While the Department of Veterans Affairs prides itself on running the nation’s largest integrated health system, the agency suffers from a chronic disease of its own making — whistleblower retaliation.

Each year, 9 million veterans get good care at VA’s 1,243 health-care facilities, but they would be better served if the ingrained culture of retribution were remedied. It was whistleblowers who exposed the scandal in 2014 involving the coverup of long patient wait times. That led to ongoing efforts, with some success, to fix the system.

For whistleblowers facing management revenge, it’s not fixed yet.

A new Government Accountability Office (GAO) report reveals serious problems related to holding employees accountable, particularly when it comes to whistleblowing.

Correcting that should be a top item on the agenda of Robert Wilkie, who is scheduled to be sworn in Monday as the new VA secretary. As my colleague Lisa Rein has reported, he is taking over a department that has become highly politicized under President Trump.

One sentence leaps from the GAO’s findings — “Whistleblowers were 10 times more likely than their peers to receive disciplinary action within a year of reporting misconduct.”

Another disturbing finding — the GAO “found instances where managers investigated themselves for misconduct, presenting a conflict of interest.”

VA has a policy against such a clearly flawed practice but does not have appropriate oversight measures to ensure the policy is enforced.

While the White House is pledging to crack down on "leakers," there are ways to disclose information and concerns lawfully. (Jenny Starrs/The Washington Post)

“The independence of officials conducting or reviewing the results is paramount to the integrity of the process both in deed and appearance,” the GAO said. A VA directive cited in the report indicates the obvious: “The decision whether to conduct an investigation should not be made by an official who may be a subject of the investigation, or who appears to have a personal stake or bias in the matter to be investigated.”

VA’s Office of Inspector General refers complaints to management but “is unsure where cases go once they are referred,” according to the GAO. Furthermore, “VA did not consistently ensure that allegations of misconduct involving senior officials were reviewed according to investigative standards and these officials were held accountable.”

Rep. Michelle Lujan Grisham (D-N.M.), who requested the report along with two other House members, has urged the Justice Department to appoint a federal monitor to examine the misconduct-adjudication process.

“The findings from this nearly three-year investigation are beyond disturbing and reflect complaints from VA employees, veterans and their loved ones that I have received for years,” she said. “The investigation describes an agency in crisis that has failed to protect whistleblowers and hold senior VA officials accountable for misconduct, jeopardizing veteran health and well-being. The investigation also uncovered that VA allowed several individuals to investigate their own accusations, which is a glaring conflict of interest and completely unacceptable for the adjudication process.”

The first instinct of the department’s public affairs office is to blame the Obama administration. Much of the report covers the 2009-2015 period.

“Everyone recognizes that in the Obama-era, VA struggled to hold employees accountable when they violated the public trust and to protect whistleblowers from retaliation. That’s why last year President Trump signed an executive order [va.gov] establishing VA’s Office of Accountability and Whistleblower Protection (OAWP),” said Curt Cashour, VA’s press secretary, said by email.

“The first office of its kind in the federal government, OAWP has changed dramatically the way VA handles accountability and whistleblower issues, ensuring adequate investigation and correction of wrongdoing throughout VA, and protecting employees who lawfully disclose wrongdoing from retaliation.”

The Office of Inspector General also complained that information regarding its oversight role was dated “and includes inaccurate findings.”

Whistleblower advocate Tom Devine, legal director of the nongovernmental Government Accountability Project, is no fan of in-house whistleblower projects like VA’s office. He said they too often “are a trap” for employees who are subjected to an investigation because they exposed waste, fraud or abuse.

But Devine praised some VA whistleblower office efforts, while expressing frustration with others. Calling the office “schizophrenic,” he said, “the jury is out on whether this is going to be a Trojan horse or a breakthrough in the government’s most repressive agency.”

Most repressive agency? Consider this: VA had 18 percent of the federal workforce but accounted for 31 percent of cases submitted in 2016 to the Office of Special Counsel, which investigates whistleblower complaints across the government.

“The GAO report confirms what every whistleblower knows. If you raise a concern, you will be subjected to retaliation,” said Stephen M. Kohn, executive director of the National Whistleblower Center. “The VA has a ‘shoot the messenger’ culture that is alive and well.”

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