forced to move or take another job, which is not always consistent with their job description, and in turn, may impact their performance rating and opportunities for promotion.

Often, OIG and OSC investigations at the VA and other federal agencies can take as long as 2 years. During that time the whistleblower may remain in a lesser or unwanted position or leave the agency. However, even when OIG substantiates claims of wrongdoing, the agency can make recommendations only to leadership, which may or may not be enacted. Whistleblowers report having to submit Freedom of Information Act requests to learn of the outcome of an OIG investigation when leadership chooses to ignore the recommendation.

Civilian government employees are undervalued by society in general, and the negative stereotypes of lazy, shiftless workers abound, even though many civil servants work to protect the nation’s health, welfare, and safety. Civil servants are familiar with derogatory expressions, such as “bureaucratic bean-counter,” and “good enough for government work.” Even President Trump stated that he would come to Washington, DC, and “drain the swamp.” Yet civil servants can go years without a cost of living increase, a promotion, or a bonus but still be asked to perform additional duties or work long hours to the sacrifice of a work/life balance.

In the Federal Employee Viewpoints Survey and other employee environmental climate scans, high levels of workforce stress often are related to the number of grievances filed, the level of morale, the rates of absenteeism and retention, recruitment shortages, and lost productivity.⁵  Success in toxic environments usually is based on trying to maintain a “go along to get along” status quo, which means looking the other way when contracts are fraudulently awarded or employee discrimination occurs. If leadership is antagonistic to reform, then identifying wrongdoing may come at significant personal risk.

Retaliatory Practices

Once a whistleblower has stepped forward, retaliatory practices may follow. There are tangible legal, financial, social, emotional, and physical tolls to whistleblowing. “Be in for a penny. Be in for a pound,” an OIG official advised one whistleblower. Once a disclosure is made, the process may become arduous for the whistleblower and require individual resilience to face adversity.

Keeping in mind that OIG, EEO, EAP, and OSC are government agencies that investigate, police, and monitor the system, they do not represent the civil servants who document and identify much of the evidence of wrongdoing on their own. Most civil service employees are not subject matter experts on the U.S. legal code that outlines prohibited personal practices or the Federal Acquisition Regulation.

The Notification and Federal Employee Antidiscrimination and Retaliation (NO FEAR) Act authorized in 2002 (U.S. Code § 2301) is designed to inform and protect those who file grievances or disclosures, but operationalizing those protections can be overwhelming and confusing. If a whistleblower wants advice, he or she must retain legal counsel often at a substantial personal cost. Whistleblowers report spending from $10,000 to more than $100,000 in legal fees for a 1- to 2-year investigation.

These legal fees may force whistleblowers to use family finances or borrow money while hoping for justice along with remuneration in the end. In some cases, the financial impact is compounded when the whistleblower has been demoted, denied a promotion, or fired. For medical professionals, the impact might result in the loss of hospital privileges, professional credentials, or state licensure. The loss of income also can lead to loss of health insurance. The legal and financial burdens impact marriages, spousal job options, retirement, and other family choices (eg, vacations, children’s schools, and caregiving obligations).

During investigations, social status and the reputation of the whistleblower are often impugned. For example, whistleblowers are sometimes depicted as snitches, moles, spies, or tattletales and may be categorized as paranoid, disloyal, or disgruntled by leadership. Rarely are whistleblowers labeled protectors, patriots, or heroes, despite the few high profile cases that come to light, such as Karen Silkwood, Erin Brockovich, or Frank Serpico.

More often, whistleblowers’ reputations, especially in civil sectors, are damaged through acts of discrimination, such as bullying; mobbing (asking other employees to monitor and report on the activities of the whistleblower); ostracizing the employee from the team; devaluing the contributions or the performance of the whistleblower; blackballing from other jobs or opportunities; doublebinding with difficult tasks to complete; gaslighting by calling into question the memory of the whistleblower, the reality of the accusation, or its scope; and marginalization. Accusations of misusing funds, inaccurately recording time and attendance, and disputing their judgement are all tactics used to socially isolate and harass whistleblowers into dropping their case or leaving the organization.³

Furthermore, this level of ostracism has documented impact on the psychological and physical well-being of the employee and negative consequences to the overall functioning of the organization.⁶ Consequences, such as physical violence and property damage at the time of termination and at other betrayals have occurred.^3,7 Other whistleblowers have reported being threatened in person or on social media, harassed, and assaulted, especially in the military.

Whistleblowers, similar to others who are bullied in the workplace often described feelings such as fear, depression, anxiety, loneliness, and humiliation.⁸ These feelings can lead to whistleblowers needing treatment for substance abuse, depression, anxiety, posttraumatic stress disorder (PTSD) and suicidal ideation.⁹ Multiple studies on depression and PTSD show a correlation to increased morbidity and mortality.¹⁰ However, whistleblowing retaliation is not clearly established as a traumatic stressor in relation to PTSD.¹¹

Insomnia and other sleep disturbances are not uncommon among whistleblowers who also note they have resorted to smoking, overeating, alcohol misuse, or medication to manage their distress. Health consequences also include migraines, muscle tension, gastrointestinal conditions, increased blood pressure, and cardiovascular disease.¹²

Peer Support Models

Studies of peer-to-peer programs for veterans, law enforcement officers, widows, cancer patients, disaster victims, and others bound by survivorship suggest that peer groups can be an effective means of support, even though the model may vary or be adapted to a specific population. In general, peer support is centered on a common experience, shared credibility, confidentiality, and trust. The approach is meant to provide nonjudgmental support that assists with decision making and resilience and provides comfort and hope. Most peer support or mentorship models require some level of peer counselor screening, competency training on an intervention model, supervision, monitoring, and case management by a more senior or credentialed mental health professional.¹³

The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) recognized that health care systems that support civil servants, military members, and veterans can benefit from partnerships with internal (eg, human resources, unions, or dedicated EAP) or external (eg, nonprofit and service organizations) employee peer support programs. The DCoE noted that peer networks facilitate referrals to medical care when threats of suicide or harm to others exists, offer additional case management support, and assist professionals in understanding the patient experience.¹³

Peer support offered at VA hospitals is conducted by peers who are supervised by mental health clinic staff (usually social workers).¹⁴ Law enforcement EAP is another example of peer support within an organization to augment mental health and resilience among officers who have experienced first-responder trauma.

External peer support resources can be accessed through partnerships or referrals. For example, the Tragedy Assistance Program for Survivors (TAPS) relies on survivors of military deaths to support each other through bereavement. Although the DoD offers casualty assistance and mental health care to grieving families, the level of peer support differs from TAPS.¹⁵ In another example, Castellano documented the benefits of a reciprocal peer support model implemented across 10 peer-based call center programs that manage high risk-populations.¹⁶ Core training was consistent across all programs, and mental health professionals supervised call center peer support providers. This peer/clinician collaboration enhances the overall community mental health efforts.

Temple University documented the patient care benefits for behavioral health services that augmented treatment with evidence-based peer support interventions.¹⁷ The researchers found that hospitals that used a peer model improved patient outcomes as demonstrated by fewer hospitalizations, increased life satisfaction and enhanced coping skills, increased medication adherence, and reduced substance abuse or suicidal ideation. Additionally, the peer providers themselves experienced positive health benefits based on their ability to help others, improved their own self-efficacy and gained social and economic growth based on their employment satisfaction.¹⁷

Peer Support Interventions

Peer support interventions have been effective with various populations and may be effective for whistleblowers as well. Since whistleblowing tends to involve legal processes that call for privacy and the confidentiality of all parties, whistleblowers experience isolation and alienation. Other whistleblowers can better understand the retaliation, discrimination, and isolation that results. In some instances, whistleblowers discovered years later that other employees had similar experiences. An organized, structured program dedicated to peer support can help employees within a health care system or EAP manage the impacts of identifying wrongdoing.¹⁸ Peers may be able to break down this isolation and help establish a new network of support for those involved in whistleblowing cases. Restoring a sense of purpose, meaning, and belonging in the workplace is of significant value for the whistleblower.¹⁹ Peers can mentor a whistleblower through the investigative process and help determine next steps. Peers can address building, maintaining, and sustaining resilience to overcome adversity.

Peers who already have experienced their own legal, financial, social, emotional, and physical risks and have developed the necessary resiliency skills to survive make ideal peer counselors.²⁰ These peers have faced similar challenges but have perservered.²¹

Although peer counselors cannot replace an attorney or mental health provider, they can provide background information on the roles and functions of EEO, EAP, OIG, OSC, and the MSPB and how to navigate those systems. Peers can assist whistleblowers in preparing testimony before congressional hearings or for press interviews. Peer supporters also can encourage whistleblowers to seek care for mental and physical health care and to remain adherent to treatment regimens. They case manage a team effort to enable the whistleblower to overcome the adversity of retaliation.

Creating A New Normal

After the Civil War, the False Claims Act, known as the Lincoln Law, served to protect federal reconstruction activities in the South from individuals who attempted to defraud the federal government.²² Today, most Americans are familiar with WikiLeaks. For generations, whistleblowers have exposed wrongdoing in order to protect or reform governmen programs. Whistleblowers have exposed graft and corruption at the highest levels and in daily operations. They have fought for diversity and inclusion and a workplace free of sexual harassment and assault. They have protected taxpayer dollars from waste, fraud, and abuse.

Despite the personal sacrifices often required, most whistleblowers’ spirits are bolstered by the positive outcomes that their disclosures may produce. However, whistleblowers need compassionate and competent assistance throughout the process. Peers can foster the resilience needed to survive the adversarial nature of the whistleblowing process. Therefore, whistleblowers need to be viewed in a new light that involves advocacy, transparency, and peer support so that positive outcomes in government can be realized for all Americans.

Whistleblowers report illegalities, improprieties, or injustices. They step forward wittingly or unwittingly to report perceived wrongdoing. But when a whistleblower takes on powerful and entrenched systems or people, retribution and retaliation often ensue, endangering their career and reputation. These negative consequences can have longterm impacts on the lives of those who believed they were acting in the public interest especially when patient care or public safety was at risk.

The following account is based on personal and professional experiences, conversations with more than a dozen other whistleblowers at the DoD, VA, several other organizations, and a literature review. This documentation of those informal peer conversations, combined with the research, is meant to provide insight into the experiences of a whistleblower and the need for peer support so that employees can remain resilient.

Adverse Whistleblower Experiences

Most employees do not set out to be whistleblowers. The process begins when the whistleblower perceives wrongdoing or harm that is being committed in their workplace. At a health care organization, whistleblowing often is focused on individual or organizational illegal or unethical activities, such as funding or contracting fraud, corruption, theft, discrimination, sexual harassment, public health safety or security violations, persistent medical errors, nepotism, or other violations of workplace rules and regulations. VA employees who experience, witness, or discover wrongdoing may choose to disclose their concerns to a supervisor, senior leader, the Office of the Inspector General (OIG), Human Resources or Equal Employment Opportunity (EEO) Office, Employee Assistance Program (EAP), Office of Special Counsel (OSC), Congress, or to a news organization.

According to the 2013 National Business Ethics Survey, more than 6 million American workers who reported misconduct experienced some form of retaliation.^1,2 Retribution can manifest in various overt or covert ways, ranging from outright retaliation and further discrimination to other forms of marginalization. For example, a VA physician alleged that he was detailed to an empty office with no patients after reporting patient wait list mismanagement at his hospital. Other whistleblowers report having misconduct charges levied against them, demotions or loss of position, obstruction from promotion, poor performance evaluations, details to more minor assignments, relocation to more meager office space, or pressure to resign or retire.³

Whistleblowers are rarely rewarded for reporting misconduct within their organization. The Joint Commission describes barriers to reporting sentinel events by medical professionals fearing humiliation, litigation, peer pressure, and oversight investigations if they identify medical errors.⁴

Once allegations are made, the information often is conveyed to a supervisor or leader. For example, some whistleblowers who have reported a hostile work environment to the DoD EAP have noted that the EAP representative contacted the whistleblower’s manager to mediate the situation. This process can take months or years to resolve. In those instances, the managers are rarely relocated. The whistleblower usually is the one forced to move or take another job, which is not always consistent with their job description, and in turn, may impact their performance rating and opportunities for promotion.

Often, OIG and OSC investigations at the VA and other federal agencies can take as long as 2 years. During that time the whistleblower may remain in a lesser or unwanted position or leave the agency. However, even when OIG substantiates claims of wrongdoing, the agency can make recommendations only to leadership, which may or may not be enacted. Whistleblowers report having to submit Freedom of Information Act requests to learn of the outcome of an OIG investigation when leadership chooses to ignore the recommendation.

Civilian government employees are undervalued by society in general, and the negative stereotypes of lazy, shiftless workers abound, even though many civil servants work to protect the nation’s health, welfare, and safety. Civil servants are familiar with derogatory expressions, such as “bureaucratic bean-counter,” and “good enough for government work.” Even President Trump stated that he would come to Washington, DC, and “drain the swamp.” Yet civil servants can go years without a cost of living increase, a promotion, or a bonus but still be asked to perform additional duties or work long hours to the sacrifice of a work/life balance.

In the Federal Employee Viewpoints Survey and other employee environmental climate scans, high levels of workforce stress often are related to the number of grievances filed, the level of morale, the rates of absenteeism and retention, recruitment shortages, and lost productivity.⁵  Success in toxic environments usually is based on trying to maintain a “go along to get along” status quo, which means looking the other way when contracts are fraudulently awarded or employee discrimination occurs. If leadership is antagonistic to reform, then identifying wrongdoing may come at significant personal risk.

Retaliatory Practices

Once a whistleblower has stepped forward, retaliatory practices may follow. There are tangible legal, financial, social, emotional, and physical tolls to whistleblowing. “Be in for a penny. Be in for a pound,” an OIG official advised one whistleblower. Once a disclosure is made, the process may become arduous for the whistleblower and require individual resilience to face adversity.

Keeping in mind that OIG, EEO, EAP, and OSC are government agencies that investigate, police, and monitor the system, they do not represent the civil servants who document and identify much of the evidence of wrongdoing on their own. Most civil service employees are not subject matter experts on the U.S. legal code that outlines prohibited personal practices or the Federal Acquisition Regulation.

The Notification and Federal Employee Antidiscrimination and Retaliation (NO FEAR) Act authorized in 2002 (U.S. Code § 2301) is designed to inform and protect those who file grievances or disclosures, but operationalizing those protections can be overwhelming and confusing. If a whistleblower wants advice, he or she must retain legal counsel often at a substantial personal cost. Whistleblowers report spending from $10,000 to more than $100,000 in legal fees for a 1- to 2-year investigation.

These legal fees may force whistleblowers to use family finances or borrow money while hoping for justice along with remuneration in the end. In some cases, the financial impact is compounded when the whistleblower has been demoted, denied a promotion, or fired. For medical professionals, the impact might result in the loss of hospital privileges, professional credentials, or state licensure. The loss of income also can lead to loss of health insurance. The legal and financial burdens impact marriages, spousal job options, retirement, and other family choices (eg, vacations, children’s schools, and caregiving obligations).

During investigations, social status and the reputation of the whistleblower are often impugned. For example, whistleblowers are sometimes depicted as snitches, moles, spies, or tattletales and may be categorized as paranoid, disloyal, or disgruntled by leadership. Rarely are whistleblowers labeled protectors, patriots, or heroes, despite the few high profile cases that come to light, such as Karen Silkwood, Erin Brockovich, or Frank Serpico.

More often, whistleblowers’ reputations, especially in civil sectors, are damaged through acts of discrimination, such as bullying; mobbing (asking other employees to monitor and report on the activities of the whistleblower); ostracizing the employee from the team; devaluing the contributions or the performance of the whistleblower; blackballing from other jobs or opportunities; doublebinding with difficult tasks to complete; gaslighting by calling into question the memory of the whistleblower, the reality of the accusation, or its scope; and marginalization. Accusations of misusing funds, inaccurately recording time and attendance, and disputing their judgement are all tactics used to socially isolate and harass whistleblowers into dropping their case or leaving the organization.³

Furthermore, this level of ostracism has documented impact on the psychological and physical well-being of the employee and negative consequences to the overall functioning of the organization.⁶ Consequences, such as physical violence and property damage at the time of termination and at other betrayals have occurred.^3,7 Other whistleblowers have reported being threatened in person or on social media, harassed, and assaulted, especially in the military.

Whistleblowers, similar to others who are bullied in the workplace often described feelings such as fear, depression, anxiety, loneliness, and humiliation.⁸ These feelings can lead to whistleblowers needing treatment for substance abuse, depression, anxiety, posttraumatic stress disorder (PTSD) and suicidal ideation.⁹ Multiple studies on depression and PTSD show a correlation to increased morbidity and mortality.¹⁰ However, whistleblowing retaliation is not clearly established as a traumatic stressor in relation to PTSD.¹¹

Insomnia and other sleep disturbances are not uncommon among whistleblowers who also note they have resorted to smoking, overeating, alcohol misuse, or medication to manage their distress. Health consequences also include migraines, muscle tension, gastrointestinal conditions, increased blood pressure, and cardiovascular disease.¹²

Peer Support Models

Studies of peer-to-peer programs for veterans, law enforcement officers, widows, cancer patients, disaster victims, and others bound by survivorship suggest that peer groups can be an effective means of support, even though the model may vary or be adapted to a specific population. In general, peer support is centered on a common experience, shared credibility, confidentiality, and trust. The approach is meant to provide nonjudgmental support that assists with decision making and resilience and provides comfort and hope. Most peer support or mentorship models require some level of peer counselor screening, competency training on an intervention model, supervision, monitoring, and case management by a more senior or credentialed mental health professional.¹³

The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) recognized that health care systems that support civil servants, military members, and veterans can benefit from partnerships with internal (eg, human resources, unions, or dedicated EAP) or external (eg, nonprofit and service organizations) employee peer support programs. The DCoE noted that peer networks facilitate referrals to medical care when threats of suicide or harm to others exists, offer additional case management support, and assist professionals in understanding the patient experience.¹³

Peer support offered at VA hospitals is conducted by peers who are supervised by mental health clinic staff (usually social workers).¹⁴ Law enforcement EAP is another example of peer support within an organization to augment mental health and resilience among officers who have experienced first-responder trauma.

External peer support resources can be accessed through partnerships or referrals. For example, the Tragedy Assistance Program for Survivors (TAPS) relies on survivors of military deaths to support each other through bereavement. Although the DoD offers casualty assistance and mental health care to grieving families, the level of peer support differs from TAPS.¹⁵ In another example, Castellano documented the benefits of a reciprocal peer support model implemented across 10 peer-based call center programs that manage high risk-populations.¹⁶ Core training was consistent across all programs, and mental health professionals supervised call center peer support providers. This peer/clinician collaboration enhances the overall community mental health efforts.

Temple University documented the patient care benefits for behavioral health services that augmented treatment with evidence-based peer support interventions.¹⁷ The researchers found that hospitals that used a peer model improved patient outcomes as demonstrated by fewer hospitalizations, increased life satisfaction and enhanced coping skills, increased medication adherence, and reduced substance abuse or suicidal ideation. Additionally, the peer providers themselves experienced positive health benefits based on their ability to help others, improved their own self-efficacy and gained social and economic growth based on their employment satisfaction.¹⁷

Peer Support Interventions

Peer support interventions have been effective with various populations and may be effective for whistleblowers as well. Since whistleblowing tends to involve legal processes that call for privacy and the confidentiality of all parties, whistleblowers experience isolation and alienation. Other whistleblowers can better understand the retaliation, discrimination, and isolation that results. In some instances, whistleblowers discovered years later that other employees had similar experiences. An organized, structured program dedicated to peer support can help employees within a health care system or EAP manage the impacts of identifying wrongdoing.¹⁸ Peers may be able to break down this isolation and help establish a new network of support for those involved in whistleblowing cases. Restoring a sense of purpose, meaning, and belonging in the workplace is of significant value for the whistleblower.¹⁹ Peers can mentor a whistleblower through the investigative process and help determine next steps. Peers can address building, maintaining, and sustaining resilience to overcome adversity.

Peers who already have experienced their own legal, financial, social, emotional, and physical risks and have developed the necessary resiliency skills to survive make ideal peer counselors.²⁰ These peers have faced similar challenges but have perservered.²¹

Although peer counselors cannot replace an attorney or mental health provider, they can provide background information on the roles and functions of EEO, EAP, OIG, OSC, and the MSPB and how to navigate those systems. Peers can assist whistleblowers in preparing testimony before congressional hearings or for press interviews. Peer supporters also can encourage whistleblowers to seek care for mental and physical health care and to remain adherent to treatment regimens. They case manage a team effort to enable the whistleblower to overcome the adversity of retaliation.

Creating A New Normal

After the Civil War, the False Claims Act, known as the Lincoln Law, served to protect federal reconstruction activities in the South from individuals who attempted to defraud the federal government.²² Today, most Americans are familiar with WikiLeaks. For generations, whistleblowers have exposed wrongdoing in order to protect or reform governmen programs. Whistleblowers have exposed graft and corruption at the highest levels and in daily operations. They have fought for diversity and inclusion and a workplace free of sexual harassment and assault. They have protected taxpayer dollars from waste, fraud, and abuse.

Despite the personal sacrifices often required, most whistleblowers’ spirits are bolstered by the positive outcomes that their disclosures may produce. However, whistleblowers need compassionate and competent assistance throughout the process. Peers can foster the resilience needed to survive the adversarial nature of the whistleblowing process. Therefore, whistleblowers need to be viewed in a new light that involves advocacy, transparency, and peer support so that positive outcomes in government can be realized for all Americans.

On Friday June 23, President Trump signed into law the VA Accountability and Whistleblower Protection Act, which established a revised disciplinary system for VA employees who are accused of poor performance or misconduct and protects those who report them. The bill amends Title 38 of the U.S. Code, adding VA employees to the list of those that the VA Secretary can remove if necessary. The act speeds up the termination and suspension processes for civil servants. The VA also claims that the bill will shorten the process of hiring new administrators. Still unclear is what this bill means for VA health care providers.

VA employees are protected under both Title 5 and Title 38 of the U.S. code. Title 5 governs the employment of all federal civil servants. Title 38 specifically governs the employment of VA employees in certain health care fields. Both titles specify processes for termination, demotion, or suspension and an appeals process.

Critics, including VA Secretary David J. Shulkin, MD, have complained that the previous civil service protections were time consuming and made it difficult to penalize or remove problem employees. Supporters insist that Title 5 and Title 38 protected the rights of good employees and whistleblowers from unfair workplace retaliation.

Under the new law, the VA Secretary can more easily remove, demote, or suspend any employee who warrants a penalty, including executives and supervisors. Although many of the Title 5 and Title 38 protections still cover VA employees, there are several notable changes.

What’s changing for VA employees?

• Time line: The act shortens time between the initial report, employee notification, Secretary’s decision, and appeal request/decision.
• Standard of proof: Previously, the standard of proof for misconduct was “preponderance of evidence.” The new bill lowers this standard to “supported by substantial evidence.” Changing the standard of proof effectively means that the Secretary will need to present less evidence of wrongdoing/negligence for the employee to be removed, demoted, or suspended.
• Appeals: Employees may still appeal removal, demotion, or suspension decisions, but rather than going through the Disciplinary Appeals Board, the Merit Systems Protection Board will hear appeals. Appeals must be filed within 10 days of the Secretary’s final decision. Additionally, administrative judges are instructed to uphold the decision of the Secretary if the evidence meets the “substantial evidence” standard. Administrative judges are prohibited from reducing the penalty.

Analysis

Although these changes are meant to increase the accountability of health care providers in the VA, there are several other legal implications for VA employees. Ultimately, the bill gives the VA Secretary more discretion. Whether this is a good or bad change is open to debate. Even though the bill easily passed in both the House of Representatives and the Senate, some lawmakers remain skeptical because the act increases the power of the Secretary and limits due process for VA employees. Under the new law, VA employees will have less time to prepare their defense and be held to a lower standard of proof, which will make it easier to remove VA employees from their jobs.

The Fifth Amendment of the U.S. Constitution guarantees that all Americans shall not be “deprived of life, liberty, or property, without due process of law.” Furthermore, due process rights increase when the limitations on ones’ rights are greater; this is why the burden of proof falls on the prosecution and why the standard of proof is “beyond a reasonable doubt” in criminal cases, because the rights that are at risk are liberty and, in some cases, life.

Due process is particularly important for civil servants because they are employed by the federal government. The rights to property are at risk of being limited if they are to be removed, demoted, or suspended from their jobs. The VA Accountability and Whistleblower Protection Act limits the due process of VA civil servants. However, it also is important to highlight that under this law, the VA Secretary has the right to remove, demote, or suspend any person who threatens the function and service of the VA or endangers veterans. In other words, while the VA employee’s due process may have decreased, it has increased for those whose lives depend on their service.

On Friday June 23, President Trump signed into law the VA Accountability and Whistleblower Protection Act, which established a revised disciplinary system for VA employees who are accused of poor performance or misconduct and protects those who report them. The bill amends Title 38 of the U.S. Code, adding VA employees to the list of those that the VA Secretary can remove if necessary. The act speeds up the termination and suspension processes for civil servants. The VA also claims that the bill will shorten the process of hiring new administrators. Still unclear is what this bill means for VA health care providers.

VA employees are protected under both Title 5 and Title 38 of the U.S. code. Title 5 governs the employment of all federal civil servants. Title 38 specifically governs the employment of VA employees in certain health care fields. Both titles specify processes for termination, demotion, or suspension and an appeals process.

Critics, including VA Secretary David J. Shulkin, MD, have complained that the previous civil service protections were time consuming and made it difficult to penalize or remove problem employees. Supporters insist that Title 5 and Title 38 protected the rights of good employees and whistleblowers from unfair workplace retaliation.

Under the new law, the VA Secretary can more easily remove, demote, or suspend any employee who warrants a penalty, including executives and supervisors. Although many of the Title 5 and Title 38 protections still cover VA employees, there are several notable changes.

What’s changing for VA employees?

• Time line: The act shortens time between the initial report, employee notification, Secretary’s decision, and appeal request/decision.
• Standard of proof: Previously, the standard of proof for misconduct was “preponderance of evidence.” The new bill lowers this standard to “supported by substantial evidence.” Changing the standard of proof effectively means that the Secretary will need to present less evidence of wrongdoing/negligence for the employee to be removed, demoted, or suspended.
• Appeals: Employees may still appeal removal, demotion, or suspension decisions, but rather than going through the Disciplinary Appeals Board, the Merit Systems Protection Board will hear appeals. Appeals must be filed within 10 days of the Secretary’s final decision. Additionally, administrative judges are instructed to uphold the decision of the Secretary if the evidence meets the “substantial evidence” standard. Administrative judges are prohibited from reducing the penalty.

Analysis

Although these changes are meant to increase the accountability of health care providers in the VA, there are several other legal implications for VA employees. Ultimately, the bill gives the VA Secretary more discretion. Whether this is a good or bad change is open to debate. Even though the bill easily passed in both the House of Representatives and the Senate, some lawmakers remain skeptical because the act increases the power of the Secretary and limits due process for VA employees. Under the new law, VA employees will have less time to prepare their defense and be held to a lower standard of proof, which will make it easier to remove VA employees from their jobs.

The Fifth Amendment of the U.S. Constitution guarantees that all Americans shall not be “deprived of life, liberty, or property, without due process of law.” Furthermore, due process rights increase when the limitations on ones’ rights are greater; this is why the burden of proof falls on the prosecution and why the standard of proof is “beyond a reasonable doubt” in criminal cases, because the rights that are at risk are liberty and, in some cases, life.

Due process is particularly important for civil servants because they are employed by the federal government. The rights to property are at risk of being limited if they are to be removed, demoted, or suspended from their jobs. The VA Accountability and Whistleblower Protection Act limits the due process of VA civil servants. However, it also is important to highlight that under this law, the VA Secretary has the right to remove, demote, or suspend any person who threatens the function and service of the VA or endangers veterans. In other words, while the VA employee’s due process may have decreased, it has increased for those whose lives depend on their service.

On Friday June 23, President Trump signed into law the VA Accountability and Whistleblower Protection Act, which established a revised disciplinary system for VA employees who are accused of poor performance or misconduct and protects those who report them. The bill amends Title 38 of the U.S. Code, adding VA employees to the list of those that the VA Secretary can remove if necessary. The act speeds up the termination and suspension processes for civil servants. The VA also claims that the bill will shorten the process of hiring new administrators. Still unclear is what this bill means for VA health care providers.

VA employees are protected under both Title 5 and Title 38 of the U.S. code. Title 5 governs the employment of all federal civil servants. Title 38 specifically governs the employment of VA employees in certain health care fields. Both titles specify processes for termination, demotion, or suspension and an appeals process.

Critics, including VA Secretary David J. Shulkin, MD, have complained that the previous civil service protections were time consuming and made it difficult to penalize or remove problem employees. Supporters insist that Title 5 and Title 38 protected the rights of good employees and whistleblowers from unfair workplace retaliation.

Under the new law, the VA Secretary can more easily remove, demote, or suspend any employee who warrants a penalty, including executives and supervisors. Although many of the Title 5 and Title 38 protections still cover VA employees, there are several notable changes.

What’s changing for VA employees?

• Time line: The act shortens time between the initial report, employee notification, Secretary’s decision, and appeal request/decision.
• Standard of proof: Previously, the standard of proof for misconduct was “preponderance of evidence.” The new bill lowers this standard to “supported by substantial evidence.” Changing the standard of proof effectively means that the Secretary will need to present less evidence of wrongdoing/negligence for the employee to be removed, demoted, or suspended.
• Appeals: Employees may still appeal removal, demotion, or suspension decisions, but rather than going through the Disciplinary Appeals Board, the Merit Systems Protection Board will hear appeals. Appeals must be filed within 10 days of the Secretary’s final decision. Additionally, administrative judges are instructed to uphold the decision of the Secretary if the evidence meets the “substantial evidence” standard. Administrative judges are prohibited from reducing the penalty.

Analysis

Although these changes are meant to increase the accountability of health care providers in the VA, there are several other legal implications for VA employees. Ultimately, the bill gives the VA Secretary more discretion. Whether this is a good or bad change is open to debate. Even though the bill easily passed in both the House of Representatives and the Senate, some lawmakers remain skeptical because the act increases the power of the Secretary and limits due process for VA employees. Under the new law, VA employees will have less time to prepare their defense and be held to a lower standard of proof, which will make it easier to remove VA employees from their jobs.

The Fifth Amendment of the U.S. Constitution guarantees that all Americans shall not be “deprived of life, liberty, or property, without due process of law.” Furthermore, due process rights increase when the limitations on ones’ rights are greater; this is why the burden of proof falls on the prosecution and why the standard of proof is “beyond a reasonable doubt” in criminal cases, because the rights that are at risk are liberty and, in some cases, life.

Due process is particularly important for civil servants because they are employed by the federal government. The rights to property are at risk of being limited if they are to be removed, demoted, or suspended from their jobs. The VA Accountability and Whistleblower Protection Act limits the due process of VA civil servants. However, it also is important to highlight that under this law, the VA Secretary has the right to remove, demote, or suspend any person who threatens the function and service of the VA or endangers veterans. In other words, while the VA employee’s due process may have decreased, it has increased for those whose lives depend on their service.

The VA and the Department of Energy (DoE) have formed a new partnership focused on secure analysis of “big data.” The VA-DoE Big Data Science Initiative will use digital health and genomic data from the Million Veteran Program (MVP), the VA’s electronic health records system, DoD, Centers for Medicare and Medicaid Services, and the CDC’s National Death Index.

The partnership is based in DoE’s National Laboratory system, one of the world’s top resources for supercomputing, where machines are capable of millions of billions of calculations per second. The partnership will allow thousands of researchers access to this unprecedented data resource over time in a secure environment, said VA Secretary David J. Shulkin, MD.

An initial suite of specific studies is already being planned, the VA says. One group of researchers will build algorithms to generate “highly tailored” risk scores for suicide, which could help VA clinicians and researchers predict which patients are at highest risk and evaluate prevention strategies.

Other projects include one to find new ways to distinguish lethal from nonlethal prostate cancer and another to determine which risk factors best predict certain forms of cardiovascular disease.

“The transformative science that will be developed through this partnership,” Shulkin says, “will improve health care for veterans and all Americans.”

The VA and the Department of Energy (DoE) have formed a new partnership focused on secure analysis of “big data.” The VA-DoE Big Data Science Initiative will use digital health and genomic data from the Million Veteran Program (MVP), the VA’s electronic health records system, DoD, Centers for Medicare and Medicaid Services, and the CDC’s National Death Index.

The partnership is based in DoE’s National Laboratory system, one of the world’s top resources for supercomputing, where machines are capable of millions of billions of calculations per second. The partnership will allow thousands of researchers access to this unprecedented data resource over time in a secure environment, said VA Secretary David J. Shulkin, MD.

An initial suite of specific studies is already being planned, the VA says. One group of researchers will build algorithms to generate “highly tailored” risk scores for suicide, which could help VA clinicians and researchers predict which patients are at highest risk and evaluate prevention strategies.

Other projects include one to find new ways to distinguish lethal from nonlethal prostate cancer and another to determine which risk factors best predict certain forms of cardiovascular disease.

“The transformative science that will be developed through this partnership,” Shulkin says, “will improve health care for veterans and all Americans.”

The VA and the Department of Energy (DoE) have formed a new partnership focused on secure analysis of “big data.” The VA-DoE Big Data Science Initiative will use digital health and genomic data from the Million Veteran Program (MVP), the VA’s electronic health records system, DoD, Centers for Medicare and Medicaid Services, and the CDC’s National Death Index.

The partnership is based in DoE’s National Laboratory system, one of the world’s top resources for supercomputing, where machines are capable of millions of billions of calculations per second. The partnership will allow thousands of researchers access to this unprecedented data resource over time in a secure environment, said VA Secretary David J. Shulkin, MD.

An initial suite of specific studies is already being planned, the VA says. One group of researchers will build algorithms to generate “highly tailored” risk scores for suicide, which could help VA clinicians and researchers predict which patients are at highest risk and evaluate prevention strategies.

Other projects include one to find new ways to distinguish lethal from nonlethal prostate cancer and another to determine which risk factors best predict certain forms of cardiovascular disease.

“The transformative science that will be developed through this partnership,” Shulkin says, “will improve health care for veterans and all Americans.”

In testimony before the Senate Veterans Affairs Committee, VA Secretary David J. Shulkin, MD, outlined a vision for a revamped Veterans Choice Program that would allow veterans to access an integrated network of private health care providers for services not currently available at the VA. “We believe redesigning community care will result in a strong VA that can meet the special needs of our veteran population,” Shulkin told the committee. “Where VA excels, we want to make sure that the tools exist to continue performing well in those areas…. We need to move from a system where eligibility for community care is based on wait times and geography to one focused on clinical need and quality of care.”

During the hearing, Dr. Shulkin laid out the basic elements of the new Veterans Choice Program. The proposed changes include the following:

1. Shifting from determining eligibility for community care based on wait times and geography to clinical need and quality of care;
2. Streamlining process for veterans to access urgent care when they need it;
3. Creating what VA is calling a "high performing integrated network,” which would include VA; other federal health care providers, such as military treatment facilities and IHS; academic affiliates; and community providers;
4. Coordinating care across all providers; and
5. Adopting recognized industry standards for quality, patient satisfaction, payment models, health care outcomes, and exchange of health information.

Over the past year, major veterans service organizations (VSOs), VA officials, the Commission on Care, and members of the House and Senate have worked together to develop the newly introduced Veterans Choice program. The major stakeholders came together at the hearing to “support the concept of developing an integrated network that combines the strength of the VA health care system with the best of community care to offer seamless access for enrolled veterans,” explained Adrian Atizado, the deputy national legislative director at Disabled American Veterans (DAV) in his prepared remarks.

The joint effort was in part a response to calls from some VA critics to provide veterans with unlimited choice to outside providers or to fully privatize veteran care.

In the hearing, Committee Chairman Johnny Isakson (R-GA) suggested that he would be willing to work with the VA on the changes to the Veterans Choice Program and was largely in support of the effort. “We need to see to it that the VA…is unleashed to provide the highest quality service that it can and make the decisions that it needs to make on the ground at the time we need to make them,” he reported in a release following the hearing. “We need to give them the funding, commitment and resources to be able to do that.”

At the hearing, VSOs praised the VA for its efforts to improve the Veterans Choice Program but still expressed frustration with problems that continue to dog the program. “The VFW [Veterans of Foreign Wars] has also heard from veterans that the breakdown in communication between VA, contractors and Choice providers often delays their care because their Choice doctors do not receive authorization to provide needed treatments,” reported Carlos Fuentes, VFW director national legislative services. “What is concerning is that veterans are left to piece together the entire story or else they do not.”

“While many veterans initially clamored for ‘more Choice’ as a solution to scheduling problems within the VA healthcare system, once this program was implemented, most have not found it to be a solution,” noted Jeff Steele, assistant director national legislative division of The American Legion. “Instead, they have found it to create as many problems as it solves.…What we have found over the past decade, directly interacting with veterans, is that many of the problems veterans encountered with scheduling appointments in VA are mirrored in the civilian community outside VA.

In testimony before the Senate Veterans Affairs Committee, VA Secretary David J. Shulkin, MD, outlined a vision for a revamped Veterans Choice Program that would allow veterans to access an integrated network of private health care providers for services not currently available at the VA. “We believe redesigning community care will result in a strong VA that can meet the special needs of our veteran population,” Shulkin told the committee. “Where VA excels, we want to make sure that the tools exist to continue performing well in those areas…. We need to move from a system where eligibility for community care is based on wait times and geography to one focused on clinical need and quality of care.”

During the hearing, Dr. Shulkin laid out the basic elements of the new Veterans Choice Program. The proposed changes include the following:

1. Shifting from determining eligibility for community care based on wait times and geography to clinical need and quality of care;
2. Streamlining process for veterans to access urgent care when they need it;
3. Creating what VA is calling a "high performing integrated network,” which would include VA; other federal health care providers, such as military treatment facilities and IHS; academic affiliates; and community providers;
4. Coordinating care across all providers; and
5. Adopting recognized industry standards for quality, patient satisfaction, payment models, health care outcomes, and exchange of health information.

Over the past year, major veterans service organizations (VSOs), VA officials, the Commission on Care, and members of the House and Senate have worked together to develop the newly introduced Veterans Choice program. The major stakeholders came together at the hearing to “support the concept of developing an integrated network that combines the strength of the VA health care system with the best of community care to offer seamless access for enrolled veterans,” explained Adrian Atizado, the deputy national legislative director at Disabled American Veterans (DAV) in his prepared remarks.

The joint effort was in part a response to calls from some VA critics to provide veterans with unlimited choice to outside providers or to fully privatize veteran care.

In the hearing, Committee Chairman Johnny Isakson (R-GA) suggested that he would be willing to work with the VA on the changes to the Veterans Choice Program and was largely in support of the effort. “We need to see to it that the VA…is unleashed to provide the highest quality service that it can and make the decisions that it needs to make on the ground at the time we need to make them,” he reported in a release following the hearing. “We need to give them the funding, commitment and resources to be able to do that.”

At the hearing, VSOs praised the VA for its efforts to improve the Veterans Choice Program but still expressed frustration with problems that continue to dog the program. “The VFW [Veterans of Foreign Wars] has also heard from veterans that the breakdown in communication between VA, contractors and Choice providers often delays their care because their Choice doctors do not receive authorization to provide needed treatments,” reported Carlos Fuentes, VFW director national legislative services. “What is concerning is that veterans are left to piece together the entire story or else they do not.”

“While many veterans initially clamored for ‘more Choice’ as a solution to scheduling problems within the VA healthcare system, once this program was implemented, most have not found it to be a solution,” noted Jeff Steele, assistant director national legislative division of The American Legion. “Instead, they have found it to create as many problems as it solves.…What we have found over the past decade, directly interacting with veterans, is that many of the problems veterans encountered with scheduling appointments in VA are mirrored in the civilian community outside VA.

In testimony before the Senate Veterans Affairs Committee, VA Secretary David J. Shulkin, MD, outlined a vision for a revamped Veterans Choice Program that would allow veterans to access an integrated network of private health care providers for services not currently available at the VA. “We believe redesigning community care will result in a strong VA that can meet the special needs of our veteran population,” Shulkin told the committee. “Where VA excels, we want to make sure that the tools exist to continue performing well in those areas…. We need to move from a system where eligibility for community care is based on wait times and geography to one focused on clinical need and quality of care.”

During the hearing, Dr. Shulkin laid out the basic elements of the new Veterans Choice Program. The proposed changes include the following:

1. Shifting from determining eligibility for community care based on wait times and geography to clinical need and quality of care;
2. Streamlining process for veterans to access urgent care when they need it;
3. Creating what VA is calling a "high performing integrated network,” which would include VA; other federal health care providers, such as military treatment facilities and IHS; academic affiliates; and community providers;
4. Coordinating care across all providers; and
5. Adopting recognized industry standards for quality, patient satisfaction, payment models, health care outcomes, and exchange of health information.

Over the past year, major veterans service organizations (VSOs), VA officials, the Commission on Care, and members of the House and Senate have worked together to develop the newly introduced Veterans Choice program. The major stakeholders came together at the hearing to “support the concept of developing an integrated network that combines the strength of the VA health care system with the best of community care to offer seamless access for enrolled veterans,” explained Adrian Atizado, the deputy national legislative director at Disabled American Veterans (DAV) in his prepared remarks.

The joint effort was in part a response to calls from some VA critics to provide veterans with unlimited choice to outside providers or to fully privatize veteran care.

In the hearing, Committee Chairman Johnny Isakson (R-GA) suggested that he would be willing to work with the VA on the changes to the Veterans Choice Program and was largely in support of the effort. “We need to see to it that the VA…is unleashed to provide the highest quality service that it can and make the decisions that it needs to make on the ground at the time we need to make them,” he reported in a release following the hearing. “We need to give them the funding, commitment and resources to be able to do that.”

At the hearing, VSOs praised the VA for its efforts to improve the Veterans Choice Program but still expressed frustration with problems that continue to dog the program. “The VFW [Veterans of Foreign Wars] has also heard from veterans that the breakdown in communication between VA, contractors and Choice providers often delays their care because their Choice doctors do not receive authorization to provide needed treatments,” reported Carlos Fuentes, VFW director national legislative services. “What is concerning is that veterans are left to piece together the entire story or else they do not.”

“While many veterans initially clamored for ‘more Choice’ as a solution to scheduling problems within the VA healthcare system, once this program was implemented, most have not found it to be a solution,” noted Jeff Steele, assistant director national legislative division of The American Legion. “Instead, they have found it to create as many problems as it solves.…What we have found over the past decade, directly interacting with veterans, is that many of the problems veterans encountered with scheduling appointments in VA are mirrored in the civilian community outside VA.

The VA, which pioneered the electronic health record (EHR) system with the in-house development of VistA, will adopt a new EHR system based on the DoD’s MHS Genesis. “VA’s adoption of the same EHR system as DoD will ultimately result in all patient data residing in one common system and enable seamless care between the Departments without the manual and electronic exchange and reconciliation of data between two separate systems,” Secretary of Veteran Affairs David J. Shulkin, MD, explained in a press briefing.

To expedite the process, Dr. Shulkin issued a Determination and Findings, which allows the VA to circumvent the normal acquisition procedures and move forward more quickly. According to Dr. Shulkin, it took the DoD more than 2 years to complete the acquisition process. The MHS Genesis EHR system is based on the Cerner Millennium database. “It’s time to move forward, and as Secretary I was not willing to put this decision off any longer,” Dr. Shulkin said.

The move away from VistA and toward closer integration with the DoD has been a long time in coming. VistA was one of the first EHR systems, but the VA has struggled in recent years to maintain the system. It has been nearly 2 decades since Congress first asked VA and DoD to work more closely together, but integration of the 2 health systems has been expensive and incomplete.

“While we have established interoperability between VA and DoD for key aspects of the health record, seamless care is fundamentally constrained by ever-changing information sharing standards, separate chains of command, complex governance, separate implementation schedules that must be coordinated to accommodate those changes from separate program offices that have separate funding appropriations, and a host of related complexities requiring constant lifecycle maintenance,” Dr. Shulkin explained.  

President Trump expressed his support for the move in a tweet.

Even with the expedited acquisitions process, the process should still take 3 to 6 months to develop the specifications and determine the costs of the major technology overhaul. The DoD contract with Cerner is $4.3 billion, and the VA contract is expected to be larger. DoD officials involved in the MHS Genesis implementation will work with the VA, Dr. Shulkin noted, allowing the VA to leverage their experience in the EHR roll out.

The VA, which pioneered the electronic health record (EHR) system with the in-house development of VistA, will adopt a new EHR system based on the DoD’s MHS Genesis. “VA’s adoption of the same EHR system as DoD will ultimately result in all patient data residing in one common system and enable seamless care between the Departments without the manual and electronic exchange and reconciliation of data between two separate systems,” Secretary of Veteran Affairs David J. Shulkin, MD, explained in a press briefing.

To expedite the process, Dr. Shulkin issued a Determination and Findings, which allows the VA to circumvent the normal acquisition procedures and move forward more quickly. According to Dr. Shulkin, it took the DoD more than 2 years to complete the acquisition process. The MHS Genesis EHR system is based on the Cerner Millennium database. “It’s time to move forward, and as Secretary I was not willing to put this decision off any longer,” Dr. Shulkin said.

The move away from VistA and toward closer integration with the DoD has been a long time in coming. VistA was one of the first EHR systems, but the VA has struggled in recent years to maintain the system. It has been nearly 2 decades since Congress first asked VA and DoD to work more closely together, but integration of the 2 health systems has been expensive and incomplete.

“While we have established interoperability between VA and DoD for key aspects of the health record, seamless care is fundamentally constrained by ever-changing information sharing standards, separate chains of command, complex governance, separate implementation schedules that must be coordinated to accommodate those changes from separate program offices that have separate funding appropriations, and a host of related complexities requiring constant lifecycle maintenance,” Dr. Shulkin explained.  

President Trump expressed his support for the move in a tweet.

Even with the expedited acquisitions process, the process should still take 3 to 6 months to develop the specifications and determine the costs of the major technology overhaul. The DoD contract with Cerner is $4.3 billion, and the VA contract is expected to be larger. DoD officials involved in the MHS Genesis implementation will work with the VA, Dr. Shulkin noted, allowing the VA to leverage their experience in the EHR roll out.

The VA, which pioneered the electronic health record (EHR) system with the in-house development of VistA, will adopt a new EHR system based on the DoD’s MHS Genesis. “VA’s adoption of the same EHR system as DoD will ultimately result in all patient data residing in one common system and enable seamless care between the Departments without the manual and electronic exchange and reconciliation of data between two separate systems,” Secretary of Veteran Affairs David J. Shulkin, MD, explained in a press briefing.

To expedite the process, Dr. Shulkin issued a Determination and Findings, which allows the VA to circumvent the normal acquisition procedures and move forward more quickly. According to Dr. Shulkin, it took the DoD more than 2 years to complete the acquisition process. The MHS Genesis EHR system is based on the Cerner Millennium database. “It’s time to move forward, and as Secretary I was not willing to put this decision off any longer,” Dr. Shulkin said.

The move away from VistA and toward closer integration with the DoD has been a long time in coming. VistA was one of the first EHR systems, but the VA has struggled in recent years to maintain the system. It has been nearly 2 decades since Congress first asked VA and DoD to work more closely together, but integration of the 2 health systems has been expensive and incomplete.

“While we have established interoperability between VA and DoD for key aspects of the health record, seamless care is fundamentally constrained by ever-changing information sharing standards, separate chains of command, complex governance, separate implementation schedules that must be coordinated to accommodate those changes from separate program offices that have separate funding appropriations, and a host of related complexities requiring constant lifecycle maintenance,” Dr. Shulkin explained.  

President Trump expressed his support for the move in a tweet.

Even with the expedited acquisitions process, the process should still take 3 to 6 months to develop the specifications and determine the costs of the major technology overhaul. The DoD contract with Cerner is $4.3 billion, and the VA contract is expected to be larger. DoD officials involved in the MHS Genesis implementation will work with the VA, Dr. Shulkin noted, allowing the VA to leverage their experience in the EHR roll out.

On December 13, 2016, the VA announced a change in its medical regulations to permit full practice authority for all VA advanced practice registered nurses (APRNs) when they are acting within the scope of their VA employment.This amendment removed the stipulation requiring physician supervision or collaboration for APRNs. Many states across the U.S. have similar statutes for APRNs.

Not surprisingly, the regulatorychange was met with resistance fromof the physician establishment. “TheAmerican Medical Association (AMA) is disappointed by the Department of Veterans Affairs’ unprecedented proposal to allow advanced practice nurses within the VA to practice independently of a physician’s clinical oversight, regardless of individual state law,” Stephen R. Permut, MD, JD, AMA immediate past-chair wrote in a statement.

The American Academy of Physician Assistants (AAPA) then announced that it was “actively working with senior officials at the VA to institute a similar rule for PAs (physician assistants).” The well-intentioned AAPA statement seems misguided. It implies that PAs should be granted full practice authority because APRNs were granted the authority.

No matter the rational for granting APRNs full practice authority, the VA should not pursue similar regulations for PAs only because APRNs were granted the privilege. If the VA should institute a new amendment granting full practice authority to PAs, this action should be done independent of actions taken by any other nonphysician profession. Full practice authority for PAs should be based on training, clinical experience, and competency. Rather than adjusting the previously established threshold to obtain full practice authority to meet current PA standards, PAs should pursue further training and certification to earn this privilege. Physician assistant didactic and clinical training is based on the same model as training for medical doctors.

Physician assistant programs generally have 1 year of didactic training and 1 year of clinical training before trainees are eligible to take the Physician Assistant National Certifying Exam. Many schools, such as my alma mater, George Washington University School of Medicine, have PA students in the same lecture hall training side by side with medical students.

Medical doctor training generally includes 2 years of didactic training, 2 years of clinical training in medical school, and 3 years of clinical training in residency (for internal medicine) before trainees are eligible to take the American Board of Internal Medicine (ABIM) exam. The didactic training in PA programs mirrors that of medical doctor programs. The real difference in education and preparation is the duration of clinical training; 1 year of clinical training for PAs vs 5 years of clinical training for MDs.

Therefore, my suggestion would be that leaders within the PA profession should work with the ABIM to create a pathway in which PAs who work in the VA could take the ABIM exam after 4 years of clinical experience. If a PA employed by the VA passes the ABIM exam, they would be granted full practice authority within their scope of practice at the VA. This requirement would validate that these PAs warrant this privilege and subsequently satisfy physician concerns by showing that they have passed the same exam required of physicians. Moreover, this additional level of preparation and testing would increase the competency of PAs and the quality of care they provide to the veterans they serve.

On December 13, 2016, the VA announced a change in its medical regulations to permit full practice authority for all VA advanced practice registered nurses (APRNs) when they are acting within the scope of their VA employment.This amendment removed the stipulation requiring physician supervision or collaboration for APRNs. Many states across the U.S. have similar statutes for APRNs.

Not surprisingly, the regulatorychange was met with resistance fromof the physician establishment. “TheAmerican Medical Association (AMA) is disappointed by the Department of Veterans Affairs’ unprecedented proposal to allow advanced practice nurses within the VA to practice independently of a physician’s clinical oversight, regardless of individual state law,” Stephen R. Permut, MD, JD, AMA immediate past-chair wrote in a statement.

The American Academy of Physician Assistants (AAPA) then announced that it was “actively working with senior officials at the VA to institute a similar rule for PAs (physician assistants).” The well-intentioned AAPA statement seems misguided. It implies that PAs should be granted full practice authority because APRNs were granted the authority.

No matter the rational for granting APRNs full practice authority, the VA should not pursue similar regulations for PAs only because APRNs were granted the privilege. If the VA should institute a new amendment granting full practice authority to PAs, this action should be done independent of actions taken by any other nonphysician profession. Full practice authority for PAs should be based on training, clinical experience, and competency. Rather than adjusting the previously established threshold to obtain full practice authority to meet current PA standards, PAs should pursue further training and certification to earn this privilege. Physician assistant didactic and clinical training is based on the same model as training for medical doctors.

Physician assistant programs generally have 1 year of didactic training and 1 year of clinical training before trainees are eligible to take the Physician Assistant National Certifying Exam. Many schools, such as my alma mater, George Washington University School of Medicine, have PA students in the same lecture hall training side by side with medical students.

Medical doctor training generally includes 2 years of didactic training, 2 years of clinical training in medical school, and 3 years of clinical training in residency (for internal medicine) before trainees are eligible to take the American Board of Internal Medicine (ABIM) exam. The didactic training in PA programs mirrors that of medical doctor programs. The real difference in education and preparation is the duration of clinical training; 1 year of clinical training for PAs vs 5 years of clinical training for MDs.

Therefore, my suggestion would be that leaders within the PA profession should work with the ABIM to create a pathway in which PAs who work in the VA could take the ABIM exam after 4 years of clinical experience. If a PA employed by the VA passes the ABIM exam, they would be granted full practice authority within their scope of practice at the VA. This requirement would validate that these PAs warrant this privilege and subsequently satisfy physician concerns by showing that they have passed the same exam required of physicians. Moreover, this additional level of preparation and testing would increase the competency of PAs and the quality of care they provide to the veterans they serve.

On December 13, 2016, the VA announced a change in its medical regulations to permit full practice authority for all VA advanced practice registered nurses (APRNs) when they are acting within the scope of their VA employment.This amendment removed the stipulation requiring physician supervision or collaboration for APRNs. Many states across the U.S. have similar statutes for APRNs.

Not surprisingly, the regulatorychange was met with resistance fromof the physician establishment. “TheAmerican Medical Association (AMA) is disappointed by the Department of Veterans Affairs’ unprecedented proposal to allow advanced practice nurses within the VA to practice independently of a physician’s clinical oversight, regardless of individual state law,” Stephen R. Permut, MD, JD, AMA immediate past-chair wrote in a statement.

The American Academy of Physician Assistants (AAPA) then announced that it was “actively working with senior officials at the VA to institute a similar rule for PAs (physician assistants).” The well-intentioned AAPA statement seems misguided. It implies that PAs should be granted full practice authority because APRNs were granted the authority.

No matter the rational for granting APRNs full practice authority, the VA should not pursue similar regulations for PAs only because APRNs were granted the privilege. If the VA should institute a new amendment granting full practice authority to PAs, this action should be done independent of actions taken by any other nonphysician profession. Full practice authority for PAs should be based on training, clinical experience, and competency. Rather than adjusting the previously established threshold to obtain full practice authority to meet current PA standards, PAs should pursue further training and certification to earn this privilege. Physician assistant didactic and clinical training is based on the same model as training for medical doctors.

Physician assistant programs generally have 1 year of didactic training and 1 year of clinical training before trainees are eligible to take the Physician Assistant National Certifying Exam. Many schools, such as my alma mater, George Washington University School of Medicine, have PA students in the same lecture hall training side by side with medical students.

Medical doctor training generally includes 2 years of didactic training, 2 years of clinical training in medical school, and 3 years of clinical training in residency (for internal medicine) before trainees are eligible to take the American Board of Internal Medicine (ABIM) exam. The didactic training in PA programs mirrors that of medical doctor programs. The real difference in education and preparation is the duration of clinical training; 1 year of clinical training for PAs vs 5 years of clinical training for MDs.

Therefore, my suggestion would be that leaders within the PA profession should work with the ABIM to create a pathway in which PAs who work in the VA could take the ABIM exam after 4 years of clinical experience. If a PA employed by the VA passes the ABIM exam, they would be granted full practice authority within their scope of practice at the VA. This requirement would validate that these PAs warrant this privilege and subsequently satisfy physician concerns by showing that they have passed the same exam required of physicians. Moreover, this additional level of preparation and testing would increase the competency of PAs and the quality of care they provide to the veterans they serve.

Fort Belvoir Community Hospital surgeons have performed the first small-incision lenticule extraction (SMILE) in the DoD, according to Health.mil News. The procedure to reduce or eliminate nearsightedness has been performed since 2011; the FDA recently approved it for the U.S.

The very fast and short-pulsed (femtosecond) laser creates a thin disc within the cornea, which is removed through a cut on the corneal surface. Removing the tissue changes the shape of the cornea.

The procedure takes 15 to 20 minutes with the laser activated for about 90 seconds per eye. Both eyes can be treated in the same session. With SMILE, unlike LASIK, no tissue is vaporized, meaning wound recovery time is faster, and with no corneal flap created, there is no risk of flap dislocation.

A clinical study found complications were rare, and by month 12 postsurgery there were only 4 reports of moderate or severe glare and 1 of moderate or severe halos. The most commonly reported effects were starbursts, blurred vision, and difficulty judging distance or depth perception, but at 12 months, more patients reported improvement than worsening. At the 6-month follow-up, 287 of 328 patients were seeing 20/20 or better without glasses.

“We are thrilled to extend this treatment option to active duty service members under the Warfighter Refractive Eye Surgery Program,” said U.S. Army Lt. Col. Bruce Rivers, director of the program at Belvoir Hospital.

The surgery will make a difference for patients. One of the first to have it done, Navy Petty Officer 1st Class Christopher Mahmood, a submarine mechanic, said, “On a submarine we have to be able to put our breathing equipment on in approximately 30 seconds, in case of emergency. Glasses make this difficult. Getting this surgery means I have one less thing to worry about while deployed and can focus 100 percent on the mission.”

The SMILE procedure will be available at Belvoir Hospital, San Diego Naval Medical Center, and Wilford Hall in San Antonio.

Fort Belvoir Community Hospital surgeons have performed the first small-incision lenticule extraction (SMILE) in the DoD, according to Health.mil News. The procedure to reduce or eliminate nearsightedness has been performed since 2011; the FDA recently approved it for the U.S.

The very fast and short-pulsed (femtosecond) laser creates a thin disc within the cornea, which is removed through a cut on the corneal surface. Removing the tissue changes the shape of the cornea.

The procedure takes 15 to 20 minutes with the laser activated for about 90 seconds per eye. Both eyes can be treated in the same session. With SMILE, unlike LASIK, no tissue is vaporized, meaning wound recovery time is faster, and with no corneal flap created, there is no risk of flap dislocation.

A clinical study found complications were rare, and by month 12 postsurgery there were only 4 reports of moderate or severe glare and 1 of moderate or severe halos. The most commonly reported effects were starbursts, blurred vision, and difficulty judging distance or depth perception, but at 12 months, more patients reported improvement than worsening. At the 6-month follow-up, 287 of 328 patients were seeing 20/20 or better without glasses.

“We are thrilled to extend this treatment option to active duty service members under the Warfighter Refractive Eye Surgery Program,” said U.S. Army Lt. Col. Bruce Rivers, director of the program at Belvoir Hospital.

The surgery will make a difference for patients. One of the first to have it done, Navy Petty Officer 1st Class Christopher Mahmood, a submarine mechanic, said, “On a submarine we have to be able to put our breathing equipment on in approximately 30 seconds, in case of emergency. Glasses make this difficult. Getting this surgery means I have one less thing to worry about while deployed and can focus 100 percent on the mission.”

The SMILE procedure will be available at Belvoir Hospital, San Diego Naval Medical Center, and Wilford Hall in San Antonio.

Fort Belvoir Community Hospital surgeons have performed the first small-incision lenticule extraction (SMILE) in the DoD, according to Health.mil News. The procedure to reduce or eliminate nearsightedness has been performed since 2011; the FDA recently approved it for the U.S.

The very fast and short-pulsed (femtosecond) laser creates a thin disc within the cornea, which is removed through a cut on the corneal surface. Removing the tissue changes the shape of the cornea.

The procedure takes 15 to 20 minutes with the laser activated for about 90 seconds per eye. Both eyes can be treated in the same session. With SMILE, unlike LASIK, no tissue is vaporized, meaning wound recovery time is faster, and with no corneal flap created, there is no risk of flap dislocation.

A clinical study found complications were rare, and by month 12 postsurgery there were only 4 reports of moderate or severe glare and 1 of moderate or severe halos. The most commonly reported effects were starbursts, blurred vision, and difficulty judging distance or depth perception, but at 12 months, more patients reported improvement than worsening. At the 6-month follow-up, 287 of 328 patients were seeing 20/20 or better without glasses.

“We are thrilled to extend this treatment option to active duty service members under the Warfighter Refractive Eye Surgery Program,” said U.S. Army Lt. Col. Bruce Rivers, director of the program at Belvoir Hospital.

The surgery will make a difference for patients. One of the first to have it done, Navy Petty Officer 1st Class Christopher Mahmood, a submarine mechanic, said, “On a submarine we have to be able to put our breathing equipment on in approximately 30 seconds, in case of emergency. Glasses make this difficult. Getting this surgery means I have one less thing to worry about while deployed and can focus 100 percent on the mission.”

The SMILE procedure will be available at Belvoir Hospital, San Diego Naval Medical Center, and Wilford Hall in San Antonio.

In an ongoing effort to improve oversight and to protect potential whistleblowers at the VA, President Trump has signed a new executive order creating the Office of Accountability and Whistleblower Protection. The executive order establishes an office that will report directly to VA Secretary David. J. Shulkin, MD. “Accountability is an important issue to us at VA and something that we’re focusing on to make sure that we have employees who work and are committed to the mission of serving our veterans,” Dr. Shulkin explained at an April 26 press conference. “When we find employees that have deviated from those values, we want to make sure that we can move them outside the VA and not have them working at VA.”

The new office is not the first effort at the VA to protect whistleblowers or to expedite the removal of employees. In 2014 the Office of Accountability and Review was established to increase central office scrutiny of senior-level executives at local and regional VA facilities. In contrast Dr. Shulkin noted, “This is a broader office that will be taking a look at all of our employees.” The current VA Whistleblower Office, created just last year will be incorporated into the new office, according to Dr. Shulkin.

Related: VA Secretary Shulkin Calls for New Powers to Fire VA Employees

Not everyone greeted the announcement with praise. “This rush to fire feds faster, first at VA, but with attempts to spread it across government, comes with a serious risk,” argued Washington Post columnist Joe Davidson. “Yes, due process rights can be slow and cumbersome. They protect, however, not just employees, but more importantly, also the public from a politicized system that favors citizens of one political party over another. Reforms must respect civil service protections. They should be acknowledged by government leaders and not be ignored as they were at the signing.”

Officials at the Project on Government Oversight expressed concern that whistleblowers should have an independent channel to report their concerns. Like the current whistleblower office, the new structure “may do far more damage than good,” the organization reported “It is incredibly important that whistleblowers have the ability to go to an independent office to report wrongdoing, since an internal office could be pressured to act in the VA’s interest by covering up problems and silencing whistleblowers.”

Related: VA Launches Investigation into Cincinnati Facility Mismanagement

Dr. Shulkin insisted that the office did not negate the need for the new legislation that he has called for that would speed the process of firing problem employees. Nor will the new office replace the hot line set up by the White House for veteran complaints about VA service. “These are all 3 efforts that are important for us to identify issues that are preventing us from doing the very best job that we can,” he explained. “We’re keeping our employees and our executives accountable to the values, to be able to work at the VA.  We are soliciting input from veterans who feel that they have issues that they want to share with us, and that’s what the hotline will be doing.” 

While the focus on the effort is on employees malfeasance, Dr. Shulkin cautioned that the VA was still concerned about employee morale and protecting whistleblowers from retaliation. “Our employees have to feel safe, when they see something, to tell us about it,” he explained. “The message is clear that we will not tolerate whistleblower retaliation in the [VA]. And we will take actions if we do determine that retaliation has been imposed upon an employee who has come forth with an issue.”

Related: Deputy Secretary of Veterans Affairs Gibson Defends VA Discipline Guidelines

Dr. Shulkin also announced a new task force that would tackle fraud, waste, and abuse, “to make sure that we are aggressively investigating any issues that might lead to the waste of taxpayer dollars.”

In an ongoing effort to improve oversight and to protect potential whistleblowers at the VA, President Trump has signed a new executive order creating the Office of Accountability and Whistleblower Protection. The executive order establishes an office that will report directly to VA Secretary David. J. Shulkin, MD. “Accountability is an important issue to us at VA and something that we’re focusing on to make sure that we have employees who work and are committed to the mission of serving our veterans,” Dr. Shulkin explained at an April 26 press conference. “When we find employees that have deviated from those values, we want to make sure that we can move them outside the VA and not have them working at VA.”

The new office is not the first effort at the VA to protect whistleblowers or to expedite the removal of employees. In 2014 the Office of Accountability and Review was established to increase central office scrutiny of senior-level executives at local and regional VA facilities. In contrast Dr. Shulkin noted, “This is a broader office that will be taking a look at all of our employees.” The current VA Whistleblower Office, created just last year will be incorporated into the new office, according to Dr. Shulkin.

Related: VA Secretary Shulkin Calls for New Powers to Fire VA Employees

Not everyone greeted the announcement with praise. “This rush to fire feds faster, first at VA, but with attempts to spread it across government, comes with a serious risk,” argued Washington Post columnist Joe Davidson. “Yes, due process rights can be slow and cumbersome. They protect, however, not just employees, but more importantly, also the public from a politicized system that favors citizens of one political party over another. Reforms must respect civil service protections. They should be acknowledged by government leaders and not be ignored as they were at the signing.”

Officials at the Project on Government Oversight expressed concern that whistleblowers should have an independent channel to report their concerns. Like the current whistleblower office, the new structure “may do far more damage than good,” the organization reported “It is incredibly important that whistleblowers have the ability to go to an independent office to report wrongdoing, since an internal office could be pressured to act in the VA’s interest by covering up problems and silencing whistleblowers.”

Related: VA Launches Investigation into Cincinnati Facility Mismanagement

Dr. Shulkin insisted that the office did not negate the need for the new legislation that he has called for that would speed the process of firing problem employees. Nor will the new office replace the hot line set up by the White House for veteran complaints about VA service. “These are all 3 efforts that are important for us to identify issues that are preventing us from doing the very best job that we can,” he explained. “We’re keeping our employees and our executives accountable to the values, to be able to work at the VA.  We are soliciting input from veterans who feel that they have issues that they want to share with us, and that’s what the hotline will be doing.” 

While the focus on the effort is on employees malfeasance, Dr. Shulkin cautioned that the VA was still concerned about employee morale and protecting whistleblowers from retaliation. “Our employees have to feel safe, when they see something, to tell us about it,” he explained. “The message is clear that we will not tolerate whistleblower retaliation in the [VA]. And we will take actions if we do determine that retaliation has been imposed upon an employee who has come forth with an issue.”

Related: Deputy Secretary of Veterans Affairs Gibson Defends VA Discipline Guidelines

Dr. Shulkin also announced a new task force that would tackle fraud, waste, and abuse, “to make sure that we are aggressively investigating any issues that might lead to the waste of taxpayer dollars.”

In an ongoing effort to improve oversight and to protect potential whistleblowers at the VA, President Trump has signed a new executive order creating the Office of Accountability and Whistleblower Protection. The executive order establishes an office that will report directly to VA Secretary David. J. Shulkin, MD. “Accountability is an important issue to us at VA and something that we’re focusing on to make sure that we have employees who work and are committed to the mission of serving our veterans,” Dr. Shulkin explained at an April 26 press conference. “When we find employees that have deviated from those values, we want to make sure that we can move them outside the VA and not have them working at VA.”

The new office is not the first effort at the VA to protect whistleblowers or to expedite the removal of employees. In 2014 the Office of Accountability and Review was established to increase central office scrutiny of senior-level executives at local and regional VA facilities. In contrast Dr. Shulkin noted, “This is a broader office that will be taking a look at all of our employees.” The current VA Whistleblower Office, created just last year will be incorporated into the new office, according to Dr. Shulkin.

Related: VA Secretary Shulkin Calls for New Powers to Fire VA Employees

Not everyone greeted the announcement with praise. “This rush to fire feds faster, first at VA, but with attempts to spread it across government, comes with a serious risk,” argued Washington Post columnist Joe Davidson. “Yes, due process rights can be slow and cumbersome. They protect, however, not just employees, but more importantly, also the public from a politicized system that favors citizens of one political party over another. Reforms must respect civil service protections. They should be acknowledged by government leaders and not be ignored as they were at the signing.”

Officials at the Project on Government Oversight expressed concern that whistleblowers should have an independent channel to report their concerns. Like the current whistleblower office, the new structure “may do far more damage than good,” the organization reported “It is incredibly important that whistleblowers have the ability to go to an independent office to report wrongdoing, since an internal office could be pressured to act in the VA’s interest by covering up problems and silencing whistleblowers.”

Related: VA Launches Investigation into Cincinnati Facility Mismanagement

Dr. Shulkin insisted that the office did not negate the need for the new legislation that he has called for that would speed the process of firing problem employees. Nor will the new office replace the hot line set up by the White House for veteran complaints about VA service. “These are all 3 efforts that are important for us to identify issues that are preventing us from doing the very best job that we can,” he explained. “We’re keeping our employees and our executives accountable to the values, to be able to work at the VA.  We are soliciting input from veterans who feel that they have issues that they want to share with us, and that’s what the hotline will be doing.” 

While the focus on the effort is on employees malfeasance, Dr. Shulkin cautioned that the VA was still concerned about employee morale and protecting whistleblowers from retaliation. “Our employees have to feel safe, when they see something, to tell us about it,” he explained. “The message is clear that we will not tolerate whistleblower retaliation in the [VA]. And we will take actions if we do determine that retaliation has been imposed upon an employee who has come forth with an issue.”

Related: Deputy Secretary of Veterans Affairs Gibson Defends VA Discipline Guidelines

Dr. Shulkin also announced a new task force that would tackle fraud, waste, and abuse, “to make sure that we are aggressively investigating any issues that might lead to the waste of taxpayer dollars.”