[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
U.S. DEPARTMENT OF VETERANS AFFAIRS
OFFICE OF INSPECTOR GENERAL'S
OPEN RECOMMENDATIONS:
ARE WE FIXING THE PROBLEMS?
=======================================================================
HEARING
before the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
JUNE 9, 2010
__________
Serial No. 111-83
__________
Printed for the use of the Committee on Veterans' Affairs
______
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas VERN BUCHANAN, Florida
JOE DONNELLY, Indiana DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia
Malcom A. Shorter, Staff Director
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
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C O N T E N T S
__________
June 9, 2010
Page
U.S. Department of Veterans Affairs Office of Inspector General's
Open Recommendations: Are We Fixing the Problems?.............. 1
OPENING STATEMENTS
Chairman Bob Filner.............................................. 1
Prepared statement of Chairman Filner........................ 36
Hon. Cliff Stearns............................................... 2
Hon. Jeff Miller, prepared statement of.......................... 36
WITNESSES
U.S. Department of Veterans Affairs:
Richard J. Griffin, Deputy Inspector General, Office of
Inspector General.......................................... 3
Prepared statement of Mr. Griffin........................ 37
Hon. Robert A. Petzel, M.D., Under Secretary for Health,
Veterans Health Administration............................. 20
Prepared statement of Dr. Petzel......................... 40
MATERIAL SUBMITTED FOR THE RECORD
Post-Hearing Questions and Responses for the Record:
Hon. Bob Filner, Chairman, Committee on Veterans' Affairs to
Hon. Eric K. Shinseki, Secretary, U.S. Department of
Veterans Affairs, letter dated June 10, 2010, and VA
responses.................................................. 47
U.S. DEPARTMENT OF VETERANS AFFAIRS
OFFICE OF INSPECTOR GENERAL'S
OPEN RECOMMENDATIONS:
ARE WE FIXING THE PROBLEMS?
----------
WEDNESDAY, JUNE 9, 2010
U.S. House of Representatives,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10:07 a.m., in
Room 334, Cannon House Office Building, Hon. Bob Filner
[Chairman of the Committee] presiding.
Present: Representatives Filner, Michaud, Perriello,
Rodriguez, McNerney, Walz, Adler, Kirkpatrick, Stearns, Miller,
Boozman, Buchanan, and Roe.
OPENING STATEMENT OF CHAIRMAN FILNER
The Chairman. Good morning. I want to call to order this
meeting of the Committee on Veterans' Affairs.
I ask unanimous consent that all Members may have 5
legislative days in which to revise and extend their remarks.
Hearing no objection, so ordered.
I think we all know that the U.S. Department of Veterans
Affairs (VA's) Office of Inspector General (OIG) plays a
critical role in ensuring proper and efficient oversight of the
Department's activities.
In the first half of the fiscal year 2010, from October
2009 to March 2010, the OIG issued 120 reports, identified
nearly $673 million in monetary benefits, and conducted work
that resulted in 232 administrative sanctions.
It is evident that the Inspector General is essential in
rooting out fraud, waste, and abuse within the VA. Today, we
want to examine the progress that the Department of Veterans
Affairs is making in complying with the OIG's recommendations.
Currently, the Office of Inspector General has a total of
115 open reports with almost 694 open recommendations that have
yet to be implemented by the VA. The target date for
implementation of these recommendations is within a year of
publication. Although most of these open recommendations are on
track to be completed within the 1-year timeframe, 16 reports
containing 45 open recommendations are over 1 year old.
Additionally, recommendations on VA information security
issues tracked by an independent auditor show that there are
almost 40 open recommendations, 34 of which are carried over
from previous years.
The timely implementation of these recommendations is
crucial to ensuring our Nation's veterans receive the best
care. Many of these recommendations play a critical role in
ensuring patient safety and safeguarding veterans' information.
Additionally, of course, timely implementation not only
reflects good management, but it always reflects responsible
use of taxpayer money. The monetary benefit yet to be realized
by these recommendations going unimplemented approaches $100
million.
During this country's difficult financial time brought on
by the recession, the VA must realize cost savings anywhere
practical. This can be done straightforwardly through the
elimination of waste and by acting in a timely manner to
correct the issues identified in the OIG's recommendations.
The Office of Management and Administration's Operations
Division is tasked with following up on the reporting and
tracking of OIG report recommendations while ensuring that all
allegations made by the OIG are effectively monitored and
resolved in a timely, efficient, and impartial manner.
I am pleased that they are here today with Deputy Inspector
General Griffin to share with the Committee their insights on
this issue.
The OIG's reports for followup procedures are an essential
component of the oversight process. Secretary Shinseki has
commented many times on the importance of accountability and
ensuring veterans' care comes first.
Every agency, including the VA, must be held accountable
for implementing the OIG's recommendations in a timely manner
and making certain our Nation's veterans are receiving the
quality of care that is reflective of their service and
sacrifice.
I recognize Mr. Stearns for an opening statement.
[The prepared statement of Chairman Filner appears on p.
36.]
OPENING STATEMENT OF HON. CLIFF STEARNS
Mr. Stearns. Good morning and thank you, Mr. Chairman. I
look forward to this morning's discussion on what the VA must
do to ensure the prompt and proper resolution of audit
recommendations that are issued by the Office of Inspector
General.
If you do not mind, I would like to read from the Inspector
General Act of 1978, as amended, in which it states, ``The head
of a Federal agency shall make management decisions on all
findings and recommendations set forth in an audit report of
the Inspector General of the agency within a maximum of 6
months after the issuance of this report and should complete
final action on each management decision within 12 months after
the date of the Inspector General's report.''
Now, Mr. Chairman, as of March 31st, 2010, there were 107
OIG reports with 640 open recommendations. While most of these
recommendations are on track to close within the required 1-
year period, I commend the VA for its timely implementation of
those recommendations. We also know that there are many other
recommendations that are over a year old.
The primary focus of this hearing is to get an update
regarding the 11 open reports that are over 1 year old and the
23 recommendations in these reports that are still open.
According to the OIG's report, it could save taxpayers
approximately $92 million if these recommendations are
implemented. We must ensure a concerted effort is underway to
ensure prompt implementation of the OIG's recommendations in
order to realize these savings.
So I look forward to working with both the VA and the OIG
on this as well as future collaborative efforts that will allow
us to make VA more efficient and to ensure an improved return
on investment for the taxpayers and, more importantly, Mr.
Chairman, to ensure that our veterans have access to the
highest quality health care and benefit delivery system as
possible.
I would point out the staff and I were talking this morning
that the return on investment is $14 to $1. That is for every
$1 we spend with the OIG, we get $14 back. This is an enormous
success and something that we should continue.
And I would be interested to know, Mr. Chairman, how the VA
stacks up with the U.S. Department of Health and Human Services
(HHS) and the U.S. Department of Labor (DoL) and other Federal
agencies to see how well the other agencies are complying and
implementing the OIG reports.
So, Mr. Chairman, I look forward to the testimony from our
witnesses today and I welcome them too. Thank you.
The Chairman. Thank you, Mr. Stearns.
At this time, I welcome Richard Griffin who is the Deputy
Inspector General for the Department of Veterans Affairs,
accompanied by Robert Ehrlichman who is the Assistant Inspector
General for Management and Administration.
Welcome. We appreciate you being here and look forward to
your testimony. You are now recognized, Mr. Griffin.
STATEMENT OF RICHARD J. GRIFFIN, DEPUTY INSPECTOR GENERAL,
OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS
AFFAIRS; ACCOMPANIED BY RICHARD EHRLICHMAN, ASSISTANT INSPECTOR
GENERAL FOR MANAGEMENT AND ADMINISTRATION, OFFICE OF INSPECTOR
GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS
Mr. Griffin. Mr. Chairman and Members of the Committee,
thank you for conducting this hearing and for the opportunity
to discuss one of the Office of Inspector General's major
responsibilities, which is to make recommendations to VA
management to improve programs and services provided to our
Nation's veterans.
Accompanying me today is Richard Ehrlichman who has the
responsibility for the followup activity at the Office of
Inspector General.
Followup is a critical component of OIG's oversight work.
The Office of Management and Budget (OMB) requires a process to
follow up and report on the status of OIG recommendations. The
OIG is required to report in its semiannual report to Congress
on the status of report recommendations.
In addition, after the Inspector General testified before
this Committee in February 2007, we began providing quarterly
updates to the VA Secretary and Congress on the status of open
report recommendations with an emphasis on recommendations more
than 1 year old.
On balance, VA does a good job implementing OIG report
recommendations in a timely manner. The percentage of
recommendations implemented within 1 year has increased to 94
percent from fiscal year 2007 to 2009. VA performs well based
on comparative data that other Federal OIGs periodically report
to Congress.
We will continue to focus on timely and full implementation
of recommendations for improvement across VA programs.
In some instances, VA takes corrective actions while we are
still onsite and before a final report is published. When this
happens, we close out the recommendation as implemented and
reflect that action in our final report. Nonetheless, the
majority of our reports contain open recommendations for
improvement.
Once the final report is issued, OIG followup staff in the
Office of Management and Administration begin tracking the
recommendations until they are fully implemented. For each
report, we separately list recommendations and related monetary
impact we expect VA to derive from implementation. In each
status request, we seek a description of what actions have
occurred toward implementing the recommendations during the
preceding 90 days. We set a 30-day deadline for VA officials to
respond in writing. The response must contain evidence such as
issued policies and certifications before we will close
recommendations.
The OIG also conducts followup reviews of some of our audit
and inspection work. During these reviews, we validate
implementation, evaluate the effectiveness of the recommended
changes in fixing a problem, and in some cases identify repeat
deficiencies.
Examples of followup reviews include our audit of the
Veterans Benefits Administration (VBA) Fiduciary Program and
our health care work on reusable medical equipment.
Opportunities exist for VA to improve its performance. As
of March 31st, 2010, we had two reports with open
recommendations that represented over $81 million in monetary
impact. One report from September 2007 with over $21 million in
monetary impact involved a recommendation to improve the
acquisition and management of surgical device implants. The
other report from September 2008 with over $59 million in
monetary impact has multiple unimplemented recommendations on
noncompetitive clinical sharing agreements.
Lengthy delays implementing OIG recommendations not only
cost VA money in unrealized savings but prevent veterans from
benefiting from improvements in VA programs.
We will continue to highlight those recommendations in need
of attention in our reports to the VA Secretary, Congress, and
in our regular meetings with senior VA officials.
Mr. Chairman, this concludes my statement. We would be
happy to answer any questions you or other Members of the
Committee may have.
[The prepared statement of Mr. Griffin appears on p. 37.]
The Chairman. Thank you, Mr. Griffin.
Mr. Michaud.
Mr. Michaud. Thank you very much, Mr. Chairman, for having
this hearing today.
I have a couple of quick questions. My first, and I want to
thank the panel for coming this morning, is why do you have a
centralized followup staff rather than having the auditors or
investigators who did the original report do the followup?
Would it not make more sense to have those who did the original
report do the followup?
Mr. Griffin. In reality, it is a collaborative effort. The
followup staff are really the traffic cops for receiving the
reports from VA with the policies they have implemented or the
procedures they have put in place or the training programs that
they have created, those things do not require the absolute
100-percent attention of the audit staff or the health care
personnel who did the job.
Certainly there is collaboration. If there is any question
as to whether or not a recommendation should be closed based on
the feedback that we have been given, we will consult with the
expert who did the job and make sure that everyone is in
agreement that it can and should be closed.
Mr. Michaud. Thank you.
My second question, actually it is a followup to
Congressman Stearns' interest in exactly how does the VA stack
up to other departments when you look at completing the
recommendations?
Mr. Griffin. From time to time, the Council of the
Inspectors General on Integrity and Efficiency submit a report
that goes to the Congress and goes to the White House and it
lists a number of different performance measures involving the
OIG's activities.
And as indicated in our testimony, we feel the 94-percent
rate that has been demonstrated in the past 12 months by VA
puts it on the high end of performance compared to some of the
other departments.
Mr. Michaud. Thank you.
And do you feel that the OIG has all the tools that it
needs to do an adequate job in looking at VA, the programs VA
has, or do you need additional staffing or is there something
that we can do differently that would make your job easier?
Mr. Griffin. I believe in the fiscal environment that we
are operating in today that the OIG, depending on the outcome
of the budget request from 2011, will have the tools that it
needs.
We are always looking for bright, young auditors, health
care specialists, and criminal investigators to bring on board
to attack some of the newer issues that seem to be confronting
us in the information technology (IT) world and in some of the
fraud arenas. But I feel like with the Committee's support in
recent years, we have been properly staffed.
Mr. Michaud. And does the OIG for the VA work closely with
the OIG for U.S. Department of Health and Human Services (HHS)
since, for example, the federally qualified health care
clinics, I can see where there would be a lot of synergies
there?
Mr. Griffin. There are synergies amongst a number of
different OIGs, certainly in HHS with the health care work that
they do and our health care staff. There is synergy with the
Social Security Administration, which like VA has a huge
benefits program and a process that they utilize to make
benefits decisions and so on.
So there are a lot of different agencies that do have
similar threads of activity and that is the purpose of the
Council of Inspectors General to identify common problems,
which every department might be facing. We make sure that we
are sharing best practices and are sharing findings of
shortcomings in other departments that might be happening in
VA.
Mr. Michaud. Great. Thank you.
I yield back, Mr. Chairman.
The Chairman. Thank you, Mr. Michaud.
Mr. Miller.
Mr. Miller. Thank you, Mr. Chairman. I have a statement I
would also like entered into the record.
The Chairman. So ordered.
[The prepared statement of Congressman Miller appears on p.
36.]
Mr. Miller. And I have one question, Mr. Griffin. I was
looking at your testimony. You talk about the 2005 report
recommendation to implement more effective project management
oversight. We are talking about 5 years that this oversight did
not take place and corrective action should have been done, you
say, 5 years earlier in your comments.
My question is, you know, what type of system of
accountability can you put in place to prevent a 5-year lag of
implementing recommendations?
Mr. Griffin. Is that the major construction report you are
referring to? Seven of the ten recommendations in that report
address the need for a quality assurance program in order to
make sure that we have proper oversight and proper program
management for major construction.
A quality assurance group was established and this group
was supposed to have addressed those things. When we went back
and looked at it a second time, which we will do from time to
time for validation, we found that, yes, the group was created,
but it was not properly staffed. It did not have adequate
policies and procedures in place. So it really was not a
functional program oversight activity.
The other two recommendations simply were not addressed
during that time period.
Mr. Miller. I yield back.
The Chairman. You are yielding back when he did not answer
the question. You asked, ``What can you do to make sure that
they do not go for 5 years without doing something.'' He
responded that, yes, indeed, they went 5 years without doing
something.
So how do we make sure there is oversight, if I may follow
up on your question, Mr. Miller?
Mr. Griffin. I think there are a number of things we do. We
spotlight anything that has not been accomplished in 1 year and
it goes in our semi-annual report so that the Committee can be
aware when we have slippage on an issue.
I believe very strongly that hearings like this one are
very helpful based on the flood of documentation we have
received in the last 72 hours addressing various items that
needed closure. So, again, I thank you for the hearing.
We do meet----
The Chairman. We should schedule one every week.
Mr. Griffin. We will be here.
We do meet on a monthly basis with senior leadership from
VA and certainly those issues that are the most difficult and
most dated are the subject of those discussions also.
The Chairman. Thank you, sir.
Thank you, Mr. Miller.
Mr. Rodriguez.
Mr. Rodriguez. You mentioned that the VA had responded by
establishing a committee that basically was not responsive or,
I guess, they just responded to try to fill a recommendation
that was made and it took you 3 years to go back to look at
that to see whether they were effective or not effective. And
you found that they were not effective. Is that the case?
Mr. Griffin. That is correct.
Mr. Rodriguez. Okay.
Mr. Griffin. But let me say that we, notwithstanding my
previous response about resources, we do not have sufficient
resources that we can go back and redo every audit and every
health care inspection that we do. So some of them are
selectively up for review.
Mr. Rodriguez. What do we need to do to help you out to
carry the job or what else do we need to do to try to get them
to become more responsive?
Mr. Griffin. I think the documentation of those reports
that become more than 1 year old, which do get reported twice a
year in our semi-annual report, could be a triggering mechanism
so that between the OIG organization and the Committee and the
Department, if we involve all three entities to focus on fixing
it, I think you could get some synergy from that.
Mr. Rodriguez. Because in the field, for example, I hear
reports that they were giving out contracts to contract out,
for example, somebody is given a contract to do work to pay
doctors to provide a service, however, doctors are complaining
because it takes 3 months to pay them.
And so how do we streamline that? How do we make it more
responsive in terms of trying to get it done? I hate to think
that we would have to ask for more reports and more reports
because then that also bogs it down. So how do we get the
system to become more responsive?
Mr. Griffin. I think in the area of acquisition and
procurement, it is complicated by the current division of labor
that exists between our medical specialists and our acquisition
specialists. And I think without both of those entities being
on the same page, you cannot always have the medical side
claiming that, well, I am the doctor, I know best about this
particular device or this procedure. This is what I want. You
buy it for me.
I think when it comes to acquisition, you need a little
more independence in the acquisition function.
Mr. Rodriguez. The other issues that we hear complaints
about is, and I am sure we have made assessments in the past,
the workload in the private sector versus the public sector.
The doctors will tell me, Ciro, I used to do 15 procedures and
now I am doing half of them here. I could do more, but it does
not happen.
How do we move on those? Do we have any--I am sure we have
asked for studies in that area and comparisons. How do we move
the system to become more responsive?
Mr. Griffin. You are saying that VA doctors are complaining
they do not get enough work?
Mr. Rodriguez. Yes, sir.
Mr. Griffin. I have not experienced that.
Mr. Rodriguez. Well, I have direct people that have said,
look, I used to do this and now I am being told that I only
have this. They also get clients that, because they are 10, 15
minutes late, they get told to come back 3 months later, stuff
like that.
How do we get past this situation?
Mr. Griffin. I think I would defer to the Veterans Health
Administration (VHA) on the performance measures for their
doctors.
Mr. Rodriguez. Okay. Now, you mention also you do not have
the resources to follow back. And one of the arguments that we
have talked about in trying to get the system sometimes, for
example, on the computers, we talked about getting them, even
an outside system, to look at moving them in that direction.
And have we come up with any other way of making it more
responsive?
Mr. Griffin. Making----
Mr. Rodriguez. Well, for example, you mentioned IT, and the
computer systems and all those when we make those mistakes,
trying to get one hospital to talk to another and getting all
that straightened out.
Is it going to require an outside group coming in basically
doing it because they are unable to get it done themselves?
Mr. Griffin. I think it is a combination. I think the IT
world is so rapidly changing that the planning time and the
implementation time in some instances is overcome by the next
generation of tool that becomes available.
I know that there have been a number of projects that the
Assistant Secretary has canceled because they became too old
and they were no longer viable projects. And we applaud that.
But as far as whether or not the level of expertise is
proper that exists in the Department, I would defer to
Assistant Secretary Baker on the second panel on that question.
Mr. Rodriguez. Okay. Now, if I can follow up, I know he had
talked about the Capital Asset Realignment for Enhanced
Services (CARES) Program that went around the country looking
at vacancy issues.
From that, have we seen any need to do any followup on
that? From your perspective, do you think we ought to be
looking or inspecting any of our facilities for utilization
purposes and those kind of things and maybe restructuring that?
Mr. Griffin. I do not believe that the OIG Office has done
any recent work on vacant buildings.
Mr. Rodriguez. On occupancy rates and those kind of things?
Mr. Griffin. Certainly if we have vacant buildings that we
are paying to maintain and they are not being utilized, it
would make sense that we should divest ourselves of those. But
we have not done any recent work.
Mr. Rodriguez. Are you doing any work right now on the new
piece of legislation where we fund them in advance? I know it
is going to take them a while to come into it and make the
transfers there, but, we are doing that for the first time, so
I am sure that is going to require them to do a lot of things
differently.
But it is going to be able to plan in advance, so are we
doing any assessments from your perspective or should we?
Mr. Griffin. Now you are referring to----
Mr. Rodriguez. The appropriations to fund direct
appropriations a year in advance.
Mr. Griffin. We have not looked at that. I think it makes
sense to have the flexibility though.
Mr. Rodriguez. Does it make sense for you to be able to
look at it from the onset in terms of the implementation of it
and see how that is going?
Mr. Griffin. We could examine that if you would like. We do
do the financial statement audit every year and look at all of
the financial activities of the Department. And we could make
it an adjunct to that perhaps.
Mr. Rodriguez. Okay. Thank you.
The Chairman. Thank you, Mr. Rodriguez.
Mr. Stearns.
Mr. Stearns. Thank you, Mr. Chairman.
Mr. Griffin, in reviewing the Combined Assessment Program
(CAP) reviews of VA medical centers, are there specific items
that the OIG finds recurring that would indicate a systemwide
breakdown of procedures that should be addressed not only at
the local medical center but also throughout all of the VHA
through the use of a directive from the Central Office and what
are these recurring items?
Mr. Griffin. When we do a series of CAP reviews, normally
we will look at eight or ten specific items. And when we have
multiple findings on an item, we will do a roll-up report to
VHA so that they can look at it from a systemic perspective.
One such item that we recently published was in the area of
quality management. And we looked at 44 different facilities
during the time period in question. We identified four that we
thought had serious issues.
Mr. Stearns. Was the VA medical facility in Gainesville,
Florida, one of them?
Mr. Griffin. No, it was not.
Mr. Stearns. Okay.
Mr. Griffin. But we specifically mentioned those four
facilities in our report to VHA and we would expect that there
would be followup activity by VHA on those.
Mr. Stearns. Can you tell me those four facilities? Can you
name them?
Mr. Griffin. Manila, Honolulu, Marion, Illinois, and give
me a minute and I will come up with the fourth one.
Mr. Stearns. Okay.
Mr. Griffin. Fayetteville.
Mr. Stearns. Fayetteville. Okay.
Mr. Griffin. Yes, sir.
Mr. Stearns. And what are the recurring items?
Mr. Griffin. There are occasional findings involving
environment of care in our Community-Based Outpatient Clinic
(CBOC) reviews, which mimic the CAP reviews. We have had
recurring issues over contract management at each of the CBOCs.
Mr. Stearns. But specifically are there any that involve
patient safety?
Mr. Griffin. Well, from the standpoint of quality
management being your overall umbrella, which would include how
well patients are being treated, whether you have the proper
peer review processes in place, whether you are doing the
proper after action and analysis when there is an adverse
event, whether you are properly notifying family about adverse
events, and so on.
Mr. Stearns. So patient safety in those four hospitals you
mentioned, is that a serious recurring problem?
Mr. Griffin. I would not say patient safety per se. It is
just that all of the activities, which I just touched upon,
many of those may not have occurred at all four facilities, but
some combination of those things were not happening at those
facilities.
Mr. Stearns. You mentioned in the followup audit of the VHA
major construction award administration and cite that while the
VHA officials have taken actions to address your most recent
recommendations, the corrective actions should have been put in
place 5 years earlier, I think is what you were saying.
So what do you believe is the root cause for these delays
in implementing these corrective actions? Five years is a long
time.
Mr. Griffin. It is a long time. I am not able to give you
an answer as to why it took 5 years.
Mr. Stearns. Well, should we ask the VA then? But nobody on
your staff could help us out here?
Mr. Griffin. I could give----
Mr. Stearns. Just from your observation. I mean, not
necessarily scientific.
Mr. Griffin. Again, in the followup process, when the
quality assurance activity was documented in their directive
and how it was supposed to work, someone in our organization
must have been convinced that would address the issues. And it
was only when we went back to do it, we realized that those
seven items were not properly addressed.
Mr. Stearns. Well, that is 60 months. You would think
during that time, somebody could have taken care of that. I
think a lot of us just want to see more efficiency at the VA.
And, you know, the Chairman and I and others have talked about
the backlog of processing and how slow it has been. In fact, we
have given more money and more people for this, yet the backlog
still remains there.
So thank you, Mr. Chairman.
The Chairman. Thank you, Mr. Stearns.
Mr. Walz.
Mr. Walz. Thank you, Mr. Chairman.
And, Mr. Griffin, thank you for being here and the work you
do.
I think we all understand that one of our main
responsibilities here is hearings just like this to provide the
oversight that is necessary because at the end of the day, it
is all about how do we provide the best quality care and
resources to our veterans while ensuring taxpayer dollars are
watched more.
And so I have to say there is good news in here and I think
we should applaud those things when they happen.
The endoscope issue was very troubling for many of us in
that hearing and the way that that was pointed out, the hearing
that was done, the recommendations for oversight and the
followup all happening between June and basically September of
last year. To have the VA get clear marks on that is a sign
that the system can work and it is working. So I very much
appreciate you on that.
I wanted to just ask one question, I guess. It is dealing
with, and I know it is a complicated one, the issue of
procurement and contracting and this issue. It especially hits
home in letting out of the contracts for the CBOCs that are so
important in rural America. And these things seem to just
continue to drag on and drag on and drag on. And the best
intentions of everyone is, yes, this will be the date we will
get it to you. And it just keeps getting pushed down.
And I am wondering, the recommendations go back to what Mr.
Miller asked about in terms of project management and quality
assurance programs. From the OIG's side of things, is there
anything we can do there that is better in terms of cutting out
fraud, waste, and abuse but moving these things forward? Is
there anything you can say on that, Mr. Griffin, that will help
me understand why it seems to take so long? I am not so certain
that the time lag is doing anything to improve the contracting.
Mr. Griffin. We always try to bring something to the
attention of the Department at the earliest possible moment. We
have only been doing these CBOC reviews for a number of months
now, probably several months. But in each review that we did,
we found that the contract was poorly written, each one was a
little different, most of them called for a per capita payment
basis tied to whether or not a veteran had been seen in the
last 12 months.
There are terms for removing somebody from the rolls which
means that you are not paying the contractor for that person
for that particular time period and so on. And what we found in
repeated visits to different CBOCs was that no one was paying
attention to the terms of the contract.
So Dr. Daigh, from our staff, quickly brought that to the
attention of VHA and told them you need a standardized contract
that everybody understands and that everybody can apply across
the board. And when someone dies or someone should be
disenrolled for some other reason, we need to make sure that
happens.
We need to make sure that when there are disincentive
clauses included in the contract that the people managing the
contract are aware of those and looking for opportunities to
recover moneys that should not have been paid and so on.
But we did not wait until the end of a year or a year and a
half worth of reviews. Once we realized that this was a
systemic problem, we quickly called for a meeting with VHA. And
Dr. Daigh sat down with them and explained what we were finding
so that we can cut off the bleeding as early as possible.
Mr. Walz. Well, I appreciate that because one of the things
that I talked about here, I am very proud of what we have done
in terms of enhancing VA and enhancing care for our veterans,
but one of the things I have been talking about and warning
everyone here about is if we are not good stewards of these
dollars, that is going to be a tragedy in this, that we do not
improve the care. So I appreciate you doing that as quickly as
possible.
One last thing. VBA's process on employee effectiveness of
how we are going to measure what we are getting done, how we
measure work process and everything as it deals with again the
backlog on this.
Are you seeing anything from the OIG's side of how do we
ensure that is happening?
Mr. Griffin. Well, we recently started a new initiative.
That is the Benefit Inspection Division that goes out and does
a review of five different categories to check on a number of
things.
One is to check on the accuracy of the rating that was
given to determine whether or not people have the proper
training so that they can do it right the first time and not
expend that extra amount of time redoing the claims.
And much like the contracts and CBOCs, when our staff finds
a problem in the course of doing their daily reviews in the
Regional Offices, on a daily basis, they provide to the
director those claims that we reviewed in which we found
problems with the rating determination and they fix them on the
spot.
So I think what we are finding is the volume of work
continues to grow and the lack of adequate training and the
nuances of the rating schedule and the fact that you have so
many new hires that it is like a perfect storm as far as what
you need for good performance measures and program management
that is not there right now.
Mr. Walz. Well, I am afraid you are right on that. And that
is one of the things we have a concern about at the end of the
day is none of those things are going to get a reduction in the
backlog of claims or inaccuracy which is, of course, the
paramount issue, accuracy in the claim.
I yield back. Thank you, Mr. Chairman.
The Chairman. Thank you, Mr. Walz.
Mr. Roe.
Mr. Roe. Thank you, Mr. Chairman.
And just to start off on what Congressman Rodriguez said,
I, too, Mr. Griffin, have heard exactly the same thing
specifically in colonoscopy. One of my good friends is a
gastrointestinal (GI) physician at a VA and complains all the
time that he could do twice as many colonoscopies if he were
allowed to. When he was in private practice, he did. And I
think that is a quality of care issue because it delays care of
our veterans.
And I do plan on coming back next term and the quality of
care issues are the ones that I want to focus on. I think that
is paramount. That is why we have a VA hospital system--to
provide the best quality of care that we possibly can.
And one of the questions I have is, and I really appreciate
the work you all are doing. And I know in practice, we had a
weekly conference, patient conference where we looked at all
the difficult cases. We had a standard of care, but we did not
have any person like yourself to come in because we all think
we are providing good care.
But at the end of the day, maybe we are not, when you have
someone objectively come in and look at that. So that is why it
is important for you to continue doing what you are doing.
How robust, and I think one of the things that brought this
up was the incident that occurred with the brachytherapy, that
was not very good, and how robust is the evaluation and peer
review of dysfunctional or practitioners that are outside the
standard of care?
Mr. Griffin. How dysfunctional is it for----
Mr. Roe. No. I mean, how robust is your evaluation, I guess
a peer review of practitioners who fall outside the standard of
care like this physician in the brachytherapy case that we
looked at last year?
Mr. Griffin. Well, unfortunately, sometimes it takes a call
to our hotline for a case to come to our attention or during
the course of one of our cyclical reviews at a medical center,
someone will approach a member of our staff and say you really
need to look at this or that area.
When you talk about how robust is our ability to examine
those areas----
Mr. Roe. Well, yeah, I guess. Well, both. I mean, how
robust is your ability and then how does that investigation
actually occur? And Congressman Walz brought up the colonoscopy
issue last year, which I thought was handled very well once it
was discovered.
Mr. Griffin. Well, I can tell you that from when I first
arrived at VA in 1997, we had 16 people in our health care unit
to do quality oversight for the whole VA. Clearly, an
inadequate number.
Mr. Roe. Inaccurate.
Mr. Griffin. They are presently up to 119. They have a
number of different disciplines. Dr. Daigh has been able to
hire a number of excellent physicians, but he also knows that
when we do not have the expertise on our staff we will go out
and pay for that expertise and bring in an outside expert which
is something we did in the brachytherapy work.
Mr. Roe. Well, another question I have then is on the
CBOCs. There are, I do not know, 1,200 of them in the country,
over 1,000 anyway. And the way the current oversight and
investigation, there is an investigation or evaluation, I
should say, every 20 years. And we just added $50 million to
hopefully get this down to 3 to 4 years.
Is that enough money? Do you have enough resources to do
what we have asked you to do?
Mr. Griffin. Well, the 20-year cycle is clearly
unacceptable.
Mr. Roe. Yeah, it is.
Mr. Griffin. We thought that 3 years would be a more
reasonable number to work with. And if we get the additional
funds, that is what we will do. We will make it a 3-year cycle.
Mr. Roe. And that is----
Mr. Griffin. We are still building the database. Some of
those are clinics that are run by a VA full-time equivalent.
Some of them are private contractors.
So it kind of gets back to the question about does the
private sector person have a greater caseload than the VA
person. We are going to be able to do at that type of analysis
on the CBOCs once we get a little more in depth in our
database.
Mr. Roe. So we should be able to have that information in
fairly short order, a couple of years, 3 years----
Mr. Griffin. Right.
Mr. Roe [continuing]. Something like that?
Mr. Griffin. Right. And we will do it after the 1st year
and then we will continue to build upon it.
Mr. Roe. Well, you know, it is a huge system. You have over
300,000 employees in the VA system or around 300,000 people.
That is an enormous job that we have asked you to do, but it is
an incredibly important one.
And, again, as I know, when you look at what I thought I
was doing well sometimes, when it is evaluated, you find out it
is not. And it is not a problem to change once you get accurate
information. It is not that you do not want to do the right
thing. You may not know you are not doing the right thing.
So, Mr. Chairman, I yield back.
The Chairman. Thank you, Mr. Roe.
Mr. McNerney.
Mr. McNerney. Thank you, Mr. Chairman.
Inspector Griffin, my understanding is that the OIG does
not make recommendations for improvements that are expected to
take longer than 1 year to implement. Is that correct?
Mr. Griffin. Except in rare circumstances. And if there is
a project that realistically cannot be done in a year, we will
accept those recommendations as long as there is a timeline
that shows here is phase one and by a date certain, we are
going to have the alpha portion of this project completed. And
here is the next date and the next date and we will at least
track those activities.
Mr. McNerney. Okay. You know, implementing OIG
recommendations clearly has benefits both in terms of fiscally
and in responsiveness of the VA to veterans' needs.
Are there any instances in which using VA assets to address
OIG recommendations has detrimental effects in terms of direct
services to the vets? Are there any cases that you are aware
of?
Mr. Griffin. No, I cannot say that I am. I suspect that if
that were the case, we would have heard about it.
Mr. McNerney. So you have a good feedback mechanism from
the----
Mr. Griffin. Absolutely.
Mr. McNerney [continuing]. Providers? So okay. That is
good. Do you feel that providing the OIG with additional
authority in cases where the VA is severely late in
implementing recommendations would be effective in assisting
the VA with its obligations? In other words, how can additional
resources be helpful to you or the VA in implementing your
programs?
Mr. Griffin. I do not know that it is a resource issue. I
think that some of these issues are extremely difficult. And
the reality also is that we have seen turnover in some of the
most senior positions. We see it every 4 years obviously.
But in the middle of a term, you might have somebody who
holds a top position for a couple years and he is gone. People
are in an acting capacity during that time period. They are not
always certain that they want to make a radical decision on
something that is difficult. So I think there is a combination
of factors that come into play.
Mr. McNerney. Thank you.
Well, you recommended that the time it takes the VA to
implement your recommendations has improved over the past. What
do you attribute that improvement to in the time that it takes
to implement?
Mr. Griffin. I think Mr. Ehrlichman has the percentages to
demonstrate that improvement from 2007 through 2009 and I am
sure he could answer the rest of that question.
Mr. Ehrlichman. Thank you.
What we have done, and we started it late in 2006, is
myself and the Deputy OIG at the time went around and met with
all of the principals throughout the Department, all the
Assistant Secretaries and the Under Secretaries and their
staff.
We talked about trying to change the followup process
significantly and we talked about trying to come up with
recommendations that were specific, measurable, that could be
implemented within a year, and that we were going to have a lot
more frequent contact. We were going to be a little bit more
persistent.
If we were not hearing that there was progress, we were
probably going to make an appointment, meet with them. We were
going to bring the health care inspectors, the auditors,
followup staff and we have done much better.
In 2007, we were at about 86 percent. In 2008, it went up
to 88 percent. And the last complete fiscal year, we were at 94
percent implemented within 1 year.
Mr. McNerney. So basically you made it a priority and you
held their feet to the fire once the recommendations were made?
Mr. Ehrlichman. That and a lot more direct communications,
a lot more meetings. As Mr. Griffin had mentioned, we began
meeting on a monthly basis with principals in all the
administrations and the staff offices and I think that has
helped a lot, having the communications.
Mr. McNerney. Okay. Thank you, Mr. Chairman. I yield back.
The Chairman. Thank you, Mr. McNerney.
Mr. Boozman, congratulations on your victory yesterday. You
have to get the TV networks to concentrate on Boze rather than
Booz.
Mr. Boozman. Thank you, Mr. Chairman.
I think we need an OIG investigation as to whether or not
you were behind my chair being broken over here.
I just have, and, again, this might be kind of a dumb
question, but we have all of these things outstanding and some
of them are important in regards to patient care. Others are
important in regard to a monetary sense. And it all goes back
to be important to veterans.
Do we prioritize which ones are the most important? Does
that make sense? We have all of these things. It is almost
overwhelming, and we have to be helpful and push this thing
forward. Is there the ability to kind of rank the ones that we
need to really get on the stick and use our ability with
oversight to push forward?
Mr. Griffin. I think clearly there is a need to realize
which ones are most important. But when we start an audit or we
start a health care review, we might think we know what the
condition is that we are going to find, but we really do not
know with certainty until we do it.
And when we have completed our work, if we do have
recommendations, we will forward them to the Department to fix.
I would be shocked if the Department were to say anything
other than those issues that are most critical for patient
safety and those issues that are most critical from a monetary
standpoint rise to the top of the pile. I would be very
surprised if that was not the case.
But within the OIG, we might have our own views which ones
are the most critical, but we do not rank our audits and
inspections per se.
I think that if they were easy, the fixes would be made
while we were on site which does happen on some occasions as I
already mentioned. So I think it is the complexity of some of
the issues and it is the huge decentralized health care system
and benefit system that the VA represents that makes it
difficult.
And as far as ranking them, it is not something that we do,
but I would have to believe the Department evaluates things
based on the criticality of the timing of the fixes.
Mr. Boozman. Thank you very much.
Thank you, Mr. Chairman.
The Chairman. Thank you, Mr. Boozman.
Mrs. Kirkpatrick.
Mrs. Kirkpatrick. Thank you, Mr. Chairman.
My concern is about inefficiencies in the followup process.
So my first question is, why do you use a centralized staff to
do followup rather than the auditors and the investigators who
did the initial reports?
Mr. Griffin. It is done on a centralized basis because the
auditors and the inspectors who did the audit on inspection are
doing additional work. They have moved on to do other work.
But while the followup group itself is pursuing closure of
those recommendations, they will call upon the auditor or the
lead health care inspector who did the job and consult with
them on whether or not the response that we are getting to the
recommendation satisfies the finding.
So it is a shared responsibility. It is centrally
controlled here because, frankly, that is where most of the
headquarters' replies are coming out of VHA and VBA and the
Office of Information and Technology (OI&T) and the National
Cemetery Administration (NCA). The senior managers are here.
And those are the senior managers that we will meet with on
about a monthly basis to make sure that people are aware of
what is out there and what needs to be done.
Mrs. Kirkpatrick. You talked about the need to standardize
contracts. Do you use a checklist system when you are doing
that followup review? I mean, is there some uniformity in terms
of the staff review and how they work that process?
Mr. Griffin. There is uniformity in the timing of our
request every 90 days and we ask for a response within 30 days.
But there is not a one-size-fits-all sheet that you could apply
to every health care inspection and every audit or every
administrative investigation and so on.
So that is why it is critical, as you point out, to have
the subject matter experts collaborate with our followup team
to make sure that we got it right.
Mrs. Kirkpatrick. Well, my last question is about on-site
review. It seems to me that that is probably the best way to
garner the information about whether or not the different
departments are doing their job. I guess I wonder why you do
not do on-site review on every report.
Mr. Griffin. Because it would be too manpower intensive to
try and go back and redo every one. There is a number, a
percentage, you know, that would make sense. It is not 100
percent. The exact number, I guess, depends on whether we are
suspicious as to whether or not the recommendation and the
proposed fix was the right fix. Perhaps we will get a call to
our hotline where we get 29 to 30,000 calls a year. If we get
multiple calls suggesting that we still have a problem in a
certain area, that might trigger us to go back.
And our CAP cycle, which is a 3-year cycle, every time when
we go back to a medical center, we will take a look at the
previous report and we will see what the recommendations were
in that report and we will validate whether or not, in fact,
they were addressed to our satisfaction.
Mrs. Kirkpatrick. Your answer conjures up one more
question.
Mr. Griffin. Okay.
Mrs. Kirkpatrick. Would it not be better to do the CAP
review every year as opposed to every 3 years?
Mr. Griffin. Well, that is a resource issue. You know, we
are at these medical centers for a week, which is not a long
time, and that is why their scope is such that there is no way
you can go in and look at every activity in a medical center.
So every 6 months or so, we will decide these are the pulse
points as we call them, these are the areas that we are going
to look at for the next 6 months. And if we have repeat
findings on one or more of those, we will bring that to the
attention of VHA so that we can say this is not something that
we found at one medical center. This is something that eight
out of the last ten seem to be having a problem with or, you
know, 15 out of 20, whatever the number might be. And then they
know, okay, it is not an anecdotal situation.
They either need to clarify the policy, write new policy or
get on the phone and find out why someone is not following the
policy.
Mrs. Kirkpatrick. Thank you very much.
I yield back, Mr. Chairman.
The Chairman. Thank you.
Let me just wind up our questioning. First, thank you so
much for your testimony, Mr. Griffin.
Given the open recommendations and especially the last
recommendations, what is your sense? What is the most important
outstanding recommendation either by policy issue or by money,
that we should focus on to save money?
Mr. Griffin. I think when you are talking about money and
policy, I think procurement represents a huge dollar value for
the Department. I think the acquisition area on a number of
different fronts, not just the drugs that we purchase, but the
clinical health care specialists that we contract for, the
contracts that we have with medical experts from the
affiliates, contracts at CBOCs----
The Chairman. What is the problem there? How would you
define the problem?
Mr. Griffin. I would define the problem that you have the
acquisition staff in Washington writing policy for how
procurement and acquisition should be done. You have a
contracting officer who works for the Veterans Integrated
Service Network (VISN) who is working for a different master.
And you have some Contracting Officer's Technical
Representatives (COTRs) that are working in conjunction with
the contracting officers who are also out at the medical center
taking their direction at the medical center.
And too frequently what we find is the acquisition
regulations and even VA regulations about the order that
procurements are supposed to occur in do not happen. In
addition, there is inadequate attention to monitoring the
performance of what is in the contract and there is a lot of
money left on the table as a result.
The Chairman. Money left because there are not tough enough
negotiations or is there anything----
Mr. Griffin. I think negotiation is part of it. I think
when you establish a contract, if you do adequate analysis of
what the need is and you put the proper parameters in for where
you are going to go to get that person or that item and then
after the contract which is properly competed, if it is a
competitive contract, you have a COTR that monitors compliance
with what is in the contract.
The Chairman. Give us the name of that acronym.
Mr. Griffin. I am sorry. That is the contract officer's
technical representative.
So it is a combination of things, but part of the issue is
the people who write the policy are back in Washington and
where the rubber meets the road is out in the field. And as I
alluded to earlier in some instances, we will have a medical
expert who says forget about the supply schedule or forget
about what you are hearing from them, I want this prosthetic
for my patient.
And I am sure there are occasions when for medical reasons
that is 100 percent correct and that prosthetic should be the
one used. But I think there are a lot of times where the
sentiment is we cannot be bothered with contracting and
procurement issues. We have veterans to take care of. So you
have that constant struggle.
The Chairman. I mean, the Secretary is recommending that we
have a new Under Secretary for Acquisition and Procurement.
Do you think that would help, or does that further move the
focus to Washington as opposed to the sites?
Mr. Griffin. I think given the proper authority to the
position, that can help.
The Chairman. Has the office ever looked at the
decisionmaking process for deciding what drugs may be on the
formulary that the VA uses? Have you ever looked at that?
Mr. Griffin. I am not aware that we have done any recent
work in that area.
The Chairman. There are situations where new drugs are
coming on the market and the people who are deciding on the
formulary are looking too closely at the direct cost.
Let us say hypothetically that a new diabetes drug is
online and it costs $50. The other drug costs $1. Of course, it
seems $1 versus $50 is a clear monetary decision and, yet, the
$50 drug one may help the quality of life of the patient. For
example, taking a shot once every 2 weeks instead of twice a
day may prevent complications in the future, and we are saving
money in the future.
That is a process where people have to make decisions. Have
we never looked at that directly?
Mr. Griffin. No.
The Chairman. Okay. We might want to.
How about the processes used for looking at innovation in
general in the VA, new technologies, new equipment, new ways of
doing things?
We have a lot of complaints about not having new
innovations available. Is there no real way for this
bureaucracy to make these decisions? We tend to reject new
ideas as opposed to embracing them. Have you ever looked at the
situation?
Mr. Griffin. I cannot say we have looked at that, but I
would hope that our relationship with our affiliates who do
have a number of medical innovations happening in their
facilities, and who are working hand in hand with our doctors
on sharing best practices. I think that was part of the intent
of the affiliate process in the first place, that it would be
mutually beneficial.
The Chairman. I am sorry, could you explain the affiliate
process?
Mr. Griffin. We have all these affiliates with our medical
centers. Some of these affiliates----
The Chairman. I do not know what you mean by affiliates.
Mr. Griffin. Well----
The Chairman. Is that the name given to the medical
centers?
Mr. Griffin. No. We have a VA medical center----
The Chairman. Yes.
Mr. Griffin [continuing]. That is collocated with a
university hospital. And those university hospitals often are
perhaps getting some of the new technology earlier. But because
we are in partnership with them, hopefully we benefit from
experience they may have with new innovations.
The Chairman. I do not know how we ask you to look at this
or ask the Secretary but the whole notion of a big bureaucracy
and how it deals with innovation, is a real problem.
I do not know how big companies such as Microsoft or IBM
embrace new innovation. The VA is in areas where we should be
actively searching out new innovations and new ways of doing
things. It just seems that we act as a bureaucracy that pushes
back rather than embraces innovation.
We will talk to you about that later. Maybe we need to look
at that.
I thank you both for being here with us. Thank you, Mr.
Griffin. We hope you will continue in your job. I guess in your
official position, when several people have asked you about new
resources you are not allowed to say you need new resources.
OMB says that you do, and on about six or seven different
occasions, you have said that you have a lack of resources. We
will have to look at that and talk to you in an informal way
and----
Mr. Griffin. Well, I am hopeful that the support that the
Committee gave us on the 2011 budget causes our resources in
2011 to increase. That is where I am at.
The Chairman. Thank you, sir.
Mr. Griffin. Thank you.
The Chairman. We appreciate that.
Mr. Griffin. Thank you for having the hearing, Mr.
Chairman.
The Chairman. If our next panel will join us, please? We
have the Department of Veterans Affairs, Dr. Robert Petzel, the
Under Secretary for Health; accompanied by Roger Baker, the
Assistant Secretary for Information and Technology, and Diana
Rubens, the Associate Deputy Under Secretary for Field
Operations for the VBA.
We thank you all for being here.
Dr. Petzel, your written testimony will be made part of the
record and we look forward to hearing from you.
STATEMENT OF HON. ROBERT A. PETZEL, M.D., UNDER SECRETARY FOR
HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF
VETERANS AFFAIRS; ACCOMPANIED BY HON. ROGER W. BAKER, ASSISTANT
SECRETARY FOR INFORMATION AND TECHNOLOGY AND CHIEF INFORMATION
OFFICER, OFFICE OF INFORMATION AND TECHNOLOGY, U.S. DEPARTMENT
OF VETERANS AFFAIRS; AND DIANA M. RUBENS, ASSOCIATE DEPUTY
UNDER SECRETARY FOR FIELD OPERATIONS, VETERANS BENEFITS
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
Dr. Petzel. Good morning. Chairman Filner, Congressman
Stearns, and Committee Members, we thank you for the
opportunity to appear before you today to discuss the
Department of Veterans Affairs work in responding to
recommendations from the Office of the Inspector General.
Joining me today are Roger Baker, the Assistant Secretary
for Information and Technology, and Diane Rubens, the Associate
Deputy Under Secretary for Field Operations for the Veterans
Benefits Administration.
I also want to thank the Deputy Inspector General, Mr.
Griffin, for his testimony in the previous panel. Thank you and
thank you to your employees for your tireless commitment to our
veterans and improving care within VHA and benefits within the
VBA.
I am pleased to be here today to talk about what is perhaps
the most important element of VA's mission, ensuring we deliver
the absolute best care and services to our Nation's veterans.
The Chairman. I am sorry. Let me interrupt. Did anybody
from the Office of Inspector General stay? Okay, thank you. I
believe you wanted to hear the response to your testimony, so I
am glad somebody is here. Thank you.
I'm sorry, Mr. Petzel. Please.
Dr. Petzel. In my more than 35 years with the Veterans
Health Administration, I have seen remarkable advances in the
quality of care we provide to veterans. These improvements were
due to the dedication of VA's employees. It is a dedication
that continues today.
However, these years have also had their share of setbacks,
but hindsight has revealed we could have and should have in
many ways done better by our veterans. We have an excellent
system, but it is not a perfect one.
VA is committed to identify those areas where we can do or
need to do more to improve and we value the OIG as an important
partner in ensuring the accuracy, integrity, and accountability
in the delivery of benefits and services to our Nation's
veterans.
VA OIG helps us ensure that we are being as effective and
as efficient as possible. We are also partners in identifying
areas of waste, fraud, and abuse, as well as removing persons
whose conduct is truly criminal.
This not only improves our operations as a Department in
providing services to veterans, but it saves the American
taxpayers millions of dollars every year and reaffirms the
faith that veterans have in this Department. Much of this is
about the matter of trust.
If I may provide a brief example that illustrates both the
partnership we have with the OIG and how this relationship
improves care, I direct you no further than our facility at
Marion, Illinois.
The problems we experience at that facility are well
documented. And it is thanks in part to the OIG that the
facility is on the corrective course it is today. We are
establishing a new leadership team there, changing the culture,
and our veterans are already experiencing these improvements.
The scope of the OIG's work is immense and it is far
reaching as its investigations can be specific to facilities or
result in broad reviews of VA programs. Its reports have
resulted in hundreds of recommendations for the Department
ranging from administrative actions against specific personnel
to large-scale policy reviews.
Additionally, the Department and the VA OIG maintain a
strong relationship in identifying, investigating, and bringing
to justice those who use their positions to defraud or harm
veterans.
The administrations and staff offices involved with each of
these reports work directly with the VA OIG to ensure that
action plans are developed and implemented in a timely and
appropriate manner to make this change positive.
This system gives VA the flexibility to respond quickly and
effectively to reports and recommendations that the OIG has
issued. The administrations and offices are in regular
communication with the VA OIG to track the progress in
responding to its reports and to identify what more needs to be
done.
I think the effectiveness of this partnership speaks for
itself in the 94 percent accomplishment of recommendations
within the 1st year.
While VA OIG has significantly increased the volume of its
reports and recommendations, VA is closing out these reports
and recommendations as quickly as ever has. The VA OIG has
identified 16 reports with 45 recommendations open for over a
year. These are the second lowest numbers in each of these
categories over the last 5 years.
Furthermore, Mr. Chairman, as I detailed in my written
testimony, since that report, we have provided the OIG with
progress updates on two of these reports and recommendations
and we are confident that our actions on these outstanding
reports will close them out.
In closing, Mr. Chairman, let me say it again. VA is
committed to being a veteran-centric, results-driven, forward-
looking organization that provides the best care and services
possible to our Nation's veterans. And we value the partnership
we have with the Office of the Inspector General.
Thank you again for the opportunity to appear and I and my
colleagues would be delighted to respond to any questions.
[The prepared statement of Dr. Petzel appears on p. 40.]
The Chairman. Thank you.
Mr. McNerney, do you have any questions for the Secretary?
Mr. McNerney. Thank you, Mr. Chairman.
Well, the improvements have been pretty impressive, at
least the way they have been outlined here this morning, so I
appreciate that effort, both your part and the OIG's part.
I have a specific question regarding traumatic brain injury
(TBI). The OIG mentioned that the VHA's support for veterans
with TBI is extensive, but that long-term case management is
not uniformly provided within the VA and that significant needs
remain unmet.
I recently wrote legislation that was passed into law to
direct the VA to specifically assess the needs of TBI patients
and develop initiatives to meet those needs.
Can you please inform me of an update on the VA's or give
me an update on the VA's efforts to improve TBI care and
treatment?
Dr. Petzel. Thank you, Congressman McNerney. That is an
excellent question.
The patients that are returning from Iraq and Afghanistan
with traumatic brain injury are of deep concern to the Veterans
Health Administration and to the Department in general.
We have in place now a program to screen all combat
veterans for the presence of traumatic brain injury. To date,
we have screened over 50,000 of these veterans and have
identified 16,000 people that have symptoms of traumatic brain
injury. They have undergone a second level assessment to see
how severe that traumatic brain injury is.
The Chairman. Dr. Petzel, can I interject?
Dr. Petzel. Certainly.
The Chairman. These are people who have come to the VA,
right?
Dr. Petzel. That is correct.
The Chairman. Have we not gone out to all people?
Dr. Petzel. Well, we have gone out. I will get to that in a
moment.
The Chairman. And when you say screening, can you define
that process?
Dr. Petzel. There is a tool that is used----
The Chairman. A questionnaire?
Dr. Petzel [continuing]. A questionnaire that is used by a
practitioner to assess----
The Chairman. And is that----
Dr. Petzel [continuing]. The possibility of traumatic brain
injury.
The Chairman. Does someone sit down with the questionnaire,
with the----
Dr. Petzel. That is correct. It is administered by a
practitioner.
The Chairman. The reason I am asking is because the
military uses the word screening and what they mean by that is
a questionnaire, usually a few questions, and they do not sit
down with anybody. Somebody looks at them and if there are any
yeses, they call them back, so everybody knows how to say no.
That is a little different than sitting down with a qualified
medical person for 45 minutes or an hour. I call that an
evaluation.
I think the single most important step this country can
take to deal with both traumatic brain injury and post-
traumatic stress disorder (PTSD) is to have the evaluation be
mandatory before or after combat, or at least before discharge.
We let tens of thousands of our young people out without an
evaluation, and then we wait until they come to the VA. Maybe
we do the evaluation better, but we still have hundreds of
thousands of young people without ever being evaluated.
Dr. Petzel. We would agree with you that screening while a
soldier is still in the military would be best.
The Chairman. Do me a favor. Issue a directive not to use
the word screening because----
Dr. Petzel. Evaluate.
The Chairman [continuing]. U.S. Department of Defense (DoD)
says they screen everybody and VA says we screen everybody who
comes in. But a self-administered questionnaire is not an
evaluation. I think they use the word screen advisedly and it
is not sufficient in my view to screen somebody as opposed to
evaluating them with a professional person.
I apologize, Mr. McNerney, for jumping in here, but I think
it is the real single most important thing we can do for our
young people is to have a mandatory evaluation.
Dr. Petzel. We would agree. If I may, our biggest issue is
the fact that we have only enrolled and seen 46 percent of
these veterans who are returning from Iraq and Afghanistan.
There is another 54 percent that we have not, in spite of our
outreach efforts, actually been able to see. So our biggest
issue is that we are not able to evaluate a large percentage of
the veterans from Iraq and Afghanistan.
I am comfortable that, we have a very good case management
program for the severe traumatic brain injury patients that
pass through our TBI centers and for the moderately and mildly
injured patients, but there are people who fall through the
cracks. There are individuals, and I am sure that you probably
have an example or some examples of people who have not been
case managed well by us, which we would obviously like to hear
about. We have a very extensive outreach program and a very
extensive case management program.
Mr. McNerney. Well, we talk a lot about the seamless
transition from the DoD to the VA. Is there some way that that
could be used to make this more effective in reaching those 54
percent that you are not able to get through to?
Dr. Petzel. That is a very good point, Congressman. Once
the soldier leaves their unit, their interest obviously is
getting back to their families, getting back to their jobs, et
cetera.
With the National Guard, we have the opportunities to go to
their Guard centers and we do. We have Beyond the Yellow Ribbon
Program which is very effective in getting to the Guard and
alerting them about potential problems they may have, and the
kind of services that are available.
We are doing a better job with the Reserve now, too,
because they again go back to a unit that we can visit.
The most difficult group of people are the active-duty
servicemembers who are discharged, go back to their community,
and are not in a setting where they gather that we can reach
numbers of them at one time.
The DoD has an excellent program to reach out to them in
conjunction with us, but I would say that is the most difficult
group that we have.
And, again, as the Chairman has suggested, screen at the
time of return before discharge, evaluating at the time of
return would be an effective thing to do, I think.
Mr. McNerney. Okay. Thank you.
I am going to yield back, Mr. Chairman.
The Chairman. Thank you.
Mr. Stearns, you are recognized.
Mr. Stearns. Thank you, Mr. Chairman.
Dr. Petzel, there was a July 2008 hearing on miscellaneous
expenditures, inadequate controls at the VA. The U.S.
Government Accountability Office (GAO) testified that the VHA
recorded over $6.9 billion in miscellaneous obligations during
fiscal year 2007. These obligations were for fee-based medical
services, drugs, medicine, and transportation of veterans. I
understand this amount has increased.
GAO looked at 42 case studies and all 42 cases lacked
documented oversight by contracting officials. VHA reacted by
issuing new guidance on the use of miscellaneous obligations in
2008. GAO stated that without basic controls over the billions
of dollars that the VHA is spending in miscellaneous
obligations, and I quote, ``VA is at significant risk of fraud,
waste, and abuse.''
The two OIG reports released this past Monday indicate very
little improvement over the past 2 years. I think VA is in deep
denial that procurement reform is in the VA, specifically in
VHA was broken and is severely vulnerable to billions of
dollars in fraud, waste, and abuse today.
Do you agree?
Dr. Petzel. Congressman, I agree that there were serious
problems with acquisition. I believe that it is absolutely
essential that we professionalize our acquisition and technical
contract oversight group.
The Secretary has taken this on as a fundamentally
important part of his transformation. And just to go through
some of the details that have occurred, the administrations,
and I speak particularly about VHA, has centralized its
contract administration. The contracting officers do not now
report to the VISN or to the medical center. There is a central
administration of contracting.
They have added a very strong compliance and a very strong
review process and personnel to the contract offices. We have
literally hired in the last 6 months and are continuing to hire
hundreds of people to staff the oversight staff, the
compliance, and to beef up our contracting personnel.
I am quite confident speaking today that once we have these
people hired and once we have the oversight groups in terms of
quality assurance and compliance up and functioning, you are
going to see dramatic improvements in our administration of the
miscellaneous expenses and in the contracts that we have.
Mr. Stearns. You say once they are hired. When do you think
they will be hired?
Dr. Petzel. I am sorry, Congressman. I cannot say exactly
when. I know we have already hired over 100 new people and have
authorized the hiring of an additional 100 people. So by the
end hopefully of this fiscal year, we will have hired at least
200 of these new individuals.
The Chairman. Could you yield for a second?
Mr. Stearns. Sure.
The Chairman. When you answered Mr. Stearns, the first
beneficial thing you said was centralization. I understand that
in terms of legal issues and oversight but the OIG suggested
that the provider may have some more insight to that or has
some direct health concerns rather than a monetary concern. It
also happens with IT.
Mr. Baker, I think you know there is a sense in the
hinterlands that centralization in some of these areas is
obviously very important for reform. But if it overrules local
expertise for no other reason than the fact that it is
efficient in the Central Office, that is also a problem.
How do you balance that both in the area--you are not the
acquisition guy--but----
Dr. Petzel. Mr. Chairman----
The Chairman [continuing]. The local guy versus the central
guy, how do you balance that stuff?
Dr. Petzel [continuing]. I can certainly speak about the
clinical implications of this. The issues that involve the
practitioners, the pharmacists and the physicians, are what are
you going to purchase. The example in the OIG's report that I
think is an excellent one, if you will pardon me for spending a
moment with it, is the surgical implants.
There were three items that were mentioned in that report,
coronary artery stents, aortic grafts, and aortic valves.
Coronary artery stents, the issues about what stent you put in
are not particularly controversial.
We, for the last 2 years, have been trying to get bids on a
national contract. We would love to have a national contract
with stents. We spend $59 million a year and there is general
agreement that we could do this amongst the cardiologists, but
no provider has taken us up yet on that. We are out with
another RFP and we will see if we can manage to get that
procurement completed.
Aortic grafts and aortic valves are far different. We use
very few of them, 150 aortic grafts a year and about 1,500,
which is not very many, aortic valves per year. In those
instances, it is felt that the practitioner choice is very
important, that the clinical circumstances within the aortic
valve vary tremendously from patient to patient. The surgeon
needs to be able to get the valve that they want.
The same thing with aortic grafts. They are very infrequent
and the surgeons again feel they need to get what they want.
Plus the fact that the volume is so low that we are not talking
about saving a tremendous amount of money.
So in that instance, we have recommended, we have said back
to the OIG that we are not going to get a national contract in
either one of those areas, but we are going to ask or allow the
practitioners to pick and choose what they want.
That, Mr. Chairman, is an example of how the practitioners
get involved in this acquisition process to make sure on the
one hand their needs are met and on the other hand we are doing
the fiscally responsible thing.
Mr. Baker. If I could address the IT side of that, Mr.
Chairman, just quickly. One of the things that we have lots of
great private sector examples on IT, the infrastructure, the
networks, the e-mail system, the security are best done from a
central perspective and very uniformly. But customer service
like politics is a local thing. It is the person that comes to
see you. It is the person you can see and hold directly
responsible for whether or not your services are getting done.
And we have really tried to have that focus inside of the
Office of Information and Technology here for the last year. It
is really focusing on customer service for our clients at VHA,
VBA, and the rest of the corporate folks.
Mr. Stearns. Mr. Chairman, thank you.
Dr. Petzel, I have two reports here. One is dated June 7th
and the other one is June 7th also. These are two VA OIG
reports that were released, of course, this last Monday. Both
deal with flawed VA procurement practices.
If you do not mind, let me just quickly, Mr. Chairman,
highlight some of the findings.
Contracting officers did not ensure adequate competition,
maximize use of the Federal supply schedule instead of local
contracts, or maintain required contract documentation.
Medical facility staff made unauthorized commitments.
The Procurement and Logistics Office lacked an effective
oversight process for health care staffing and service
procurements.
There was lack of guidance and training, which made
procurements more vulnerable to improper payments, higher
prices, and Federal acquisition regulations deficiency.
And, finally, 77 percent of the audited procurement orders
had not been adequately reviewed and 51 percent had ordering
and competition issues.
Were you aware of these two reports that came out on June
7th?
Dr. Petzel. I saw them on Monday, June 7th, Congressman,
when they came out.
Mr. Stearns. Were they a surprise to you?
Dr. Petzel. No, they were not.
Mr. Stearns. So a lot of this information you knew how long
ago?
Dr. Petzel. I cannot tell you, Congressman, exactly how
long ago, but we make the responses to the OIG recommendations,
so we have seen the reports previously.
Mr. Stearns. Okay. Of the different findings, is there any
one that you think can be solved immediately? All of these go
into you once we have sufficient people, will we be able to
solve them, or otherwise, will this continue?
Dr. Petzel. No, I do not think we need to wait until we
have sufficient people, Congressman.
Mr. Stearns. You know, I mean, if I got this and I was
operating a corporation, as soon as I got this, I would
implement a special task team, ad hoc Committee to go right at
it and solve the problem. And I would be able to say to my
board of directors or shareholders who also got a copy of this
report, I would say to them I hope to have this solved within 6
months to a year, but I will get back to you in 90 days what I
am going to do.
Is that a reasonable request on you?
Dr. Petzel. Oh, absolutely.
Mr. Stearns. Because the amount of money you are talking
about is enormous and here you have these two reports. You have
a copy of them. I just outlined some of the problems. And each
of these areas would mean huge amount of savings which we could
use for better care of our veterans.
Dr. Petzel. Let me describe the process.
Mr. Stearns. Well, let me just ask you a question. Do you
think it is reasonable to ask--I mean, it is possible that if I
was Chairman, I would ask you on these reports to maybe call me
in 90 days and say what you have done. Is that a reasonable
request?
Dr. Petzel. Absolutely. We do ourselves 30-day, weekly, 30-
day, and 90-day updates on what is happening with each one of
the recommendations. We are required and we do report back
every 90 days to the OIG.
Mr. Stearns. What about to Congress who appropriates the
money for you? Do you tell us what you have done?
Dr. Petzel. Sir, to be honest with you, I do not know what
the process is----
Mr. Stearns. Okay.
Dr. Petzel [continuing]. With Congress. I will find out.
Mr. Stearns. Well, you know, staff just pointed out to me
that there was a July 2008 hearing on these very items,
miscellaneous expenditures and inadequate controls. So that was
2 years ago and evidently the reports that have come out from
the Inspector General have just reiterated what we discussed 2
years ago in a VA hearing.
Were you aware of that July 2008 hearing on miscellaneous
expenditures?
Dr. Petzel. I was not.
Mr. Stearns. You were not. Does anybody on your staff know
about those hearings?
Okay. Were you in the Department 2 years ago?
Dr. Petzel. I was in the Department, not in this job.
Mr. Stearns. Not in this job. Who was in the job that you
have in 2008?
Dr. Petzel. Michael Kussman, Dr. Michael Kussman.
Mr. Stearns. Okay. So Michael Kussman must have known about
this and this hearing, so all these expenditures, miscellaneous
expenditures were talked about. It was revealed there is
inadequate controls at the VA. So 2 years later, there is
nothing changed because we have two reports that came out June
7th and we are talking about pretty much the same items.
What does that tell you?
Dr. Petzel. Congressman, that tells me that there was
inadequate followup and followthrough on the recommendations
that were done before, inadequate education, perhaps inadequate
staffing, and those, I am sure, are part of the responses to or
are part of the responses to the recommendations.
Mr. Stearns. So what you need to do is convince us here on
the Committee that your response is not going to be like the
response of your predecessor.
Dr. Petzel. I can assure you, Congressman, that that is the
case.
Mr. Stearns. Okay. Mr. Chairman, would you like to comment?
The Chairman. I think we need a followup on the issues you
are raising here, just on procurement. As you know, the
Secretary is making a suggestion for a new Under Secretary for
Procurement. Perhaps we can follow up on your questions with
the Secretary and this Deputy in a separate hearing that I
think we need to have on procurement issues.
Mr. Stearns. I think that is true and I think also that Dr.
Petzel should send a letter to the Committee with the assurance
that what occurred 2 years ago will not reoccur and perhaps
give you an update of what he is doing.
The Chairman. Yes. Correct me, Mr. Stearns, was this
directly in the Veterans Health Administration?
Mr. Stearns. It was. I am told by staff it was.
The Chairman. Okay, because Dr. Petzel is not directly
responsible for procurement and maybe we should have had the
Deputy Secretary here for that. I think we need to focus in on
those issues with the people who have to deal directly with
them.
Mr. Stearns. Okay. Thank you, Mr. Chairman.
The Chairman. I appreciate you bringing those up.
Just as a followup to what Mr. Stearns was talking about,
and this is directly in VHA, there are reports still open from
the OIG, one from September of 2008 that says an audit of VHA
noncompetitive clinical sharing agreements would have a
potential savings of $60 million. Apparently, we have not had
the response within the year.
Are you aware of that report?
Dr. Petzel. I am aware of that, Mr. Chairman.
The Chairman. What is going on?
Dr. Petzel. My understanding is, and I reviewed all 23 of
the outstanding recommendations that we had seen in the semi-
annual report, and that group associated with that particular
acquisition process all revolved around the training of our
acquisition staff.
There is a relatively newly established acquisition academy
to which everybody has to attend and the curriculum was written
around the recommendations in that OIG report. The OIG will not
close that recommendation out until we certify that every
single acquisition individual has been through that training
program.
The Chairman. I see. But you have----
Dr. Petzel. Absolutely.
The Chairman [continuing]. Eventually reacted to it. Mr.
Michaud?
Mr. Michaud. Thank you very much, Mr. Chairman.
Dr. Petzel, last month, this Committee held a hearing on
the status of the National Vietnam Veterans Longitudinal Study.
Several Members of the Committee expressed concern that the VA
has taken so long to finish conducting the study due to
problems related to VA's acquisition process.
While I am pleased that the VA has since released a request
for proposal on May 25th for this effort and expects a contract
to be awarded by the end of the year, I am concerned about the
overall number of open recommendations that VA still has not
implemented and that even once the study is finally completed,
VA will have even further delays in implementing any
recommendation that results from this study.
What plans does the VA have to ensure that this does not
happen?
Dr. Petzel. Well, first of all, Congressman Michaud, I
share your concern about the delay. This harkens back to 2005.
And just to reiterate a bit of that history, we found that we
had difficulties with the contractor and eventually have come
to the point of writing a new Request for Procurement (RFP)
which, as you pointed out, was just issued on the 25th.
I think a number of lessons have been learned from that.
One is that the RFP that has been written this time is a much
tighter document and I think it is going to allow us to find a
better contractor for that study.
Those veterans deserve that longitudinal study. There are
many issues in their minds that surround the experience in
Vietnam and I think that this study is a very important part of
the ongoing evaluation of the health effects that might have
been associated with Vietnam.
So, number one, I think we have a better RFP. Number two is
we are going to have a much tighter process of monitoring the
performance in that contract than existed previously now that
we know about the difficulties with that kind of a study and
the kinds of issues.
So I can promise you that we will keep much better track of
what is happening with that contract in the future.
Mr. Michaud. Thank you very much.
My second question is, the OIG talked about the two reports
on reusable medical equipment and indicated that at the August
2009 followup review that 129 facilities were compliant with
respect to standard of operation procedure and 128 had
appropriate documentations of demonstrated competence.
Yet, in March of this year, the OIG issued a report about
reusable medical equipment problems at three sites in Puerto
Rico. And my concern is, you know, with this report dealing
with Puerto Rico, you know, once we--it appears that we are
solving some problems.
How can these things happen, especially since they are just
recent?
Dr. Petzel. Congressman Michaud, another good question. We
have noticed in the CAP reports periodically as with Puerto
Rico that there are sometimes relatively minor but definitely
issues with reusable medical equipment. A placard is not posted
in the correct place. There is not good documentation of
training, et cetera.
I believe that this is a result in part of the fact that we
have not yet completed our response to this larger issue across
the country. There are two aspects to that.
One is that we are industrializing the process of cleansing
and sterilizing reusable medical equipment, turning it into not
a medical process, but into an actual industrial grade or level
process using the standards of what is called ISO 9000, which
is a set of industrial standards used in many different
manufacturing processes. That effort is underway, but is not
yet complete.
A corollary to that is that we are setting up a national
compliance and oversight program for reusable medical equipment
where we have a separate group of people that will be
responsible for seeing that the rules, et cetera, the
directions, the directives are being followed.
And then the third thing is that we are standardizing our
reusable medical equipment. At the time that we first began
looking at colonoscopes, there were probably 30 to 40 different
kinds of colonoscopes around the country. In an individual
medical center, it could be 20 or 25. We are asking a group of
technicians to be facile with 25 different cleaning
instructions for colonoscopes. So that is not reasonable and
that is not good practice.
We are in the process of getting RFPs and going out to
develop standardized national contracts and we will ask that
the medical center have no more than, let us say, ten, I am not
sure what the number will be yet, but ten scopes so that we can
be sure that there is a minimum stress on the part of the
people cleaning these scopes to learn a large number of
different processes.
So those two efforts, I think, are going to eventually lead
us to the point where we will not be seeing these isolated
incidents in the CAP reports as you pointed out.
Mr. Michaud. Thank you very much.
Thank you, Mr. Chairman.
The Chairman. Thank you.
Dr. Roe?
Mr. Roe. Thank you, Mr. Chairman.
Just a couple of questions to dovetail with Mr. Michaud's
points. You said there were, in some institutions, 25 different
colonoscopes?
Dr. Petzel. There could be that many, correct, Congressman.
Mr. Roe. Hmm.
Dr. Petzel. Different models perhaps in some instances of
the same scope, but absolutely.
Mr. Roe. Yeah. I mean, it would not be 25 different
procedures to clean a scope with a minor variance. I mean,
that----
Dr. Petzel. Well, each one of those scopes, Congressman,
could have different cleaning instructions. If it is a
different model of the scope, the cleaning instructions can be
different. So, yes, it is possible.
Mr. Roe. I will have some more information on that later. I
am not so sure about that.
The Chairman made a great point a minute ago when he
mentioned about new innovations that would come along, and I
know this is not your area of expertise on procurement, but
where you would have a central procurement here. And I could
understand where if you are looking at IV fluids or band-aids
or whatever it might be that are pretty generic, that are
pretty standard, whether you have D5 lactated ringers made by
somebody and somebody, I get that. But his point was a little
more specific.
And what the OIG was saying a minute ago is very true is
that when you get down to the individual patient and you are
taking care of that person, you want whatever it takes to give
quality of care to that person and as a more centralized issue,
I mean, procurement may not work for an individual person.
How does the VA, and I heard you say about the aortic
valves and the micro valves, but I hear this a lot at the VA
about when you--by an individual practitioner, I may not have
this particular medicine or that particular device, for
instance, orthopedists use a lot of different knee devices or
shoulders or fingers or whatever it may be, how do you do that?
And I worry about that because I have worked in a hospital
where a central supply tries to buy something for me that I am
trying to use in the operating room and they could not tie a
knot if they had to. So it does make a difference when you are
in the operating room using a device or piece of equipment that
you are familiar with, you know that works, and you get good
results with.
Dr. Petzel. Congressman, as you pointed out, there is a
tension between the desire to have some standardization and
provide as much value as you can for whatever it might be you
are purchasing on the one hand and on the other hand, the
individual particular desires of a practitioner.
Orthopedic surgery is an excellent example of that.
Orthopedic surgeons tend to use the equipment that they were
trained on. It does not mean that one piece is better than the
other piece. It happens to be the piece that they are familiar
with.
The question is, how far do you go in compromising the
individual person's desire to have the kinds of equipment that
they trained on versus the need to add value by being cost
effective.
Mr. Roe. Let me give you an example. I do not have much
time. Let me give you an example. We were able to buy some new
laparoscopic equipment that was expensive. It was about $2,000
for one piece of equipment. But we cut our operating time on a
laparoscopically assessed vaginal hysterectomy from 3 or 4
hours to an hour.
Is that worth doing? Did patients benefit? Absolutely.
Would it have made sense economically? I do not know, but I
know the patients certainly benefited from it.
Dr. Petzel. I can tell you it would have made sense
economically because if it cuts an hour off your operating room
time, that means you can use that operating room more
efficiently. That is the kind of decision that we would
endorse.
Mr. Roe. I think the other issue that the Chairman brought
up very well was his example about diabetes. And I realize
those are not real facts, but how do you evaluate that? And I
agree with him completely. How do you evaluate that? You can
take the dollar pill or you can take something more expensive,
but may be better and the benefits may be down the road.
Dr. Petzel. That is again a very good point, Congressman
and Chairman. You both have raised it.
The key to that in my mind is comparative effectiveness
trial. That is, these two ways of treating diabetes need to be
evaluated side by side. If the expensive drug proves to be
substantially better than the inexpensive drug in managing a
diabetic, then it will become the drug of choice.
Cost cannot be and is not ever the only thing that is being
considered. You need to look at the medical literature, you
need to look at the comparative effectiveness studies and make
a decision about whether or not the advantage of this drug, if
there is any, outweighs the cost of that particular drug.
Mr. Roe. But is that being done? I mean----
Dr. Petzel. Absolutely. Absolutely.
Mr. Roe. Okay. Could we see that here because I think that
is very important?
And just before I yield back, thank you, Mr. Chairman. I
know my time is expired. On your point on PTSD, I think an
evaluation should be mandatory when you get out, not just a
questionnaire, and then continue to evaluate these folks. And I
think what the OIG said, because I know from my own experience
as a veteran, some of those issues are dealt with then as a
young man, a 25-, 26-year-old Army Captain, you are still
dealing with now later. And some of these things amplify, and
that is what PTSD basically is. You see a lot of folks that are
having a very difficult time later in their life dealing with
issues that happened to them three decades ago.
So I think that is a good point, but to continue to do
that, and outreach, I think I heard maybe it was you or the OIG
say is it is difficult to find these folks that are regular
Army or Navy, whatever, career military folks that do not have
a way to get back to them.
Dr. Petzel. Right.
Mr. Roe. Okay. Thank you.
I yield back.
The Chairman. Mrs. Kirkpatrick?
Mrs. Kirkpatrick. Thank you, Dr. Petzel, for your testimony
today and for answering our questions.
I am going to ask you about the Fiduciary Program. We
recently had a Subcommittee hearing about the program that
raised some substantial questions in my mind about the
oversight of the fiduciaries.
You know, with the increased incidence of TBI and severe
PTSD, apparently more and more veterans are needing fiduciaries
to help them handle their money. And I think the fact that they
need this help makes them among the most vulnerable of our
veterans.
So I was troubled when I saw that the OIG's 2006 audit made
recommendations to the Fiduciary Program and then 4 years later
in 2010, there were similar problems.
And so I wondered if you could explain to me why those
recommendations were not implemented in that 4-year time
period.
Dr. Petzel. I would like to turn that question, if you do
not mind, over to my colleague from VBA, Ms. Rubens.
Ms. Rubens. Yes. Thank you. I appreciate the opportunity to
address this.
I cannot tell you how much I agree with you in terms of the
special needs our veterans have when they come back with that
TBI or been determined to be incompetent perhaps later in life.
That 2006 OIG report troubled me when I was out in the
field. And as I did my homework after now being here to say,
okay, why have we not finished implementing these
recommendations, particularly as they pertain to appropriate
levels of staffing. And, in fact, after the OIG study had come
out, VBA did go out and engage a contractor to help us take a
look at what are the work measurement issues around managing
that program to ensure we actually are providing enough
oversight.
Quite frankly, the initial study that was done was found to
be, if you will, inadequate in terms of the findings. The
recommendations were sort of scattered. As we began to look at
validating, if you will, their approach and their findings,
P.L. 110-389 was passed which required an overall work
measurement study within the Compensation Program.
So, okay, we are going to shelve the first one. We are
going to take this second study on. And, in fact, that study
was done and the results of it as we worked with the contractor
to review what they had come up with were largely qualitative.
They were not quantitative in terms of beginning to lay down
some real hard data in terms of how many incompetent veterans
requires what level of oversight.
Given that I will call it disappointing outcomes on two
studies, we are taking that information and putting together an
internal review. And before the end of this fiscal year, we
will have recommendations on what is the appropriate level of
oversight to provide to our Fiduciary Program.
Mrs. Kirkpatrick. Thank you. That is good information. I am
pleased to hear that you have a specific timetable for
completing that.
Let me ask you, is there, in the recommendations, I have
not seen them, I would like to see them, but is there a
recommendation that all the fiduciaries be certified or have a
certain standard of training?
Ms. Rubens. You know, I am not sure if that is within the
recommendations. I would tell you that VBA has begun to work to
establish, if you will, a more professional workforce overall.
There are some standardized tests in place as a result of the
training programs for our veteran services representatives. We
are also developing those studies and test instruments for the
knowledge base and ability to provide the benefits for both our
rating veteran service representatives, our decision review
officers.
We have strengthened the expertise in our Compensation and
Pension Program and are building a much more robust training
program and we will look to engage that certification program
for both our legal instruments examiners as well as our field
examiners who have real responsibility for our incompetent
veterans in the Fiduciary Program.
Mrs. Kirkpatrick. Well, thank you for your attention to
this. I think it should be a top priority. And I will look
forward to the report later on this year. Thank you.
Ms. Rubens. Terrific.
The Chairman. Thank you.
Dr. Petzel, thank you for your presence here.
You heard me ask a couple questions which are sort of off
the subject, but we referred to them again as in the formulary
determinations. And you were very confident about the process.
I am not sure about that process. I do not know who makes those
decisions.
I will give you a chance to say some more, but I want to
give you a heads up. We are going to ask the Secretary and
yourself to look at certain decisions that were made that seem
to neglect, one, the long-term cause versus the immediate cause
and, second, maybe more importantly, I will say quality of life
issues that are hard to quantify.
This diabetes situation I brought up, which was basically,
by the way, a factual situation, I may have the numbers or the
numbers were not exactly accurate, but to take a shot once
every 2 weeks instead of twice a day, how do you measure that?
And, yet, I mean, if it was up to me, I would go to the 2-week
one.
How is that considered in the formulary determinations and
effectiveness? I mean----
Dr. Petzel. Congressman, I would absolutely agree with you.
If that were I and I were diabetic, I would want the shot every
2 weeks as opposed to every 1 week or every day obviously.
I cannot tell you specifically the inner workings of the
Pharmacy Benefits Management Board, which is the group that
looks at these nationally and makes these decisions, but I
would welcome the inquiry.
The Chairman. I think I would like to bring some examples
to you and the Secretary to see how that decisionmaking is
considered good. Maybe there is a reason for it, but maybe not.
I just want to give you a heads up that we will be looking at
that.
Dr. Petzel. Thank you.
The Chairman. When I said innovations, just one sticks in
my mind where a Food and Drug Administration (FDA) approved
technology for TBI victims that would expand the field of
vision from a few percent to 50 percent and gives that patient
the chance to read. This would be an incredible increase in the
quality of life, right? And, again, FDA approved the technology
and the manufacturer could not get past the acquisitions staff
at VA. This is what we are dealing with that. That is just the
one example that sticks in my mind. But, I would multiply those
examples.
I think we are going to bring a bunch of these situations
to you and the Secretary. Technology changes so quickly, and it
can be hard to evaluate but when these smaller innovative
companies come to the VA with new processes, new techniques,
new technologies, they seem to be met with a bureaucratic lull.
We will be looking at the process.
Dr. Petzel. Well, we would be delighted to, in these
specific instances particularly, to respond to you about how we
have evaluated a particular drug or particular technology. I
think that would be an excellent dialogue to have.
The Chairman. By the way, on the formulary, you said it is
in pharmacy. You mentioned some department.
Dr. Petzel. Well.
The Chairman. Is that directly under the VHA?
Dr. Petzel. Yes, that is in the Veterans Health
Administration. We have a Pharmacy Benefits Management Board
that looks at the national formulary.
The Chairman. Is that sort of self-contained, or do you
know? You do not interfere in that or----
Dr. Petzel. Absolutely not.
The Chairman. See, that may be what's wrong. You want
independence but on the other hand, if they are the shopkeepers
and one costs $50 and the next one costs $1, we will take the
one that is less expensive.
Dr. Petzel. There is a process, Mr. Chairman, by which in
theory any practitioner can get any drug they want by making a
request to purchase something or have something dispensed off
formulary. There is a very clearly mapped out process by which
one goes through. You would be quite surprised, I think both of
you would be, at the number of off formulary drugs that we do
use.
The Chairman. Maybe the practitioner does not even know
about it though. Part of what the VA should be doing is looking
for this stuff and working to help.
I think this is the first time you have testified before
the full Committee.
Dr. Petzel. It is, sir.
The Chairman. I want to say I appreciate your testimony. I
appreciate the way you handled the questions. I appreciate your
expertise and your willingness to work with us.
Mr. Baker, you all were good witnesses as well and we
appreciate that. We usually do not say that to folks. We look
forward to working with you and we thank you for being here.
This hearing is adjourned.
Dr. Petzel. Thank you, Mr. Chairman.
[Whereupon, at 12:03 p.m., the Committee was adjourned.]
A P P E N D I X
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Prepared Statement of Hon. Bob Filner,
Chairman, Committee on Veterans' Affairs
The Department of Veterans Affairs Office of Inspector General
plays a critical role in ensuring proper and efficient oversight of the
Department's activities.
In the first half of fiscal year 2010, from October 2009 to March
2010, the OIG issued 120 reports, identified nearly $673 million in
monetary benefits, and conducted work that resulted in 232
administrative sanctions.
It is evident by these numbers that the high quality of OIG's work
is essential in rooting out fraud, waste and abuse within the VA.
Today, we will examine the progress that the Department of Veterans
Affairs is making in complying with the OIG's recommendations.
Currently, the Office of Inspector General has a total of 115 open
reports with almost 694 open recommendations that have yet to be
implemented by the VA.
The OIG's target date for implementation of these recommendations
is within a year of publication.
Although most of these open recommendations are on track to be
completed within the 1-year timeframe, 16 reports containing 45 open
recommendations are over 1 year old.
Additionally, recommendations on VA information security issues
tracked by an independent auditor show that there are almost 40 open
recommendations, 34 of which are carried over from prior years.
The timely implementation of these recommendations is crucial to
ensuring our Nation's veterans receive the best care. Many of these
recommendations play a critical role in ensuring patient safety and
safeguarding veterans' information.
Additionally, timely implementation not only reflects good
management, but it always reflects a responsible use of taxpayer money.
The monetary benefit yet to be realized by these recommendations going
unimplemented is almost $92 million.
During the country's difficult financial time brought on by the
recession, the VA must realize cost savings anywhere practical. This
can be done straightforwardly through the elimination of waste and by
acting to correct the issues identified in the OIG's recommendations in
a timely manner.
The Office of Management and Administration's Operations Division
is tasked with followup reporting and tracking of OIG report
recommendations while ensuring that all allegations made by the OIG are
effectively monitored and resolved in a timely, efficient and impartial
manner. I am pleased that they are here today with Deputy Inspector
General Griffin to share with the Committee their insights on this
issue.
The OIG's reports for followup procedures are an essential
component of the oversight process. Secretary Shinseki has said many
times before this Committee the importance of accountability and
ensuring veterans' care comes first.
The VA must be held accountable for implementing the OIG's
recommendations in a timely manner, and make certain our Nation's
veterans are receiving the quality of care that is reflective of their
service and sacrifice.
Prepared Statement of Hon. Jeff Miller,
a Representative in Congress from the State of Florida
Thank you, Mr. Chairman.
The existence, and independence, of the Office of Inspector General
is an incredibly important tool in not only helping VA identify
shortcomings but also to help us here on this Committee do our job more
effectively.
Maintaining the OIG's full capabilities is of importance to all of
us here, and that starts with the budget process. As that office
identifies areas of redundancy, poor performance, or potential cost-
savings, I see no reason to flatline or even cut its budget. As the
authorizing Committee, this is one step we can take every year toward
doing our part.
VA has acted on an overwhelming majority of IG recommendations, in
accordance with their standardized process. That much I am glad to see.
What I hope others on this Committee share with me is concern about
the lack of action on IG recommendations that have been open over a
year. The total number of recommendations as a percentage might be
comparatively small, but as an actual number are high.
These recommendations aren't simply ways for VA to cut costs or
eliminate waste, fraud, and abuse. They are potential ways to better
deliver services to veterans across all departments within VA. That
objective cannot--and must not--be overlooked.
I look forward to today's testimony about VA's implementation of
the OIG's recommendations, and, in cases where there has been no
implementation, to hearing the reasons why. VA, its Office of Inspector
General, and this Committee can make great progress together, and this
hearing is one step in making that progress.
I yield back.
Prepared Statement of Richard J. Griffin, Deputy Inspector General,
Office of Inspector General, U.S. Department of Veterans Affairs
Mr. Chairman and Members of the Committee, thank you for the
opportunity to discuss one of the Office of Inspector General's (OIG)
major responsibilities, which is to make recommendations to VA
management to improve programs and services provided to veterans.
Accompanying me today is Mr. Richard Ehrlichman, Assistant Inspector
General for Management and Administration.
On balance, VA does a good job of implementing OIG report
recommendations in a timely manner. The percentage of recommendations
implemented within 1 year has increased each year from fiscal year 2007
through 2009, reaching a level of 94 percent. VA performs relatively
well based on comparative data that other Federal OIGs periodically
reported to Congress. OIG will continue to invest resources and keep a
focus on timely and full implementation on recommendations for
improvement across VA programs and operations.
The OIG provides summaries on open recommendations in our
Semiannual Report to Congress. The most recent Semiannual Report to
Congress for the period October 1, 2009, through March 31, 2010, shows
107 open OIG reports with 640 open recommendations. Of the 107 open
reports, 11 reports with 23 recommendations and monetary impact of over
$92 million, were pending over 1 year. The oldest open report was
issued on September 30, 2005. In preparation for this hearing, we
reviewed our inventory and as of May 31, 2010, we are now tracking 124
open reports that contain 756 recommendations for implementation. Of
these 124 open reports, 16 are pending over 1 year and contain 45
unimplemented recommendations, with a monetary impact of just under $92
million.
OIG FOLLOWUP PROGRAM
Followup is an important component of OIG oversight work. The
Office of Management and Budget requires a process to follow up and
report on the status of OIG report recommendations. The OIG is also
required to report in its Semiannual Report to Congress on the status
of report recommendations. Moreover, after the Inspector General
testified before this Committee in February 2007, we began providing
quarterly updates to Congress and the VA Secretary on the status of
open report recommendations, with an added emphasis on those
recommendations pending over 1 year.
OIG staff take great care in developing recommendations for
improvement that are clear and specific; provide a yardstick to measure
improvement and gauge full implementation; and afford VA program
officials an opportunity to implement the improvements within 1 year.
Since 2007, we have worked closely with VA officials to develop
recommendations for corrective action that can be realistically
implemented within a year. As such, OIG no longer accepts VA
implementation plans that take more than a year to complete, except
under the rarest of circumstances and only when measurable timelines
are provided. In some instances, based on OIG staff evaluation, VA
program offices take corrective action while we are onsite or in the
period between issuing a draft report and when the final report is
published. When this happens, we close out the recommendation as fully
implemented and reflect the action in our final report.
However, a majority of the reports we issue contain open
recommendations for improvement. Once a final report is issued, OIG
followup staff in the Office of Management and Administration begin a
process of tracking them until fully implemented. Independent public
accounting firms collaborate with the OIG to track recommendations
contained in the Federal Information Security Management Act of 2002
audit and the Audit of VA Consolidated Financial Statement.
For each report, we separately list recommendations for improvement
and any related monetary impact we expect VA to derive from
implementation. The staff begin a tracking process, with controls in
place to focus on full implementation within our 1-year goal. The first
OIG followup request is sent to the responsible VA program office 90
days after the report is published.
In each followup status request we seek a description of what
actions have occurred toward implementing the recommendations during
the preceding 90 days. We set a 30-day deadline for VA officials to
respond in writing. The response must contain documentary evidence such
as issued policies, certifications, or other material supporting any
request to close recommendations. Our intermediate goal is to obtain
evidence that VA is making progress in implementing recommendations. If
we do not receive a timely reply, or if we determine VA's efforts
appear to be falling behind schedule, we schedule a face-to-face
meeting to discuss how to get implementation back on track.
OIG followup staff coordinate with OIG line officials who worked on
the report. To ensure VA's implementation plans remain on track, they
discuss the documentary evidence VA submits with the status reports. If
a report recommendation remains unimplemented, OIG staff repeat this
followup cycle every 90 days. Once a report passes the 6-month mark and
we determine implementation is unlikely within the 1-year goal, we
increase the frequency of discussions with OIG line staff and VA
program officials, and ensure the appropriate senior management
officials in the OIG and VA recognize the probability of missing the 1-
year target for implementation.
In Appendix B of our Semiannual Report to Congress, we present
tables on open reports and recommendations. In the first table, we
provide a matrix with totals for both open reports and the associated
unimplemented recommendations. The table further breaks the data into
those open less than or more than 1 year, and provides the same data by
VA Administration or Staff Office. The second table shows only those
reports and recommendations that are unimplemented for more than 1
year. In this table, we show the report title, date of issue,
responsible VA organization, monetary impact, full text of each
recommendation, and an indication of how many recommendations on each
report are still open.
OIG FOLLOWUP OVERSIGHT REVIEWS
The OIG also conducts followup reviews of our audit and inspection
work. For example, our Office of Healthcare Inspections conducts
Combined Assessment Program (CAP) reviews of VA medical centers. These
cyclical reviews evaluate how well VA medical centers are accomplishing
their mission of providing high quality medical services to veterans.
When health care inspectors return to a VA medical facility on a
subsequent CAP, they review VA's implementation plans from the earlier
CAP in order to validate implementation, evaluate the effectiveness of
the recommended changes in fixing problems, or in some cases to
identify repeat deficiencies.
We also perform followup reviews on our national projects. For
example, in May 2008, the OIG issued Follow-Up Healthcare Inspection--
VA's Role in Ensuring Services for Operation Enduring Freedom/Operation
Iraqi Freedom Veterans after Traumatic Brain Injury Rehabilitation.
This followed up on a July 2006 report, Healthcare Inspection--Health
Status of and Services for Operation Enduring Freedom/Operation Iraqi
Freedom Veterans after Traumatic Brain Injury Rehabilitation, which
described the health status of and services provided for a group of
servicemembers and veterans who had received inpatient rehabilitative
care in VA facilities for traumatic brain injury (TBI).
Three years after completion of initial inpatient rehabilitation
for TBI, many of these patients continue to have significant
disabilities. Veterans Health Administration (VHA) and Veterans
Benefits Administration (VBA) support for TBI patients is extensive.
While case management has improved, long-term case management is not
uniformly provided for these patients, and significant needs remain
unmet. OIG will continue to monitor VHA's progress toward achieving
consistent delivery of case management services for this select group
of injured veterans.
In another pair of reviews, Healthcare Inspection--Use and
Reprocessing of Flexible Fiberoptic Endoscopes at VA Medical Facilities
(June 2009) and Healthcare Inspection Follow-Up--Colonoscope
Reprocessing at VA Medical Facilities (September 2009), we reported on
reusable medical equipment reprocessing (RME) issues. The first report
determined that facilities had not complied with management directives
to ensure compliance with reprocessing of endoscopes, resulting in a
risk of infectious disease to veterans. The failure of medical
facilities to comply on such a large scale with repeated alerts and
directives suggests fundamental defects in organizational structure. A
followup inspection 2 months later provided results for all facilities
not previously inspected and for facilities previously found to be
noncompliant with VHA's directive on RME reprocessing. Among the 129
facilities inspected in August 2009 during our followup review, all 129
were compliant with respect to posting model specific standard
operating procedures, and all facilities had adequate documentation of
demonstrated competence for reprocessing staff except for one facility.
However, we continue to be concerned about this issue and we are
reviewing and reporting on RME processing as part of our CAP reviews.
In March 2010, we issued Audit of the Fiduciary Program's
Effectiveness in Addressing Potential Misuse of Beneficiary Funds,
which found similar to those in our June 2006 report, Audit of VBA
Fiduciary Program Operations. In fact, we found that VBA had failed to
take and complete promised actions in response to three recommendations
made in our 2006 report. For example, in 2006 we recommended that VBA
determine appropriate Fiduciary Program staff caseload levels and
staffing requirements. In response to this recommendation, the then-
Under Secretary for Benefits stated that VBA would conduct a work
measurement study and convene a work group to closely examine Fiduciary
Program staffing at VA regional offices (VARO) and to make
recommendations regarding case workloads. During our 2010 audit, we
found that VBA did not implement the actions they had previously agreed
to take, including not issuing a staffing and workload model. Fiduciary
Program staffing has been left to the judgment of individual VAROs. As
a result, we found that a wide variation exists in the number of
beneficiaries managed by individual Legal Instrument Examiner, ranging
from 188 to 1,576 beneficiaries.
In April 2009 we issued Follow-Up Audit of Veterans Health
Administration Major Construction Contract Award and Administration
Process to determine whether VA implemented corrective action plans in
response to the recommendations we made in the February 2005 Audit of
Veterans Health Administration Major Construction Contract Award and
Administration Process. This report contained 12 recommendations to
strengthen VHA's contract award, administration, and project
management. The then-Under Secretary for Health concurred with the 2005
report recommendations and provided corrective action plans. Nine of
the 12 recommendations involved the establishment of a Quality
Assurance Program. VHA had established a Quality Assurance (QA)
Service, but this service lacked written policies, procedures, and
performance measures. Further, the QA Service lacked a staffing plan to
ensure it met all of its major quality control responsibilities. We
also found that VHA did not fully implement the 2005 report
recommendation to implement more effective project management oversight
to manage and reduce construction schedule slippage from a national
perspective or the recommendation to establish an effective program to
ensure the timely close-out of major construction contracts. VHA
officials have taken actions to address our most recent
recommendations; however, the corrective actions should have been put
in place 5 years earlier.
VA'S PROGRESS IN IMPLEMENTING OIG RECOMMENDATIONS
In the area of OIG's benefits inspections of VBA's regional
offices, VBA officials have taken timely action to correct monthly
benefits paid to veterans that we identify during our inspections as
inaccurate. We provide a daily list of identified claims processing
errors during our site visits. VBA's efforts to establish a process to
track and quickly fix these errors is a positive step toward ensuring
veterans receive accurate benefits. We have had similar results
correcting problems on the spot at VA medical facilities during our CAP
reviews and Community Based Outpatient Clinic inspections.
In July 2009, we issued an Oversight Review of Specialty Service
Issues at the VA Montana Health Care System, Fort Harrison, Montana.
This was a review of actions taken by VHA to address allegations that a
physician was providing substandard care and engaging in improper
medical record documentation practices. In the course of performing
this review, we had numerous concerns on the overall operation of a
particular clinical service. As a result of the followup process, over
5,000 veterans had their care in this specialty area reviewed and,
where necessary, some were contacted for further care. In addition, we
found that the waiting times for one procedure were excessive; this has
now been corrected.
In January 2008, we issued a report, Healthcare Inspection--Quality
of Care Issues, VA Medical Center, Marion, Illinois, that concluded
that the Surgical Specialty Care Line at Marion was in disarray, the
oversight reporting structure for Quality Management (QM) reviews was
fragmented and inconsistent, and there were significant deficiencies in
the privileging of physicians, which is the process by which physicians
are granted permissions by a medical center to perform specific
diagnostic and therapeutic procedures. Although some of the
recommendations dealt with specific issues that needed correction at
Marion, there were also systemic recommendations for VHA, such as the
need to standardize the collection and reporting of QM data throughout
VHA and to ensure that VHA's diagnostic and therapeutic interventions
are appropriate to the capabilities of the medical facility.
We used our cyclical CAP process to return to Marion in August
2009, and in a CAP report published in November 2009, we reported that
of 13 QM areas reviewed, we found deficiencies in 10. Several QM-
specific corrective actions initiated in response to the January 2008
report had not been fully implemented and did not consistently correct
the conditions identified.
Since that time, VHA has worked in earnest to review and rewrite
VHA guidance on Peer Review, Credentialing and Privileging, and Quality
Management. In addition, in May 2010, VHA released their Surgical
Complexity Initiative: Aligning VA Medical Center Infrastructure with
the Performance of Inpatient Surgery directive. This model matches the
capabilities of all aspects of a medical facility with the complexity
of permitted procedures. This is a major step to ensure that VHA's
diagnostic and therapeutic interventions are appropriate to the
capabilities of the medical facility, thus ensuring that veterans
receive surgical care in the appropriate setting.
OPPORTUNITIES FOR IMPROVEMENT
Opportunities exist for VA to improve on its performance. As of
March 31, 2010, we had two reports with open recommendations that
represented over $81 million in monetary impact. One report from
September 2007, Audit of the Acquisition and Management of Selected
Surgical Device Implants, with over $21 million in monetary impact,
involved an open recommendation to improve the acquisition and
management of selected surgical device implants (stents, aortic valves,
and thoracic grafts). The other report from September 2008, Audit of
Veterans Health Administration Noncompetitive Clinical Sharing
Agreements, with over $59 million in monetary impact, has multiple
unimplemented recommendations related to noncompetitive clinical
sharing agreements.
Although we have not reached the 1-year mark on two significant
administrative investigations issued in August 2009, Administrative
Investigation--Misuse of Position, Abuse of Authority, and Prohibited
Personnel Practices, Office of Information & Technology, Washington,
DC, and Administrative Investigation--Nepotism, Abuse of Authority,
Misuse of Position, Improper Hiring, and Improperly Administered
Awards, OI&T, Washington, DC, we have concerns about the progress being
made and commitment to implementation of OIG recommendations agreed to
by VA program officials. Almost 10 months after we issued the final
reports, only 3 of 45 recommendations are fully implemented.
CONCLUSION
Lengthy delays implementing OIG recommendations not only cost VA
money in unrealized savings but prevent veterans from benefiting from
improvements in VA programs and services. We will continue to highlight
those recommendations in need of attention in our reports to the VA
Secretary, Congress, and in our regular meetings with senior VHA, VBA,
and other VA officials.
Mr. Chairman, this concludes my statement. We would be happy to
answer any questions you or other Members of the Committee may have.
Prepared Statement of Hon. Robert A. Petzel, M.D.,
Under Secretary for Health, Veterans Health Administration,
U.S. Department of Veterans Affairs
Good morning, Chairman Filner, Ranking Member Buyer, and Committee
Members. Thank you for the opportunity to appear before you today to
discuss the Department of Veterans Affairs' (VA) work in responding to
recommendations from the VA Office of the Inspector General (VAOIG).
Joining me today are Roger Baker, Assistant Secretary for Information
and Technology, and Diana Rubens, Associate Deputy Under Secretary for
Field Operations for the Veterans Benefits Administration (VBA).
The scope of VA's missions extends far beyond the provision of
health care to include providing educational benefits so veterans can
receive the knowledge and skills to continue serving the needs of a
21st century America; processing compensation and pension claims in our
regional claims processing offices; and showing the utmost respect for
veterans and their families at the end of life in our national
cemeteries. For example, VA:
Provides educational benefits of $9 billion annually,
second only to the amount provided by the Department of Education.
Guarantees nearly 1.3 million individual home loans with
an unpaid balance of $175 billion. VA foreclosure rate is among the
lowest in all categories of mortgage loans.
Insures veterans' lives as the Nation's eighth largest
life insurance enterprise with $1.3 trillion in coverage, 7.2 million
clients, and a 96 percent customer satisfaction rating.
To accomplish its diverse mission, VA employs more than 300,000
people--the second largest department in the Federal Government. The
standard for each employee who works at one of our facilities is to be
fully aware of and committed to our mission to serve veterans. I trust
that every employee, up to and including our leadership, strives to
meet that mission daily with the utmost professionalism and integrity.
However, improvement is also a goal. With that in mind, VA
recognizes the VAOIG's valuable work as our partner in ensuring
accuracy, integrity, and accountability in the delivery of benefits and
services to our Nation's veterans. VA is committed to doing everything
possible to ensure that it is delivering the best possible service to
our veterans, and we also recognize the value of working with VAOIG in
our current ``check and balance'' system to ensure that we are being as
effective and efficient as possible. Additionally, VAOIG's work helps
VA to identify areas of waste, fraud, and abuse, as well as to remove
persons whose conduct is truly criminal. This not only improves our
operations as a Department in providing services to our veterans, but
it saves the American taxpayer millions of dollars every year.
The scope of the VAOIG's work is immense and far-reaching, as its
investigations can be specific to facilities, or result in broad
reviews of VA programs. Its reports have resulted in hundreds of
recommendations for the Department, ranging from administrative actions
against specific personnel to large-scale policy reviews. Additionally,
the Department and VAOIG maintain a strong relationship in identifying,
investigating, and bringing to justice those who use their positions to
defraud or harm our veterans.
In order to provide timely and appropriate responses to VAOIG's
recommendations, the administrations and staff offices involved with
each report work directly with VAOIG to ensure that action plans are
developed and implemented to result in positive change.
Veterans Health Administration
VAOIG conducts several different types of reviews of Veterans
Health Administration (VHA) facilities and programs. VAOIG reviews:
National programs through audits, broadly focused
Healthcare Inspections, and other nationally focused reviews.
Single VA medical centers or community-based outpatient
clinics (CBOC) through Combined Assessment Program (CAP) reviews and
individual CBOC reviews.
Roll-ups of CAP reviews can summarize a number of
findings from several facilities and include recommendations with a
broader scope than a single CAP review.
Healthcare Inspections can result from a nationwide or
broad review initiated by VAOIG, an individual CAP review, or a finding
after a review of an allegation made by a call to the VAOIG hotline.
These Healthcare Inspections can be specific to a facility or involve a
broader scope.
VHA has a standardized process to identify and respond to VAOIG
recommendations from each type of review. Initially, once the VAOIG has
issued a final report including recommendations and VA responses, VHA
staff use its database (VHA Electronic GAO and VAOIG Recommendation
Status System--EGORS) to track progress of closing recommendations.
When VHA program offices submit reports about completing tasks that are
part of an action plan, VHA records and reports that to VAOIG. Also,
VAOIG requests a status update on the progress in closing a report's
recommendations 90 and 180 days after the issuance of the final report.
At these 90-day intervals, VHA communicates with program offices on the
progress of the action plans previously submitted and documents the
completion of any items, regularly reporting to VAOIG about the status
of closing recommendations. This process is repeated until VAOIG closes
all pending recommendations. If progress in implementing changes is
delayed, VHA leadership meets with the responsible office to expedite
action and close the assignment. For recommendations that are open more
than 6 months, the VHA Chief of Staff meets directly with the program
office to review the status of closing a recommendation and does so
monthly until the action has been completed.
For the more narrowly focused CAP reviews, VAOIG requests a status
update from VHA 90 days after the issuance of the final VAOIG CAP
report. This request is sent directly to the Veterans Integrated
Service Network (VISN), the VA medical center, and VHA leadership in
Central Office. The facility provides an update of its progress in
completing the action plan included with the final CAP report directly
to VAOIG and informs VHA leadership at the same time. VHA leadership
tracks the facility's progress in implementing the action plan and
communicates with the facility directly when there are delays or
questions. This process is repeated until VAOIG closes all
recommendations from a CAP. This same process applies to Healthcare
Inspections that result from a CAP or a finding resulting from a review
of an allegation made to the VAOIG hotline.
VHA leadership, including the Chief of Staff, the Office of the
Deputy Under Secretary for Health for Operations and Management, the
Office of the Principal Deputy Under Secretary for Health, and the
Director of the Management Review Service, meet on a monthly basis with
VAOIG leadership and staff to discuss ongoing and future reviews and
how to continue improving communications. Less formal discussions
between VHA and VAOIG are more frequent.
Veterans Benefits Administration
VBA takes very seriously VAOIG reports' findings and
recommendations, and it works diligently to implement recommendations
made in those reports to further strengthen benefit programs.
VBA works closely with VAOIG, Office of Audits and Evaluations and
the Office of Management and Administration, to provide timely and
accurate status updates on all open recommendations. VBA provides
status updates to VAOIG every 90 days to describe the actions taken or
in progress to fully address recommendations until they are
satisfactorily closed by VAOIG. VBA tracks and maintains current
information on the status and target completion dates for all open
recommendations, and works proactively with VAOIG to reconcile data and
address outstanding questions.
The VAOIG Benefits Inspection Division (BID) implemented
independent inspections beginning in fiscal year 2009 to provide
recurring oversight of VA regional offices by focusing on disability
compensation claims processing and performance of Veterans Service
Center operations. The BID's audits of regional offices include reviews
of local claims processing, data integrity, management controls,
information security, and public contact. These inspections incorporate
claim file reviews, employee interviews, and management feedback. VBA
leadership reviews and responds to the recommendations provided by the
BID, ensuring errors are corrected and recommendations are implemented
in a timely manner. The issuance of the audit report follows 60 days
after the BID team conducts a site visit and all initial and followup
responses to inspection recommendations are reviewed and concurred upon
by the regional office, area office, and Office of Field Operations.
Once these steps are completed, the BID determines the recommendation
is implemented and the report can be closed. VBA currently has nine
open BID reports of specific VBA regional offices.
While VAOIG's audit work in VBA is primarily focused on the
compensation and pension program, VAOIG is also currently reviewing the
implementation of the Post-9/11 GI Bill.
Office of Information and Technology
Upon receipt of VAOIG's status request, a notification is sent by
the Project Coordination Service to the appropriate points of contact
in the Office of Information and Technology (OI&T) staff office
responsible for implementing the open VAOIG recommendation. The Project
Coordination Service conducts followup reporting and tracking of VAOIG
report recommendations to ensure implementation.
IT staff offices are directed to address each open recommendation
individually, stating the progress made over the preceding 90 days and
providing supporting documentation, if applicable. Their response also
indicates whether OI&T recommends closing any recommendations. OI&T
staff offices then prepare a soft and hard copy submission, to include
background information on the IG report/recommendation, a signed
briefing note, a memorandum for Senior Level Executive (SES)-level
signature, and an attachment containing status updates.
All status updates are submitted to the Project Coordination
Service for review no later than five business days before the VAOIG
due date. Once the Assistant Secretary for OI&T signs the memorandum,
the response is sent to the VAOIG Operations Division, Office of
Management and Administration.
Recommendations Open for Over One Year
The ``Federal Acquisition Streamlining Act 1994,'' P.L. 103-355,
requires VA to complete final action on each VAOIG report
recommendation within 1 year after the report is finalized. Although VA
strives to meet this target, and does so for the overwhelming majority
of reports issued, OIG has identified recommendations that have been
open for over 1 year.
VHA Recommendations Open for Over One Year
VHA has eight VAOIG reports with 19 recommendations that have been
open more than 1 year.
First, the ``Audit of VA Acquisition Practices for the National
Vietnam Veterans Longitudinal Study (NVVLS)'' has one of three
recommendations still open. This recommendation involves initiating
formal acquisition and planning and proper contracting processes to
expeditiously and successfully complete the NVVLS and ensure that
assigned project management and contracting staff have the required
knowledge and skills to effectively plan, procure, administer and
manage the NVVLS in accordance with pertinent legal, procedural and
technical requirements. We acknowledge that deciding how to proceed
with the NVVLS has been a long process. Since VA decided to re-initiate
its work on NVVLS in late 2009, significant progress has been made, and
I am pleased to report that VA released a request for proposals (RFP)
on May 25, 2010, and expects an award will be made later this year.
Details about the timeline are available in the testimony provided
before this Committee on May 5, 2010. VAOIG has indicated it will close
the recommendation when the contract award is made.
Second, the ``Review of Access to Care in the Veterans Health
Administration'' report, issued in 2006, has two of nine
recommendations that remain open. These involve standardizing tracking
methods and appropriate performance metrics to evaluate and improve the
timeliness of elective procedures as well as implementing
prioritization processes to ensure that veterans receive clinically
indicated elective procedures according to their clinical needs.
Through VHA's Surgical Quality Improvement Program (SQIP), VA is
developing long-term information technology (IT) solutions, and in the
interim has standardized appropriate tracking methods to improve the
evaluation and timeliness of elective procedures. VHA has been advised
that the IT solution will be implemented in early 2012. Also, VHA
recently issued Directive 2010-018, ``Facility Infrastructure
Requirements to Perform Standard, Intermediate or Complex Surgical
Procedures'' in May 2010, requiring each facility to establish a
transfer policy based on clinical need. VHA is currently working with
VAOIG to close these recommendations based on these recent and ongoing
actions.
Third, the ``Review of the Acquisition and Management of Selected
Surgical Device Implants'' report from 2007 has one recommendation
still open. This recommendation directed VHA to evaluate aortic valve,
coronary stent, and thoracic graft procedures to study the feasibility
of establishing national contracts and blanket purchase agreements
(BPA) and, where indicated, initiate national contracts and BPAs.
When OIG issued the recommendation, VHA had been actively seeking
national contracts for coronary stents for 2 years; however, few
existing manufacturers indicated a willingness to participate. VHA has
continued to evaluate the procurement history for these products to
identify possible targets for standardization.
This spring, a Request for Information (RFI) related to coronary
stents was again sent to industry, and VHA expects to respond to the
vendor's questions mid-June as well as develop and distribute an RFP by
the end of summer 2010. VHA acknowledges that based on the current
surveys, the price of drug-eluting stents, on average, are likely to
decrease by $300-$400 per stent, resulting in significant cost
reduction for VA if the RFP process is successful.
In regard to aortic valves and thoracic grafts, VHA recently
completed comprehensive reviews of the procurement history for these
devices to determine if the use of national contracts or BPAs were
feasible. The completion of these reviews has been time consuming to
ensure that the analysis was complete and comprehensive.
For aortic valves, the procurement history does not support use of
a national contract or BPA because of issues involving the complexity
of the clinical decisions resulting in vendor choice, the variety and
availability requirements of implant types (mechanical, bioprosthetic,
etc.) in relationship to the complexity of the disease being treated,
the relatively low number of devices implanted by VHA, and the
established safety of the devices currently utilized.
Neither does the review of the procurement history related to
thoracic grafts indicate that use of a national contract or BPA is
recommended. This is based on the overall low number of thoracic aortic
grafts being implanted by VHA, the complexity of the disease process
requiring a choice of available and emerging vendor products, and the
established safety of the devices currently utilized.
This information is currently being shared with VAOIG to determine
if it is sufficient to close the recommendation.
Fourth, the ``Audit of Veterans Health Administration's Oversight
of Nonprofit Research and Education Corporations'' report from 2008 has
four of five recommendations still open related to establishing
oversight authority parameters for Non-Profit Corporations (NPC);
defining minimum control requirements for NPCs and subsequently
training NPC Directors about these requirements; implementing oversight
procedures to perform substantive reviews of NPC financial and
management controls to ensure NPCs fully comply with Federal laws, VHA
policies, and control standards; and developing and implementing
procedures to review, monitor and enforce NPC compliance with conflict
of interest laws and policies.
To address these concerns, the Under Secretary for Health (USH)
chartered the Nonprofit Corporation Oversight Steering Committee
(Steering Committee) in 2008 to develop a plan to assess existing NPC
financial and management controls and use that information to develop
and implement future processes. The reviews were completed in December
2009, and a white paper has been subsequently issued. Also, legislation
that would significantly change the operations of NPCs has been pending
since early 2009. Congress passed legislation in April 2010, and Public
Law 111-163 was enacted in May 2010. On May 7, 2010, in response to the
new law, the VA Nonprofit Oversight Board decided to delay issuance of
any pending changes to NPC practices so that the elements from Public
Law 111-163 could be included. The USH has directed that issuance of a
handbook to implement this legislation and respond to the VAOIG
concerns will be completed no later than December 7, 2010. Also, the
VHA Nonprofit Program Office is using the results of the reviews
completed in December 2009 to guide its continuing review of NPC
operations.
Fifth, an ``Audit of Veterans Health Administration's Government
Purchase Card Practices'' issued in 2008 has one of four
recommendations still open. Recommendation 2 directed VHA to provide
approving officials refresher training on using the revised Approving
Official Checklist to ensure cardholders maintain adequate
documentation to support their purchases. On February 18, 2010, the
Deputy Under Secretary for Health for Operations and Management
(DUSHOM) mandated that all purchase card approving officials receive
this refresher training. Each VISN Purchase Card Manager was to submit
written certification when the training was complete. VHA has received
documentation that the training is complete, and it anticipates that
OIG will close this recommendation.
Sixth, the ``Audit of Veterans Health Administration Noncompetitive
Clinical Sharing Agreements'' issued in 2008 still has all seven
recommendations open. An action plan to close these recommendations was
developed in September 2008; however, that action plan had to be
amended in December 2009 to add a mandatory training component to
ensure consistent implementation of new policies and procedures. The
curriculum for this training has been developed and submitted to the VA
Office of Acquisition, Logistics, and Construction's (OAL&C)
Acquisition Academy. The Academy is currently working to contract the
completion of the provided material into curriculum for instruction.
The course is scheduled to be available in 2nd Quarter FY 2011.
In regard to Recommendation 5 that directed VHA to instruct the
VISN contracting officers to initiate recovery of overpayments
identified by the VAOIG audit, as appropriate, VHA has instructed its
VISN contracting officers how to initiate recovery of overpayments
identified by this audit, and VHA is compiling documentation of this
process. To date, all VISNs have completed their audits, and VA
continues to work to resolve questions about the overpayments.
Seventh, the ``Audit of Procurements Using Prior-Year Funds for VA
Health Care Facilities'' issued in 2008 has two of seven
recommendations still open. Recommendation 5 directed VHA to initiate
appropriate administrative action against contracting officers who
entered inaccurate contract award dates in the electronic procurement
accounting system and later signed the contracts after they should have
known the funds had expired. Recommendation 7 directed VHA and the
Assistant Secretary for Management to develop plans to implement
controls over obligation of expired funds in other VHA programs,
projects, or activities. VHA has sent documentation to VAOIG showing
administrative actions taken in nine VISNs in response to
Recommendation 5; VHA believes this may be sufficient to close the
recommendation. Concerning the other item, VHA is working with VAOIG to
determine if data extracted from VHA's sources other than nonrecurring
maintenance obligation during FY 2009 for FYs 2004 through 2008 is
acceptable to close the recommendation.
The final report, ``Combined Assessment Program Review of the VA
Central Iowa Health Care System, Des Moines, Iowa'' issued in 2009 has
1 of 13 recommendations still open. Recommendation 4 directed VHA to
ensure that the System Director requires the identified safety,
infection control and patient privacy deficiencies be corrected. VHA
continues to communicate with VAOIG about whether the documentation
submitted earlier this year is sufficient to close the recommendation.
The VISN has taken other actions to ensure the high quality of
current safety, infection control, and patient privacy practices. For
example, the VISN 23 Readiness/Annual Work Evaluation (AWE) Team
surveyed the organization March 8-12, 2010. A primary purpose of the
Readiness/AWE Team visit was to ensure that there was follow up and
closure regarding previous findings by VAOIG, the Joint Commission, and
others. Items cited in Recommendation 4 were reviewed by the team and
considered compliant.
Also the Joint Commission surveyed VA Central Iowa Health Care
System April 27 to April 30, 2010. No previous OIG recommendations were
identified in the Joint Commission survey as noncompliant at the time
of the survey.
We are working with VAOIG to verify that the VISN has implemented
the system changes necessary to attain compliance, and that these
changes are being sustained. The VISN currently reports ongoing
compliance above the 90 percent level.
VBA Recommendations Open for Over One Year
VBA has one VAOIG report with two recommendations that have been
open more than 1 year.
The VAOIG Audit of ``Veterans Benefits Administration Transition
Assistance for Operations Enduring and Iraqi Freedom Servicemembers and
Veterans'' was issued on July 17, 2008. Two of the eight report
recommendations remain open and VA action is ongoing.
Recommendation 6 directed the Acting Under Secretary for Benefits
to develop a mechanism to obtain the DD-214 information needed to
identify discharged veterans who should receive outreach letters. The
goal is to use separation data from the VA/DoD Identity Repository
(VADIR) to systemically issue outreach packages to separating
Servicemembers, replacing the current manual process that utilizes the
Veterans Assistance at Discharge System. VBA is working with VA's
Office of Information and Technology and the Department of Defense to
address unresolved technical and data quality issues. VA anticipates
resolving these technical and data quality matters by September 2010.
Recommendation 8 directed the Acting Under Secretary for Benefits
to establish policies and procedures that require staff to provide
special outreach to veterans who do not have a high school diploma or
equivalent. Full implementation of this recommendation is dependent on
the receipt of complete and accurate information from DoD's Defense
Manpower Data Center (DMDC) through VADIR. VBA continues to work with
the DMDC to resolve discrepancies in the data necessary to implement
this outreach effort. VBA is also writing the procedures for field
offices, which will allow for full implementation once the data issues
are resolved and construction is completed for an electronic mechanism
to assign and track field outreach activities for this target
population.
OI&T Recommendations Open for Over One Year
OI&T has one VAOIG report with one recommendation that has been
open more than 1 year. The report, ``Review of Issues Related to the
Loss of VA Information Involving the Identify of Millions of
Veterans,'' was issued on July 7, 2006. Recommendation 1d directed the
Secretary to ensure all position descriptions (PD) are evaluated and
have proper sensitivity level designations, that there be consistency
nationwide for positions that are similar in nature or have similar
access to VA protected information and automated systems, and that all
required background checks are completed in a timely manner.
As a result of the recommendation, the Department has worked
diligently to implement use of the U.S. Office of Personnel Management
(OPM)-developed Position Designation System and Automated Tool (PDAT).
The PDAT assists VA human resources specialists, managers, and security
specialists to designate position risk levels for PDs. The PDAT has
been in use since March 2009. Many VA organizations have used the PDAT
to review current PDs and the PDAT is used for new PDs. Although the
PDAT and the resultant new business processes meets the intent of
recommendation 1d, the recommendation remains open pending issuance of
VA Directive 0710, ``Personnel Security and Suitability Program.'' The
VA Office of Operations, Security, and Preparedness (OSP) was tasked
with authoring the Directive, which has been approved by the Assistant
Secretary for Operations, Security, and Preparedness. The Directive was
signed on June 4, 2010.
VA will communicate the new Directive to the field in order for the
field to understand the changes from the previous edition, as well as
the mandated use of the PDAT. The 0710 Handbook is under development,
and an inter-agency workgroup will be established to assist with the
Handbook.
OSP Recommendations Open for Over One Year
VAOIG's Semiannual Report to Congress, October 1, 2009-March 31,
2009, lists one VAOIG report with one recommendation more than 1 year
old for VA's Office of Operations, Security and Preparedness.
The report, ``Audit of the Veterans Health Administration's
Domiciliary Safety, Security and Privacy,'' issued on October 4, 2008,
directed the Assistant Secretary for OSP to strengthen controls to
ensure physical security surveys are conducted at domiciliaries with
controlled substances. On May 28, 2010, OSP provided information on its
directive to VAOIG, following the publication of Appendix B, ``Physical
Security Requirements and Options, VA Directive and Handbook 0730.02.''
We are awaiting VAOIG's response, although we anticipate that this
recommendation and report will be closed.
Conclusion
As a Department, we strive to meet our mission to care and serve
our veterans to the greatest possible measures of success and
professionalism. However, we value the partnership with VAOIG's work to
identify and work with us to ensure that we appropriately and quickly
improve. In so doing, we are able to provide the kind of service to our
veterans that they deserve and have earned. Thank you again for the
opportunity to appear. We are prepared to answer any questions you may
have.
POST-HEARING QUESTIONS AND RESPONSES FOR THE RECORD
Committee on Veterans' Affairs
Washington, DC.
June 10, 2010
The Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Mr. Secretary:
In reference to our full Committee hearing entitled ``U.S.
Department of Veterans Affairs Office of Inspector General's Open
Recommendations: Are We Fixing the Problems?'' on June 9, 2010, I would
appreciate it if you could answer the enclosed hearing questions by the
close of business on July 23, 2010.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full
Committee and Subcommittee hearings. Therefore, it would be appreciated
if you could provide your answers consecutively and single-spaced. In
addition, please restate the question in its entirety before the
answer.
Due to the delay in receiving mail, please provide your response to
Debbie Smith by fax at 202-225-2034. If you have any questions, please
call 202-225-9756.
Sincerely,
BOB FILNER
Chairman
MH:ds
__________
Questions for the Record
The Honorable Bob Filner, Chairman
House Committee on Veterans Affairs
U.S. Department of Veterans Affairs Office of Inspector General's
Open Recommendations: Are We Fixing the Problems?
June 9, 2010
Question 1: The Inspector General's Benefits Inspection program
identifies approximately 40 (28 percent) out of 145 errors identified
by the Veterans Benefits Administration's internal quality assurance
program (Sustained Treatment and Rehabilitation Program--STAR) that
were not covered by regional office staff. What is your plan to ensure
these offices follow the national quality assurance program?
Response: The Compensation & Pension (C&P) Service conducts monthly
Systematic Technical Accuracy Reviews (STAR) and other quality reviews
to assess national accuracy and consistency of claims processing. When
errors are identified regional offices must take corrective action or
request reconsideration of the error. If C&P Service withdraws the
error, no further action is required.
Regional offices are required to report the corrective actions
taken on errors identified through national STAR review during that
quarter or indicate that a request for reconsideration has been
submitted. Regional office management is required to ensure that all
STAR errors and problem quality areas are reviewed and addressed in the
regional office's periodic Systematic Analysis of Operations covering
the quality of rating, authorization, and fiduciary actions.
Additionally, the C&P Program Operations Staff conduct oversight
compliance visits of regional offices at least every three years.
During the regional office site visit, claims with STAR errors are
reviewed and the reported corrective actions validated. Any
discrepancies are reported and appropriate followups are conducted with
the regional office to validate improvement in deficient areas.
Remediation plans are required from stations for all cited action
items.
Thus far, in fiscal year 10, 11 percent of STAR error calls have
been identified as pending corrective action. Some of the discrepancy
in our internal validation reports and the numbers reported by the OIG
can be easily explained. VBA's site visit team only identifies errors
when corrective action has not been taken. The OIG identifies errors
not only for failure to take corrective action, but also for such
procedural discrepancies as leaving the STAR checklist in the claims
folder.
VA is strengthening the STAR process. C&P Service will provide the
Associate Deputy Under Secretary for Field Operations, through the
Associate Deputy Under Secretary for Policy and Program Management with
a quarterly report of uncorrected error calls for which reconsideration
has not been requested. The report will identify those error calls that
are uncorrected for more than 60 days.
Question 2: What are the primary reasons for the delays in
implementing the recommendation for the Office of Inspector General's
Audit of Veterans Health Administration Noncompetitive Clinical Sharing
Agreements?
Response: The primary reason for the delay in implementing the
recommendation for the Office of Inspector General's Audit of Veterans
Health Administration Noncompetitive Clinical Sharing Agreement was the
underestimation of the time required to draft a clinic sharing
curriculum and develop the curriculum into a formal training class.
As the formal training class will not be available for attendance
until the second quarter of fiscal year 2011, VHA's Chief Procurement
and Logistics Office is taking interim measures to correct the
weaknesses identified in the report. The measures include establishing
standardized written procedures for monitoring and ensuring proper
payment of noncompetitive clinical sharing contracts and the creation
of a mandated interim training initiative for all contracting officers
and contracting officer technical representatives. The training will be
completed by August 31, 2010.
Question 3: The OIG talked about the two reports on reusable
medical equipment and indicated that at the August 2009 followup
review, 129 facilities were compliant with respect to SOPs and 128 had
appropriate documentation of demonstrated competence. Yet in March
2010, the IG issued a report (Healthcare Inspection Patient Safety
Issues VA Caribbean Healthcare System San Juan, Puerto, Rico Report
Number 09-03055-103, 3/16/2010) about reusable medical equipment
problems at three sites in Puerto Rico. How can this happen?
Response: Office of Inspector General (OIG) published a report on
June, 16, 2009, ``Use and Reprocessing of Flexible Fiberoptic
Endoscopes at VA Medical Facilities.'' During the inspections related
to this report, OIG found that several VHA medical facilities had
deviated from recommended procedures in the reprocessing of endoscopes.
On September 17, 2009, OIG issued the report, ``Followup Colonoscope
Reprocessing at VA Medical Facilities.'' OIG indicated that this report
provided results from August 2009 inspections of all facilities not
previously inspected in relation to the June 2009 report and a followup
for facilities previously found to be not compliant with Directive
2009-004, Use and Reprocessing of Reusable Medical Equipment in
Veterans Health Administration Facilities. The September 2009 report
specified that the August 2009 inspections were limited to colonoscope
reprocessing. This report found that among the 129 facilities inspected
in August, all 129 of those inspected were compliant with respect to
the OIG's review about standard operating procedures while 128 had
adequate documentation of demonstrated competence for reprocessing
staff. The VA Caribbean Healthcare System in San Juan, Puerto Rico, was
one of the 129 facilities visited by the OIG on August 5, 2009, for the
followup review, and the OIG did not indicate any concerns in the scope
of their review.
According to the reports, the scope of the March 2010 report,
``Patient Safety Issues, VA Caribbean Healthcare System, San Juan,
Puerto Rico,'' differed from the OIG's 2009 review of colonoscope
reprocessing. The March 2010 report involving Puerto Rico was a result
of an OIG Hotline call that prompted a visit on August 25-28, 2009, to
the VA Caribbean Healthcare System. This report did not specifically
address colonoscope reprocessing that was addressed in the June 2009,
and September 2009 reports. The report addressed several issues such as
training of staff, equipment concerns, and processes that the facility
had identified previously and were already working to correct prior to
the August 2009 site visit as follows:
July 2009: The Veterans Integrated Service Network (VISN)
8 Reusable Medical Equipment (RME) Committee conducted a site visit/
review and made recommendations to further enhance the San Juan RME
program.
July 2009: The VA Caribbean Healthcare System aligned the
RME Committee under the leadership of the Associate Director for
Patient Care Services and changed its membership. Committee Members
underwent a comprehensive orientation on the purpose and expectation of
the RME Committee.
July/August 2009: Staff involved in the cleaning and
reprocessing of RME underwent retraining and the recertification of
competencies. RME orientations were held with Service Chiefs outlining
their responsibilities. Leadership conducted inspections at RME pre-
cleaning and reprocessing sites.
Recently, during the week of June 7, 2010, the VA Caribbean
Healthcare System completed their tri-annual unannounced Joint
Commission survey. The Joint Commission conducted a focused review on
reusable medical equipment during this survey and had no findings.
Question 4: If the Office of Inspector General made recommendations
to fix the Fiduciary Program in a 2006 audit, why did they find similar
problems in a 2010 audit? It would seem that veterans who need
fiduciaries to manage their funds are among the most vulnerable of
veterans.
Response: VA agrees that beneficiaries who need fiduciaries to
manage their funds are among the most vulnerable veterans. VA is
committed to strengthening the program and safeguarding the welfare of
veterans and survivors with fiduciaries.
Although VA concurred in the findings of the report, the Acting
Under Secretary for Benefits comments indicated that we continued to
have serious concerns about the quality of the report.
VA has made significant progress since 2006. The current report
identified four recommendations as similar dealing with documenting
receipts, staffing, training and the fiduciary IT system FBS. Here is
an update on each recommendation and the actions taken.
Documentation of receipts: Conducted a training
conference for Legal Instruments Examiners from all regional offices,
providing in-depth training in areas including account audits, estate
administration, misuse identification, and surety bonds;
Completed a total revision, reorganization, and update of
the Legal Instruments Program Guide; and
Released Fast Letter 07-12, Quarterly Review of Selected
Fiduciary Accounting Work Products to further monitor fiduciaries that
are required to submit accountings; and verified and updated all estate
values in the Fiduciary Beneficiary System, and required annual updates
in the future.
The IG's most recent report expressed their view that more can be
done. VA concurred in the finding and strengthened policy guidance in
Fast Letters dealing with fund usage; misuse allegation review,
investigation and determination; collection of Social Security numbers
and taxpayer identification numbers; and onsite reviews. Policy
guidance was also updated to require a Legal Instruments Examiner to
obtain receipts for any item, regardless of the amount or its inclusion
in the fund Usage Agreement, if documentation is determined necessary.
C&P Service further strengthened the program by deploying improved
oversight of allegations on the misuse of beneficiary funds. Effective
fiscal year 2010, C&P Service Fiduciary Staff is required to complete
an annual Systematic Analysis of Operations of the misuse process. This
analysis will identify the following: areas in which regional offices
are following prescribed policies and procedures; areas in which
current VBA policies and procedures may be enhanced; and any weaknesses
in the fiduciary program as it relates to misuse. In addition, the C&P
Service Fiduciary Site Survey Protocol was amended to include a review
of all documentation pertaining to any misuse issues addressed.
The IG's second finding was that a fiduciary program staffing model
was needed to assure that the Department identifies the needed
resources to conduct the program. An analysis of current staffing and
workload has been completed and a proposed staffing model has been
developed to be used as a guide developed and are currently under
review in VBA.
With respect to training, the third area of ``similar'' findings,
the IG focused on their preference for centralized training for Legal
Instrument Examiners.
C&P Service deployed a comprehensive training program for all
fiduciary activity personnel nationwide. This is a week-long training
program to provide clear and consistent training that is delivered by
C&P Fiduciary Staff. Additionally, a National Fiduciary Managers
Training Conference was conducted in June 2010. As noted in our
response to the report, VBA conducts monthly training calls with the
fiduciary staff around the country. We believe these calls are
effective training tools and we are providing appropriate guidance. The
true measure of training is the outcome not the format. We will
continue to conduct training of our staff to improve effectiveness.
The fourth area of similar findings relates to the current FBS
system. VBA convened a workgroup to evaluate the current electronic
fiduciary case management system and to provide recommendations for
either enhancements or a replacement system. The workgroup presented
its findings and recommendations in June 2010. Based on those findings
we have concluded that the current system should be replaced. A Request
for Information (RFI) has been prepared and it is planned for release
by September 30, 2010. That RFI seeks industry recommendations on how
best to design the replacement system to meet the needs of the
fiduciary program. Input from that RFI will inform a solicitation for
development of the program.
Question 5: Regarding the two administrative investigations reports
that were released in August 2009 (while it has only been 10 months) at
this rate of 3 recommendations closed out of 45, we don't think you
will close all recommendations out within a year. What is the delay and
why have you not acted on the egregious behavior of several senior
officials?
Response: The VA Office of Information & Technology (OI&T) has
initiated corrective action on all recommendations and completed
corrective actions on a number of recommendations detailed in the two
administrative investigation reports. OI&T has conferred with the
Office of Human Resources and Administration and the General Counsel on
the recommendations, and made various determinations based on the
advice given to each of the claims.
In regards to Investigation Report No. 09-1123-195,
``Administrative Investigation Misuse of Position, Abuse of Authority,
and Prohibited Personnel Practices Office of Information & Technology
Washington, DC'' the former Deputy Assistant Secretary for Information
Protection and Risk Management, a Senior Executive and the primary
subject of the report, was removed from the Department of Veterans
Affairs. Additionally, appropriate administrative actions ranging from
admonishment to suspension were taken against various management
officials for engaging in prohibited personnel practices. In fact, 8 of
the 11 recommendations presented in this report are now closed. OI&T
continues to update OIG and is working toward completing the tasks that
are necessary to close the remaining recommendations.
In regards to Investigation Report No. 09-1123-0196,
``Administrative Investigation--Nepotism, Abuse of Authority, Misuse of
Position, Improper Hiring, and Improperly Administered Awards, OI&T,
Washington, DC'' the former Director, OI&T Human Resources Operations,
a primary subject of the investigation, was removed from his
supervisory position and demoted to a position that does not require
any direct or indirect human resources responsibility. Several of the
OIG recommendations included collecting funds from employees whose
college tuition was funded by the VA. More specifically, six
nonsupervisory employees were identified as having received funds
improperly expended to pay for their academic degree. The Office of the
General Counsel (OGC) is currently conducting a review of this issue
and will soon provide OI&T with a legal opinion regarding the
employees' liability. OI&T will forward this information to OIG for
final resolution. In the meantime, OI&T issued new guidelines
clarifying the approval of government funds for college tuition.
Also, Investigation Report No. 09-1123-0196 identified 10
individuals that were erroneously appointed and/or appointed at a rate
above the minimum. OI&T has established a procedure for requesting
above minimum rate for new appointees, and continues to confer with the
Office of Human Resources & Administration so that the appointment
status of all OI&T employees is in accordance with the law.
The Assistant Secretary for OI&T has implemented a new policy
regarding the authorization of awards and bonuses over $2,000, and any
award amount where the employee's prior cumulative awards exceed $5,000
in any fiscal year. The new policy requires that any award
recommendation over $2,000 must be reviewed by the OI&T Office of Human
Capital Management--this includes all types of awards, i.e. monetary
awards, honor awards, and nonmonetary awards.
OI&T continues to update OIG and is working toward completing the
tasks that are necessary to close all remaining recommendations.
Question 6: Why will it take 2 years to complete the
standardization of coronary stents and why has the Veterans Health
Administrations only started surveying facilities about the aortic
valves and thoracic grafts when this recommendation was made in
September of 2007?
Response: In 2007, the VA National Director of Surgery determined
that there was no need to pursue a national contract for aortic valves
and thoracic grafts based upon an independent assessment of relevant
surgical volumes for aortic valve and thoracic aortic graft procedures.
In November 2008, a new National Director of Surgery was appointed and
in July, 2009 an internal review identified that a formal response to
the 2007 OIG recommendations had not been submitted. The National
Director of Surgery initiated a survey of the field, and two Integrated
Product Teams (IPT) were established in October 2009. The teams
reviewed survey data, information from the VA Surgical Quality
Improvement Program, and prosthetics data. The findings of the IPT
reviews are summarized below:
With regard to aortic valve implant devices, the IPT
determined that a national contract and Blanket Purchase Agreement
(BPA) was not recommended. The basis for this decision considered the
complexity of the clinical decisions resulting in vendor choice, the
variety and availability requirements of implant types (mechanical,
bioprosthetic, etc) in relationship to the complexity of the disease
being treated, the relatively low number of devices implanted by the
VHA, and the established safety of the devices currently utilized.
With regard to thoracic aorta grafts, the IPT did not
recommend either a national contract or BPA. The basis for this
decision was the overall low number of thoracic aortic grafts being
implanted by the VHA, the complexity of the disease process requiring a
choice of available and emerging vendor products, and the established
safety of the devices currently utilized.
The recommendations of the Aortic Valve IPT and the Thoracic Aortic
Graft IPT were submitted to and accepted by the National Director of
Surgery. The National Director of Surgery submitted a declarative
statement, consistent with the findings of the IPTs, to the OIG for
review and consideration for closing the recommendation.