[House Hearing, 112 Congress]
[From the U.S. Government Printing Office]
PREVENTING SEXUAL ASSAULTS AND SAFETY
INCIDENTS AT U.S. DEPARTMENT OF
VETERANS AFFAIRS FACILITIES
SUBCOMMITTEE ON HEALTH
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TWELFTH CONGRESS
JUNE 13, 2011
Serial No. 112-17
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
CLIFF STEARNS, Florida BOB FILNER, California, Ranking
DOUG LAMBORN, Colorado CORRINE BROWN, Florida
GUS M. BILIRAKIS, Florida SILVESTRE REYES, Texas
DAVID P. ROE, Tennessee MICHAEL H. MICHAUD, Maine
MARLIN A. STUTZMAN, Indiana LINDA T. SANCHEZ, California
BILL FLORES, Texas BRUCE L. BRALEY, Iowa
BILL JOHNSON, Ohio JERRY McNERNEY, California
JEFF DENHAM, California JOE DONNELLY, Indiana
JON RUNYAN, New Jersey TIMOTHY J. WALZ, Minnesota
DAN BENISHEK, Michigan JOHN BARROW, Georgia
ANN MARIE BUERKLE, New York RUSS CARNAHAN, Missouri
TIM HUELSKAMP, Kansas
Helen W. Tolar, Staff Director and Chief Counsel
SUBCOMMITTEE ON HEALTH
ANN MARIE BUERKLE, New York, Chairwoman
CLIFF STEARNS, Florida MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida CORRINE BROWN, Florida
DAVID P. ROE, Tennessee SILVESTRE REYES, Texas
DAN BENISHEK, Michigan RUSS CARNAHAN, Missouri
JEFF DENHAM, California JOE DONNELLY, Indiana
JON RUNYAN, New Jersey
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C O N T E N T S
June 13, 2011
Preventing Sexual Assaults and Safety Incidents at U.S.
Department of Veterans Affairs Facilities...................... 1
Chairwoman Ann Marie Buerkle..................................... 1
Prepared statement of Chairwoman Buerkle..................... 34
Hon. Michael H. Michaud, Ranking Democratic Member............... 3
Prepared statement of Congressman Michaud.................... 34
Hon. Jeff Miller................................................. 2
Prepared statement of Congressman Miller..................... 35
U.S. Government Accountability Office, Randall B. Williamson,
Director, Health Care.......................................... 5
Prepared statement of Mr. Williamson......................... 36
U.S. Department of Veterans Affairs:
Joseph G. Sullivan, Jr., Deputy Assistant Inspector General for
Investigations, Office of Investigations, Office of Inspector
Prepared statement of Mr. Sullivan......................... 52
William Schoenhard, FACHE, Deputy Under Secretary for Health
for Operations and Management, Veterans Health Administration 8
Prepared statement of Mr. Schoenhard....................... 55
American Legion, Verna Jones, Director, National Veterans Affairs
and Rehabilitation Commission.................................. 23
Prepared statement of Ms. Jones.............................. 58
Disabled American Veterans, Joy J. Ilem, Deputy National
Legislative Director........................................... 25
Prepared statement of Ms. Ilem............................... 61
Veterans of Foreign Wars of the United States, Marlene Roll,
Member, National Women Veterans Committee...................... 26
Prepared statement of Ms. Roll............................... 63
Vietnam Veterans of America, Richard F. Weidman, Executive
Director for Policy and Government Affairs..................... 27
Prepared statement of Mr. Weidman............................ 65
SUBMISSION FOR THE RECORD
Carnahan, Hon. Russ, a Representative in Congress from the State
of Missouri, statement......................................... 66
MATERIAL SUBMITTED FOR THE RECORD
Dean Stoline, Deputy Director, National Legislative Commission,
The American Legion, to Diane Kirkland, Printing Clerk,
Committee on Veterans' Affairs, follow-up letter dated
September 12, 2011............................................. 67
PREVENTING SEXUAL ASSAULTS AND SAFETY
INCIDENTS AT U.S. DEPARTMENT OF
VETERANS AFFAIRS FACILITIES
MONDAY, JUNE 13, 2011
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
The Subcommittee met, pursuant to notice, at 3:58 p.m., in
Room 334, Cannon House Office Building, Hon. Anne Marie Buerkle
[Chairwoman of the Subcommittee] presiding.
Present: Representatives Buerkle, Bilirakis, Roe, Benishek,
Runyan, and Michaud.
Also Present: Representative Miller.
OPENING STATEMENT OF CHAIRWOMAN BUERKLE
Ms. Buerkle. Good afternoon. This hearing will come to
I ask unanimous consent that all Members be allowed to sit
on the dais and ask questions of our witnesses today.
Without objection, so ordered. Today the House Veterans'
Affairs Subcommittee on Health will address a very serious
issue, the vulnerability and the underreporting of sexual
assaults and other safety instances at the U.S. Department of
Veterans Affairs (VA) residential and inpatient psychiatric
As a registered nurse and a woman who has been involved in
and a counselor for domestic violence, I have seen firsthand
the pervasive and damaging effects sexual assault can have on
the lives of those who experience it. Last week, the GAO, the
U.S. Government Accountability Office, released a deeply
troubling report entitled ``VA Health Care: Actions Needed to
Prevent Sexual Assaults and Other Safety Incidents.''
GAO found that between January 2007 and July 2010, nearly
300 sexual assault incidents, including 67 alleged rapes, were
reported to the VA Police. Many of these alleged crimes were
not reported to VA leadership officials or the VA Office of the
Inspector General (OIG), in direct violation of VA policy and
The findings of the GAO are disturbing for many reasons.
Foremost, they represent a betrayal of trust by a system that
was designed to treat our veterans at their most vulnerable.
The gross failure of VA leadership to protect the safety and
security of our veterans and VA staff, and systematically
report and respond to sexual assault and safety instances is a
contempt of justice that also requires immediate action.
This is not the way to run a health care system, and it is
certainly no way to treat the men and women who sacrificed so
much on behalf of our Nation. Abuse like the kind the GAO
references in their report is repugnant and inexcusable. But
for it to occur in what should be an environment of healing for
our wounded warriors is an affront to the VA's very mission.
So disturbed was I upon reading an early draft of the GAO's
report that I, along with Chairman Miller, introduced
legislation to ensure a safer and more secure VA medical
facility. Our bill, H.R. 2074, the ``Veterans Sexual Assault
Prevention Act,'' would address the Department's safety
vulnerabilities, security problems, and oversight failures, and
create a fundamentally safer environment for our veterans and
our VA employees.
Never should a warrior in need take the brave step of
getting help and be met with anything less than safe,
supportive, and high quality care in an atmosphere of hope,
health, and healing. Let me assure each of you that I and the
other Members of this Committee will remain committed to
righting the many wrongs uncovered by the GAO. I am honored
that our esteemed Chairman of the Veterans' Affairs Committee
has joined us today, Mr. Jeff Miller, to participate in this
And I yield to you, Mr. Chairman, for any comments you may
[The prepared statement of Chairwoman Buerkle appears on p.
OPENING STATEMENT OF HON. JEFF MILLER
Mr. Miller. Thank you, Madam Chairwoman, for yielding and
giving me the opportunity to speak here today. I, like I think
all Members of this Committee, were sickened by what we read in
the GAO report. The prevalence of sexual assault incidents at
VA facilities, the lack of accountability from VA and its
leadership, and the lack of safeguards in place for the
victims. As a co-requester of the investigation, along with the
Ranking Member, Bob Filner, I contacted Secretary Shinseki and
urged him to provide an immediate response to the GAO report
and to make it public so that we could have this hearing today.
I appreciate the Secretary working diligently to do that so
that we could move forward.
We found these findings so egregious that Ms. Buerkle and I
decided to act immediately by introducing what you have just
talked about, H.R. 2074. We intend to move this legislation
expeditiously so that veterans are not undermined by the very
system which is supposed to be protecting them.
In the past week, some have dismissed these allegations,
comparing the size of the VA system and the number of
allegations to the private sector. Let me be very clear: there
is no comparison. Just one assault of this nature, one sexual
predator, one veteran's rights being violated within the VA is
one too many, and is absolutely unacceptable. If we need to do
more as a Committee to protect our veterans and employees at
VA, we will.
I understand that rape in particular has always been a
difficult charge to prosecute. And though we have made strides
in getting victims to speak out, we know that for every rape
that is reported, many more go unreported. Therefore, we need
to know how many victims have not spoken out and how we can
reach out to them so that not only is justice done, but so that
we can provide them with the proper care and support.
Today we expect to get answers to the following questions:
How widespread are assaults at VA facilities due to the lack of
reporting protocols at VA? How many cases have been prosecuted?
How many are still pending? How many employees who allegedly
perpetrated assaults are still working at VA? What has been
done to protect patients from fellow patients? And, what is VA
doing to ensure that this never, never happens again?
I was looking in some of the citations of the report, on
page eight specifically, where it says criminal matters
involving felonies must be immediately referred to the VA
Office of Inspector General (OIG) Office of Investigations. VA
management officials with information about possible criminal
matters involving felonies are responsible for prompt referrals
to the OIG. It goes on to talk about examples of the felonies.
One of those is in fact rape.
Also, VA defines serious incidents as incidents including
incidents on VA property that result in serious illness, bodily
injury, including sexual assaults. Why were these not forwarded
The safety and security of our veterans is paramount. This
Committee will demand answers to assure fellow veterans and the
public that VA facilities are safe havens for our veterans and
VA employees, and that nobody's rights are violated.
Madam Chairwoman, thank you for your interest in taking
this issue so seriously and working on this piece of
legislation. I appreciate the opportunity to be here today with
you and my good friend, the Ranking Member, Mr. Michaud, and I
[The prepared statement of Congressman Miller appears on p.
Ms. Buerkle. Thank you, Mr. Chairman.
And thank you for joining us this afternoon.
I will now recognize the Ranking Member, Mr. Mike Michaud.
OPENING STATEMENT OF HON. MICHAEL H. MICHAUD
Mr. Michaud. Thank you very much, Madam Chair, and good
I first of all would like to thank everyone for attending
this extremely important hearing this afternoon. The purpose of
today's hearing is to examine how changes in patient
demographics present unique challenges for VA in providing safe
environments for all veterans treated at VA facilities. In
2008, I requested the GAO report on women's veterans services,
such as research on unique physical and mental health treatment
needs of female veterans, how VA was addressing the needs of
women veterans, what health care services offered by VA are
tailored to women veterans, and barriers that may prevent women
veterans from accessing VA health care services.
In July of 2009, this Subcommittee held a hearing on the
findings of that report. During the conduct of this report, GAO
was made aware of safety issues involving women veterans and
sexual assaults in some VA facilities. Subsequent to that
report, then the full Chairman, Mr. Filner, submitted a request
for GAO to look further into sexual assault incidents.
We know that the wars in Afghanistan and Iraq have been an
unprecedented call upon our National Guard and Reserve
components. Today, women serve in the Guard and Reserves at a
rate over 17 percent, which is 3 percent higher than that of
active-duty military. VA recently reported that within 10
years, women are expected to become 10 percent of VA's patient
population. However, the VA health care system was built to
accommodate the war-related illnesses and injuries of male
As women are serving in combat conditions alongside their
male counterparts, it is important for the Department to
embrace and recognize the needs of all veterans, both men and
women alike. In the 110th and 111th Congresses, this Committee
held a series of hearings to examine the needs of women
veterans. The veterans who testified shared their stories of
feeling unwelcome, alienated, and disrespected in some VA
medical centers, so that they are now reluctant to pursue the
benefits and services that they have earned with their service
to our country.
Women veterans should not have to worry about being subject
to cat calls upon entering a facility. And they should
certainly not have to worry about falling victim to sexual
assault while receiving care.
While sexual assault is often considered an issue only
affecting women, in fact, both men and women have suffered
sexual assaults. Further, victims may be assaulted by predators
of the same or the opposite sex. Like other types of trauma,
sexual trauma can leave lasting scars upon the physical and
mental health of its victims.
The GAO has recently uncovered many of the nearly 300
sexual assault incidents reported to the VA Police since 2007
that were not reported to the VA leadership. Incidents like
this simply should not happen and need not happen. When
policies and procedures are not in place or, worse, not
followed, we fall short of our national commitment to provide
the utmost level of care possible.
I want to thank our panelists today for appearing today. I
am committed to working with you and the Chairwoman of this
Subcommittee to ensure that the safeguards are in place so that
no veterans, male or female, fall victim to sexual assault
under the VA care.
With that, I yield back, Madam Chair.
[The prepared statement of Congressman Michaud appears on
Ms. Buerkle. Thank you, Mr. Michaud.
We will now welcome our first panel to the table. Joining
us is Mr. Randall Williamson, Director of Health Care for the
Government Accountability Office; Mr. Joseph G. Sullivan,
Deputy Assistant Inspector General for Investigations from the
VA Office of the Inspector General; and Mr. William Schoenhard,
VA's Deputy Under Secretary for Health Operations and
Management, Veterans Health Administration (VHA).
Accompanying Mr. Schoenhard is Dr. Arana, the Acting
Assistant Deputy for Health for Clinical Operations; and Mr.
Kevin Hanretta, the Deputy Assistant Secretary for Emergency
Gentlemen, thank you all for joining us this afternoon.
Mr. Williamson, if you would please proceed.
STATEMENTS OF RANDALL B. WILLIAMSON, DIRECTOR, HEALTH CARE,
U.S. GOVERNMENT ACCOUNTABILITY OFFICE; JOSEPH G. SULLIVAN, JR.,
DEPUTY ASSISTANT INSPECTOR GENERAL FOR INVESTIGATIONS, OFFICE
OF INVESTIGATIONS, OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT
OF VETERANS AFFAIRS; AND WILLIAM SCHOENHARD, FACHE, DEPUTY
UNDER SECRETARY FOR HEALTH FOR OPERATIONS AND MANAGEMENT,
VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
AFFAIRS; ACCOMPANIED BY GEORGE W. ARANA, M.D., ACTING ASSISTANT
DEPUTY UNDER SECRETARY FOR HEALTH FOR CLINICAL OPERATIONS,
VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
AFFAIRS; AND KEVIN HANRETTA, DEPUTY ASSISTANT SECRETARY FOR
EMERGENCY MANAGEMENT, OFFICE OF OPERATIONS, SECURITY, AND
PREPAREDNESS, U.S. DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF RANDALL B. WILLIAMSON
Mr. Williamson. Thank you, Chairwoman Buerkle, Ranking
Member Michaud, Mr. Miller, and Members of the Subcommittee.
I am pleased to be here today to discuss GAO's recent
report on sexual assault incidents at VA medical centers, known
as VAMCs. On a prior GAO study, VA clinicians had expressed to
us concerns about the safety of patients treated in VA mental
health programs that also housed veterans who had previously
committed sex crimes.
Subsequently, we performed this study of sexual assault
incident reporting and safety precautions. Our review of
incident reporting examined these incidents VA-wide, while our
review of safety precautions focused on five selected VAMCs,
focusing on residential treatment and inpatient mental health
units. We found numerous areas that need improvement to better
ensure the safety of VA patients and staff alike.
For the period January 2007 to July 2010, we identified 284
sexual assault incidents that were reported by VA Police at 105
different VAMCs. These incidents were suspected, alleged,
attempted, and confirmed sexual assaults involving both men and
women, including 67 rapes, 185 inappropriate touching
incidents, and 32 other types of sexual assaults. Most of the
alleged perpetrators and victims were VA patients and
We found that many of the alleged sexual assault incidents
were not reported to VA management or to the VA Office of
Inspector General. For example, of the 67 alleged rape
incidents reported to the VA Police, only 25 were reported to
the Office of Inspector General, as required by VA regulation.
Also, we contacted officials at four Veterans Integrated
Services Networks (VISNs), and found that of the 102 alleged
sexual assault incidents reported to VA Police at 29 VAMCs
within these VISNs, only 16 were reported to VISN leadership,
and only 11 of these were forwarded to the VA Central Office.
Several factors may contribute to this underreporting.
First, VA does not have a common definition of sexual assault
for reporting purposes. VAMCs we visited varied in the level of
detail of their definitions, including one with no definition
at all. VISNs had no definitions in their written VISN
policies, and VA Central Office has no definition of sexual
assault in its reporting guidance.
Second, VA at all levels does not have clear expectations
about the types of incidents that should be reported. For
example, VA Police files from one VAMC we visited showed that
three alleged perpetrators had been involved in previous sexual
assault incidents that were not reported to VA Police because
VA clinicians believed that these behaviors were a
manifestation of a clinical condition. Also, leadership at one
VISN told us they expected to be informed of all alleged sexual
assault incidents. However, we found three alleged incidents of
rape and one oral sex incident that was not reported to this
We also identified a number of shortcomings that may hinder
effective oversight of sexual assault incidents by Central
Office. For one, VA has no system that ensures that pertinent
program offices receive all reports of sexual assault incidents
that occur in their areas of responsibility. For example, we
found that VA Central Office managers of the residential and
inpatient mental health programs were not always aware of the
sexual assault incidents that had been reported by their units
in the field.
Also, there is no central database to collect and store
reports of sexual assault or any mechanism to systemically
analyze reports and identify trends. Such analyses are
important to assess the extent of sexual assaults across VAMCs
and to identify methods for preventing future incidents.
Finally, we observed and tested security precautions at
five VAMCs we visited, with some disturbing results. For
example, police command centers at these VAMCs were sometimes
unattended, understaffed, or could not monitor residential
treatment facilities due to incompatibility in surveillance
We also noted malfunctions in panic alarm systems. For
example, at four VAMCs the panic alarms we tested either did
not appropriately alert VA Police of the location of an alarm
or were previously disabled without notifying staff. Finally,
at all five VAMCs, panic alarm systems did not alert both VA
Police and staff on the unit. While we found significant
security lapses at these five VAMCs, we did not attempt to link
such lapses to specific sexual assault incidents.
In summary, underreporting and poor oversight of sexual
assault incidents, coupled with security lapses at VAMCs, can
severely compromise the safety of patients and VA staff alike.
Decisive actions are needed to correct weaknesses and to better
ensure that VAMCs maintain a safe and secure environment. In
our report, we recommended a number of specific actions VA can
take to accomplish this. That concludes my opening remarks.
[The prepared statement of Mr. Williamson appears on p.
Ms. Buerkle. Thank you, Mr. Williamson.
Mr. Sullivan, you may proceed.
STATEMENT OF JOSEPH G. SULLIVAN, JR.
Mr. Sullivan. Thank you, Madam Chairwoman, Members of the
Subcommittee. Thank you for the opportunity to discuss with you
how the Office of Inspector General interacts with the VA
Police with regards to reporting felonies, to include sexual
assaults at VA facilities and also to tell you what we provided
to the GAO for their report.
I am the Deputy Inspector General For Investigations. The
Office of Investigations is responsible for conducting criminal
and administrative investigations where wrongdoing occurs or is
alleged in VA programs or operations, as well as serious
misconduct by senior officials. We have 141 criminal
investigators at 29 field offices across the country.
The VA Police are a separate entity from the Office of
Inspector General in that they are a uniformed police service
located at and responsible for the security of the medical
centers and other Department facilities. And they have
jurisdiction for crimes that occur on VA property. There are
two sections of the Code of Federal Regulations (CFR), which we
have been mentioned that require all VA employees to report
suspected criminal behavior to VA management and/or the OIG: 38
CFR, Section 1.201, requires employees with knowledge or
information of possible criminal violations related to VA
programs and operations to report that information to their
supervisor, any management official, and the OIG; 38 CFR,
Section 1.204, requires VA management with information about
possible criminal matters involving felonies are to ensure and
be responsible for reporting that information to us.
While our field supervisors report that generally VA Police
chiefs are complying with this reporting requirement in the
CFR, they are aware of instances where failure to timely report
suspected felonies does occur. When we become aware of such
situations, our field supervisors will visit with the police
chief, share our concerns with them, and remind them of their
reporting responsibilities under the CFR
Now, with regards to the GAO report, I would like to share
with the Subcommittee what we provided to GAO. They requested
information about allegations of sexual assaults for the period
of January 1, 2007, as was said, through August 1, 2010. And we
provided detailed information about our 130 closed
investigations. We also provided GAO with de-identified
information regarding nine sexual assault investigations that
remained open back on August 1, 2010.
Next, GAO asked that we review 42 scenarios regarding
alleged sexual assaults that had occurred on VA property but
were not, according to GAO research, referred to us by the VA
Police. We had four senior agents look at these scenario
descriptions and concluded the following: In 23, or 55 percent
of the scenarios, we would not have expected VA Police to
notify us. Examples included allegations that lacked any
evidence of sexual assault obtained as a result of a medical
examination, and a victim who quickly recanted her original
In 14, or 33 percent of the scenarios, we would have
expected VA Police to notify us. Examples included a victim
with dirt and leaves on her clothes and in her hair, who
reported that she had been raped while walking the grounds of
the VA facility. We also had a female physician who reported
that a male sexually assaulted her while she was conducting a
medical examination. Those are two examples we would have
expected to be referred.
In five, or 12 percent of the scenarios, we just couldn't
make a judgment because they were either too ambiguous or
inadequate information was provided in the scenario
description. We welcome GAO's recommendations to automate
reminders to VA Police to notify us when entering a felony
offense into the police database, and we are pleased with VA
Police's intention to also implement an automated notice to our
field offices whenever the record of such an offense is
created. We believe both measures will greatly reduce the
number of times where we will not be notified in the future.
Madam Chairwoman, this concludes my statement, and I would
be happy to answer any questions you or Members of the
Subcommittee may have.
[The prepared statement of Mr. Sullivan appears on p. 52.]
Ms. Buerkle. Thank you, Mr. Sullivan.
Mr. Schoenhard, you may proceed.
STATEMENT OF WILLIAM SCHOENHARD, FACHE
Mr. Schoenhard. Chairman Miller, Chairwoman Buerkle,
Ranking Member Michaud, and Members of the Committee, thank you
for the opportunity to discuss the safety and security of our
veterans, employees, and visitors.
This issue is a top priority of Secretary Shinseki and of
our Department. We constantly strive to ensure a safe
environment, and we appreciate and accept the eight
recommendations in the GAO report. We owe a safe environment to
everyone who enters our doors, whether they be visitor,
patient, staff. Anyone who is in our work environment deserves
a safe environment.
And as Chairman Miller said, one incident in which one of
our patients, visitors, or staff feels victimized is one too
many. We deeply regret that anyone would feel victimized and
experience any kind of victimization at one of our facilities.
As a Vietnam veteran and someone who comes to VA with 34
years of experience in the private sector, I am impressed that
VHA provides exceptional service in what is the most mission-
driven organization I have ever been accustomed to or
experienced. We are a large integrated system, and we have 14
points of care, but as Chairman Miller pointed out, one
incident of anyone feeling victimized is one too many.
The GAO report rightly identifies recommendations for
improvements in preventing assaults and in reporting incidents.
First, we must do all we can to prevent harm. We need to
explore every opportunity we can for prevention of anyone
feeling victimized in our facilities. That starts with VA
staff, with police officers, with all of our staff involved in
training, background investigations, and ongoing vigilance of
watching our environments and in taking immediate steps when
anyone looks as if they may be at risk.
It also requires that we have physical systems in place,
such as panic alarms and closed-circuit television, locks on
our doors, and all that is important for physical security.
Last Friday evening, I issued a directive to all of our VISN
directors asking for a report by June 24 of all review of
physical infrastructure in terms of prevention that goes into
serving as a deterrence for anyone feeling victimized.
And in terms of reporting, when we look at that, as
Secretary Shinseki says, we cannot solve a problem we cannot
see. Full and complete reporting is essential to a full
investigation of any incident that has been reported. It is
also important in that we can aggregate this data, develop
system review of the trends, and develop best practices, and
learn from our experience in order to make, again in the
prevention area, our facilities even safer.
Our Under Secretary for Health, Dr. Petzel, has
commissioned a work group chaired by Dr. Arana and Dr. Patricia
Hayes, who is our chief consultant for women's services, and
that work group is undertaking review of all eight
recommendations, but particularly focused on the reporting,
with a requirement that by July 15, we receive an initial
action report, with a final report of its work by September 30.
As we did Friday, we will be immediately following up on any
action the work group stimulates for our review. And they have
met several times, including this afternoon.
One of the important advances in reporting is the standup
of our Integrated Operations Center, or IOC, which was stood up
in 2009. This operates 24 hours a day, 7 days a week. It has a
VHA watch officer as part of that team. And it is important
that we, as was pointed out by Mr. Williamson and others,
ensure timely reporting of any report that especially has to do
with criminal behavior to the IOC. The requirement is that that
be accomplished within 2 hours. While GAO has identified
instances where senior VA leadership were not informed, I do
wish to assure the Committee that I have every confidence at
the local level, when an incident is reported, that local
management, in cooperation with the VA Police and with local
law enforcement, are investigating these allegations in every
way that we possibly can, working closely with law enforcement
also to pursue criminal prosecution to the extent the law
Let me repeat again: One incident is one too many. We owe
our veterans, our staff, our patients, our visitors, everyone
who is associated in our work environment, a safe environment.
Our veterans have served this country with distinction. As
Madam Chairwoman so eloquently said, we owe them a place of
healing, of hope, of respect. And as a mission-driven
organization, this is important I think beyond policy, beyond
reporting. That is all important. It gets to the culture of
VHA. It gets to a care and concern on the part of everyone for
what is going on in their environment, and a commitment to
ensuring that the utmost of respect is afforded everyone with
whom we serve and that we serve.
Thank you for the opportunity to testify. My colleagues and
I will be happy to answer questions.
[The prepared statement of Mr. Schoenhard appears on p.
Ms. Buerkle. Thank you, Mr. Schoenhard.
I yield to Chairman Miller for 5 minutes for questions.
Mr. Miller. Thank you for yielding. The report covers 2007
to July of 2010. Can you tell me what the statistics are from
July of 2010 until today of sexual assaults that have been
reported within the system?
Mr. Schoenhard. Sir, we do not have that information
available here today, but we will provide that to you.
Mr. Miller. Would it have been a reasonable expectation
that somebody might be asking that question?
Mr. Schoenhard. We had not anticipated that question. But
we do have the information, and we can provide that to you in
short order, sir.
Mr. Miller. If you would, for the record, so that we can
make sure that all Members have the answer to that question.
When can we expect it?
Mr. Schoenhard. We would provide that, sir, within 3 weeks?
Mr. Miller. Three weeks?
Mr. Schoenhard. Yes, sir. I want to make sure that we have
all the information together in a complete way. We will try to
provide it sooner.
[The VA subsequently provided the following information:]
Thursday, June 30, 2011
INTERIM REPORTS OF RAPE, INAPPROPRIATE TOUCHING OR
OTHER SEXUAL ASSAULT IN VHA WORKPLACES
BETWEEN AUGUST 1, 2010 AND MAY 31, 2011 \=\
National Counts of Sexual Assault Incidents in VHA \*\
Substantiated \**\ Un-Substantiated \***\
Reported to Reported to
Type of Incident \\ Total Total OIG Total OIG
Alleged/Attempted Rape 6 2 2 4 4
Inappropriate Touching of a Sexual 78 31 7 47 4
Alleged Sexual Assault/Other 57 21 7 36 5
TOTALS 141 54 16 87 13
\*\ Information is still under review regarding facility reports, police reports and substantiation of
\\ As reported in the 10N Sexual Assault Management/Police Roll-up Database.
\**\ Sexual Assault Incidents as defined below and verified by VA Police and/or Clinical Staff.
\***\ Sexual Assault Incidents as defined below, which following VA Police and/or Clinical Staff investigation/
review were not substantiated.
\\ [Update as of September 23, 2011: This report is still interim as cases remain under investigation and so may
change categories. VA will be sure to present a final report once it can confirm that all cases have closed.]
To ensure accurate reporting, sexual assault is defined as:
``Any type of sexual contact or attempted sexual contact that
occurs without the explicit consent of the recipient of the
unwanted sexual activity. Assaults may involve psychological
coercion, physical force, or victims who cannot consent due to
mental illness or other factors. Falling under this definition
of sexual assault are sexual activities such as [but not
limited to] forced sexual intercourse, sodomy, oral
penetration, or penetration using an object, molestation,
fondling, and attempted rape. Victims of sexual assault can be
male or female. This does not include cases involving only
indecent exposure, exhibitionism, or sexual harassment.''
Of t he 54 substantiated incidents, the relationship of
perpetrators to victims includes:
Patient on employee (charges filed)
Patient on patient (U.S. Attorney declined
prosecution based on evidence compiled)
(19) Patient on employee
(13) Patient on patient
(11) Employee on patient
(6) Employee on employee
(2) Non-patient or employee on employee
(1) Volunteer on employee
Actions VA is Taking
It should be noted that VA is undertaking efforts to ensure
that every alleged sexual assault event is identified and
tracked by the Department.
Timely Reporting: The VA has established a policy
to ensure that every alleged sexual assault incident is
reported to a national incident center within 2 hours. This
reporting provides leadership with visibility to ensure that
each event is resolved.
Integrating VA Law Enforcement with Clinical Care:
The VA is performing a review of VA law enforcement personnel
classification and compensation. Currently, VA law enforcement
staff members are graded below those of comparable staff from
other agencies. The VA is assessing integration of VA law
enforcement personnel within Title 38. It is critical that VA
facility staff and policies view VA law enforcement as an
integral team member in establishing a safe, secure environment
Focusing on Prevention: VA will review critical
elements for the prevention of sexual assault in our work areas
by focusing on:
1. behavioral surveillance by all VHA staff;
2. environmental surveillance through the use of
technology and specific safety equipment;
3. education of patients, staff and visitors; and
4. review and revision of VHA policy as it pertains to
Mr. Miller. I hope that you have all the information
together, and it won't take you 3 weeks. Further, ongoing
investigations by Oversight and Investigations, our
Subcommittee, shows that senior leadership at least one
facility that we are aware of siphoned money away from facility
security to provide funds for other projects. I have also been
told that staffing security billets, there is some evidence
that senior leadership at VA do not see the value of their own
security forces. And these consequences of failures involving
these is unacceptable, as you might imagine. But what I want to
know is, how can we be sure that VA is spending the money that
this Congress allocates to them appropriately?
Mr. Schoenhard. Sir, that is incumbent on us in leadership
to ensure that the funds that are allocated for the purposes
that are intended are spent for the purpose that the Congress
and all of our appropriators assure. And I guarantee you we
will follow up with any instance in which that is not done.
Mr. Miller. And then thirdly, I think it is ironic, I went
to your Web site this afternoon and found a tab, ``Women
Veterans Health Care, Military Sexual Trauma.'' And of course,
this deals with women's sexual trauma. But as we know from the
report, this is men and women.
Mr. Schoenhard. Yes.
Mr. Miller. But it just opens up with the question, ``Did
you experience any unwanted sexual attention, uninvited sexual
advances, or forced sex while in the military? Does this
experience continue to affect your life today?'' And I guess my
question is, don't you find that ironic that this is on the
VA's home page?
Mr. Schoenhard. Well, sir, we want to be able to invite our
veterans who have made--perhaps have experienced that to come
forward so that we can treat them.
Mr. Miller. I yield back.
Ms. Buerkle. Thank you, Mr. Chairman.
I will just use the last few minutes of the time, if that
is okay. Mr. Schoenhard, I want to just go back to some of your
comments that you made in your opening statement that I find
disturbing and really don't assure me that things are going to
happen quickly enough.
Mr. Schoenhard. Okay.
Ms. Buerkle. You mentioned that you are going to review all
eight GAO recommendations, and then by July 18, we are going to
get an initial action report. What is an initial action report?
Mr. Schoenhard. Madam Chairwoman, the requirement by July
15 would be that an action set of recommendations be put forth
to the Under Secretary for our review. But we are looking for
any information that can be forthcoming sooner than that. I
don't know if Dr. Arana may want to speak. He is co-chairing
that group, and may want to elaborate.
Dr. Arana. Madam Chairwoman, the group has met about four
times in the past week and a half. It is an interdisciplinary
group that includes security, includes caretakers, providers.
It includes specialists in sexual trauma from all over the
country. And the plan is, by July 15, to have a clear
definition of what sexual assault is, and a clear way to track
and trend that over the next few years. The plan is to put that
in place by July 15.
Also, the plan is to look at behavioral surveillance
techniques that we already use in some facilities but we want
to promulgate out to the entire system. And we also will look
at technical surveillance devices so that we can improve our
ability to survey clearly behaviors during off hours and in
more remote places. So the plan is if we find something in the
next week or 10 days that we want to execute and put in place,
the Under Secretary and Mr. Schoenhard have told us, tell us
what it is, and we will deploy it immediately. So I think the
plan is to really move on this as quickly as we can and be able
to report out finally sometime in August about what actions we
have taken and how we plan to track and trend that.
Ms. Buerkle. Thank you.
I yield 5 minutes to the Ranking Member, Mr. Michaud.
Mr. Michaud. Thank you very much, Madam Chair.
At the VA, of the 46 incidents where the employees of the
VA were charged or involved in patient sexual assault, what has
been the disciplinary action to those employees, if any?
Mr. Schoenhard. Mr. Ranking Member, we are working with the
GAO to make sure we understand the specific cases that are
mentioned in the 284. And we will be following up. I can assure
you this: Every disciplinary action appropriate has an
important element of ensuring first and foremost that the
veteran or the patient is no longer at risk. And so we are
working with the GAO to identify specifically who they have
identified in order for that information to be provided.
Mr. Michaud. So you don't know if you fired anyone because
of rape or sexual assault?
Mr. Schoenhard. Yes, we have.
Mr. Michaud. You have?
Mr. Schoenhard. Yes. Let me be clear. We certainly have
cases where employees have been terminated. We have had cases
where employees have been convicted. And we have certainly a
variety of other instances of disciplinary action. What I want
to be clear about, Mr. Ranking Member, is that we are working
with the GAO to be sure we understand what 284 instances were
identified in their review, which we do not have at this time.
Mr. Michaud. And the Vietnam Veterans of America, actually
they recommend or point out the need for separate facilities or
wards for female patients seeking long-term care. Do you have
any comment on that? What settings have the VA set up that
actually would allow for separate wards or separate facilities?
Mr. Schoenhard. Well, it is certainly important that we
provide privacy, respect, and courtesy to our female veterans,
an ever-growing number of veterans in our service of those who
have served this country. A number of facilities have been
constructed throughout VHA in order to provide separate access
and concentration of women's services for female veterans. And
we are committed, sir, to continuing that investment. It is
important that our veterans be treated with dignity and
The comment was made earlier regarding cat calls and the
rest. We need to ensure that there is privacy. With regard to
residential treatment centers and community living centers,
female veterans are isolated closer to the nursing stations so
that they can be more closely monitored by the nurses and are
certainly kept, as much as we can, separate from male veterans.
And we will continue that commitment to ensuring we have the
facilities and the program to treat our female veterans, an
ever-growing number of veterans that we serve.
Mr. Michaud. And what type of training do the VA Police go
through? Are they all VA employees? Or do you contract those
services out? And if so, what type of training do they have to
Mr. Schoenhard. Sir, that is a great question. If I could
call on Mr. Hanretta to perhaps comment.
Mr. Hanretta. Sir, the VA Police, every VA Police officer
attends the law enforcement training academy, the VA law
enforcement training academy in Little Rock, Arkansas. It is an
8-week program, where they are certified as VA Police officers
and working in a health care environment. So their sensitivity
to respect responding to incidents and reporting is emphasized
throughout the training.
Mr. Michaud. My last question, I only have 40 seconds, is
how is the VA staff notified that they are treating or housing
a convicted sex offender?
Mr. Schoenhard. I might call on Dr. Arana, who could give
more experience from his own clinical care. But there are
universal precautions that are taken in being able to interview
our patients and our veterans. And this, by the way, is a
subject of our work group that will be undertaking the best
practices, a full literature search. We think there is an
opportunity to improve our capacity to determine those who may
be at risk in order to protect those that are treated in our
I don't know, Dr. Arana, if you would want to add to that.
Dr. Arana. The expectation is that all patients who are
seen in mental health services, whether they are long term or
acute, have a what we call biopsychosocial assessment, which
includes a legal history and a history of trauma. And the plan,
therefore, is put together for the care of that particular
veteran based on that history. Now, it is the case that the GAO
did outline one of the recommendations is we needed to improve
our ability do that. And we agree 100 percent with that.
Mr. Michaud. Thank you.
Ms. Buerkle. Thank you, Mr. Michaud.
I now yield 5 minutes to the gentleman from Michigan, Dr.
Mr. Benishek. Thank you, Madam Chairwoman.
I just have a couple questions about the testimony. And one
of the things that sort of surprised me was from Mr. Sullivan's
statement here, that the GAO had requested the review of some
scenarios that hadn't been reported by the VA Police to the
OIG, and that 45 percent of the cases that they brought up, you
know, 33 percent said they should have been expected to be
reported, and the other five cases, there was an inability to
make a judgment because of the ambiguous or inadequate
information in the scenario description. It just seems to me
that, you know, nearly half of the cases that weren't reported
seem to show some sort of lack of police procedure really. I
mean, five cases don't have adequate information in the report
to make a decision and 33 percent seem like they just were
improperly reported. That is a relatively high number.
Do you have any information, Mr. Sullivan, on whether there
is any investigation into the caliber of training? I mean 8
weeks doesn't seem like a very long period of time I guess for
officer training. Have we done anything about this statistic?
Mr. Sullivan. To your first question, I would be reluctant
to comment on the training that is afforded the VA Police
But by contrast, recognizing that the majority of our
agents already come to us well trained from other traditional
Federal law enforcement agencies, such as the Federal Bureau of
Investigation, the Secret Service, the Postal Inspection
Service, Immigration and Customs Enforcement, they come ready
to work and with a wealth of experience to be able to adapt to
any criminal investigation because of their experience. To
transition to Inspector General investigations they will then
attend Inspector General training for 3 days. Should we hire
new agents, they will attend an 18-week course at the Federal
Law Enforcement Training Center in Georgia. That is followed by
courses offered at the Inspector General Academy. It is a very
robust training program that continues throughout the remainder
of their career. Even I have to go through periodic training.
So it is a healthy program. It is a good program. I suggest Mr.
Hanretta comment on the police training.
Mr. Benishek. I just say, doesn't it seem somewhat
remarkable there were 45 percent of the cases that were brought
forth without a very good answer?
Mr. Sullivan. It was difficult for us to interpret. As I
understand it, the GAO took the scenario description directly
from the uniform officer report of the VA Police. They didn't
add anything to it; they didn't delete anything from it. Nor
would they share with us any specifics as to the victim, the
perpetrator, or the facility. Had they done so we could have
tracked the allegations back to the VA station where this may
have occurred. We could have formulated in our minds a sense of
what has gone on at the particular facility in the past to
assist us with making our decision as to whether or not the
case should be referred.
Mr. Benishek. So you are saying that you haven't been able
to investigate any of these cases then because you don't know
which ones you are talking about?
Mr. Sullivan. That is right. We don't know. We can't, with
the information provided, go into our system and tell you
whether or not those 42 scenarios are in our open or closed
Mr. Benishek. It seems like we should investigate those
cases, don't you think?
Mr. Sullivan. I do. I think we will follow up once we get a
better understanding of when these alleged crimes took place.
We will also have a conversation with the VA Police officials.
I will tell you, though, in answer to the Congressman's
question, we have presently in our inventory, 17 open sexual
assault allegations that we are investigating. We had a total
of 139 during the period of the GAO review. And 23 were
successfully prosecuted of the 139.
Mr. Benishek. All right. I guess my time is up. But I would
like to ask the Chairwoman if we could get some additional
information going further here to make sure that we actually
follow up on these, in that the GAO and the Inspector General's
office figure out where these cases came from and if there is
really a problem.
Mr. Sullivan. Yes. The exercise for us was nothing more
complicated than here are some scenarios; would you or would
you not expect the VA Police to refer them to you? Not would
you or would you not choose to investigate.
Mr. Benishek. I see.
Ms. Buerkle. Thank you, Dr. Benishek.
I now yield 5 minutes to Mr. Bilirakis from Florida.
Mr. Bilirakis. Thank you, Madam Chair.
I appreciate it very much. This question is for Mr.
Schoenhard. One of the GAO's recommendations was to increase
security by involving stakeholders into facility design and
redesign. I just received word, a VA announcement that a $92
million contract was awarded to construct a new mental health
facility at Bay Pines in Florida. This facility will provide
residential rehabilitation, acute inpatient mental health
services, and outpatient mental health services. This is the
question: Were stakeholders, including the clinicians who will
provide the care, involved, were they involved in the design of
this project? And if not, why?
Mr. Schoenhard. Sir, if I could take that question, I will
find out for sure. It is absolutely essential that they are
involved, because it is important that when an alarm is
activated that not only law enforcement, but clinicians are
immediately notified. So I will follow up and take that
question, sir, and find out.
Mr. Bilirakis. Please. I would like you to please get back
to me on that as soon as possible.
Mr. Schoenhard. Yes, sir.
[The VA subsequently provided the following information:]
It is standard practice to provide clinical professionals
extensive input opportunities in each phase of the design for a
new facility. Participants from the Bay Pines Mental Health
clinical staff, including the Chief of Mental Health and the
Chief Nurse for Mental Health, attended numerous meetings to
provide input into the location of the building, the
architectural design, and the layout and function of each room
and in design review meetings at each phase in the process.
Overall, representatives from the Medical Center have been
active throughout the design process. The design phase of the
new Mental Health Center at Bay Pines VAMC is complete and a
construction contract has been awarded. Clinical staff will
continue to be consulted as construction progresses. Updates
are regularly provided to our Mental Health Consumer Council,
comprised of Veterans.
Mr. Bilirakis. Then also how are the needs of veterans, and
I know you touched upon this, especially women veterans, and
you just touched on it briefly, so if you can elaborate on
that, with regard to privacy and safety being taken into
consideration? How are women veterans and veterans in general,
as far as privacy is concerned, taken into consideration when
these buildings are designed?
Mr. Schoenhard. Well, it is important that we have the
physical security of electronic locks and key cards to ensure
privacy. I think that especially as it relates to care for
female veterans, we need to continue to focus not only on
facility development to serve their needs, but programmatic
development. And we do have a strong program office that is
working to ensure that we have both.
Mr. Bilirakis. Give me an example of what you have done so
Mr. Schoenhard. Well, we have constructed on a number of
our campuses specific new clinics that are separated from the
main frame medical center for care for women. And we have also
designed throughout VHA specific specialty clinics for women
who have suffered sexual trauma. Dr. Arana may want to speak
more regarding the clinical care, if you have anything that you
would want to add.
Dr. Arana. Yeah. In addition, sir, we have--the women's
program has reviewed all the facilities in the system. And
there are recommendations that have been laid out for
increasing security and also increasing privacy. And that is
something that is tracked by women's health coordinators at
Mr. Bilirakis. Thank you.
Next question for Mr. Schoenhard, and then also Mr.
Williamson. In the GAO report, one item addressed was
vulnerabilities in physical security precautions. GAO
recommended and VA agreed that alarm systems should be
routinely tested. How frequently do you believe that these
tests should be happening to ensure that they are optimally
working? And will you elaborate on where you believe
responsibility should fall to ensure these tests are happening?
Mr. Schoenhard. Sure. Sir, that is a great question. And
let me answer in reverse order. The responsibility to ensure
that the testing is done and that the alarms work lies with the
medical center director, the VISN director, myself, and on up
to the Under Secretary. We have the con for that
In hospitals throughout the Nation, this is typically a
policy that is developed at the local level in conjunction with
Joint Commission standards, our accrediting body. But part of
what we want to do in this small work group, and part of what I
want to know by June 24 from our VISN directors, is the current
state of that. And I think that we will be providing, sir,
additional guidance beyond what medical center policies have
developed over time in order to meet accreditation
requirements. And we will also do that based upon what we find
from this system-wide thorough survey of our physical alarm
Mr. Bilirakis. Okay. Thank you very much.
I yield back, Madam Chair.
Ms. Buerkle. Thank you. I now yield 5 minutes to the
gentleman from Tennessee, Dr. Roe.
Mr. Roe. Thank you for yielding.
Just an opening comment. Hospitals in general, and VA
Hospitals specific, should be places to heal, not harm, as all
medical facilities should be. And it should be a safe
environment whether you are a patient there or just a visitor
there. Having dealt with this for over 30 years, rape is one of
the most underreported crimes out there. And it is probably
handled as poorly as anything we do about how the emotional
effect on the victim, and how we deal with it. So it is
imperative that we do that.
A second thing I think that is really important that has
not been mentioned, I know that when I was mayor of Johnson
City, Tennessee, we paid a lot of attention to crime mapping.
Where did it occur? And that is why this reporting is so very
important, because if you notice a pattern, maybe it is in a
certain part of the hospital, or a community-based outpatient
clinic (CBOC), or wherever it may be, you then can point to
that area about how to secure it. So I think that is very
important about the mapping process about where these crimes
occur. If they are random, then it is much harder. But if there
is a trend there, it is pretty easy to focus on that and reduce
the problem dramatically, whether it is in the clinic or
hospital. Just a point that it is not just gathering data to be
sent up to sit on a shelf somewhere.
The other thing I would recommend you do, and you probably
have done it, but in your Committee that gets together, I would
get some worker bees, folks that are out there everyday on the
clinical side working, who are out there working with the
patients. So I don't know whether you have done that or not,
but I would strongly encourage you to do that.
And to Mr. Michaud, what he was saying a minute ago, in his
comment about someone who may be questioned, and I know Dr.
Arana was mentioning this, but there is no way to do a
background check and check and see if what somebody is telling
you is the truth? In other words, if a sexual predator, I think
that is what he was getting to, and the people there at the
hospital don't know because they don't have access to the
information, that puts them at a disadvantage in caring for
that person, number one, and number two, protecting the people
who are there from this individual. Is there any way to get at
Mr. Schoenhard. That is part of what we want to explore
further in the small group, sir. I think that is a very
important area for us to thoroughly investigate. As I mentioned
earlier, to see what other systems are doing, what literature
search may come from this. Because we have a duty to ensure
that we can identify those risk behaviors with every patient
that we serve. At the same time, we have a duty to serve that
veteran. But the first and foremost responsibility is ensure a
Mr. Roe. It is to do both. We in a community know that if a
sexual predator is in your community, you are notified of that.
Out in the real world, you can have that happen. I don't know
why that wouldn't be the same case on VA property. When someone
is noted, let's say the police investigate an alleged rape or
sexual assault, is that then--when they gather that
information, it is then reported, which wasn't done, it is
reported up the chain of command. How is that prosecuted from
there? In other words, it is on Federal property. What happens
Mr. Schoenhard. Sir, may I ask Mr. Hanretta to initially
respond to that?
Mr. Hanretta. Sir, at the VA Medical Center, as Mr.
Sullivan mentioned, every VA employee has a responsibility to
report if they suspect criminal activity. When that happens, it
is either reported to the OIG and/or the local authorities,
because the prosecution takes place in the local community, not
by the VA Police.
Mr. Roe. No, no, no, I know that. There is an attorney
general in Tennessee, but there is also a Federal court. So it
is not prosecuted in the Federal system. The local attorney
general prosecutor would bring that case, would gather the
evidence from the information gathered from the VA Police and
whoever the witnesses, however the information is gathered, and
then prosecuted. Is that correct?
Mr. Hanretta. Yes, sir. I would defer to Mr. Sullivan for
the actual procedures, but I believe that is correct.
Mr. Sullivan. We first, for prosecution purposes, have to
identify, as you said, the facility, and whether or not the
Federal Government has legislative jurisdiction. Facilities may
have exclusive jurisdiction proprietary or concurrent
jurisdiction. It is difficult to get many of these cases
prosecuted in Federal court. We do rely on the State courts to
accomplish this. What we did not have when we reviewed these
scenarios, but will have when we look into how we proceed now
with these allegations is the State. Because rape and sexual
assault definitions can vary by State. So, in order for us to
know what we have and where to refer it, we need a little bit
Mr. Roe. The prosecutor decides that in that State.
Mr. Sullivan. He does indeed. And it starts back at the
beginning with determining the jurisdiction of the medical
center. Is it exclusive once the Federal Government has
jurisdiction? Is it concurrent where both Federal and State
Mr. Roe. I will finish up, I know my time is up, but I
think what I started out by saying about how underreported it
is, is that there needs to be an attitude that this is a very
serious issue and that it needs to be addressed seriously
because it is that. And I want to be sure that the VA is
handing off to the local prosecutor the information they need
to go ahead if a crime has been committed and investigate that
crime. That is what I was getting at.
I yield back.
Ms. Buerkle. Thank, Dr. Roe.
I now yield 5 minutes to the gentleman from New Jersey, Mr.
Mr. Runyan. Thank you, Madam Chair.
Mr. Sullivan, as you were just responding to that last
question, you talked a little bit about--I understand the
political State jurisdiction thing. If it is a situation where
the State is involved, are the local police departments
involved from the get-go?
Mr. Sullivan. Yes.
Mr. Runyan. They are?
Mr. Sullivan. Yes.
Mr. Runyan. And they are within the reporting process that
we are having problems with getting the information on?
Mr. Sullivan. Yes. And typically when we have such serious
offenses, they are the first to be notified by the VA Police.
Mr. Runyan. Okay.
Mr. Sullivan. The sheriff's department, the local police,
whoever that may be. We just ask for timely notification. We
are not saying we have to be the first to be notified. And in
these instances, it is important that the VA Police go to the
local jurisdiction immediately.
Mr. Runyan. Very well. Mr. Schoenhard, the GAO found a
number of facilities that were understaffed. Specifically,
there was one, that by criteria, suggested there was supposed
to be 19, but there was only 9 on hand. Why have you not been
able to staff these facilities fully?
Mr. Schoenhard. Congressman, that is a very important
question because we need to be fully staffed with police
coverage. And that is part of what I am seeking to understand
in our current survey of our field. I want to understand better
what the retention and the recruitment difficulties are with
that and see what steps need to be taken to address those.
Mr. Runyan. That was going to be my next question. Do you
have an idea of retention problems? Is there a major turnover
within the system?
Mr. Schoenhard. There is turnover which varies, sir, by
facility, and that too is part of what I want to get a better
sense of in conjunction with our VSIN and medical center
directors, because this is an extremely important part of our
Mr. Runyan. It really is, because having the people around
and being used to the procedures is the first step of getting
these reported correctly and into prosecution.
Mr. Schoenhard. Yes.
Mr. Runyan. So it is a huge step.
Madam Chair, I don't have any further questions. I yield
Ms. Buerkle. Thank you, Mr. Runyan.
I now will begin the second round of questions and I will
yield myself 5 minutes. I am just so concerned about what I am
hearing this afternoon. Correct me if I am wrong, but I
understood you to say, Mr. Schoenhard, that as of July 18th
this workgroup is going to come together and define sexual
Mr. Schoenhard. Madam Chairwoman, let me clarify. The
initial action plan for the work group's review of all eight
recommendations is due July 15th. However, we are urging Dr.
Arana and Dr. Hayes to hold frequent meetings of this work
group. And we will be bringing forward everything we can as
soon as we can. We are not waiting for July 15th to develop
One of the items that was discussed today in the work group
was the definition. And so we feel, Madam Chairwoman, a sense
of urgency about this, and we will work as quickly as we can to
address all eight recommendations.
Ms. Buerkle. My concern is that you are going to get caught
up with defining sexual assault, which has been defined on a
number of occasions. I am sure if you looked around you could
find a satisfactory definition and not waste the time of this
Committee, but to get on within getting these procedures in
place and getting a chain of command in place. You talked about
employees; some lost their jobs.
Mr. Schoenhard. Right.
Ms. Buerkle. Some perhaps are being disciplined.
Mr. Schoenhard. Yes.
Ms. Buerkle. Without a definition of sexual assault, how do
you even know who is guilty and who is not?
Mr. Schoenhard. Well, I would agree with you that it should
not take us long to develop a common definition. But that is
essential in order to ensure we have complete reporting. And we
are consistent in that going forward. So we will put that as a
But let me clarify as it relates to investigation of any
incident involving an employee. This is really not a function
of a definition. If there is any risk or harm or victimization
that someone has reported, we don't need a definition to fully
investigate that and take appropriate action with regard to our
Ms. Buerkle. I am also concerned with the fact that there
doesn't seem to be a clear chain of command once an incident is
reported. As was discussed by my colleagues, there are issues
of jurisdiction, but if it is a criminal case oftentimes the
county and the district attorney's office will handle it. Is
there not a protocol in place right now to act as a roadmap
that clarifies, if an incident occurs, who it gets reported to,
what actions are taken? It seems to me I hear from the various
agencies that it is not clear.
It seems to me we should be able to put on a big sheet of
paper all of the cases that the GAO reported, and for each one
of those victims who shall remain nameless, we should be able
to track who it was reported to and the resolution and what
happened to the perpetrator. It should all be very clear.
And when I hear the testimony, I don't get any sense of any
definition, any clear path here. I am very concerned that it is
going to come up on July 15th and we are still going to be
struggling with a definition. I think the Committee shares the
feeling that this is an outrage that the veteran community,
male or female, or the employees of the Department of Veterans
Affairs would be victims of a system that isn't taking care of
them. Time is of the essence.
You mentioned earlier that this is a priority of Secretary
Shinseki. Now, just because it has been brought up, or since
2009 when the Ranking Member made the request and a report was
issued now it is just becoming an issue; or has it been a
priority right along? These are my concerns, that the clock is
ticking and our veterans are paying for this delay.
Mr. Schoenhard. Madam Chairwoman, if I could respond. It is
clear, as was earlier testified, that anyone who suspects that
there is criminal behavior that has been initiated must report
that to the OIG. And part of the benefit of the stand-up of the
integrated operation center is that we have those reports
within 2 hours after they are reported to local police.
There is also an expectation that we would be fully
reporting this up the management line. And this is a subject
that I want to get improved process for. And that will be in
part aided by a common definition, so we know for sure
everything is being reported within what consistently, across
all of VHA, is determined to be sexual assault. That definition
But I can assure you we cannot, as I said earlier, solve a
problem, track a problem, develop the kind of mapping that Dr.
Roe spoke about before, Congressman Roe, unless we have full
adequate reporting of all incidents, and we must have that.
Ms. Buerkle. Thank you. I yield to the Ranking Member, Mr.
Mr. Michaud. Thank you very much, Madam Chair. I too am
extremely concerned when you look at the numbers in the GAO
report. That was only in five facilities out of the 111
facilities who offer these types of services, so it is probably
fair to assume that this is more--the numbers are much greater
in that regard.
The question that I have, and actually gets back to,
similar to Mr. Roe, when you look at jurisdiction, whether it
is a State court or Federal court--and I am not sure--is there
a different definition for rape at the Federal level or sexual
assault versus at the State level; and if so, why wouldn't that
be in Federal court? Because my big concern, for instance, when
you look at police officers--and actually this occurred in
Maine last year where a Togus police officer shot a veteran and
was being investigated. The investigation actually was done by
the State, not Federal, because of a memorandum of
So I am just kind of concerned about are there any other
memorandums of understanding that the VA has as it relates to
prosecuting rape or sexual assault? Because it gets back to Mr.
Williamson's comments in his report. He indicated that the VA
medical facilities have the authority to customize and design
their own onsite reporting systems in policy.
So I guess my question is: Do you feel that it is better to
have a consistent policy within the VA system versus a
customized policy, depending on where the VA is located? That
is my first question.
And my second question as it gets back to a memorandum of
understanding: Are there any memorandums of understanding
within the VA system as it relates to sexual assault or rape,
whether it will be prosecuted in State or Federal court, and
who does the prosecution? Would it be the DA or would it be a
U.S. attorney? Those are my three questions.
Mr. Schoenhard. Sir, I don't know if Mr. Sullivan should
begin with that or Mr. Williamson.
Mr. Sullivan. I can speak to the definition, Federal
definition of sexual assault, rape, and what have you, which
can be found in 18 U.S.C. 2441, which tracks pretty closely
with the definition that the GAO used in looking at rapes. So
this is the definition we use in the VA OIG for the sexual
To the State crimes, my experience has been that each one
may be a little different. Ones that apply perhaps to a
juvenile, the language may be a little different when you talk
about rape or assaults with a 14- or 15-year old child. With
adult perpetrators of crimes in violation of Sate law again in
not knowing which States we are talking about, I can't give you
a definitive answer: Here is one example in Alabama, here is an
example in Massachusetts. I can't do that. But know that they
are different. However slightly, they are different.
Mr. Michaud. And I mean that is a concern I have is under
that definition. And if there are memorandum of understanding,
whether it be prosecuted in State court, who does the
prosecution, the outcome could become different.
Mr. Sullivan. A memorandum of understanding does not enter
into our decision or the way we proceed with an investigation.
I don't know if they even exist, so I would defer back to the
Mr. Michaud. Well, for a shooting incident they do, because
in a shooting incident, whether that shooting incident at Togus
was a justified shooting or not, it wasn't the Federal agencies
that are investigating it, it is actually the State agency
because of a memorandum of understanding. So that is a concern
I have when you transfer that over to rape or sexual assault;
are there any cases where it is going to be just turned over to
the State versus a Federal agency? It gets back to Mr. Roe's
original question about jurisdiction issues.
Mr. Sullivan. I don't have the answer on the shooting. If
we look at a medical center that has exclusive jurisdiction,
all criminal cases will have to be changed by the Federal
Government. If you take something like a restraining order,
there is sexual abuse going on in the family, or with relatives
or whomever, the restraining order is taken in the State
courts. The crime has been committed off VA property, but the
perpetrator who violated the restraining order today is on
property, and the local police arrest. In that circumstance,
because it is Federal property, that must be brought in Federal
court. I don't know if that confuses the issue or it lends
clarity to the issue, but different scenarios present different
challenges, and it all goes back to that jurisdiction.
Mr. Michaud. I see my time is expired. But it does. I mean,
this incident occurred on Federal property by a Federal
employee, but the justification actually went over to the
State. So that is why I was kind of curious as it relates to
rape or sexual assault, whether that might be the same case
even if it is on Federal property.
Mr. Sullivan. I am not well versed on that case so I am
reluctant to even speculate on that.
Mr. Michaud. Thank you. Thank you, Madam Chair.
Ms. Buerkle. Thank you, Mr. Michaud. The gentleman from
Michigan, Dr. Benishek.
Mr. Benishek. Madam Chair, I don't really have any more
questions. I agree with you that it is sort of appalling there
are not better procedures in place to handle this problem, and
certainly it should be the focus of our attention in the
future. And with that I yield back.
Ms. Buerkle. Thank you, Dr. Benishek. Dr. Roe from
Mr. Roe. Again, back to where we were talking about how
underreported rape is in the military, it is estimated 80 to 90
percent are not reported. So I think there is an attitude about
how serious you take these sexual-assault issues on our
campuses around the country. Because if the attitude is this is
going to be dealt with as the serious crime that it is--and I
think that also is because the victims many times realize the
harassment that they go through just to get it done, and so
they don't report it. There is no telling what the real numbers
are, the times that this has happened. And I do think the
definition shouldn't be all that hard. I think the courts--I
mean that should be pretty easy, really. And it has been
defined by the courts many, many times, so I think that won't
be very hard for you to do.
But just once again, back to what the Chairman said about
how important I believe that this issue is and how important it
is for us to take it seriously. I yield back.
Ms. Buerkle. Thank you, Dr. Roe. The gentleman from New
Jersey, Mr. Runyan.
Mr. Runyan. I have no further questions, Madam Chair.
Ms. Buerkle. Thank you, Mr. Runyan.
On behalf of the Subcommittee, thank you all for your time
and your testimony today. You are now excused.
I invite the second panel to the witness table. Joining us
on our second panel are representatives from many of our
veteran service organizations. We have Verna Jones, Director of
the Veterans Affairs and Rehabilitation Division of the
American Legion; Joy Ilem, Deputy National Legislative Director
for the Disabled American Veterans (DAV); Marlene Roll, a
member of the National Women Veterans Committee of the Veterans
of Foreign Wars (VFW); and Mr. Rick Weidman, Executive Director
for Policy and Government Affairs for the Vietnam Veterans of
Thank you all very much for being here this afternoon and
for being such strong advocates for your fellow veterans.
Ms. Jones, we will start with you if you would like to
begin your testimony.
STATEMENTS OF VERNA JONES, DIRECTOR, NATIONAL VETERANS AFFAIRS
AND REHABILITATION COMMISSION, THE AMERICAN LEGION; JOY J.
ILEM, DEPUTY NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN
VETERANS; MARLENE ROLL, MEMBER, NATIONAL WOMEN VETERANS
COMMITTEE, VETERANS OF FOREIGN WARS OF THE UNITED STATES; AND
RICHARD F. WEIDMAN, EXECUTIVE DIRECTOR FOR POLICY AND
GOVERNMENT AFFAIRS, VIETNAM VETERANS OF AMERICA
STATEMENT OF VERNA JONES
Ms. Jones. Thank you, Madam Chairwoman Buerkle, Ranking
Member Michaud. On behalf of the American Legion I would like
to thank you for inviting us to testify this afternoon about
the disturbing findings of the recent GAO report on sexual
assaults and safety incidents within the VA health care system.
By now everyone has heard in detail the horrifying implications
of this report, so there is little need to recite the litany of
grievances. Suffice it to say this is quite simply
We cannot ask veterans, men or women, to go to health care
system for treatment if they must fear their own physical
integrity. This state of affairs must end, and it must end now.
How can we ask VA to clean up its shop if it doesn't even
know how to define the problem? The report states that there is
no clear guidance within VA to even define these incidents, let
alone standard operating procedures for screening for problems
or reporting them as they arise. If you can't even define the
problem, how can we hope to fix it?
H.R. 2074, the ``Veterans Sexual Assault Prevention Act,''
directs VA to define terms and policies and to accept
accountability with mandatory reporting. The American Legion
applauds and fully supports this legislation as a first step
toward fixing the problem. But let's not allow this to be
another opportunity to add high-level bureaucrats to the system
and further exacerbate the problems of a top-heavy operational
This problem doesn't require a battalion of senior
executives; it requires VA authorizing the employees they have
to take charge and manage this on a local level, but with
consistency. It requires VA to implement clear accountability
goals for the people already in place. Every medical facility
is required to have a military sexual trauma coordinator; yet
in most facilities, this is not even a full-time job. More
often it is an afterthought, additional duties assigned to an
employee with other obligations elsewhere.
The American Legion recommends elevating this position to a
full-time employee whose duties are fully focused on dealing
with the effects of sexual trauma, whether they occurred in
service or at any time. Let these employees, already dedicated
at least in part to helping these victims, become the front-
line soldiers in this battle.
It has often been said of VA facilities in general, if you
have seen one VA medical center, you have seen one VA medical
center. Consistency is what has to count; even enforcement of
The American Legion urges Congress to continue their
oversight of VA to ensure consistency becomes a standard.
Through the Legion's own System Worth Saving visits, we strive
to document and hopefully improve this consistency. Yet the
addition of outside eyes is always helpful. Try as we might, we
cannot remove the horror that comes from hearing of these
experiences, nor should we. Indeed, only by facing the
difficult truth can we hope to overcome them. This is not
something to shy away from, this must be confronted head on.
It is important to remember, however, that while the path
beyond this crisis is arduous, it is not terribly complicated.
Provide clear definitions and policies so all who come to VA,
whether patient or employee, know exactly what will not be
tolerated and how to proceed when the unthinkable happens.
Commit to the seriousness of this topic by upgrading the part-
time military sexual trauma coordinator to a full-time job that
reflects the importance of its role as a front-line defender of
these veterans. Be consistent and clear in the implementation
of these policies.
The American Legion again thanks this Committee for
including us in this discussion, and we are happy, of course,
to answer any questions the Subcommittee may have.
[The prepared statement of Ms. Jones appears on p. 58.]
Ms. Buerkle. Thank you, Ms. Jones.
Ms. Ilem, you may proceed. Thank you.
STATEMENT OF JOY J. ILEM
Ms. Ilem. Thank you, Chairwoman Buerkle, Ranking Member
Michaud and Members of the Subcommittee. On behalf of the
Disabled American Veterans, we appreciate being invited to
present our views on GAO's report on the actions needed to
prevent sexual assaults and other safety issues in VA health
The deficiencies identified by GAO have uncovered VHA's
lack of any consistent or systematic approach to documenting,
reporting, and preventing sexual assaults from occurring in its
Given the findings of the report, it is clear VA must
revise and strengthen its safety policies to ensure the
environment of care at the VA health facilities keeps veterans,
staff, and visitors safe from harm.
As recommended by GAO, VA should establish a comprehensive,
consistent approach to documenting, investigating, and
reporting sexual assaults as serious crimes of personal
Madam Chairwoman, we noted a statement in the report
indicating that many of these matters were brought to
leadership's attention and that in early 2011, efforts were
said to be underway to correct these problems. However,
according to GAO in mid-June, today it does not appear that
substantive systemwide changes have been made or instituted. We
see this delay not as a deficiency of program management, but a
failure of VA leadership.
Sexual assault is not solely a woman's issue, and likewise
it is not a health care issue per se. Nevertheless, VHA has
assigned the Director of its Women's Health Program Office to
be a significant leader in the task force VA created to address
it. While we have faith that this office will work hard in an
effort to correct these problems and will do so in a
responsible manner, we believe the accountability for this
problem and for these changes and improvements rests much
higher in the organization. Given the serious nature of these
issues, it is troublesome that once VA was informed of these
incidents that no action, it appears, was immediately taken to
institute a comprehensive plan or solution.
GAO noted in its analysis that VA was experiencing
significant demographic changes in its health care programs. We
agree VA patients are trending younger, with a more visible
female presence. These shifts and pressures produce stresses
that VA has not previously or recently experienced and may be
contributing to the culture of safety challenges that GAO has
We see in the current report, in relationship to the
residential program sites visited, that only one of the three
compensated work-therapy programs evaluated accepted women into
the program due to safety and privacy concerns. These safety
concerns continue to negatively impact women veterans. In
essence, they are denied access to these highly specialized
services because VA is not confident that they can provide a
safe environment for these women.
Likewise, GAO notes that several clinicians they
interviewed for a previous report on women's health services in
VA expressed concern for the safety of women veterans placed in
VA inpatient mental health programs.
These types of concerns highlight the potential for further
assaults unless corrective action is taken. Among the security
precautions that must be in place for residential programs are
secure accommodations for women veterans, with periodic
assessments of facility safety and security issues. We have
brought this issue to the attention of the Subcommittee in
previous hearings and hope you will consider oversight to
ensure as VA moves forward to improve their overall culture of
safety in VA facilities, that it specifically addresses these
safety issues related to the care of women veterans.
Additionally, VA must establish a risk assessment tool to
ensure the safety of all VA patients.
While acknowledging its findings could not be generalized
to VA as a whole, GAO outlined eight recommendations, we
endorse these ideas and note that VA has concurred with each of
them as well. We urge VA to move forward expeditiously to
implement them and to provide regular reports to Congress on
Madam Chairwoman, every veteran should be assured of the
highest level of quality care and patient safety while
receiving care in a VA facility. A veteran should never fear
for his or her own personal safety.
We are pleased that VA has taken action with the
establishment of a multidisciplinary work group to define what
actions need to be taken to prevent sexual assault and to
respond appropriately to reports and allegations of sexual
victimization of veterans or VA employees.
In closing, we are hopeful that GAO's findings can serve VA
and veterans in providing a roadmap to promote a new
environment of care and safety, one that should be closely
monitored by this Subcommittee as VA completes these changes.
That completes my statement and I am happy to answer any
questions that you or the Subcommittee Members may have.
[The prepared statement of Ms. Ilem appears on p. 61.]
Ms. Buerkle. Thank you, Ms. Ilem.
Ms. Roll, you may proceed.
STATEMENT OF MARLENE ROLL
Ms. Roll. Madam Chairwoman, Members of the Subcommittee,
thank you for asking me here today. As a female veteran and an
accredited service officer, I can tell you what the seriousness
is of the GAO findings for all our veterans, but especially for
our women veterans.
To sit and talk to a woman who has been sexually assaulted,
you see a person who is unsure of themselves and everyone
around them. They are anxious and they may make little eye
contact or no eye contact at all, but glance at the door every
little while. I have witnessed them physically recoil at the
sight of a man walking into a room. I have met with victims at
neutral sites because of their reluctance to come to my office
and use an elevator because of their fear that a man might
enter that elevator.
Anyone who has been sexually assaulted has had their life
changed forever. That is unacceptable. The damage is often
lifelong and ``trust'' is a word that they can no longer use.
Our soldiers have volunteered to keep their country safe and
they deserve nothing less when seeking treatment. The VA
hospitals and clinics are there to help and heal our veterans,
and trust is the very foundation of that service. That is why a
zero tolerance has to be implemented and maintained.
The GAO findings are disturbing, and now that we have the
information, what will be done to ensure that ``trust'' and
``safety'' are two words that we can use to describe the VA
The VFW understands that protocols have been in place, but
they are weak. We also believe that they need to be unified
throughout the VA system, and to remove the ability at each
management level to stop the upward reporting of these
incidences because they have determined that the issue has been
resolved. Reporting is how a problem is acknowledged and then
Staff training with the emphasis on reporting at all levels
needs to be enhanced and enforced. I know the VA does online
PowerPoint presentations for their staff, but they cannot
impress the importance of a topic like having a face-to-face
class with an instructor, or the additional comments of other
attendees. Definitions need to be clear so that there are no
Additionally, camera monitoring in all units, outpatient
clinics, can help deter behavior as well as sustain
allegations. I believe that the directors of each VISN and
hospitals are in the best position to ensure all protocols are
followed and to set the tone of safety and secure environment
for all our veterans to seek treatment in.
The VFW trusts VA will address these issues swiftly and the
VA will continue to monitor their progress. This concludes my
testimony and thank you.
[The prepared statement of Ms. Roll appears on p. 63.]
Ms. Buerkle. Thank you, Ms. Roll.
Mr. Weidman, you may proceed.
STATEMENT OF RICHARD F. WEIDMAN
Mr. Weidman. Madam Chairwoman, thank you for including
Vietnam Veterans of America in this hearing to take our
comments. In our legislative agenda, it is typical that the
number one legislative priority of an organization be a
particular piece of law or a particular policy to change. But
our number one priority for the 112th Congress is
accountability. And that is really what is broken down here
within the VA.
The GAO report--you certainly are to be commended, you and
Mr. Michaud, for having this hearing today. And Chairman Miller
and Mr. Filner sure are to be commended for just focusing
attention on it.
Dr. Roe hit the nail on the head earlier when he said if,
in fact, people take sexual assault seriously, they are much
more likely to report it. And I think he is probably right,
that we are only seeing the tip of the iceberg, and it is that
taking of these heinous acts seriously by VA management that
has been lacking throughout.
This is not something that, if it was taken seriously by
the hospital directors and the network directors, would have
asked for a definition a long time ago, and apparently it has
not been taken seriously. So it is something that the work
group needs to--shouldn't waste too much time, and it should be
able to come to the conclusion pretty quickly.
The eight recommendations from GAO all seem pretty logical
and pretty sensible. One of the things that GAO recommended,
though, was nowhere in the VA response to the General
Accountability Office, and that is to have stakeholder
involvement at every step of the process. Stakeholders include
employees who work on these wards and work various places in
the hospital, but it also includes veterans. And there is not
one single mention anywhere in the VA's response of including
women veteran leaders and the veteran service organizations in
finding the solutions. This is not because we are looking
around for something to do, Madam Chairwoman, but because we
bring something to the table. And certainly if I can't bring
it, my three distinguished colleagues to my right certainly
bring experiences that need to be taken into account as they
set forth to modify facilities, physical facilities, and as
they put in place the training and the--policies first, and
then training that will work at the local level.
The old saw in the military is a unit does well that which
a commander checks well. And the commander has not been
checking this issue carefully, because it has not even been
defined, much less reported properly.
There was one VISN, which actually startled me, if you look
through one of the tables that reported no sexual assaults over
a 2\1/2\ year period. I wish to God that is true, but I don't
believe it. I just think that it is so lax in that VISN that
nothing was reported and pushed up the line.
So the final recommendations that I would have to this
Committee, Madam Chairwoman, is not for more statutes, but for
more oversight hearings in association with your colleagues at
the Oversight and Investigation Subcommittee and continued
pressure and follow-up.
One of the things that those of us who have been reading
GAO reports for years and OIG reports for years is there is
always a great flurry when the report comes out, and the press
covers it and Members get excited about it--and genuinely so--
and are committed to seeing something done. But then it is not
in the limelight and nothing happens, and nobody inside the VA
follows up to find out did they in fact carry out that
correction plan that VA management said they were going to do.
And that is what I implore you, Madam Chair and Mr.
Michaud, to make sure that this Subcommittee and this Committee
as a whole follows up to keep the pressure on until this
problem becomes resolved at each and every VHA facility
Thank you very much for the opportunity to share our views
here this afternoon and thank you so much for having this
[The prepared statement of Mr. Weidman appears on p. 65.]
Ms. Buerkle. Thank you, Mr. Weidman.
Thank you to all of our witnesses for their testimony
I will now yield myself 5 minutes for questions. This
question is for all four of you: Has the VA reached out to any
one of your organizations or any other organizations that you
might know of, to participate in this work group that we just
heard about, previous to this hearing?
Ms. Ilem. Not to the DAV.
Ms. Jones. Not to the American Legion.
Ms. Roll. Not to the VFW.
Mr. Weidman. No, ma'am.
Ms. Buerkle. Thank you.
In the written testimony, the VA states that it currently
uses both VA staff and physical infrastructure systems to
ensure the security of VA facilities, for example: closed
circuit cameras, locks, alarms, separate facilities,
Do you have any comment--and we can just go right down
starting with Ms. Jones--do you have any comment on that
Ms. Jones. I think that approach would be great. Those
closed circuit cameras would help them to be able to monitor
the activities that are going on and hopefully deter that kind
of activity from happening.
You know, we recently did a national survey of women
veterans in January. We had 3,012 respondents, and one of the
questions was about security. And 25 percent of those women who
answered our question about security indicated that they were
uncomfortable, they didn't feel safe in a VA environment. So I
think that the use of those security cameras would certainly
Ms. Buerkle. Ms. Ilem.
Ms. Ilem. I think we have heard of longstanding problems in
VA with infrastructure issues related to women veterans. It has
been an ongoing focus in the GAO reports over the years. And
although I don't have specifics, I think even in this GAO
report, it is pointed out about the concern, or in previous
reports, that clinicians have concerns about putting a female
veteran on an inpatient mental health unit. So that really
gives me pause in terms of, you know, as being a veteran
myself, among veterans, who uses the VA system, should I be
hospitalized, I would surely hate to be worrying about those
types of issues.
I would like to know that all VA patients are safe and I
don't feel that I should be isolated. I feel I should be safe
in a VA facility and that the people that are charged for my
care would be watching out and making sure all of those systems
are in place to make sure a safe environment for any patient,
Ms. Buerkle. Thank you. Ms. Roll.
Ms. Roll. Well, while the cameras and other security issues
would certainly deter, I still believe that the line defense is
from our staff itself. They have to be the ones to stand up for
the veterans and advocate for them that this will not be
tolerated; and if anything does come down and does present
itself, that it is dealt with swiftly and they know about it,
that the veterans themselves know that it was taken care of and
it has been addressed and that they are being looked after. I
think that is their main issue. They just want to know that
while they are there, they have eyes that have their back.
Ms. Buerkle. Mr. Weidman.
Mr. Weidman. I would associate myself with the remarks of
my three colleagues in that it is much more a question of
corporate culture than anything else. You can have all the
bells and whistles and all the fancy equipment you want, but if
you don't monitor the monitors, if you will, and if you don't
have swift and sure action when something untoward happens,
then you don't have a corporate culture where people feel safe,
one; and two, where miscreants know that if they step out of
line, that justice will be swift and sure. And that is much
more important than anything else.
And it is really when you think about it, particularly the
veteran-on-veteran violence that is done is the ultimate
betrayal. We have a saying in Vietnam Veterans of America that
is their founding principle, which is, ``Never again shall one
generation of American veterans abandon another.'' And we have
boiled that down into a button that just says, ``Leave no
And to perpetrate a sexual assault upon someone else who
has pledged their life in defense of the Constitution is really
the ultimate betrayal. And it is something that needs to be
hammered home and it is something that needs to be taken
seriously by VA management at every level, and it will permeate
down. But it is not a question of bells and whistles, it is a
question of organizing things and holding the senior people at
each facility accountable for clear guidelines on how do you
keep people safe.
Ms. Buerkle. Thank you very much. I now yield 5 minutes to
the Ranking Member, Mr. Michaud.
Mr. Michaud. Thank you very much, Madam Chair. Mr. Weidman,
my question to you--because if I understood correctly Ms.
Jones, Ms. Ilem, Ms. Roll, they all agreed that the VA should
have a standardized policy throughout the VA system rather than
leaving it up to each individual to determine what policies and
what definitions are.
I am not sure about VVA. Do you believe that there should
be a standardized definition in policy throughout the VA
Mr. Weidman. I do, sir. And the only thing that I regret,
which is that working group doesn't include one of the two most
important groups, and that is--in fact, it doesn't include the
other one either--there is no union representation on that of
the Nurses Association. They are not represented either, and
neither are women veterans.
Mr. Michaud. My next question gets back to actually what
Dr. Roe was mentioning earlier, is jurisdiction issues. So if
the VA does adopt a standardized policy nationwide on how to
deal with reporting and what the definition is, that definitely
could conflict with actually what State laws in different
States are. So I can see that that could cause a problem for a
My next question, actually for all organizations: Do you
feel that if we have a standardized system and definitions for
rape and sexual assault, that that should be dealt with in
Federal court versus State court? And I will start with Ms.
Jones and work on down.
Ms. Jones. My feeling is that it should be dealt with in
Federal court. On a Federal facility, it is the VA, and it
should be standardized so there are no questions, no room for
leeway, you know, for each State. I think it should be
standardized across the board. If it happens it should be dealt
with in Federal court in a systematic manner.
Ms. Ilem. I don't know that I can provide a response to
that, just not knowing enough to feel that I have the
expertise. But certainly let me provide something to the
Committee for a response on that from our organization.
[Ms. Ilem subsequently provided the following information:]
Ranking Member Michaud, Disabled American Veterans (DAV) does
not have a national resolution from our membership that deals
with the specific issue of courts of jurisdiction in the case
of rape or other sexual assaults that may occur on Department
of Veterans Affairs (VA) property. Therefore, we can take no
formal position on the matter. Nevertheless, we believe that
any sexual assault, of a veteran or non-veteran, on VA grounds,
should be reported to proper legal authorities and receive
justice through the courts. Additionally, veterans should have
access to treatment to assuage the effects of this violent and
highly personal crime.
On the specific question of jurisdiction, we suggest this
matter be reviewed either by the VA General Counsel or by the
Attorney General, either of which is in better position than
DAV to advise you and the Subcommittee on this matter.
Ms. Roll. I, too, do not come from a background that I can
speak intelligently to that, so if I could also bring that back
to the Committee.
[Ms. Roll subsequently provided the following information:]
In a perfect world, yes, the VFW would like to see a
standardized system and definitions and that all crimes should
be heard in Federal courts, seeing that most Veterans Affairs
property is federally owned. However, many properties are
leased or shared. In cases when the Federal Government has sole
ownership of property, they have exclusive jurisdiction, unless
law enforcement is shared between the Federal Government and a
State or local government. In these cases, the jurisdiction
becomes concurrent legislative. Title 38 U.S.C., Section 902,
allows VA to enter into agreements with other law enforcement
agencies, making these properties concurrent legislative
The question VFW has is why does VA have this authority? Is
it because there are so many leased properties or properties
that are shared with private or public institutions that would
cause them to be in fact concurrent legislative jurisdictions,
making the jurisdiction shared? If this is true, to insist that
all crimes in VA facilities be investigated and tried in
Federal court may violate the 4th Amendment ``Property
Clause.'' VFW does not have expertise in property ownership or
law enforcement jurisdiction, but these are things to consider.
Also, if the property is remote and it is not economically
feasible to employ a full criminal investigative team, then
perhaps allowing concurrent legislative jurisdiction might be
the only solution to quickly and accurately investigate a
There is no doubt there need to be a very clear, linear
process to investigating and prosecuting crimes that occur in
VA facilities. These guidelines must be developed, taught to VA
law enforcement personnel, and followed. There may need to be
multiple guidelines, depending on the jurisdiction(s) of the
facility. At the end of the day, a quality investigation and
prosecution rests on two things: (a) the resources to conduct
the investigation, and (b) the reliability of the investigators
to do a thorough investigation.
The VFW suggests that to ensure that victims of crimes have
due process and a quality investigation, that VA produce clear
procedural regulations for each jurisdictional scenario and
insist on training to those regulations.
Mr. Weidman. I think, perhaps fool-heartedly, I will go
ahead and give you an answer. But, you know, this is really
part of taking this issue seriously. What the gentleman from
the OIG's office didn't come out and clearly say is that the
U.S. attorneys don't want to prosecute this. They consider it a
minor crime. This is not a minor crime. This is a major crime
and it is--against any citizen--but it is made all the more
heinous because it was committed against an individual who put
their life and limb on the line in defense of the Constitution
and of their country. So part of taking it seriously is perhaps
this Committee working closely with the Judiciary Committee,
and make sure that our Federal court system starts to take rape
and sexual assault seriously.
Mr. Michaud. And like some of you, I am not an expert in
this area either and it brings back the situation where deadly
force was used, and there was a memorandum of understanding.
Actually, the State took jurisdiction to investigate whether
deadly force was justified. So I can see a problem if we do
have a standardized definition systemwide, that actually the
enforcement piece could be different; because whether it is
State versus Federal so I don't know if that is something that
we actually could and should do and work with the Judiciary
Committee to make sure that there is some type of consistency
there as well.
My last question actually is for the Legion. You mentioned
that 25 percent of female veterans do not feel secure. If there
is any specific one issue that we should deal with, what should
that be? I know you talked about cameras, the security issue,
but is there any specific issue that we should focus on?
Ms. Jones. Well, the question we asked was about security.
In this particular survey, we just talked to them about
physical security and information security. I do not have the
breakdown with me about physical security or information
security. I will get back to you with the information.
Dissatisfaction levels of over 25 percent for this
attribute, which was for security, suggested there is
considerable room for improvement in security-related issues
for the VA to include physical security and a degree of
sensitivity around the patient's personal information. So I
will get back with you with a breakdown of those who felt the
most need of physical security.
[Ms. Jones subsequently provided the following
Mr. Michaud. Thank you very much. And thank you very much,
Madam Chairwoman, and look forward to working with you to move
this issue forward to the forefront, and hopefully we will be
able to keep a close eye on it as well. Thank you.
Ms. Buerkle. And I thank the Ranking Member. Thank you very
Mr. Weidman. Madam Chair, may I comment? Mr. Michaud
referred to an incident that I am familiar with. And that is a
perfect case about why it should be under Federal control.
There were four different local and State law enforcement
officials involved in that incident, and that veteran did not
have to die. If the VA police had been in charge and well-
trained in how to deal with him, he only had a .22 and he never
discharged his weapon and yet he was shot several times. I
think it was like nine times.
It didn't have to happen. And it was only because there
wasn't a clear policy and a clear Federal mandate that this be
handled internally by the VA because it occurred on Federal
property. And I think the same thing is true of sexual assault
and other crimes on VA property, because it is Federal
property. If you get a whole pastiche of local law enforcement
officials, you are going to have the kind of miscommunication
that is going to lead to veterans needlessly dying.
Ms. Buerkle. Thank you, Mr. Weidman.
I now yield 5 minutes to the gentleman from Michigan, Dr.
Mr. Benishek. I would like to thank all of you for coming.
It has been very educational for me. I don't really have any
more questions. I just want to comment that I am so thankful
that you guys are involved, and that we just hope that we can
get the VA to cooperate with the veteran service organizations
to develop a plan to stop this. So I am all behind that.
And with that I yield back my time.
Ms. Buerkle. Thank you, Dr. Benishek. Are there any further
questions from the Committee?
Thank you to our second panel for sharing your time and
your expertise with us this afternoon, and you are now all
excused. Thank you.
I ask unanimous consent that all Members have 5 legislative
days to revise and extend their remarks and include any
extraneous materials. Without objection, so ordered.
Ms. Buerkle. Thank you once again to all of our witnesses
and to our members in the audience for joining today's
extremely difficult but very necessary conversation. We will
hold the VA leadership accountable at the highest level and we
will work to ensure justice is served for our veterans, our
heroes, who have served our Nation across the country. The
hearing now is adjourned.
[Whereupon, at 5:47 p.m., the Subcommittee was adjourned.]
A P P E N D I X
Prepared Statement of the Hon. Ann Marie Buerkle, Chairwoman,
Subcommittee on Health
Good afternoon, this hearing will come to order.
Today, the VA's Subcommittee on Health will address a very serious
issue: the vulnerability and underreporting of sexual assault and other
safety incidents at VA residential and inpatient psychiatric treatment
As a registered nurse and domestic violence counselor, I have seen
firsthand the pervasive and damaging effects sexual assault can have on
the lives of those who experience it.
Last week, the Government Accountability Office (GAO) released a
deeply troubling report entitled ``VA Health Care: Actions Needed to
Prevent Sexual Assaults and Other Safety Incidents. ``GAO found that
between January 2007 and July 2010, nearly 300 sexual assault
incidents, including 67 alleged rapes, were reported to VA police. Many
of these alleged crimes were not reported to VA leadership officials or
the VA Office of the Inspector General, in direct violation of VA
policy and Federal regulations.
The findings of the GAO are disturbing for many reasons. Foremost,
they represent a betrayal of trust by a system that was designed to
treat our veterans at their most vulnerable time.
The gross failure of VA leadership to protect the safety and
security of our veterans and VA staff and systematically report and
respond to sexual assault and safety incidents is a contempt of
justice. It also requires immediate action. This is not the way to run
a health care system and it is certainly no way to treat the men and
women who sacrificed so much on our Nation's behalf.
Abuse like the kind GAO references in their report is repugnant and
inexcusable in any corner of our society. But for it to occur in what
should be an environment of healing for our wounded warriors is an
affront to VA's very mission.
So disturbed was I upon reading an early draft of GAO's report,
that I--along with Chairman Miller--introduced legislation to ensure a
safer and more secure VA medical facilities. Our bill, H.R. 2074, the
Veterans Sexual Assault Prevention Act, would address the Department's
safety vulnerabilities, security problems, and oversight failures and
create a fundamentally safer environment for our veterans and VA
Never should a warrior in need take the brave step of getting help
and be met with anything less than safe, supportive, and high quality
care in an atmosphere of hope, health, and healing.
Let me assure each of you, that I and the other Members of this
Committee will remain committed to righting the many wrongs uncovered
by the GAO.
Prepared Statement of Hon. Michael H. Michaud, Ranking Democratic
Member, Subcommittee on Health
Good morning. I would like to thank everyone for attending this
important hearing today.
The purpose of today's hearing is to examine how changes in patient
demographics present unique challenges for VA in providing safe
environments for all veterans treated in VA facilities.
In 2008, I requested that GAO report on women veterans' services,
such as research on the unique physical and mental health treatment
needs of female veterans, how VA is addressing the needs of women
veterans, what health care services offered by VA are tailored to women
veterans, and what barriers may prevent female veterans from accessing
VA health care services.
In July 2009, this Subcommittee held a hearing on the findings of
the report. During the conduct of this report, GAO was made aware of
safety issues involving women veterans and sexual assault in some VA
Subsequent to that report, then Full Committee Chairman, Mr.
Filner, submitted a request for GAO to look further into sexual assault
We know that the wars in Afghanistan and Iraq have seen the
unprecedented call up of the National Guard and Reserve components.
Today, women serve in the Guard and Reserve at a rate of over 17
percent which is 3 percent higher than that of the active duty
VA recently reported that within 10 years, women are expected to
become 10 percent of VA's patient population.
However, the VA health care system was built to accommodate the war
related illnesses and injuries of male veterans.
As women are serving in combat conditions alongside their male
counterparts, it is important that the Department embrace and recognize
the needs of all veterans, both men and women alike.
In the 110th and 111th Congresses, this Committee held a series of
hearings to examine the needs of women veterans.
The veterans who testified shared stories of feeling unwelcomed,
alienated, and disrespected in some VA medical centers so that they are
now reluctant to pursue the benefits and services that they have earned
with their service to our country.
Women veterans should not have to worry about being subject to
``cat calls'' upon entering a facility, and they certainly should not
have to worry about falling victim to sexual assault while receiving
While sexual assault is often considered an issue only affecting
women, in fact, both men and women suffer sexual assaults.
Further, victims may be assaulted by perpetrators of the same or of
the opposite sex.
Like other types of trauma, sexual trauma can leave lasting scars
upon the physical and mental health of its victims.
As Government Accountability Office (GAO) has recently uncovered,
many of the nearly 300 sexual assault incidents reported to the VA
police since 2007 were not reported to VA leadership.
Incidents like these simply need not happen.
When policies and procedures are not in place--or worse-- not
followed, we fall far short of our national commitment to provide the
utmost level of care possible.
Thank you to our panelists for appearing today.
I am committed to working with you to ensure that safeguards are in
place so that no veteran, male or female, falls victim to sexual
assault while under VA care.
Madam Chair, I yield back.
Prepared Statement of Hon. Jeff Miller, Chairman,
Committee on Veterans' Affairs
Thank you Madam Chairwoman for having me here today at this very
important hearing. Upon reading GAO's draft report, I was sickened by
its findings--the prevalence of sexual assault incidents at VA
facilities, the lack of accountability from VA leadership and the lack
of safeguards in place for these victims.
As a co-requester of the GAO investigation (with Ranking Member
Filner), I immediately contacted Secretary Shinseki and urged him to
provide an immediate official response to GAO so the report could be
made public and we could hold this hearing today. I thank the Secretary
for complying with my request.
These findings are intolerable, so Ms. Buerkle and I decided to act
immediately by introducing H.R. 2074--the Veteran Sexual Assault
Prevention Act. We intend to move this legislation expeditiously so
that veterans are not undermined by the very system which is supposed
to protect them.
In the past week, some have dismissed these allegations, comparing
the size of the VA system and the number of allegations, to the private
sector. Let me be very clear on this point--there is no comparison.
Just one assault of this nature, one sexual predator, or one veteran's
rights being violated within the VA is one too many and is absolutely
unacceptable. If we need to do more to protect our veterans and VA
employees, we will.
Rape, in particular, has always been a hard charge to prosecute.
And though we have made strides in getting victims to speak out, we
know that for every rape that is reported, that many more are not.
Therefore, we need to know how many victims have not spoken out and how
we can reach to them so that not only is justice done, but that we can
provide them with the proper care and support. Today, we expect to get
answers to the followings questions:
How widespread are assaults at VA facilities, because as
found by GAO the lack of protocols at VA are not conducive to reporting
How many cases have been prosecuted? How many are still
How many employees who allegedly perpetrated assaults are
still working in VA?
What has been done to protect patients from fellow
What is VA doing to ensure this never happens again in
The safety and security of our veterans is paramount. We demand
these answers so to assure fellow veterans and the public that VA
facilities are safe havens for veterans, VA employees are safe, and no
one's rights are violated.
Again, thank you for the time, Madam Chairwoman. I yield back.
Prepared Statement of Randall B. Williamson, Director, Health Care,
U.S. Government Accountability Office
VA Health Care: Improvements Needed for Monitoring and Preventing
Sexual Assaults and Other Safety Incidents
Why GAO Did This Study
During GAO's recent work on services available for women veterans
(GAO-10-287), several clinicians expressed concern about the physical
safety of women housed in mental health programs at a Department of
Veterans Affairs (VA) medical facility. GAO examined (1) the volume of
sexual assault incidents reported in recent years and the extent to
which these incidents are fully reported, (2) what factors may
contribute to any observed underreporting, and (3) precautions VA
facilities take to prevent sexual assaults and other safety incidents.
This testimony is based on recent GAO work, VA Health Care: Actions
Needed To Prevent Sexual Assaults and Other Safety Incidents, (GAO-11-
530) (June 2011). For that report, GAO reviewed relevant laws, VA
policies, and sexual assault incident documentation from January 2007
through July 2010. In addition, GAO visited five judgmentally selected
VA medical facilities that varied in size and complexity and spoke with
the four Veterans Integrated Service Networks (VISN) that oversee them.
What GAO Recommends
GAO reiterated recommendations that VA improve both the reporting
and monitoring of sexual assault incidents and the tools used to
identify risks and address vulnerabilities at VA facilities. VA
concurred with GAO's recommendations and provided an action plan to
What GAO Found
GAO found that many of the nearly 300 sexual assault incidents
reported to the VA police were not reported to VA leadership officials
and the VA Office of the Inspector General (OIG). Specifically, for the
four VISNs GAO spoke with, VISN and Veterans Health Administration
(VHA) Central Office officials did not receive reports of most sexual
assault incidents reported to the VA police. Also, nearly two-thirds of
sexual assault incidents involving rape allegations originating in VA
facilities were not reported to the VA OIG, as required by VA
GAO identified several factors that may contribute to the
underreporting of sexual assault incidents. For example, VHA lacks a
consistent sexual assault definition for reporting purposes and clear
expectations for incident reporting across its medical facility, VISN,
and VHA Central Office levels. Furthermore, VHA Central Office lacks
oversight mechanisms to monitor sexual assault incidents reported
through the management reporting stream.
VA medical facilities GAO visited used a variety of precautions
intended to prevent sexual assaults and other safety incidents.
However, GAO found some of these measures were deficient, compromising
medical facilities' efforts to prevent sexual assaults and other safety
incidents. For example, medical facilities used physical security
precautions--such as closed-circuit surveillance cameras to actively
monitor areas and locks and alarms to secure key areas. These physical
precautions were intended to prevent a broad range of safety incidents,
including sexual assaults. However, GAO found significant weaknesses in
the implementation of these physical security precautions at the five
VA medical facilities visited, including poor monitoring of
surveillance cameras, alarm system malfunctions, and the failure of
alarms to alert both VA police and clinical staff when triggered.
Inadequate system configuration and testing procedures contributed to
these weaknesses. Further, facility officials at most of the locations
GAO visited said the VA police were understaffed. (See table below.)
Such weaknesses could lead to delayed response times to incidents and
seriously erode VA's efforts to prevent or mitigate sexual assaults and
other safety incidents.
Weaknesses in Physical Security Precautions in Residential Programs and
Inpatient Mental Health Units at Selected VA Medical Facilities
Staff awareness and
Monitoring precautions Security precautions preparedness
Inadequate Alarm VA police
monitoring of closed- malfunctions of staffing and workload
circuit surveillance stationary, computer- challenges
cameras based, and personal Lack of
panic alarms stakeholder
Inadequate involvement in unit
documentation or redesign efforts
review of alarm
alarms to alert both
unit staff and VA
Limited use of
personal panic alarms
Chairwoman Buerkle, Ranking Member Michaud, and Members of the
I am pleased to be here today as the Subcommittee discusses
policies and actions to prevent sexual assaults and other safety
incidents at Department of Veterans Affairs (VA) medical facilities.
During our recent work on services available for women veterans in VA
medical facilities, several clinicians expressed concern about the
safety of women veterans housed in mental health programs at a VA
medical facility's residential mental health unit that also housed
veterans who had committed past sexual crimes.\1\ Clinicians were also
concerned about the adequacy of existing safety precautions to protect
women veterans being treated in the inpatient mental health units of
this same facility. These concerns highlight the importance of VA
having effective security precautions to protect all patients--
especially those with residential and inpatient mental health
programs--and a consistent way to exchange information about and
discuss safety incidents, including sexual assaults. \2, 3\
\1\ See GAO, VA Health Care: VA Has Taken Steps to Make Services
Available to Women Veterans, but Needs to Revise Key Policies and
Improve Oversight Processes, GAO-10-287 (Washington D.C.: Mar. 31,
\2\ In this report, we use the term safety incident to refer to
intentionally unsafe acts--including criminal and purposefully unsafe
acts, clinician and staff alcohol or substance abuse-related acts, and
events involving alleged or suspected patient abuse of any kind. These
safety incidents are excluded from the reporting requirements outlined
by the VA National Center for Patient Safety (NCPS).
\3\ In this report, we use the term sexual assault incident to
refer to suspected, alleged, attempted, or confirmed cases of sexual
assault. All reports of sexual assault incidents do not necessarily
lead to prosecution and conviction. This may be, for example, because
an assault did not actually take place or there was insufficient
evidence to determine whether an assault occurred.
My testimony today is based on our June 7, 2011 report: \4\ (1) the
volume of sexual assault incidents reported in recent years and the
extent to which these incidents are fully reported, (2) what factors
may contribute to any observed underreporting, and (3) the precautions
in place in residential and inpatient mental health settings to prevent
sexual assault and other safety incidents and any weaknesses in these
\4\ See GAO, VA Health Care: Actions Needed To Prevent Sexual
Assaults and Other Safety Incidents, GAO-11-530 (Washington, D.C.: June
To examine the volume of sexual assault incidents reported to VA in
recent years, the extent to which these incidents were fully reported,
and factors that may contribute to any observed underreporting, we
reviewed relevant VA and Veterans Health Administration (VHA) policies,
handbooks, directives, and other guidance documents regarding the
reporting of safety incidents.\5\ We also interviewed VA and VHA
Central Office officials involved with the reporting of safety
incidents--including officials with VA's Office of Security and Law
Enforcement (OSLE) and VHA's Office of the Deputy Under Secretary for
Health for Operations and Management and Office of the Principal Deputy
Under Secretary for Health.\6\ In addition, we conducted site visits to
five VA medical facilities. These judgmentally selected medical
facilities were chosen to ensure that our sample: (1) had both
residential and inpatient mental health settings; (2) reflected a
variety of residential mental health specialties, including military
sexual trauma; (3) had medical facilities with various levels of
experience reporting sexual assault incidents; and (4) varied in terms
of size and complexity.\7\ During the site visits, we interviewed VA
medical facility leadership officials and residential and inpatient
mental health unit managers and staff to discuss their experiences with
reporting sexual assault incidents. We also spoke with officials from
the four Veterans Integrated Service Networks (VISN) responsible for
managing the five selected VA medical facilities to discuss their
expectations, policies, and procedures for reporting sexual assault
incidents.\8\ Information obtained from these VISNs and VA medical
facilities cannot be generalized to all VISNs and VA medical
facilities. In addition, we interviewed officials from the VA Office of
the Inspector General's (OIG) Office of Investigations--Criminal
Investigations Division to discuss information they receive from VA
medical facilities about sexual assault incidents that occur in these
facilities. Further, we reviewed Federal statutes related to sexual
offenses and sentencing classification for felonies to verify that all
rape allegations included in our review met the statutory criteria for
felonies under Federal law. Finally, we reviewed documentation of
reported sexual assault incidents at VA medical facilities provided by
VA's OSLE, the VA OIG, and VISNs from January 2007 through July 2010,
to determine the number and types of incidents reported, as well as
which VA and VHA offices were notified of those incidents. For this
analysis, we used a definition of sexual assault that was developed for
the purpose of this report.\9\ Our analysis of VA police and VA OIG
reports was limited to only those incidents that were reported and
cannot be used to project the volume of sexual assault incident reports
that may occur in future years. Following verification that VA police
and VA OIG incidents met our definition of sexual assault and
comparisons of sexual assault incidents reported by the two groups
within VA, we found data derived from these reports to be sufficiently
reliable for our purposes.
\5\ Within VA, VHA is the organization responsible for providing
health care to veterans at medical facilities across the country.
\6\ We also spoke with officials from VHA's Office of Mental Health
Services and the Women Veterans Health Strategic Health Care Group.
\7\ VA medical facilities were selected to ensure that at least one
facility with no experience reporting sexual assault incidents was
included in our judgmental sample of facilities. Other selected medical
facilities all had some experience reporting sexual assault incidents.
To determine facilities' histories of reporting sexual assault
incidents, we reviewed closed investigations conducted by the VA Office
of the Inspector General (OIG) Office of Investigations--Criminal
Investigations Division. This selection allowed us to ensure that a
greater variety of perspectives on sexual assault incidents were
captured during our field work.
\8\ Two of the facilities we visited were located within the same
\9\ For the purposes of this report, we define sexual assault as
any type of sexual contact or attempted sexual contact that occurs
without the explicit consent of the recipient of the unwanted sexual
activity. Assaults may involve psychological coercion, physical force,
or victims who cannot consent due to mental illness or other factors.
Falling under this definition of sexual assault are sexual activities
such as forced sexual intercourse, sodomy, oral penetration or
penetration using an object, molestation, fondling, and attempted rape
or sexual assault. Victims of sexual assault can be male or female.
This does not include cases involving only indecent exposure,
exhibitionism, or sexual harassment.
To examine the precautions in place to prevent sexual assault and
other safety incidents, we reviewed relevant VA, VHA, VISN, and
selected medical facility policies related to the security of
residential and inpatient mental health programs. We also interviewed
VA, VHA, VISN, and selected VA medical facility officials about the
precautions in place to prevent sexual assault incidents and other
violent activities in the residential and inpatient mental health
units. Finally, to assess any weaknesses in physical security
precautions at the VA medical facilities selected for this review, we
conducted an independent assessment of the precautions in place at each
of our selected medical facilities--including the testing of alarm
systems. These assessments were conducted by physical security experts
within our Forensic Audits and Investigative Services team using
criteria based on generally recognized security standards and selected
VA security requirements. Our review of physical security precautions
was limited to only those medical facilities we reviewed and does not
represent results from all VA medical facilities.
We conducted our performance audit from May 2010 through June 2011
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives. We conducted our related
investigative work in accordance with standards prescribed by the
Council of the Inspectors General on Integrity and Efficiency.
VHA Central Office has responsibility for monitoring and overseeing
both VISN and medical facility operations, including security
precautions.\10\ Day-to-day management of medical facilities, including
residential and mental health treatment units, is the responsibility of
\10\ VHA oversees VA's health care system, which includes 153
medical facilities organized into 21 VISNs.
VA has 237 residential programs at 104 of its medical facilities.
These programs provide residential rehabilitative and clinical care to
veterans with a range of mental health conditions, including those
diagnosed with post-traumatic stress disorder and substance abuse. VA
operates three types of residential programs in selected medical
facilities throughout its health care system:
Residential rehabilitation treatment programs (RRTP).
These programs provide intensive rehabilitation and treatment services
for a range of mental health conditions in a 24 hours per day, 7 days a
week structured residential environment at a VA medical facility.
Domiciliary programs. In its domiciliaries, VA provides
24 hours per day, 7 days a week, structured and supportive residential
environments, housing, and clinical treatment to veterans. Domiciliary
programs may also contain specialized treatment programs for certain
mental health conditions.
Compensated work therapy/transitional residence (CWT/TR)
programs. These programs are the least intensive residential programs
and provide veterans with community-based housing and therapeutic work-
based rehabilitation services designed to facilitate successful
\11\ Compensated work therapy is a VA vocational rehabilitation
program that matches work-ready veterans with competitive jobs,
provides support to veterans in these positions, and consults with
business and industry on their specific employment needs.
Inpatient Mental Health Units
Most (111) of VA's 153 medical facilities have at least one
inpatient mental health unit for patients with acute mental health
needs. These units are generally a locked unit or floor within each
medical facility, and the size of these units varies throughout VA.
Care on these units is provided 24 hours per day, 7 days a week, and
consists of intensive psychiatric treatment designed to stabilize
veterans and transition them to less intensive levels of care, such as
RRTPs and domiciliary programs. Inpatient mental health units are
required to comply with VHA's Mental Health Environment of Care
Checklist that specifies several safety requirements for these units,
including several security precautions, such as the use of panic alarm
systems and the security of nursing stations within these units.
VA's Two Reporting Streams for Safety Incidents
Safety incidents, including sexual assaults, may be reported to
senior leadership as part of two different streams--a management stream
and a law enforcement stream. The management reporting stream--which
includes reporting responsibilities at the VA medical facility, VISN,
and VHA Central Office levels--is intended to help ensure that
incidents are identified and documented for leadership's attention. In
contrast, the purpose of the law enforcement stream is to document
incidents that may involve criminal acts so they can be investigated
and prosecuted, if appropriate. VHA policies outline what information
staff must report for each stream and define some mechanisms for this
reporting, but medical facilities have the flexibility to customize and
design their own site-specific reporting systems and policies that fit
within the broad context of these requirements. (Fig. 1 summarizes the
major steps involved in each stream.)
Management reporting stream. Reporting responsibilities at each
level for this stream are as follows.
Local VA medical facilities. Local incident reporting is
typically handled through a variety of electronic facility-based
systems. It is initiated by the first staff member who observed or was
notified of an incident, who completes an incident report in the
medical facility's electronic reporting system that is then reviewed by
the medical facility's quality manager. VA medical facility leadership
is then notified, and is responsible for reporting serious incidents to
VISNs. VA medical facilities can report serious incidents
to their VISN through two mechanisms--issue briefs that document
specific factual information and ``heads up'' messages that allow
medical facility leadership to provide a brief synopsis of the issue
while facts are being gathered for documentation in an issue brief.
VISN offices are typically responsible for direct reporting to the VHA
VHA Central Office. VISNs typically report all serious
incidents to the VHA Office of the Deputy Under Secretary for Health
for Operations and Management, which then communicates relevant
incidents to other VHA offices, including the Office of the Principal
Deputy Under Secretary for Health, through an e-mail distribution list.
Law enforcement reporting stream. Responsibilities at each level
are described below.
Local VA police. Most VA medical facilities have a cadre
of VA police officers, who are Federal law enforcement officers charged
with protecting the medical facility by responding to and investigating
potentially criminal activities. Local policies typically require
medical facility staff to notify the medical facility's VA police of
incidents that may involve criminal acts, such as sexual assaults. VA
medical facility police also often notify and coordinate with local
area police departments and the VA OIG when criminal activities or
potential security threats occur.
VA's OSLE. This office is the department-level VA office
responsible for developing policies and procedures for VA's law
enforcement programs at local VA medical facilities. VA OSLE receives
reports of incidents at VA medical facilities through its centralized
police reporting system. Additionally, local VA police are required to
immediately notify VA OSLE of serious incidents, including reports of
rape and aggravated assaults.
VA's Integrated Operations Center (IOC). The IOC,
established in April 2010, serves as the department's centralized
location for integrated planning and data analysis on serious
incidents.\12\ Serious incidents on VA property are reported to the IOC
either by local VA police or the VHA Office of the Deputy Under
Secretary for Health for Operations and Management. The IOC then
presents information on serious incidents to VA senior leadership
officials through daily reports and, in some cases, to the Secretary
through serious incident reports.
\12\ VA defines serious incidents as those that involve: (1) public
information regarding the arrest of a VA employee; (2) major disruption
to the normal operations of a VA facility; (3) deaths on VA property
due to suspected homicide, suicides, accidents, and/or suspicious
deaths; (4) VA police-involved shootings; (5) the activation of
occupant emergency plans, facility disaster plans, and/or continuity of
operations plans; (6) loss or compromise of VA sensitive data,
including classified information; (7) theft or loss of VA-controlled
firearms or hazardous material, or other major theft or loss; (8)
terrorist event or credible threat that impacts VA facilities or
operations; and (9) incidents on VA property that result in serious
illness or bodily injury, including sexual assault, aggravated assault,
and child abuse. See VA Directive 0321, Serious Incident Reports (Jan.
VA OIG. Federal regulation requires that all potential
felonies, including rape allegations, be reported to VA OIG
investigators.\13\ VHA policy reiterates this by specifying that the
OIG must be notified of sexual assault incidents when the crime occurs
on VA premises or is committed by VA employees.\14\ Typically, either
the medical facility's leadership team or VA police are responsible for
reporting potential felonies to the VA OIG.\15\ Once a case is
reported, VA OIG investigators can be the lead agency on the case or
advise local VA police or other law enforcement agencies conducting the
\13\ See 38 CFR Sec. 1.204 (2010). Criminal matters involving
felonies must be immediately referred to the OIG, Office of
Investigations. VA management officials with information about possible
criminal matters involving felonies are responsible for prompt
referrals to the OIG. Examples of felonies include but are not limited
to, theft of government property over $1,000, false claims, false
statements, drug offenses, crimes involving information technology
systems, and serious crimes against the person, i.e., homicides, armed
robbery, rape, aggravated assault, and serious physical abuse of a VA
patient. Additionally, another VA regulation requires that all VA
employees with knowledge or information about actual or possible
violations of criminal law related to VA programs, operations,
facilities, contracts, or information technology systems immediately
report such knowledge or information to their supervisor, any
management official, or directly to the VA OIG. 38 CFR Sec. 1.201
\14\ VHA Directive 2010-014, Assessment and Management of Veterans
Who Have Been Victims of Alleged Acute Sexual Assault (May 25, 2010).
\15\ The VA OIG may also learn of incidents from staff, patients,
congressional communications, or the VA OIG hotline for reporting
fraud, waste, and abuse.
Nearly 300 Sexual Assault Incidents Reported to VA Police, but Many
Were Not Reported to VHA or the VA OIG
We found that there were nearly 300 sexual assault incidents
reported to the VA police from January 2007 through July 2010--
including alleged incidents that involved rape, inappropriate touching,
forceful medical examinations, forced or inappropriate oral sex, and
other types of sexual assault incidents. Many of these sexual assault
incidents were not reported to officials within the management
reporting stream and to the VA OIG.
Nearly 300 Sexual Assault Incidents Reported to VA Police From January
2007 Through July 2010
We analyzed VA's national police files from January 2007 through
July 2010 and identified 284 sexual assault incidents reported to VA
police during that period. \16,17\ These cases included incidents
alleging rape, inappropriate touching, forceful medical examinations,
oral sex, and other types of sexual assaults (see table 1).\18\
However, it is important to note that not all sexual assault incidents
reported to VA police are substantiated. A case may remain
unsubstantiated because an assault did not actually take place, the
victim chose not to pursue the case, or there was insufficient evidence
to substantiate the case. Due to our review of both open and closed VA
police sexual assault incident investigations, we could not determine
the final disposition of these incidents.\19\
\16\ Our analysis was limited to only those reports that were
provided by the VA OSLE and does not include reports that may never
have been created or were lost by local VA police or VA OSLE.
\17\ We could not systematically analyze sexual assault incidents
reported through VA's management stream due to the lack of a
centralized VA management reporting system for tracking sexual assaults
and other safety incidents.
\18\ To conduct this analysis, we placed VA police case files into
these categories to describe the allegations contained within them.
\19\ We could not consistently determine whether or not these
sexual assault incidents were substantiated due to limitations in the
information VA provided, including inconsistent documentation of the
disposition of some incidents in the police files.
Table 1: Number of Sexual Assault Incidents by Category Reported to VA Police by Year, January 2007 through July
Forceful Forced or
Year Rape \a\ Inappropriate medical inappropriate Other \c\ Total
touch \b\ examination oral sex
2010 \d\ 14 44 3 5 0 66
2009 23 66 3 3 9 104
2008 \e\ 13 42 1 3 1 60
2007 \e, f\ 17 33 1 2 1 54
Total \g\ 67 185 8 13 11 284
Source: GAO (analysis); VA (data).
Note: In this report, we use the term sexual assault incident to refer to suspected, alleged, attempted, or
confirmed cases of sexual assault. All reports of sexual assault incidents do not necessarily lead to
prosecution and conviction. This may be, for example, because an assault did not actually take place or there
was insufficient evidence to determine whether an assault occurred.
\a\ The rape category includes any case involving allegations of rape, defined as vaginal or anal penetration
through force, threat, or inability to consent. For cases that included allegations of multiple categories
including rape (i.e., inappropriate touch, forced oral sex, and rape) the category of rape was applied. Cases
where staff deemed that one or more of the veterans involved were mentally incapable of consenting to sexual
activities described in the case were considered rape.
\b\ The inappropriate touch category includes any case involving only allegations of touching, fondling,
grabbing, brushing, kissing, rubbing, or other like terms.
\c\ The other category included any allegations that did not fit into the other categories or if the incident
described in the case file did not contain sufficient information to place the case in one of the other
\d\ Analysis of 2010 records was limited to only those received by VA police through July 2010.
\e\ Due to the lack of a centralized VA police reporting system prior to January 2009, VA medical facility
police sent reports to VA's OSLE for the purpose of this data request, which may have resulted in not all
reports being included in this analysis.
\f\ Our ability to review files for the entire year was limited because VA police are required to destroy files
after 3 years under a records schedule approved by the National Archives and Records Administration (NARA).
\g\ Cases not reported to VA police were not included in our analysis of sexual assault incidents.
In analyzing these 284 cases, we observed the following:
Overall, the sexual assault incidents described above
included several types of alleged perpetrators, including employees,
patients, visitors, outsiders not affiliated with VA, and persons of
unknown affiliation. In the reports we analyzed, there were allegations
of 89 patient-on-patient sexual assaults, 85 patient-on-employee sexual
assaults, 46 employee-on-patient sexual assaults, 28 unknown
affiliation-on-patient sexual assaults, and 15 employee-on-employee
\20\ Other allegations by relationship included: 1 employee-on-
outsider assault, 2 employee-on-visitor assaults, 2 outsider-on-
employee assaults, 2 outsider-on-outsider assaults, 1 outsider-on-
patient assault, 1 outsider-on-visitor assault, 3 patient-on-visitor
assaults, 3 unknown-on-employee assaults, 3 unknown-on-visitor
assaults, 1 visitor-on-employee assault, and 2 visitor-on-patient
Regarding gender of alleged perpetrators, we also
observed that of the 89 patient-on-patient sexual assault incidents, 46
involved allegations of male perpetrators assaulting female patients,
42 involved allegations of male perpetrators assaulting male patients,
and 1 involved an allegation of a female perpetrator assaulting a male
patient. Of the 85 patient-on-employee sexual assault incidents, 83
involved allegations of male perpetrators assaulting female employees
and 2 involved allegations of male perpetrators assaulting male
Sexual Assault Incidents Are Underreported to VISNs, VHA Central
Office, and the VA OIG
VISN and VHA Central Office officials did not receive reports of
all sexual assault incidents reported to VA police in VA medical
facilities within the four VISNs we reviewed. In addition, the VA OIG
did not receive reports of all sexual assault incidents that were
potential felonies as required by VA regulation, specifically those
involving rape allegations.
VISNs and VHA Central Office Receive Limited Information on Sexual
VISNs and VHA Central Office leadership officials are not fully
aware of many sexual assaults reported at VA medical facilities. For
the four VISNs we spoke with, we examined all documented incidents
reported to VA police from medical facilities within each network and
compared these reports with the issue briefs received through the
management reporting stream by VISN officials. Based on this analysis,
we determined that VISN officials in these four networks were not
informed of most sexual assault incidents that occurred within their
network medical facilities.\21\ Moreover, we also found that one VISN
did not report any of the cases they received to VHA Central Office.
(See table 2.)
\21\ Our review of the reports received by both VISN and VA Central
Office officials was limited to only those documented in issue briefs
and did not include the less formal heads-up messages. This is because
heads-up messages are not formally documented and often are a
preliminary step to a more formal issue brief.
Table 2: Sexual Assault Incidents Reported to Four Selected VISNs and VHA Central Office Leadership, January
2007 through July 2010
Total number of
Total number of sexual Total number of sexual sexual assault
assault incidents assault incidents incidents reported
VISN reported to VA police reported to VISN by VISNs to VHA
from VISN medical leadership by VISN Central Office
facilities \a, b\ medical facilities leadership
VISN A 13 0 0
VISN B 21 10 5
VISN C 34 4 4
VISN D 34 2 2
Source: GAO (data and analysis); VA (data).
Note: In this report, we use the term sexual assault incident to refer to suspected, alleged, attempted, or
confirmed cases of sexual assault. All reports of sexual assault incidents do not necessarily lead to
prosecution and conviction. This may be, for example, because an assault did not actually take place or there
was insufficient evidence to determine whether an assault occurred.
\a\ Cases not reported to VA police were not included in our count of sexual assault incidents.
\b\ Due to the absence of systemwide requirements on what medical facilities must report to these VISNs, we
could not determine the accuracy of VISN reporting.
VA OIG Did Not Receive Reports of about Two-Thirds of Sexual Assault
Incidents Involving Rape Allegations
To examine whether VA medical facilities were accurately reporting
sexual assault incidents involving rape allegations to the VA OIG, we
reviewed the 67 rape allegations reported to the VA police from January
2007 through July 2010 and compared these cases with all investigation
documentation provided by the VA OIG for the same period. We found no
evidence that about two-thirds (42) of these rape allegations had been
reported to the VA OIG.\22\ The remaining 25 had matching VA OIG
investigation documentation, indicating that they were correctly
reported to both the VA police and the VA OIG.
\22\ We did not require VA OIG to provide documentation for 9
incidents currently under investigation due to the sensitive nature of
these ongoing investigations. Since we did not require this
documentation, it is possible that some of these 9 ongoing
investigations were included in the 42 rape allegations we could not
confirm were reported to the VA OIG.
By regulation, VA requires that: (1) all criminal matters involving
felonies that occur in VA medical facilities be immediately referred to
the VA OIG and (2) responsibility for the prompt referral of any
possible criminal matters involving felonies lies with VA management
officials when they are informed of such matters.\23\ This regulation
includes rape in the list of felonies provided as examples and also
requires VA medical facilities to report other sexual assault incidents
that meet the criteria for felonies to the VA OIG. \24,25\ However, the
regulation does not include criteria for how VA medical facilities and
management officials should determine whether or not a criminal matter
meets the felony reporting threshold. We found that all 67 of these
rape allegations were potential felonies because, if substantiated,
sexual assault incidents involving rape fall within Federal sexual
offenses that are punishable by imprisonment of more than 1 year.
\23\ See 38 CFR Sec. 1.204 (2010). Examples of felonies listed in
this regulation include theft of government property over $1,000, false
claims, false statements, drug offenses, crimes involving information
technology systems, and serious crimes against the person, i.e.,
homicides, armed robbery, rape, aggravated assault, and serious
physical abuse of a VA patient.
\24\ The VA Security and Law Enforcement Handbook defines a felony
as any offense punishable by either imprisonment of more than 1 year or
death as classified under 18 U.S.C. Sec. 3559. See VA Handbook 0730,
Security and Law Enforcement (Aug. 11, 2000). Federal statutes define
certain sexual acts and contacts as Federal crimes. See 18 U.S.C.
Sec. Sec. 2241-2248. All Federal sexual offenses are punishable by
imprisonment of more than 1 year; therefore all Federal sexual offenses
are felonies and must be immediately referred to the VA OIG for
investigation in accordance with VA regulation.
\25\ For the purposes of our analysis, we focused only on sexual
assault incidents involving rape allegations. Neither Federal statutes
nor VA regulations define rape; however, the definition of rape we
developed for our analysis falls within the Federal sexual offenses of
either aggravated sexual abuse or sexual abuse. See 18 U.S.C.
Sec. Sec. 2241 and 2242. These two offenses are felonies under Federal
statute; therefore, all rapes that meet our definition are felonies.
In addition, we provided the VA OIG the opportunity to review
summaries of the 42 rape allegations we could not confirm were reported
to them by the VA police. To conduct this review, several VA OIG
senior-level investigators determined whether or not each of these rape
allegations should have been reported to them based on what a
reasonable law enforcement officer would consider a felony. According
to these investigators, a reasonable law enforcement officer would look
for several elements to make this determination, including (1) an
identifiable and reasonable suspect, (2) observations by a witness, (3)
physical evidence, or (4) an allegation that appeared credible. These
investigators based their determinations on their experience as Federal
law enforcement agents. Following their review, these investigators
also found that several of these rape allegations were not
appropriately reported to the VA OIG as required by Federal regulation.
Specifically, the VA OIG investigators reported that they would have
expected about one-third (33 percent) of the 42 rape allegations to
have been reported to them based on the incident summary containing
information on these four elements. The investigators noted that they
would not have expected approximately 55 percent of the 42 rape
allegations to have been reported to them due to either the incident
summary failing to contain these same four elements or the presence of
inconsistent statements made by the alleged victims.\26\ For the
remaining approximately 12 percent, the investigators noted that the
need for notification was unclear because there was not enough
information in the incident summary to make a determination about
whether or not the rape allegation should have been reported to the VA
\26\ The VA OIG senior-level investigators who conducted this
review noted that they identified at least one incident summary that
was readily identifiable as a case currently under investigation by the
VA OIG. Due to the general nature of the incident summaries we provided
for their review and the sensitive nature of specific details of
ongoing investigations, we did not require the VA OIG to provide
specific details on exactly how many of the 42 rape allegations we
asked them to review were currently under investigation by their
office; however, the total number of ongoing sexual assault incident
investigations for the time period of our analysis was only 9.
VHA Guidance and Oversight Weaknesses May Contribute to the
Underreporting of Sexual Assault Incidents
Several factors may contribute to the underreporting of sexual
assault incidents to VISNs, VHA Central Office, and the VA OIG--
including VHA's lack of a consistent sexual assault definition for
reporting purposes; limited and unclear expectations for sexual assault
incident reporting at the VHA Central Office, VISN, and VA medical
facility levels; and deficiencies in VHA Central Office oversight of
sexual assault incidents.
VHA Does Not Have a Consistent Sexual Assault Definition for Reporting
VHA leadership officials may not receive reports of all sexual
assault incidents that occur at VA medical facilities because there is
no VHA-wide definition of sexual assault used for incident reporting.
We found that VHA lacks a consistent definition for the reporting of
sexual assault through the management reporting stream at the medical
facility, VISN, and VHA Central Office levels. At the medical facility
level, we found that the medical facilities we visited had a variety of
definitions of sexual assault targeted primarily to the assessment and
management of victims of recent sexual assaults. Specifically,
facilities varied in the level of detail provided by their policies,
ranging from one facility that did not include a definition of sexual
assault in its policy at all to another facility with a policy that
included a detailed definition. At the VISN level, officials with whom
we spoke in the four networks said they did not have definitions of
sexual assault in VISN policies.\27\ Finally, while VHA Central Office
does have a policy for the clinical management of sexual assaults, this
policy is targeted to the treatment of victims assaulted within 72
hours and does not include sexual assault incidents that occur outside
of this time frame. In addition, no definition of sexual assault is
included in VHA Central Office reporting guidance.
\27\ However, some VISN officials stated they used other common
definitions, including those from the National Center for Victims of
Crime and The Joint Commission.
VHA Central Office, VISNs, and VA Medical Facilities' Expectations for
Reporting Are Limited and Unclear
In addition to failing to provide a consistent definition of sexual
assault for incident reporting, VHA also does not have clearly
documented expectations about the types of sexual assault incidents
that should be reported to officials at each level of the organization,
which may also contribute to the underreporting of sexual assault
incidents. Without clear expectations for incident reporting there is
no assurance that all sexual assault incidents are appropriately
reported to officials at the VHA Central Office, VISN, and local
medical facility levels. We found that expectations were not always
clearly documented, resulting in either the underreporting of some
sexual assault incidents or communication breakdowns at all levels.
VHA Central Office. An official from VHA's Office of the
Deputy Under Secretary for Health for Operations and Management told us
that this office's expectations for reporting sexual assault incidents
were documented in its guidance for the submission of issue briefs.
However, we found that this guidance does not specifically reference
reporting requirements for any type of sexual assault incidents. As a
result, VISNs we reviewed did not consistently report sexual assault
incidents to VHA Central Office.
VISNs. Officials from the four VISNs we reviewed did not
include detailed expectations regarding whether or not sexual assault
incidents should be reported to them in their reporting guidance,
potentially resulting in medical facilities failing to report some
incidents.\28\ For example, officials from one VISN told us they expect
to be informed of all sexual assault incidents occurring in medical
facilities within their network, but this expectation was not
explicitly documented in their policy. We found several reported
allegations of sexual assault incidents in medical facilities in this
VISN--including three allegations of rape and one allegation of
inappropriate oral sex--that were not forwarded to VISN officials.\29\
\28\ While two of the four VISN policies reference The Joint
Commission's definition of sentinel events, which includes rape, this
definition does not include the broader category of sexual assault
incidents as defined in this report.
\29\ When asked about these four allegations, VISN officials told
us that they would only have expected to be notified of two of them--
one allegation of rape and one allegation of inappropriate oral sex--
because the medical facilities where they occurred contacted outside
entities, including the VA OIG. VISN officials explained that the
remaining two rape allegations were unsubstantiated and were not
reported to their office; the VISN also noted that unsubstantiated
incidents are not often reported to them.
VA medical facilities. At the medical facility level, we
also found that reporting expectations may be unclear. In particular,
we identified cases in which the VA police had not been informed of
incidents that were reported to medical facility staff. For example, we
identified VA police files from one facility we visited where officers
noted that the alleged perpetrator had been previously involved in
other sexual assault incidents that were not reported to the VA police
by medical facility staff. In these police files, officers noted that
staff working in the alleged perpetrators' units had not reported the
previous incidents because they believed these behaviors were a
manifestation of the veterans' clinical condition. In addition, at this
same medical facility, quality management staff identified five sexual
assault incidents that had not been reported to VA police at the
medical facility, despite these incidents being reported to their
Oversight Deficiencies at VHA Central Office Contribute to the
Underreporting of Sexual Assault Incidents
We found weaknesses both in the way sexual assault incidents are
communicated to VHA Central Office and in the way that information
about such incidents is collected and analyzed for oversight purposes.
Poor Communication About Sexual Assault Incidents Resulted in
Incomplete Reporting Within VHA Central Office
Currently, VHA Central Office relies primarily on e-mail messages
to transfer information about sexual assault incidents among its
offices and staff. (See fig. 2.) Under this system, VHA Central Office
is notified of sexual assault incidents through issue briefs submitted
by VISNs via e-mail to the VHA Office of the Deputy Under Secretary for
Health for Operations and Management.\30\ Following review, the
Director for Network Support forwards issue briefs to the Office of the
Principal Deputy Under Secretary for Health for distribution to other
VHA offices on a case-by-case basis, including the program offices
responsible for residential programs and inpatient mental health units.
Program offices are sometimes asked to follow up on incidents in their
area of responsibility.
\30\ VISNs may also send a heads-up message to this office either
by e-mail or phone to inform the Office of the Deputy Under Secretary
for Health for Operations and Management of emerging incidents. These
heads-up messages are typically the precursor to issue briefs received
by the office.
We found that this system did not effectively communicate
information about sexual assault incidents to the VHA Central Office
officials who have programmatic responsibility for the locations in
which these incidents occurred. For example, VHA program officials
responsible for both residential programs and inpatient mental health
units reported that they do not receive regular reports of sexual
assault incidents that occur within their programs or units at VA
medical facilities and were not aware of any incidents that had
occurred in these programs or units. However, during our review of VA
police files, we identified at least 18 sexual assault incidents that
occurred from January 2007 through July 2010 in the residential
programs or inpatient mental health units of the five VA medical
facilities we reviewed. If the management reporting stream were
functioning properly, these program officials should have been notified
of these incidents and any others that occurred in other VA medical
facilities' residential programs and inpatient mental health units.\31\
Without the regular exchange of information regarding sexual assault
incidents that occur within their areas of programmatic responsibility,
VHA program officials cannot effectively address the risks of such
incidents in their programs and units and do not have the opportunity
to identify ways to prevent incidents from occurring in the future.
\31\ See GAO, Internal Control: Standards for Internal Control in
the Federal Government,
GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999). Standards for
internal control in the Federal Government state that information
should be recorded and communicated to management and others within the
agency that need it in a format and time frame that enables them to
carry out their responsibilities.
In early 2011, VHA leadership officials told us that initial
efforts, including sharing information about sexual assault incidents
with the Women Veterans Health Strategic Health Care Group and VHA
program offices, were underway to improve how information on sexual
assault incidents is communicated to program officials. However, these
improvements have not been formalized within VHA or published in
guidance or policies and are currently being performed on an informal
ad hoc basis only, according to VHA officials.
VHA Does Not Systematically Monitor and Track Sexual Assault Incidents
In addition to deficiencies in information sharing, we also
identified deficiencies in the monitoring of sexual assault incidents
within VHA Central Office. VHA's Office of the Deputy Under Secretary
for Health for Operations and Management, the first VHA office to
receive all issue briefs related to sexual assault incidents, does not
currently have a system that allows VHA Central Office staff to
systematically collect or analyze reports of sexual assault incidents
received from VA medical facilities through the management reporting
stream. Specifically, we found that this office does not have a central
database to store the issue briefs that it receives and instead relies
on individual staff to save issue briefs submitted to them by e-mail to
electronic folders for each VISN. In addition, officials within this
office said they do not know the total number of issue briefs submitted
for sexual assault incidents because they do not have access to all
former staff members' files. As a result of these issues, staff from
the Office of the Deputy Under Secretary for Health for Operations and
Management could not provide us with a complete set of issue briefs on
sexual assault incidents that occurred in all VA medical facilities
without first contacting VISN officials to resubmit these issue
briefs.\32\ Such a limited archive system for reports of sexual assault
incidents received through the management reporting stream results in
VHA's inability to track and trend sexual assault incidents over time.
While VHA has, through its National Center for Patient Safety (NCPS),
developed systems for routinely monitoring and tracking patient safety
incidents that occur in VA medical facilities, these systems do not
monitor sexual assaults and other safety incidents. Without a system to
track and trend sexual assaults and other safety incidents, VHA Central
Office cannot identify and make changes to serious problems that
jeopardize the safety of veterans in their medical facilities.
\32\ See GAO/AIMD-00-21.3.1. Standards for internal control in the
Federal Government state that agencies should design internal controls
that assure ongoing monitoring occurs in the course of normal
operations, is continually performed, and is ingrained in agency
Serious Weaknesses Observed in Several Types of Physical Security
Precautions Used in Selected Medical Facilities
Physical precautions in the residential programs and inpatient
mental health units at the medical facilities we visited included
monitoring precautions used to observe patients, security precautions
used to physically secure facilities and alert staff of problems, and
staff awareness and preparedness precautions used to educate staff
about security issues and provide police assistance. However, we found
serious deficiencies in the use and implementation of certain physical
security precautions at these facilities, including alarm system
malfunctions and inadequate monitoring of security cameras.
Several Types of Physical Security Precautions Are in Place in Selected
VA medical facilities we visited used a variety of physical
security precautions to prevent safety incidents in their residential
programs and inpatient mental health units. Typically, medical
facilities had discretion to implement these precautions based on their
own needs within broad VA guidelines.
In general, physical security precautions were used as a measure to
prevent a broad range of safety incidents, including sexual assaults.
We classified these precautions into three broad categories: monitoring
precautions, security precautions, and staff awareness and preparedness
precautions. (See table 3.)
Table 3: Physical Security Precautions in Residential Programs and
Inpatient Mental Health Units at Selected VA Medical Facilities
Staff awareness and
Monitoring precautions Security precautions preparedness
Closed-circuit Locks and Staff
surveillance camera alarms at entrance and training
use and monitoring exit access points VA police
Unit rounds by Locks and presence on units
VA staff alarms for patient VA police
bedrooms and bathrooms staffing and command
Stationary, and control
computer-based, and operations
areas for women
Note: Physical security precautions varied by VA medical facility and
program and were not necessarily in place at all VA medical facilities
and programs we visited.
Monitoring precautions. These measures were those designed to
observe and track patients and activities in residential and inpatient
settings. For example, at some VA medical facilities we visited,
closed-circuit surveillance cameras were installed to allow VA staff
to monitor areas and to help detect potentially threatening behavior
or safety incidents as they occur. Cameras were also used to passively
document any incidents that occurred.
Security precautions. These precautions were those designed to
maintain a secure environment for patients and staff within
residential programs and inpatient mental health units and allow staff
to call for help in case of any problems. For example, the units we
visited regularly used locks and alarms at entrance and exit access
points, as well as locks and alarms for some patient bedrooms. Another
security precaution we observed was the use of stationary, computer-
based, and portable personal panic alarms for staff.\33\****
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Staff awareness and preparedness precautions. These measures
were designed to educate and prepare residential program and inpatient
mental health unit staff to deal with security issues and to provide
police support and assistance when needed. For example, there was a
regular VA police presence within some residential programs we
visited. Also, all medical facilities we visited had a functioning
police command and control center, which program staff could contact
for police support when needed.
Significant Weaknesses Existed in the Use and Implementation of Certain
Physical Security Precautions at Selected VA Medical Facilities
\33\ Stationary panic alarms are fixed to furniture, walls, or
other stationary items and can be used to alert VA staff of a problem
or call for help if staff feel threatened. Computer-based panic alarms
are activated by depressing a specified combination of keys on a
medical center keyboard. Portable personal panic alarms are small
devices that staff can carry with them while on duty that can also
alert VA staff of a problem if activated.
While security precautions have been established in most cases to
prevent patient safety incidents, including sexual assaults, these
precautions had not been effectively implemented by VA medical facility
staff in the five facilities we visited. During our review of the
physical security precautions in use at the five VA medical facilities
we visited, we observed seven weaknesses in these three categories.\34\
(See table 4.)
\34\ Our review of physical security precautions at the five VA
medical facilities we visited was limited to the residential programs,
inpatient mental health units, and medical facility command and control
Table 4: Weaknesses in Physical Security Precautions in Residential
Programs and Inpatient Mental Health Units at Selected VA Medical
Staff awareness and
Monitoring precautions Security precautions preparedness
Inadequate Alarm VA police
monitoring of closed- malfunctions of staffing and workload
circuit surveillance stationary, computer- challenges
cameras based, and personal Lack of
panic alarms stakeholder
Inadequate involvement in unit
documentation or redesign efforts
review of alarm
alarms to alert both
unit staff and VA
Limited use of
personal panic alarms
Inadequate monitoring of closed-circuit surveillance cameras. We
observed that VA staff in the police command and control center were
not continuously monitoring closed-circuit surveillance cameras at all
five of the VA medical facilities we visited. For example, at one
medical facility, the system used by the residential programs at that
medical facility could not be monitored by the police command and
control center staff because it was incompatible with systems installed
in other parts of the medical facility. According to VA police at this
medical facility, the residential program staff did not consult with VA
police before installing their own system. At another medical facility,
where staff in the police office monitor cameras covering the
residential programs' grounds and parking area, we found that the
police office was unattended part of the time. In addition, at the
remaining three medical facilities we visited, staff in the police
command and control centers assigned to monitor medical facility
surveillance cameras had other duties, such as serving as telephone
operators and police/emergency dispatchers. These other duties
sometimes prevented them from continuously monitoring the camera feeds
in the police command and control center.\35\ Although effective use of
surveillance camera systems cannot necessarily prevent safety incidents
from occurring, lapses in monitoring by security staff compromise the
effectiveness of these systems.
\35\ At some facilities, just one person was assigned to serve both
functions, while at another location two people were expected to share
those functions but only one person was present at the time of our
visit due to staffing vacancies, illness, or shortages.
Alarm malfunctions. At least one form of alarm failed to work
properly when tested at four of the five medical facilities we visited.
For example, at one medical facility, we tested the portable personal
panic alarms used by residential program staff and found that the
police command and control center could not accurately pinpoint the
location of the tester when an alarm was activated outside the
building. At another medical facility that used stationary panic alarms
in inpatient mental health units, residential programs, and other
clinical settings, almost 20 percent of these alarms throughout the
medical facility were inoperable. At an inpatient mental health unit in
a third medical facility, three of the computer-based panic alarms we
tested failed to properly pinpoint the location of our tester because
the medical facility's computers had been moved to different locations
and were not properly reconfigured. Finally, at a fourth medical
facility, alarms we tested in the inpatient mental health unit sounded
properly, but staff in the unit and VA police responsible for testing
these alarms did not know how to turn them off after they were
activated. In each of the cases where alarms malfunctioned, VA staff
were not aware the alarms were not functioning properly until we
Inadequate documentation or review of alarm system testing. One of
the five sites we visited failed to properly document tests conducted
of their alarm systems for their residential programs, although testing
of alarms is a required element in VA's Environment of Care Checklist.
Testing of alarm systems is important to ensure that systems function
properly, and not having complete documentation of alarm system testing
is an indication that periodic testing may not be occurring. In
addition, three medical facilities reported using computer-based panic
alarms that are designed to be self-monitoring to identify cases where
computers equipped with the system fail to connect with the servers
monitoring the alarms. Officials at all three of these medical
facilities stated that due to the self-monitoring nature of these
alarms, they did not maintain alarm test logs of these systems.
However, we found that at two of these three medical facilities, these
alarms failed to properly alert VA police when tested. Such alarm
system failures indicate that the self-monitoring systems may not be
effectively alerting medical facility staff of alarm malfunctions when
they occur, indicating the need for these systems to be periodically
Alarms failed to alert both police and unit staff. In inpatient
mental health units at all five medical facilities we visited,
stationary and computer-based panic alarm systems we tested did not
alert staff in both the VA police command and control center and the
inpatient mental health unit where the alarm was triggered. Alerting
both locations is important to better ensure that timely and proper
assistance is provided. At four of these medical facilities, the
inpatient mental health units' stationary or computer-based panic
alarms notified the police command and control centers but not staff at
the nursing stations of the units where the alarms originated. At the
fifth medical facility, the stationary panic alarms only notified staff
in the unit nursing station, making it necessary to separately notify
the VA police. Finally, none of the stationary or computer-based panic
alarms used by residential programs notified both the police command
and control centers and staff within the residential program buildings
\36\ One of the residential programs we reviewed did not use
stationary panic alarm systems. This facility relied on portable
personal panic alarms for its residential program staff.
Limited use of portable personal panic alarms. Electronic portable
personal panic alarms were not available for the staff at any of the
inpatient mental health units we visited and were available to staff at
only one residential program we reviewed. In two of the inpatient
mental health units we visited, staff were given safety whistles they
could use to signal others in cases of emergency, personal distress, or
concern about veteran or staff safety. However, relying on whistles to
signal such incidents may not be effective, especially when staff
members are the victims of assault. For example, a nurse at one medical
facility we visited was involved in an incident in which a patient
grabbed her by the throat and she was unable to use her whistle to
summon assistance. Some inpatient mental health unit staff with whom we
spoke indicated an interest in having portable personal panic alarms to
better protect them in similar situations.
VA police staffing and workload challenges. At most medical
facilities we visited, VA police forces and police command and control
centers were understaffed, according to medical facility officials. For
example, during our visit to one medical facility, VA police officials
reported being able to staff just two officers per 12-hour shift to
patrol and respond to incidents at both the medical facility and at a
nearby 675-acre veteran's cemetery. While this staffing ratio met the
minimum standards for VA police staffing, having only two police
officers to cover such a large area could potentially increase the
response times should a panic alarm activate or other security incident
occur on medical facility grounds. Also, we found that there was an
inadequate number of officers and staff at this medical facility to
effectively police the medical facility and maintain a productive
police force. The medical facility had a total of 9 police officers at
the time of our visit; according to VA staffing guidance, the minimum
staffing level for this medical facility should have been 19 officers.
Not all medical facilities we visited had staffing problems. At one
medical facility, the VA police appeared to be well staffed and were
even able to designate staff to monitor off-site residential programs
and community-based outpatient clinics.
Lack of stakeholder involvement in unit redesign. As medical
facilities undergo remodeling, it is important that stakeholders are
consulted in the design process to better ensure that new or remodeled
areas are both functional and safe. We found that such stakeholder
involvement on remodeling projects had not occurred at one of the
medical facilities we visited. At this medical facility, clinical and
VA police personnel were not consulted about a redesign project for the
inpatient mental health unit. The new unit initially included one
nursing station that did not prevent patient access if necessary. After
the unit was reopened following the renovation, there were a number of
assaults, including an incident where a veteran reached over the
counter of the unit's nursing station and physically assaulted a nurse
by stabbing her in the neck, shoulder, and leg with a pen. Had staff
been consulted on the redesign of this unit, their experience managing
veterans in an inpatient mental health unit environment would have been
helpful in developing several safety aspects of this new unit,
including the design of the nursing station. Less than a year after
opening this unit, medical facility leadership called for a review of
the units' design following several reported incidents. As a result of
this review, the unit was split into two separate units with different
veteran populations, an additional nursing station was installed, and
changes were planned for the structure of both the original and newly
created nursing stations--including the installation of a new shoulder-
height Plexiglas barricade on both nursing station counters.
In conclusion, weaknesses exist in the reporting of sexual assault
incidents and in the implementation of physical precautions used to
prevent sexual assaults and other safety incidents in VA medical
facilities. Medical facility staff are uncertain about what types of
sexual assault incidents should be reported to VHA leadership and VA
law enforcement officials and prevention and remediation efforts are
eroded by failing to tap the expertise of these officials. These
officials can offer valuable suggestions for preventing and mitigating
future sexual assault incidents and help address broader safety
concerns through systemwide improvements throughout the VA health care
system. Leaving reporting decisions to local VA medical facilities--
rather than relying on VHA management and VA OIG officials to determine
what types of incidents should be reported based on the consistent
application of known criteria--increases the risk that some sexual
assault incidents may go unreported. Moreover, uncertainty about sexual
assault incident reporting is compounded by VA not having: (1)
established a consistent definition of sexual assault, (2) set clear
expectations for the types of sexual assault incidents that should be
reported to VISN and VHA Central Office leadership officials, and (3)
maintained proper oversight of sexual assault incidents that occurred
in VA medical facilities. Unless these three key features are in place,
VHA will not be able to ensure that all sexual assault incidents will
be consistently reported throughout the VA health care system.
Specifically, the absence of a centralized tracking system to monitor
sexual assault incidents across VA medical facilities may seriously
limit efforts to both prevent such incidents in the short and long term
and maintain a working knowledge of past incidents and efforts to
address them when staff transitions occur.
In addition, ensuring that medical facilities maintain a safe and
secure environment for veterans and staff in residential programs and
inpatient mental health units is critical and requires commitment from
all levels of VA. Currently, the five VA medical facilities we visited
are not adequately monitoring surveillance camera systems, maintaining
the integrity of alarm systems, and ensuring an adequate police
presence. Closer oversight by both VISNs and VHA Central Office staff
is needed to provide a safe and secure environment throughout all VA
To improve VA's reporting and monitoring of allegations of sexual
assault, we are making numerous recommendations--in a report that we
issued last week. We recommended VA improve the reporting and
monitoring of sexual assault incidents, including ensuring that a
consistent definition of sexual assault is used for reporting purposes,
clarifying expectations for reporting incidents to VISN and VHA
leadership, and developing and implementing mechanisms for incident
monitoring. To address vulnerabilities in physical security precautions
at VA medical facilities, we recommended that VA ensure that alarm
systems are regularly tested and kept in working order and that
coordination among stakeholders occurs for renovations to units and
physical security features at VA medical facilities.
In responding to a draft of the report on which this testimony is
based, VA generally agreed with the report's conclusions and concurred
with our recommendations. In addition, VA provided an action plan,
which described the creation of a multidisciplinary workgroup to manage
the agency's response to many of our recommendations. According to VA's
comments, this workgroup will provide the Under Secretary for Health
and his deputies with monthly verbal updates on its progress, as well
as an initial action plan by July 15, 2011, and a final report by
September 30, 2011.
Chairwoman Buerkle, Ranking Member Michaud, and Members of the
Subcommittee, this concludes my prepared statement. I would be happy to
respond to any questions either of you or other Members of the
Subcommittee may have.
Contacts and Acknowledgments
For further information about this testimony, please contact
Randall B. Williamson at (202) 512-7114 or [email protected] Contact
points for our Offices of Congressional Relations and Public Affairs
may be found on the last page of this testimony. Individuals who made
key contributions to this testimony include Marcia A. Mann, Assistant
Director; Emily Goodman; Katherine Nicole Laubacher; and Malissa G.
Prepared Statement of Joseph G. Sullivan, Jr., Deputy Assistant
Inspector General for Investigations, Office of Inspector General,
U.S. Department of Veterans Affairs
Madam Chairwoman and Members of the Subcommittee, thank you for the
opportunity to discuss how the Office of Inspector General (OIG)
interacts with the Department of Veterans Affairs (VA) with regards to
reporting alleged felonies, including sexual assaults at VA medical
facilities. I would also like to share some other work by the OIG in
the area of safety at VA medical facilities.
The OIG's Office of Investigations conducts criminal and
administrative investigations involving crimes impacting the
Department's programs and operations and serious misconduct by senior
management. When evidence of a crime or serious misconduct is developed
during an investigation, we seek appropriate prosecution and/or
administrative action to assist the VA in maintaining an environment
that is safe for employees, patients, and visitors and protected
against criminal activity.
VA maintains a police force at all VA Medical Centers (VAMCs) that
has jurisdiction over alleged crimes that happen on VA property. In the
last few years, the relationship between the OIG and VA Police has
improved. The OIG requires all of our field supervisors to, whenever
possible, identify a specific special agent to each VAMC Director,
Pharmacy Chief, and Police Chief to serve as a primary liaison with
Additionally, in order to deter crime, criminal investigators
continue to provide approximately 200 crime awareness briefings each
fiscal year to about 13,000 employees at VA facilities nationwide.
These briefings are intended to ensure that VA employees are aware of
the many types of fraud and criminal activity that can victimize VA, VA
employees, and veterans. These briefings have resulted in additional
referrals of alleged criminal activity.
Finally, either the Assistant Inspector General for Investigations
or I have addressed the VA Police Chiefs at their annual conference for
the last 3 years. In each of these liaison efforts, we remind VA Police
and other VA personnel of the requirement to report suspected felonies
to the OIG. We emphasize that failure to provide timely notification
may jeopardize our ability to successfully investigate an allegation.
Recognizing our limited staffing and geographic footprint, we advise
that we do not expect to be notified before local law enforcement but
that we do expect to be notified in a timely manner. We provide nearly
immediate feedback whether or not we will open an investigation.
The Code of Federal Regulations (CFR) require all VA employees to
report suspected criminal behavior to VA management and/or the OIG.
38 CFR Sec. 1.201--Employee's duty to report--All VA
employees with knowledge or information about actual or possible
violations of criminal law related to VA programs, operations,
facilities, contracts, or information technology systems shall
immediately report such knowledge of information to their supervisor,
any management official, or directly to the Office of Inspector
38 CFR Sec. 1.204--Information to be reported to the
Office of Inspector General--Criminal matters involving felonies will
also be immediately referred to the Office of Inspector General, Office
of Investigations. VA management officials with information about
possible criminal matters involving felonies will ensure and be
responsible for prompt referrals to the OIG. Examples of felonies
include but are not limited to, theft of Government property over
$1000, false claims, false statements, drug offenses, crimes involving
information technology systems and serious crimes against the person,
i.e., homicides, armed robbery, rape, aggravated assault and serious
physical abuse of a VA patient.
Government Accountability Office review
When the Government Accountability Office (GAO) contacted the OIG
for information involving allegations of sexual assault, we provided
detailed information and OIG investigative reports about 119 OIG
investigations completed between January 2005 and June 2010 that
involved allegations of sexual assault ranging from inappropriate
touching to rape. Subsequently, GAO advised that the 2005 and 2006 data
would not be used in their analysis; however, they requested an
additional 6 weeks of 2010 data as well as any cases that were open
during the previous search, but were now closed. We found information
associated with 11 additional closed cases that we provided to GAO. We
also provided GAO with de-identified information about nine sexual
assault investigations that remained in an open status as of August 1,
Later, GAO requested that we review 42 scenarios regarding alleged
sexual assaults that had occurred on VA property, but were not,
according to GAO's research, referred by VA Police to the OIG. We had
four senior agents review the information and they concluded the
In 23 (55 percent) of the scenarios, we would not have
expected VA Police to notify the OIG. Examples included allegations
that lacked any evidence of sexual assault obtained as a result of a
medical examination, to include a sexual assault collection kit that
did not reveal signs of sexual assault, and a victim who quickly
recanted the original allegation. Also included in this group were
allegations of a rape by a ``celestial being'' and consensual sex
engaged in by two inpatients.
In 14 (33 percent) of the scenarios, we would have
expected VA Police to notify the OIG. Examples included a victim with
dirt and grass on her clothing and in her hair who reported that she
had been raped while walking on the grounds of a VA Medical Center, and
a female physician who reported that a male patient sexually assaulted
her while conducting an examination.
In 5 (12 percent) of the scenarios, we could not make a
judgment because of either ambiguous or inadequate information in the
We also advised GAO that we recognized at least one scenario as an
open case that had been originally reported to us by VA Police. Because
GAO would not provide us any information that might identify the
victim, accused subject, or facility associated with any of the 42
scenarios, we could not determine if there were other open cases that
may have been reported to us.
The following examples illustrate cases originally reported to us
by the VA Police that we worked jointly with them:
A female veteran reported that a VA employee had made
sexually inappropriate conversation and physical contact with her
during several treatment sessions. The employee has been charged with
attempted criminal sexual abuse and simple battery.
A VA patient reported that a fellow inpatient at the VAMC
sexually assaulted her on a number of occasions during her stay in a
locked psychiatric unit. The suspect pled guilty to sexual assault in
the 3rd degree and was sentenced to 1 year of incarceration and 3
A VA patient residing in a VAMC assisted living area
reported being sexually assaulted by his roommate, a convicted sex
offender. The suspect was indicted on two counts of rape, two counts of
sexual battery, and two counts of gross sexual imposition. He pled
guilty to two counts of sexual battery and was sentenced to 6 months in
county custody and 3 years of community controls by the county's sex
offender unit. In addition, the judge classified him as a Tier III sex
offender, and he will have to register his address in person every 90
days for life.
A VA Chief Financial Officer sexually assaulted his minor
daughter on numerous occasions in his apartment, which was located on
VAMC property. This employee was recently sentenced to 36 months'
incarceration. Our investigation also revealed that the defendant
sexually assaulted the same daughter in a Las Vegas hotel.
Subsequently, he was sentenced to a year's incarceration in Nevada.
While these examples demonstrate VA Police complying with the CFR
reporting requirements, we are aware of instances of failure to timely
report suspected felonies to the OIG. This decreases the likelihood of
a successful resolution especially if VA Police have already conducted
interviews and done other work. For example, after receiving a report
from a female inpatient that 2 days earlier she had been raped, VA
Police interviewed both the victim and the suspect, searched the
vehicles of both the suspect and victim, took possession of the
suspect's cell phone, and interviewed common acquaintances prior to
contacting our local office, which is approximately 15 to 20 minutes
from the VAMC. When OIG special agents joined the investigation, they
added value by obtaining additional information from the victim and
transporting her to a local hospital where she was examined by a Sexual
Assault Response Team nurse. Additionally, when the OIG agents searched
the suspect's vehicle, they discovered potential evidence, a used
condom. Finally, had the victim not withdrawn her allegation and
admitted to the consensual nature of the event, some evidence recovered
prior to our involvement in the investigation may have been suppressed
because the consent obtained to search the suspect's cell phone was
verbal, not written.
We welcome GAO's recommendation to automate reminders to VA Police
to notify the OIG when entering a felony offense into the VA Police
database. We are pleased with the VA Police's intention to also
implement an automated notice to our field offices whenever the record
of such an offense is created. We believe both measures will greatly
reduce the number of instances when we are not notified of alleged
OTHER OIG WORK
The OIG, in October 2008, issued an Audit of the Veterans Health
Administration's Domiciliary Safety, Security, and Privacy (October 9,
2008) in which we assessed the effectiveness of safety, security, and
privacy of veterans residing in VA domiciliaries. We found that the
Veterans Health Administration needed to implement additional national
procedures and clarify national guidance to ensure that safety,
security, and privacy issues are sufficiently identified, reported, and
corrected throughout the year. We reported on three issues that
impacted all 49 domiciliaries:
There is a need to establish national procedures for the
inspections of veterans' room.
Additional safety, security, and privacy procedures are
needed for female veterans along with security initiatives for all
Improvements are needed in annual safety, security, and
privacy reporting as well as the follow-up process.
The report contained eight recommendations, which according to VA
have all been implemented.
The OIG and the VA Police have enhanced our working relationship
over the last several years in order to protect patients, visitors, and
employees at VA medical facilities. It is a commitment that both
organizations take seriously. The Director of VA's Law Enforcement and
Security Office e-mailed me recently stating ``As we all agree, we are
one team of law enforcement professionals and I and my senior team
believe in working together.'' We in the Office of Inspector General
share that sentiment.
Madam Chairwoman, this concludes my statement and I would be happy
to answer any questions that you or other Members of the Subcommittee
Prepared Statement of William Schoenhard, FACHE, Deputy
Under Secretary for Health for Operations and Management,
Veterans Health Administration, U.S. Department of Veterans Affairs
Chairwoman Buerkle, Ranking Member Michaud, and Members of the
Committee: Thank you for the opportunity to appear and discuss the
Department of Veterans Affairs' (VA) policies and actions to prevent
sexual assaults and other safety incidents at VA medical facilities.
The safety and security of our Veterans, employees, and visitors are
paramount to us, and we appreciate the work of the Government
Accountability Office (GAO) to help us further improve our programs and
facilities. Secretary Shinseki has made this issue a top priority for
the Department, and this commitment is reflected in our investments
over the last 2 years. This includes integrating safety and security
considerations into our Strategic Capital Investment Decision Model,
which evaluates and ranks proposed construction and renovation
projects, as a high priority consideration that is significantly
weighted. As a result, those projects designed to improve facility
security are consistently among the highest rated projects we support.
I am accompanied today by my colleagues George Arana, M.D., Acting
Assistant Deputy Under Secretary for Health for Clinical Operations,
and Kevin Hanretta, Deputy Assistant Secretary for Emergency
VA currently uses both VA staff and physical infrastructure systems
to ensure the security of our facilities, particularly residential and
inpatient mental health programs. Closed circuit cameras, locks,
alarms, separate facilities, and specialized training for health care
professionals are some of the steps we have taken so far. However, to
develop an even more robust and secure health care system, we have
convened a multi-disciplinary Workgroup to define what the Veterans
Health Administration (VHA) must do to prevent sexual assault incidents
and to respond to allegations of sexual victimization. This Workgroup
includes representatives from VHA and VA corporate offices, including
the Office of Operations, Security, and Preparedness, and the Office of
General Counsel. The Workgroup held its first meeting on June 6, 2011.
VA must, and will, proactively assess and manage risks and
institute appropriate precautions to maximize prevention and response
measures. We must also improve our mechanisms for Veterans and staff to
report incidents to law enforcement so that offenders can be held
accountable. These mechanisms must also provide information to VA
management so that concerns can be monitored and addressed
appropriately and timely.
My testimony today will first discuss the prevalence of sexual
assault and other safety incidents in VA medical facilities. It will
then cover VA policies and procedures for reporting and monitoring such
incidents. I will next detail the use of physical security precautions
and the ability of VA's Central Office to respond, provide oversight,
and address vulnerabilities. I will conclude by discussing VA's next
steps as we continue to improve the safety of our facilities for all
those on our property.
Prevalence of Sexual Assault and Other Safety Incidents
VA provided health care services to 6 million unique patients in
fiscal year (FY) 2010 at more than 1,300 sites of care, and VHA employs
more than 244,000 individuals. While the overwhelming majority of
experiences in VA facilities are safe, no system is perfect. During the
3 and a half year period of the GAO review, VA provided approximately
240 million outpatient visits and more than 2 million inpatient
admissions. As stated in GAO's report, ``VA HEALTH CARE: Actions Needed
to Prevent Sexual Assaults and Other Safety Incidents'' (GAO-11-530),
between January 2007 and July 2010, a period of 43 months, there were
284 alleged sexual assault incidents reported to VA police. Even one
incident is one too many, and we must take every step we can to prevent
assaults before they happen.
The GAO report indicates that these events may be under-reported.
We must have procedures in place to provide the best data we can
obtain. To reduce the potential for under-reporting, we will continue
to encourage Veterans, families, employees and visitors to report
information about an incident or a threatened incident to VA clinicians
and VA police officers. We also will take additional steps, such as
improving staff training, improving lighting, promoting awareness among
staff and visitors, expanding access for reporting options, improving
the reliability of panic alarms, and posting signs that advise staff
and visitors how to report any incidents to the proper authorities. It
is VHA's policy that emergency departments, urgent care clinics,
outpatient clinics, and all inpatient and residential settings have
plans in place to appropriately manage the medical and psychological
assessment, treatment, and collection of evidence from male and female
Veterans who report acute sexual assault. We also will develop a
consistent definition for these incidents that will ensure the data we
collect are as accurate and reliable as possible.
VA Policies and Procedures for Reporting and Monitoring Safety
The GAO's investigation found that many of these alleged assaults
were not reported to VA leadership officials and the Office of
Inspector General (OIG) as required by VA regulation. We appreciate
this finding and recognize the need to improve structures for reporting
incidents involving sexual victimization and other safety concerns. We
are identifying several mechanisms and reporting structures to ensure
the effective coordination of both prevention and response activities,
and we will focus principally on strategies that provide universal
precautions against sexual victimization. In addition, we recognize the
importance of our risk assessment and risk management mechanisms.
Critically important, though, is a clear definition of what acts
constitute an offense and how this information should be used within
the required limits of patient confidentiality and privacy protections.
This was GAO's first recommendation. We agree that there is a need to
establish consistent definitions of sexual assault and other safety
incidents for reporting information from medical facilities to VA
leadership at the Veterans Integrated Service Network (VISN) level and
to VA Central Office. We will develop action plans with clear and
aggressive timelines for implementation developed by July 15, and a
final report to GAO on implementation by September 30, 2011, to address
The GAO report identified two mechanisms for reporting incidents:
the management stream of reporting and the law enforcement stream of
reporting. GAO recommended that VA implement a centralized tracking
mechanism to allow both alleged and substantiated sexual assault
incidents to be monitored consistently and reported to senior
leadership; this information will be de-identified to protect the
confidentiality of victims and will be subject to strict controls on
access by VA employees. VA agrees with this recommendation, and will
build on our work to establish a common set of definitions to support
this objective. Already, we have begun to review the existing
organizational strategies, structures, and policies to identify how
best we can change or strengthen oversight and reporting processes. The
multi-disciplinary Workgroup has been charged with developing and
implementing this centralized reporting mechanism. VA will prepare a
detailed action plan with specific deadlines by July 15 and a final
report by September 30, 2011.
An important element in ensuring the accuracy and timeliness of our
procedures for reporting and monitoring safety and security incidents
is the establishment and growth of the Integrated Operations Center
(IOC). Established in 2009, the IOC, which operates 24 hours a day, 7
days a week, serves as a fusion point for operational, safety and
security information. The IOC was established, in part, to provide the
Secretary with a single office responsible for ``proactively
collecting, coordinating, and analyzing information in order to make
recommendations to VA leadership.'' VA Directive 0322, dated April 29,
2010. The IOC manages VA's Serious Incident Report Directive
(published, January 25, 2010), which mandates reporting of among other
things, incidents of alleged sexual assault that occur on VA property.
Existing Security Precautions and VA Response
The GAO report notes that VA has a number of systems in place to
identify potential safety risks, but concluded that these systems are
deficient in critical aspects. For example, the GAO found that some
physical security precautions are not properly maintained or monitored
and that inadequate installation or testing procedures contributed to
these weaknesses. The GAO's concern is that these weaknesses could lead
to delayed response times to incidents and otherwise undermine our
efforts to prevent or mitigate sexual assaults and other safety
We agree with these findings and will take the necessary steps to
improve our systems accordingly. While VA medical centers are currently
expected to have policies addressing the use and testing of panic alarm
systems in compliance with the standards of The Joint Commission, VA
will re-emphasize the need for routine testing of these panic alarms to
ensure they are functioning properly. We will review whether existing
policy needs to be revised to ensure regular preventative maintenance
occurs consistent with manufacturer requirements. Regular testing of
alarms is critical to ensuring the safety and security of Veterans,
staff, and visitors. VA will require VISN Directors to ensure that
local facilities have established systems that meet the unique needs of
that location and Veteran population. Furthermore, by mid-July, the
multidisciplinary Workgroup will complete an action plan, with specific
deadlines, that will recommend any necessary policy changes.
Next Steps to Improve Safety
As VA continues to improve its incident reporting and safety
monitoring systems, we know there are additional, more immediate,
measures we can take to improve the safety of all those within our
facilities. Participants in the multi-disciplinary Workgroup have begun
already to analyze deficiencies in our system based on GAO's
recommendations, and propose specific solutions to these issues. The
full Workgroup met on June 6, 2011, and began to identify solutions for
improvement. VA will brief the Committee and GAO in August after these
near term recommendations are complete. VA has taken steps to improve
the quality of reporting alleged incidents so we have a better
understanding of the context and frequency of events. In January 2010,
VA published Directive 0321 on Serious Incident Reporting, which
required VA facilities to report such data in a consistent manner. This
Directive did not include, however, a common definition for alleged
sexual assaults. We are correcting that omission. VA's
multidisciplinary Workgroup will identify the scope and develop
definitions for sexual victimization of Veterans, employees, and
visitors. The Workgroup will also prescribe how these incidents are to
be reported. Having a consistent definition for sexual assault and
standardized reporting procedures will enable the IOC to collect more
data that are reliable, and more easily identify trends. Analysis of
this data will help VA leaders gain a better understanding of the
prevalence of sexual assaults and other safety incidents in VA health
care facilities and will support the development of solutions that will
make our facilities even safer. Another important step towards safer
facilities will be to expand the involvement of security experts in the
planning and construction phases of renovation or construction projects
to ensure that safety and security issues are identified and addressed
as early as possible. We will also review the availability of existing
resources to determine if further training, support, or assistance is
needed to improve the safety and security of our facilities.
While the VA health care system provides exceptional service to
millions of Veterans and family members every year, even one incident
that threatens the safety and well-being of a Veteran, a family member,
an employee, or a visitor is unacceptable. Sexual assault is a
devastating experience for victims. We are using external reviews, such
as GAO's report, and internal assessments to identify deficiencies and
to correct them immediately. The Veterans Health Administration is
working together with the IOC to identify, report, and monitor
incidents in an almost real-time environment. We will use the Workgroup
to recommend solutions with specific timelines to improve our
prevention and surveillance efforts. These are important steps toward
ensuring a safer and more secure system. We take a zero tolerance
approach to sexual assault and will enforce the law and our policies to
the maximum extent in the best interests of our Veterans, their
families, and our staff. Thank you again for the opportunity to testify
today. My colleagues and I would be pleased to answer any questions you
Prepared Statement of Verna Jones, Director, National Veterans Affairs
and Rehabilitation Commission, American Legion
Mr. Chairman and Members of the Committee:
The American Legion applauds this Committee for utilizing its
oversight authority to delve into this deeply troubling issue. The men
and women of our armed forces are trained to go into hazardous
locations in the performance of their duties. They are trained to
operate under some of the most grueling and psychologically challenging
circumstances. When they swear their oath they take on these
challenges, and meet them with grace and valor unlike any other armed
force in history.
They should not, and must not, meet grueling and psychologically
challenging conditions undertaking the most basic of tasks in their
civilian life post military service--seeking and receiving the health
care services they have earned in the Department of Veterans Affairs
The findings of the most recent Government Accountability Office
(GAO) report ``Actions Needed to Prevent Sexual Assaults and Other
Safety Incidents'' (GAO-11-530) and previous reports addressing this
matter such as ``VA Has Taken Steps to Make Services Available to Women
Veterans, but Needs to Revise Key Policies and Improve Oversight
Procedures'' (GAO-10-287) are disturbing. There are veterans who do not
feel safe using the facilities provided for them for health care, and
they don't feel safe for a reason. In the last 3 years alone, nearly
300 incidents of sexual assault were reported to the VA police.
Staggeringly, the vast majority of these reported incidents were not
reported to VA leadership and/or the Office of the Inspector General
(OIG). VA cannot be expected to solve patient security issues if they
remain unaware of the problem at critical leadership levels.
The American Legion is aware of these concerns. Furthermore, the
Legion believes the overall VA Health Care system is generally an
excellent and deserved resource, and no veterans should feel they
cannot utilize the system for fear of inappropriate behavior. With that
in mind, The American Legion offers the following insights into the GAO
report and our own research, and recommendations to improve the system
and preserve the sanctity of the VA Health Care system.
What GAO Found
GAO's most recent report tackled the period ranging from January
2007-July 2010 with recognition that changing patient demographics were
presenting unique challenges to VA in terms of providing a safe
environment for all veterans. In particular, this study examined
security issues stemming from unwanted sexual behavior and advances.
Whether such behavior took the form of rape, inappropriate touching,
forced examination, forced oral sex or other forms of sexual assault,
the findings were clear. Not only were such illegal and horrifying
actions occurring, over two thirds of these incidents went unreported
to VA management and the OIG despite being reported to VA police.
GAO found fault with the risk assessment protocols. The protocols
are simply a self-reporting process utilized to inform clinicians of
sexual assault related risks, specifically regarding the lack of
guidance about information collection. Because of a lack of ``evidence
based risk assessment tools'' VHA relies on ``professional judgment of
clinicians'' which is subjective at best. This is clearly problematic
when dealing with an organization as large as VA, and one as criticized
as VA is for a lack of consistency on a regional level. Because the
information used to make these assessments is self-reported it is
frequently incomplete, further complicating the issue.
The report found a lack of adequate precautions in place at VA
residential and inpatient facilities. While the sample of facilities
examined was relatively small, GAO surveyed five facilities out of a
system that includes 153 full medical centers, the omissions in
procedures and security precautions raise large warning flags. Basic
measures such as security cameras, alarm systems and so forth are
inadequate or not present. In other places, there was inconsistency in
the types of precautions taken, ranging from ``patient behavior
contracts'' that varied from facility to facility, to a difference of
procedures in place.
Perhaps one of the most common themes in the findings of the report
was the lack of clear guidance. VA Staff had questions about what
should and should not be reported. Staff frequently noted they were
unclear as to the proper procedures for reporting, or even as noted
above, taking histories.
Amongst other considerations, the findings seem to solidify one of
the chief concerns about the entire medical system cited often in the
past by The American Legion--inconsistency. As the saying goes ``If
you've seen one VA Medical Center, you've seen one VA Medical Center.''
From VAMC to VAMC to VISN to VISN to CBOC to CBOC, each seems sometimes
to operate as its own private fiefdom without consistency. The American
Legion believes that while the overall plan for VA is strong,
inconsistent application of that plan only leads to failure on a local
level. VA must increase consistency.
What The American Legion Found
The American Legion utilizes multiple tools to find firsthand
information about patients in the VA Health Care system. Annually, The
American Legion conducts site visits to VA medical facilities as the
basis of our ``System Worth Saving'' (SWS) report. The SWS report
covers all aspects of VA medical facility operations, and concerns of
veterans utilizing the system are one of the many facets of these
information gathering site visits.
In December of 2010, The American Legion further contracted with
ProSidian Consulting to conduct a survey of women veterans to assess
their satisfaction with the quality of health care delivered by the VA
system. While women are by no means the only targets of sexual assault
in VA and DoD facilities, Military Sexual Trauma (MST) is one of the
key concerns noted specifically with reference to women veterans, and
the Women Veterans Survey addressed concerns about security within VA
In the survey, 18 percent of women, or approximately one in five,
stated they were ``dissatisfied or very dissatisfied'' with their sense
of security in the VA health care system. When compared with recent
figures which indicate approximately the same percentage of women in
DoD have experienced military sexual trauma--21 percent according to
Department of Defense Sexual Assault Prevention and Response Office
(SAPRO)--it is not unreasonable to start asking questions about whether
there are lingering artifacts of the pervasive culture of the military
that foster sexual assault without long term consequences.
The American Legion is deeply concerned to learn the VA and DoD
actions to address this dire issue are lagging. In March 2010 the GAO
conducted site visits to nine VA medical centers and ten Community
Based Outpatient Clinics (CBOCs) to examine the availability of health
care to women veterans, VA's compliance with their policies and the
challenges that they face in providing care. The GAO reported only two
of the VAMCs visited had specialized residential treatment programs
specifically for women who have experienced MST. Although the VA has
taken steps to inform staff about their various programs offering MST
treatment and counseling, VA has been thus far ineffective in informing
veterans of these options. The VA has not provided this information on
their external Web site where veterans can easily access it.
In site visits conducted as a part of the System Worth Saving Task
Force, one American Legion staffer noted a woman came to VA enrollment
desk seeking to report military sexual trauma. The veteran was directed
to ``fill out that packet over there and send it in'' with no further
follow up or concern from the VA employee. This veteran could have, and
should have, been connected with the facility's Military Sexual Trauma
Coordinator and the employee could further have assisted the veteran by
asking to speak to her in a more appropriate setting instead of drawing
out the conversation in full view of the public in the waiting area.
Sensitivity in this area goes a long way towards establishing trust
with veterans whose trust has already been damaged. While the Legion
staffer was able to conduct outreach to that veteran on the spot and
immediately to ensure she got the treatment and aid needed, VA should
not and must not rely on outside service organizations to conduct their
vital role of outreach.
Put simply, The American Legion has found all too often that even
if proper programs are in place and the resources are available to
veterans, staff indifference and poor advertisement of these programs,
including but not limited to poorly conveyed information in facilities
and on VA's own Web site, contributes to an veterans feeling there is
no support for them in the system. The findings of GAO indicate there
are serious flaws in the system to begin with, but when VA cannot even
implement what is there already in the system, they are failing
veterans. These veterans need to have access to and utilize the tools
available to them.
What The American Legion Recommends
The problems represented within VA are hardly unique to VA. The
American Legion recognizes there are cultural considerations both DoD
and VA have long strove to overcome. Previous testimony has addressed
concerns about those cultural considerations. If there is to be
substantial change to rectify the unsatisfactory state of affairs, the
change must affect the cultural environment. Clearly, no agency would
support the sad state described in the GAO report. VA has regulations
and policies already existing which attempt to provide a means to
counter unwanted sexual behavior. However, it is abundantly clear these
policies are not being consistently enforced, if enforced at all.
Actions speak louder and more convincingly than words. VA's actions
must show their commitment to a policy geared towards ending the sexual
assaults and other security incidents.
There are signs of an encouraging start. VHA Directive 2010-033
issued July 14, 2010 provided for VISN level MST Coordinators, as well
as MST Coordinators at a facility level. The American Legion supports
the establishment of such coordinators and recognizes the strength of
such assets in outreach to veterans and spreading the message of
support services available as well as following up on behalf of any
veterans within the system who may experience these issues. However,
although the Legion has determined all facilities now have such a
coordinator, in many or most locations, the position is not a full time
position, and is often an additional duty of an employee tasked with
The American Legion strongly recommends enhancing the role of these
coordinators to full time status, and giving them the authority and
scope of mission to act as advocates within the system for veterans who
experience sexual trauma, and to ensure policies are carried out in VA
facilities in keeping with the nature of the expectations of VA Central
Office. Utilize these employees to be the front line defenders for
those veterans who experience sexual trauma, whether it be in DoD or in
The disorganized nature of VA's overall plan for dealing with
incidents of this nature requires revision. In this The American Legion
agrees with the findings of the GAO report. Clarity and direction is
necessary in multiple areas, including standards procedures for
reporting, risk assessment and ensuring implementation of procedures
again as noted by GAO.
VA must act now to meet the basic needs found in the GAO report.
Promote a clear understanding of the definition of sexual assault.
Establish a clear set of expectations regarding what should and should
not be reported up the chain of command. GAO's recommendations also
call for an automated system to forward all reports of a criminal
nature brought to the attention of VA security to the attention of OIG
for investigation. Given previous records of reporting of material to
OIG for proper follow up and investigation, automating this procedure
may overcome whatever institutional roadblocks are already in place.
One of the stated concerns was the establishment of a centralized
tracking system to monitor sexual assault incidents across VA medical
facilities. Obviously this idea has merit and is an important tool.
VA's existing medical health care record system is already a recognized
tool of excellence in necessary information sharing for medical
treatment. However, given VA's past record regarding data security, and
the extremely sensitive nature of the subject matter involved and the
already damaged psychological picture of the victims involved, the
absolute utmost care is necessary to ensure such a system is secure
beyond doubt. This is material of the most sensitive nature possible,
and past VA mistakes and missteps with data security must not be
allowed to compromise this reporting system. In The American Legion's
survey of women veterans, fully one quarter of these veterans felt VA's
handling of personal and sensitive information was ``Poor to Moderate
[Moderate being defined as less than Good]''.
The American Legion would note the most important consideration in
reacting to this problem is to avoid the previous pattern exemplified
by VA response to incidents of concern. In the past, VA policy has been
to create an expanded section of Central Office to ``manage and provide
oversight'' over a certain field, and enhanced Central Office bloat
while allowing the problem to perpetuate at the local level because of
a lack of direct oversight to the ground level operating environment.
What is not needed is another floor of VA bureaucracy to deal with this
What is needed is a clearly dictated policy made transparent to
employees and the public at all levels, increased scrutiny at a ground
floor level to ensure operations are complying with the stated mission,
and accountability for those employees who fail to meet the standards.
Put simply, hold individuals accountable for their actions, and make
clear in no uncertain terms that this kind of behavior will not be
tolerated. Then allow the local level to act out that policy without
need for another hundred bureaucrats in Washington.
House Resolution 2074, the ``Veterans Sexual Assault Prevention
Act'' works very much in the spirit of what The American Legion is
proposing here. The bill provides for exactly the sort of concise and
clear definitions and consistent policy required to help right the ship
of VA's treatment of these matters. The American Legion supports this
legislation, but also notes continued oversight and follow up will be
necessary to ensure compliance. The lack of clarity and consistency
within VA on this matter indicate a potentially resistant culture,
which will require the actions of all stakeholders to rectify. The
American Legion stands ready to work with Congress, the VA, and all
affected veterans and veteran service organizations to ensure proper
due diligence is exercised and this matter does not slip from the
forefront of our attention. This is a problem we all must work to
solve, and The American Legion is eager to help.
Prepared Statement of Joy J. Ilem, Deputy National Legislative
Director, Disabled American Veterans
Chairwoman Buerkle, Ranking Member Michaud and Members of the
On behalf of the Disabled American Veterans (DAV) and our 1.2
million members, all of whom are wartime disabled veterans, I am
pleased to be here today to present our views on a recently released
Government Accountability Office (GAO) report (GAO-11-530)--Actions
Needed to Prevent Sexual Assaults and Other Safety Incidents (herein
after GAO report or Report) to the Committee on the issue of the
prevention of sexual assaults and other related safety incidents
occurring in Department of Veterans Affairs (VA) health care
In reading the GAO Report we were disturbed to find that between
2007 and 2010, GAO identified 284 alleged sexual assaults reported
through one of two reporting streams. However, many times, the victims'
reports were mishandled or inappropriately acted upon based on
decisions made by local physicians or administrators and most had not
been reported to appropriate program officials and leadership in VA--
even though rape allegations are considered potential felonies and are
required by regulation to be reported to the VA's Office of the
Inspector General (OIG). Although VA officials at one sampled facility
noted they did expect to be notified of all sexual assault incidents--
this expectation was not specifically documented in their policy.
At the outset, let it be known that DAV believes in the strongest
possible terms that veterans, VA employees, visitors and others who
occasion visits to VA facilities should always be assured of their
physical safety and personal security. Likewise, every veteran
hospitalized or housed at a VA medical center (VAMC) or treatment
facility should be afforded a safe, secure environment and be treated
with respect and dignity. In addition to the Veterans Health
Administration's (VHA's) benchmark of continuous quality improvement
programs ensuring that patients receive safe and effective health care,
VA must reevaluate and strengthen its safety program to ensure that the
environment of care at VA health facilities keeps veterans, staff and
visitors safe from physical harm, including sexual assaults.
VA has received numerous prestigious national awards and been
lauded by the National Academy of Science's Institute of Medicine for
its outstanding patient safety programs, including alerts embedded in
its Veterans Health Information Systems and Technology Architecture
(VistA)/Computerized Patient Record System (CPRS) electronic health
record, its barcode medication administration program that reduces
medication errors, and its patient safety reporting systems. It is
therefore surprising that the National Patient Safety Center has not
encouraged VAMCs to perform: (1) a root cause analysis on incidents
involving sexual assaults, (2) a national data roll-up and analysis of
methods to prevent or mitigate the risk of sexual assault, or (3)
further study of this important patient safety issue.
GAO's report concerns us on several levels. Initially, it documents
loose and inattentive reporting of incidents of personal violence
committed in VAMCs against veterans, staff and visitors; the failure of
or reluctance to share information about these incidents; inadequate
police staffing and monitoring of security cameras in certain
facilities; the lack of proper investigative procedures and follow up;
the lack of a uniform definition of sexual assault to ensure consistent
reporting; lack of a centralized database for tracking and trending
assault incidents; destruction of incident reports and police records;
and lack of information sharing by VHA Operations and Management staff
with other internal stakeholders. We are also concerned that the lack
of information sharing could be further complicated with the recent VHA
reorganization that has separated the operations and policy functions
of many service lines, including mental health programs, if recommended
policy changes are not implemented. We concur with GAO that without the
regular exchange of sexual assault report incidents that occur within
their areas of programmatic responsibility, VHA officials cannot
effectively address potential risks in their programs and local
facilities do not have the opportunity to identify ways to prevent such
incidents. These critical deficiencies identified by GAO have uncovered
not only the individual program and policy gaps noted, but also
highlight VHA's lack of a methodical and systematic approach to
eradication of sexual assaults from its facilities.
In addition to its failure to communicate with VHA Program Offices,
it appears VHA lacks an open approach to communication regarding sexual
assaults with other VA offices, including the OIG. According to the
report, by regulation, all potential felonies, including rape
allegations, must be reported to VA OIG investigators. GAO also found
that VAMC Police are not consistently reporting felony sexual assaults
to the other VA offices with responsibility for investigating crimes.
These practices and lack of systemic consistency cannot be defended
and must be addressed by VHA with a sense of urgency. VA must establish
a comprehensive, consistent approach to documenting, investigating and
reporting sexual assaults--a serious crime of personal violence
apparently occurring at several VA health care facilities. Given the
limited number of facilities surveyed by GAO, we are concerned about
the extent of the problem systemwide. For these reasons we suggest the
creation of a task force to ensure the VA adopts a culture of safety
and promptly develops a uniform policy for the reporting of all sexual
assaults. It is clear these reports cannot be solely handled by the
local facility involved and that mandatory reporting of these incidents
to all the appropriate officials is necessary. We are pleased to see
that VA has established a ``multi-disciplinary workgroup'' to define
what actions need to be taken to prevent sexual assault incidents and
to respond to reports and allegations of sexual victimization of
veterans and VA employees.
We noted in the report a footnote on page 13 that indicates VA
police routinely destroy their investigation reports of VA sexual
assaults 3 years after making such reports, under a records retention
policy of the National Archives and Records Administration. We oppose
the destruction of these reports on the same basis that we oppose the
destruction of reports of military sexual trauma (MST) that occur
within the military services. More information on our position with
respect to destruction of MST records may be found in DAV's testimony
before this Subcommittee on May 20, 2010. The destruction of these
reports contributes to the problem of the lack of consistent
information and information sharing, and obstructs analysis that could
be immensely helpful not only to improve safety in VA facilities but to
promote a better understanding of the incidence of sexual assaults in
VA. Also, a number of these cases could result in tort claims or VA
disability claims. The lack of documentation can contribute to loss of
benefits and equity for these victims.
GAO noted in its analysis that VA is experiencing significant
demographic changes in its health care programs due to initiatives
targeting several specific veteran populations--including women
veterans, veterans who have served in Operations Enduring and Iraqi
Freedom (Web site/OIF), and veterans facing legal issues or those
currently incarcerated. New VA enrollees are trending younger, with a
more visible presence of women veterans. According to VA, about one-
half of all women who served in OEF/OIF and separated from the military
since September 11, 2001, are enrolled in VA health care. VA is also
outreaching to justice-involved veterans with post-deployment mental
health problems, such as combat-related post-traumatic stress disorder
(PTSD) to help them avoid incarceration and enter into appropriate
specialized VA programs for PTSD, traumatic brain injury (TBI) and
substance-use disorder treatment. The same holds true for homeless
veterans and family caregivers of severely injured and ill veterans. VA
is also seeing a significant new workload in mental health care while
trying to use the least-restrictive environment to do so.
VA is also under stress to treat a seriously and moderately
disabled young veteran population returning from war with myriad unmet
needs and high expectations for state of the art services across the
continuum of health care and rehabilitation. This changing demographic
and the need for comprehensive mental health care and polytrauma care
has made it even more crucial that VA address the safety and security
issues raised by GAO. Of the 1.2 million individuals who have served in
the wars in Iraq and Afghanistan, over 654,000 (more than 50 percent)
have enrolled in VA health care since fiscal year 2002. Although these
patient populations are a small percentage of the overall enrolled
population using VA, we believe these changes have affected VA's
environment of care, in both expected and unexpected ways.
In addition to the environment of care issues, VA must also raise
awareness among its staff through education and training in order to
enhance its climate and culture of safety. VA's clinical care staff are
accustomed to caring for a predominantly older, male population with
chronic medical conditions rather than the one they are now being
charged to treat. These shifts and pressures produce stresses that VA
has not previously or recently experienced and may be contributing to
the culture of safety challenges that GAO aptly uncovered and
documented in this report. These demographic changes are projected to
continue in the foreseeable future.
GAO primarily focused on three distinct VA settings in its report--
residential rehabilitation treatment programs (RRTP), inpatient and
residential mental health units and compensated work therapy/
transitional residence (CWT/TR) settings. For years GAO has addressed
safety and privacy deficiencies in VA health care facilities,
specifically related to women veterans. We see in the current report,
in relationship to the residential program sites, that only one of the
three CWT/TR programs evaluated accepted women due to safety and
privacy concerns. These safety concerns continue to negatively impact
women veterans--in essence they are denied access to needed specialized
services because VA is not confident they can provide a safe
environment for women. Likewise, GAO notes that several clinicians they
interviewed for a previous report on women's health services in VA
expressed concern for the safety of women veterans placed in VA
inpatient mental health programs. These types of concerns highlight an
inequity in access to care for women veterans and the potential for
further assaults unless corrective action is taken. Among the security
precautions that must be in place for residential programs are secure
accommodations for women veterans with periodic assessments of facility
safety and security issues. We have brought this issue to the attention
of the Subcommittee over the years and hope you will consider oversight
to ensure as VA moves forward to improve their overall culture of
safety in VA facilities, and that VA specifically address these safety
issues related to care for women veterans.
While acknowledging its findings could not be generalized to VA as
a whole, and that the report was based on visits to only five VA
medical centers in four networks of care, GAO tendered nine
recommendations from its review. We endorse these ideas and note that
VA has concurred in each of them as well. Given the seriousness of this
issue, we urge VA to move forward expeditiously to implement them
within the spirit in which they were made. While not one of the
recommendations, we also believe that the organizational placement of
VA's police force should be a subject of review, as well as the
sufficiency of its staffing levels across the system and its operating
mandate. Historically, VA police officers were VA medical center
employees, appointed locally and directly responsible to the VAMC
director to ensure safety of persons and property, including real
property. In recent years, however, the VA police force has been
organizationally centralized to report to a Deputy Assistant Secretary
for Law Enforcement.
Madam Chairwoman, every veteran should be assured of the highest
level of quality care and patient safety while receiving health care in
a VA facility. A veteran should never fear for his or her own personal
safety while visiting a VA facility. VA was established as a place of
care, not a place of fear, for veterans, visitors and staff. We concur
with GAO that when a veteran has a history of sexual assault or violent
acts, VA must be vigilant in identifying the risks that such veterans
pose to the safety of others at its medical facilities. VA needs to
take decisive actions to improve personal safety and promote an
environment of care that includes protection from personal assaults,
including sexual assaults. To do so will take a commitment from all
levels of VA and especially VA's senior leadership. We commend GAO for
making this critical report. Hopefully, GAO's findings can serve VA and
veterans well in providing a roadmap to promote a new environment of
care that encompasses a strong consistent culture of safety, and one
that can be closely monitored by this Subcommittee as VA completes the
Madam Chairwoman, this concludes my statement, and I would be
pleased to consider questions from you and other Members of the
Prepared Statement of Marlene Roll, Member, National Women Veterans
Committee, Veterans of Foreign Wars of the United States
MADAM CHAIRWOMAN AND MEMBERS OF THIS COMMITTEE:
On behalf of the 2.1 million members of the Veterans of Foreign
Wars of the United States and our Auxiliaries, I thank you for this
opportunity to share our views on this exceedingly important topic.
The June 7 GAO report, entitled ``VA Health Care: Actions Needed to
Prevent Sexual Assaults and Other Safety Incidents,'' doesn't provide
enough detail to fully grasp the depth of this problem, but there are
some things we do know: One incident of assault, of a sexual nature or
otherwise, is one too many. We also know that interested parties--
Veterans, VA, Congress, VSOs, and the American people--cannot look the
other way once we know this is occurring. Thanks to the GAO, we now
know it's happening at VA.
Sexual assault is among the most serious of problems an individual
or any organization--especially one in the service industry like the VA
Health Administration--could ever confront. VA must immediately work to
address this problem head on.
The VFW affirms, in no uncertain terms, the need for a zero-
tolerance policy. Less than that is unacceptable and inexcusable.
Every confirmed instance of sexual assault must be dealt with
swiftly and to the maximum extent of the law. VA employees and veterans
who commit or know of these acts must be held accountable. We entrust
VA to care for the brave men and women who have gone to war and
returned home physically and/or emotionally traumatized. They must
never have to visit a VA medical facility with concerns about their
The allegations in the GAO report are as troubling as they are
unacceptable. The report makes it sound as if VHA has a culture of
condoning this type of behavior, which we believe is not the case. But
what is the case is that the facilities and networks visited by GAO
have a severe problem that we can only hope is not system-wide.
VA must swiftly address the many problems identified by the GAO in
its report. They must also clarify what constitutes sexual assault,
because the lack of a clear, consistent, VA-wide definition has
allegedly led to many events not being reported or resulted in no
action on those events that were reported. This is an appalling
abdication of a solemn responsibility, and it must stop immediately. VA
must standardize the type of information that will be recorded as well
as the type of incidents that will be immediately reported to the VA
Central Office and/or to local law enforcement officials. This will
help ensure every incident is properly documented, which will lead to
more thorough investigations, and hopefully help prevent similar
incidents from occurring at other facilities. This is a zero tolerance
issue in the military world and in the civilian world; it must be so in
the VA world, too. Only quick and decisive action will restore public
confidence in the VA.
GAO also recommended VA police create a system-wide process that
would result in cases involving potential felonies to be automatically
reported to the VA Office of the Inspector General. Frankly, we are
shocked that such a common-sense Standard Operating Procedure doesn't
Another critical suggestion by GAO--implementing a centralized
tracking mechanism for VHA Central Office personnel--speaks volumes
about the failure of leadership at many levels to understand the
importance of this issue and respond appropriately.
The most important issue that we believe is missing is the lack of
a comprehensive and continuous training program. All efforts to
properly identify sexual assault and to create programs to forward
allegations to appropriate officials are in vain if employees aren't
trained to be vigilant and to identify problem situations. We strongly
believe that VA must institute an ongoing training program that is
informative, that encourages people to report what they believe is
inappropriate, and that is mandatory for all VA employees to attend.
Today, VA is caring for an ever-increasing caseload of women
veterans. It is imperative that women come to VA for the care they have
earned and when they need it. Establishing and maintaining trust is an
essential ingredient in making sure that happens. Anything less than
immediate and comprehensive action to remedy this situation could set
VA back in the proper care of our deserving women veterans.
Total leadership is essential from everyone in VA. Secretary
Shinseki and his Senior Executive staff are sincerely involved, and the
VFW knows they will do everything within their power to end sexual
assaults in the VA workplace. Yet the solution to stamping out this
problem is not in Washington; the solution is in the field in every
Network Director, Medical Center Director, Clinic Director, and their
senior staffs, frontline supervisors and in every employee. The GAO
report identifies a shared problem that reflects upon the integrity of
the entire VA. Its eradication can only lie in a total commitment by
those very same employees at every level.
We thank Health Subcommittee Chairwoman Buerkle and Chairman Miller
for introducing H.R. 2074, the ``Veterans Sexual Assault Prevention
Act,'' to fix this fractious and ineffective policy by establishing in
law a comprehensive policy on reporting, tracking, and investigating
claims of inappropriate sexual and other safety incidents. VA
leadership has failed in their obligations for too long, and the hidden
nature of this unacceptable problem requires Congress to act quickly.
We want the guilty punished, but we also strongly believe that any
legislation signed into law should specifically direct VA to ensure
exonerated employees are not indirectly punished professionally. They
have the most to lose if allegations are not handled properly. The VFW
does not want to see dedicated employees leave the VA system for this
reason, so any successful cultural change within VA must include
protections for innocent employees wrongfully accused. VA must
recognize this and be prepared to responsibly handle allegations that
are proven to be false.
We greatly appreciate the importance this Committee places on this
issue, and we hope that you will continue to provide the necessary
oversight to ensure VA responds aggressively to address our concerns.
Prepared Statement of Richard F. Weidman Executive Director for Policy
and Government Affairs, Vietnam Veterans of America
Madam Chairwoman, Ranking Member Michaud, and distinguished Members
of the House Veterans' Affairs Subcommittee on Health, Vietnam Veterans
of America (VVA) appreciates the opportunity to present our views in
regard to the substance contained in GAO-11-530 report, Preventing
Sexual Assaults and Safety Incidents at U.S. Department of Veterans
VVA commends Chairman Miller and Ranking Member Filner for
requesting this review, commends you and Mr. Michaud for holding this
hearing, and commends the General Accountability Office (GAO) for doing
their usual measured and thorough report on this volatile issue. My
name is Rick Weidman, and I have the privilege of serving as Executive
Director for Policy and Government Affairs at VVA.
First we note that just as one veteran committing suicide is too
many, even one sexual assault within the VA facilities anywhere in
America is too many. Having said that, the context which we consider
this very serious matter is important. The United States has a rate of
reported rapes of about 3 per 10,000 of population, which ranks us as
tenth most in the world of reported rapes. We do not know how many
employees or how many patients were present at any given time during
the 30 months of the time period at the five medical centers studied by
the GAO, so do not know how to compare these terrible statistics to
that of the population at large. In addition, there does not seem to be
any way to tell how many sexual assaults go unreported. What we do know
is that the more seriously rape/sexual assault is taken by the society
or subset of the society, the more the rate of reporting goes up. That
does not mean that sexual assault increases, but rather those victims
become much more likely to report such inexcusable incidents when those
in positions of authority back up and protect the victim against
The mere fact that this study was done and that you are having this
hearing today will have a salutary effect on both making it clear that
such behavior cannot and will be tolerated against any staff member or
veteran in the Veterans Health Administration (VHA) system, and
spurring action to make it less likely that such events will occur in
The recommendations of the GAO that were accepted by the VA are
sensible steps to improve definitions and reporting, improve training
in procedures, and take physical steps to reduce risk to both patients
The initial step of creating a workgroup to define sexual assault,
and the various manifestations, as well as clarifying when and how such
incidents should be reported within the VA structure is a wise and
necessary first step, and with a reasonable deadline of July 15.
Similarly, creating a centralized tracking mechanism to allow
management to be able to monitor such assaults is also a much needed
Addressing vulnerabilities in physical structures, particularly in
regard to locked inpatient wards is also a pressing need that should be
addressed as soon as possible at each and every facility.
The recommendation about establishing legal histories on
individuals beyond the self reported information now used is, of
course, perhaps the trickiest recommendation from the GAO to implement,
as it involves elements of privacy, ethics, and legal constraints as
well as perhaps conflicting obligations to all parties concerned. While
this may be the most difficult task, it is perhaps the most important
in terms of identifying high risk individuals. Exactly how to do this
risk assessment in a way that protects others in the medical setting,
while not compromising the supportive atmosphere necessary for treating
veterans with mental health issues, will require careful thought, good
training, and conscientious supervision.
Among a number of things that would seem to be evident from the
findings is the need for a standardized ``panic button'' electronic
device that every staff member can carry on his or her person to alert
others when faced with imminent physical danger.
While it is not specifically mentioned in the GAO report in
question, it is clear that there needs to be separate facilities/wards
for female patients on the long term treatment wards. It has also long
been the position of VVA that there is a need for a specific women's
clinic that does the full range of care, including psychological
evaluations and treatment. Such a women's clinic should be large enough
to house most of the elements involved in a ``one stop shop'' for women
veterans, and be situated in a location that is not isolated within the
facility while still protecting confidentiality.
The GAO specifically noted how important it is to have involvement
of all stakeholders in planning for steps that can and should be taken
to modify physical structures to better protect personal safety. The
GAO also noted that all stakeholders should be involved in modifying
regulations, definitions, reporting pathways, and other elements that
need to be modified to make VA medical facilities as safe as possible
for all concerned.
Perhaps we should not be surprised that conspicuous by absence
anywhere in the official VA response was any mention of the veterans
who are the consumers of VA health care. The veterans are clearly
stakeholders in this process, and the majority of the incidents
discussed in the report were incidents where a veteran patient was the
victim. Yet nowhere in the guidance to the local facility or the VISN
is any mention of the need/importance of consulting veterans or
veterans' representatives. The VA response also had no mention of
consulting with veteran stakeholders at the national workgroup level,
much less having a VSO representative as part of this group.
This is unfortunately consistent with the attitudes toward veteran
stakeholders that sometimes seem to pervade much of VHA. Frankly, for
all the talk about increasing transparency, VHA was much more open and
transparent 7 years ago than it is today, and seemed to value input
from veteran stakeholders much more than is the case today. Suffice it
to say that it is important that stakeholders be consulted at every
level, and listened to seriously. Further, since the attacks delineated
in the GAO report are mostly on females, it would seem obvious to us
that in particular female veterans who are consumers or their
representatives should be involved in a meaningful way at the national,
VISN, and at the local medical facility level. Similarly VHA female
staff members at risk should be involved in the process as well.
Madame Chairwoman, thank you for the opportunity to appear here
this afternoon to express the views of VVA. I will be pleased to answer
any questions, Madam Chair.
Statement of Hon. Russ Carnahan,
a Representative in Congress from the State of Missouri
Madam Chairwoman and Members of the Subcommittee, thank you for
hosting this hearing to discuss the prevention of sexual assault and
other related safety incidents occurring in VA facilities. Sexual
assault is one the most severe concerns in any organization and can
leave lasting physical and mental trauma to the victim. The Government
Accountability Office (GAO) has helped shed light on this very pressing
issue, and we need to confront this problem head on.
We must work together to improve the safety of our VA health
facilities. And should an incident of sexual assault occur, it must be
properly documented and adjudicated with the fullest extent of the law.
Today's hearing provides a important dialogue between Congress and
those with intimate knowledge of what needs to be done to guarantee the
safety of our veterans.
The GAO's findings reveal that nearly 300 cases of sexual assault
incidents involving rape allegations went unreported to the VA Office
of the Inspector General. After fighting to protect our Nation, our
heroes have the right to safe and secure access to the Veterans Health
Administration system. They also have the right to justice if an
incident of sexual assault does occur.
We must ensure that all veterans feel completely comfortable using
their provided health care locations. This means implementing the
necessary security precautions in medical facilities, including
effective alarm systems and closed circuit cameras with continuous
Consistency and communication are vital. Currently, no VHA-wide
definition of sexual assault exists. The GAO has recommended the
creation of a workgroup to establish a new clear definition. This will
greatly help incident reporting, assessment, and management on all
levels. Only when every case is properly documented and investigated
can other similar incidents be prevented. We must work to ensure that a
centralized reporting and tracking mechanism is implemented.
Strengthened oversight is key in managing and combating sexual assault
With a growing number of women veterans, improved VA health
services are necessary. It is paramount that all veterans receive the
care they need and deserve. This can only occur if veterans feel safe
in VA facilities. No victim of sexual assault should feel reluctant to
report their case. No veteran should fear being ignored or even blamed.
I look forward to hearing from our witnesses on ways we can ensure
a safe and secure environment at all VA facilities.
MATERIAL SUBMITTED FOR THE RECORD
The American Legion
September 12, 2011
Ms. Diane Kirkland
Committee on Veterans' Affairs
House of Representatives
335 Cannon House Office Building
Washington, DC 20515
Dear Ms Kirkland:
In reply to your email dated September 7, 2011 regarding
information you requested for Ms. Verna Jones of The American Legion
please accept the following testimony:
``After a more detailed review of the survey analysis, 18
percent of the respondents stated they were ``very
dissatisfied'' or ``somewhat dissatisfied.'' Because the
question defined `security' as ``physical safety, financial
security, access to information, and other privacy
sensitivities of the patient'' it is impossible to quantify
those who were dissatisfied with physical security versus
In the second phase of the survey, yet to be initiated, we
will be meeting with focus groups and get more specific and
anecdotal background to the specific dissatisfaction. Until
that is complete, we are left with the overall survey result of
18 percent dissatisfaction levels.''
In addition, attached you will find excerpts from The American
Legion--Women Veterans Survey 2011, pp. 50-52, which provide further
information regarding Ranking Member Michaud's request.
Thank you for your assistance in this matter. If you need further
information please contact me at 202.861.2700 or [email protected]
Dean Stoline, Deputy Director
National Legislative Commission
The American Legion--WOMEN VETERANS SURVEY 2011
Security is the freedom from danger, risk or doubt. The SERVQUAL
attribute of security in The American Legion's Women Veteran's Survey
also includes consideration for the patient's best interests such as
privacy and confidentiality (Are dealings with the patient held
This includes physical safety that affirms management's commitment
to a patient and worker-supportive environment that places as much
importance on employee safety and health as on serving the patient or
Financial security is also included in this category and addresses
the increased cost of health care, to make sure patients have enough
income and health care to maintain their health care standard.
Additionally, this attribute ensures access to information is both
protected and available with an expected degree of personalization.
This attribute addresses personalization and the ability to satisfy
specific needs of individual customers while maintaining privacy for
This includes the ability to acquire customer information in
exchange for personalized services. Regardless of the nature of
environments, personalization depends on the knowledge about an
individual customer and the ability to cater to her needs.
There are four (4) questions in this category.
Question 56 Security is defined as freedom
from danger, risk or doubt.
It includes considerations
for customer's best interests
such as privacy and
confidentiality. It also
includes physical safety,
financial security, access to
information and other privacy
sensitivities of a patient.
Based on the responses, 67 percent of the Women Veterans responding
stated that they were satisfied or very satisfied with measures of
security with measures of security defined as freedom from danger, risk
or doubt, and considerations for customer's best interests in health
care provided by the VA. In contrast 18 percent of the Women Veterans
responding stated that they were either very dissatisfied or somewhat
dissatisfied with physical safety, financial security, access to
information, and other privacy sensitivities related to Women Veterans
health care at the VA when compared to private practitioners and other
health care providers. While the majority indicated favorable
responses, more than 20 percent were not. This result indicates that
practices and policies related to security may require additional
enhancement in order to increase favorable perceptions.
Question 57 Based on your perceptions of 1=Poor
and satisfaction level with 2=Moderate
Women Veterans health care in 3=Good
the VA system and other 4=Very Good
benefits delivered, how would 5=Exceptional--Best
you rank the VA Healthcare
System in terms of access to
information which is both
protected and available with
an expected degree of
Based on the responses, 27 percent of the Women Veterans responding
stated that they would rank the VA Healthcare System as Poor or
Moderate in terms of access to information which is both protected and
available with an expected degree of personalization.
There were 23 percent who ranked the VA as Good in terms of an
expected degree of personalization while ensuring information is both
protected and available. However, 16 percent of the Women Veterans
responding stated that they felt the VA was exceptional to best in this
Question 58 Based on your perceptions of 1=Poor
and satisfaction level with 2=Moderate
Women Veterans health care in 3=Good
the VA system and other 4=Very Good
benefits delivered, how would 5=Exceptional--Best
you rank the VA Healthcare
System in terms of
sensitivity to the patient's
personal information and the
collection and storing of
Fully 25 percent of the Women Veterans responding stated that they
would rank the VA Healthcare System as either Poor or Moderate in terms
of sensitivity to the patient's personal information and the collection
and storing of patient information.
There were 23 percent who ranked the VA Healthcare System as Good
in terms of sensitivity to the patient's personal information. 52
percent of the Women Veterans responding stated that they rank the VA
Healthcare System as Exceptional-Best or Very Good. While nearly 75
percent rated this area favorably, a 25 percent negative evaluation
suggests significant room for improvement in the view of Women
Question 59 How would you COMPARE the 1=Very Dissatisfied
security and privacy 2=Somewhat
protection mechanisms for Dissatisfied
health care provided by the 3=Neither Satisfied
VA to private practitioners nor Dissatisfied
and other health care 4=Somewhat Satisfied
providers? 5=Very Satisfied
When compared to private practitioners and other health care
providers, Women Veterans were slightly more positive. Of the
respondents, 17 percent stated that they were either Very Dissatisfied
or Somewhat Dissatisfied with the security and privacy protection
mechanisms for health care provided by the VA when compared to private
practitioners and other health care providers.
Of the Women Veterans responding 67 percent stated that they were
Somewhat Satisfied or Very Satisfied with security and privacy
protection mechanisms for health care provided by the VA.
Observations and Recommendations--Security
Security is defined as freedom from danger, risk, or doubt, and
includes consideration for customers' best interests such as privacy
and confidentiality. It also includes physical safety, financial
security, access to information, and other privacy sensitivities.
Nearly 75 percent of the respondents rated the sensitivity to patients'
personal information (question 58) favorably (Good or higher), and 67
percent stated that they were Satisfied or Very Satisfied with the
security and privacy protection mechanisms provided by the VA (question
59). On the other hand, 17 percent of the women veterans suggest that
there is room for improvement in Security-related issues for the VA
health care services.