[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]



 
                 VETERANS AT RISK: THE CONSEQUENCES OF
                THE U.S. DEPARTMENT OF VETERANS AFFAIRS
                     MEDICAL CENTER NON-COMPLIANCE

=======================================================================

                             FIELD HEARING

                               before the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                             JULY 13, 2010
                  FIELD HEARING HELD IN ST. LOUIS, MO

                               __________

                           Serial No. 111-90

                               __________

       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 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


                            C O N T E N T S

                               __________

                             July 13, 2010

                                                                   Page
Veterans at Risk: The Consequences of the U.S. Department of 
  Veterans Affairs Medical Center Non-Compliance.................     1

                           OPENING STATEMENTS

Chairman Bob Filner..............................................     1
    Prepared statement of Chairman Filner........................    66
Hon. Jeff Miller.................................................     4
    Prepared statement of Congressman Miller.....................    67
Hon. Russ Carnahan...............................................     5
    Prepared statement of Congressman Carnahan...................    68
Hon. Roy Blunt...................................................     7
Hon. Jerry F. Costello...........................................     8
    Prepared statement of Congressman Costello...................    69
Hon. John Shimkus................................................     9
    Prepared statement of Congressman Shimkus....................    69
Hon. Wm. Lacy Clay...............................................     9
    Prepared statement of Congressman Clay.......................    70
Hon. W. Todd Akin................................................    10
Hon. Blaine Luetkemeyer..........................................    11

                               WITNESSES

U.S. Department of Veterans Affairs, Hon. Robert A. Petzel, M.D., 
  Under Secretary for Health, Veterans Health Administration.....    43
    Prepared statement of Dr. Petzel.............................    78

                                 ______

American Legion, Barry A. Searle, Director, Veterans Affairs and 
  Rehabilitation Commission......................................    27
    Prepared statement of Mr. Searle.............................    76
Johnson, Earlene, St. Louis, MO..................................    26
    Prepared statement of Ms. Johnson............................    72
Maddux, Susan, Festus, MO........................................    13
    Prepared statement of Ms. Maddux.............................    71
Odom, Terri J., Imperial, MO.....................................    14
    Prepared statement of Ms. Odom...............................    72

                       SUBMISSIONS FOR THE RECORD

Hare, Hon. Phil, a Representative in Congress from the State of 
  Illinois.......................................................    81
McCaskill, Hon. Claire, a United States Senator from the State of 
  Missouri.......................................................    82

                   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 July 29, 2010, transmitting follow-up 
  questions from Hon. Wm. Lacy Clay, and VA responses............    85


                 VETERANS AT RISK: THE CONSEQUENCES OF
                THE U.S. DEPARTMENT OF VETERANS AFFAIRS
                     MEDICAL CENTER NON-COMPLIANCE

                              ----------                              


                         TUESDAY, JULY 13, 2010

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                                    Washington, DC.

    The Committee met, pursuant to notice, at 1:04 p.m., in the 
En Banc Courtroom of the Thomas F. Eagleton U.S. Courthouse, 
111 South 10th Street, St. Louis, Missouri, Hon. Bob Filner 
[Chairman of the Committee] presiding.

    Present: Representatives Filner and Miller.

    Also present: Representatives Carnahan, Costello, Clay, 
Blunt, Shimkus, Akin and Luetkemeyer.

              OPENING STATEMENT OF CHAIRMAN FILNER

    The Chairman. Good afternoon. This is an official hearing 
of the U.S. House of Representatives Veterans' Affairs 
Committee. I'm the Chairman of the Committee, Bob Filner from 
San Diego, California. The Ranking Member for this hearing is 
Mr. Miller from Florida.
    Thank you, Mr. Miller, for joining us.
    Mr. Miller. Uh-huh.
    The Chairman. I'm glad to see all of you, but this is not 
the kind of occasion which merits any celebration. I appreciate 
everybody's interest in looking into the sad and tragic events 
that occurred here in St. Louis with the oversight 
responsibility of Congress.
    I ask unanimous consent, Mr. Miller, for Mr. Carnahan, Mr. 
Costello, Mr. Blunt, Mr. Shimkus, Mr. Akin, Mr. Clay, and Mr. 
Luetkemeyer to be invited to join us for the full Committee 
hearing today.
    Hearing no opposition, we welcome all of you. This is a 
very large delegation of Members of Congress who are not on the 
Committee. They are here because of the importance of the 
issue, so we thank you all for being here.
    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 do want to thank the staff of the Thomas F. Eagleton 
Courthouse for their generosity in providing the space for us 
at today's hearing. We are all here because we are concerned 
about what happened with the dental clinic and the dental 
equipment at the U.S. Department of Veterans Affairs (VA) 
Medical Center in St. Louis.
    As a result of the lapse in the protocol for cleaning 
dental equipment, more than 1,800 veterans have been put at 
risk, risk for having been exposed to hepatitis B, hepatitis C, 
and HIV (human immunodeficiency virus).
    On behalf of all of us, we want to make sure you know how 
bad everybody feels about this situation. We want to apologize 
to the citizens of St. Louis for putting them through this very 
tragic situation. The probabilities of infection in this 
situation are low but they are there, and that puts families 
and the whole community at risk.
    We are not only sorry for the citizens of St. Louis, but we 
are outraged that this could occur when we are dealing with the 
veterans of our Nation--those who we always pay the highest 
honors, respect, and gratitude for their service--and now in 
our own medical system they have to face these risks.
    We want to get to the bottom of the events both leading up 
to the lapse in protocol for cleaning the equipment, and in the 
examination of the steps that VA officials took once they 
learned of this incident, and evaluate whether they have been 
effective in providing timely information to our veterans.
    I'm also very concerned with what I see as a lack of 
transparency. Members of Congress were not informed until the 
matter became public. I came off a plane from San Diego to 
Washington and Congressman Carnahan approached me in the 
cloakroom of the House of Representatives and said, ``Have you 
heard what went on here in St. Louis?'' I was very embarrassed 
because I had not heard.
    I want to especially thank Congressman Carnahan for being 
on top of this and making sure all of us were aware of what was 
happening, because the information did not come to us from our 
Executive Branch--as it should have.
    Thank you again, Mr. Carnahan, for being on top of all of 
this so quickly, as were all of you from both Missouri and I 
guess they say ``across the river'' here, don't they?
    When mistakes are made, the only way to deal with them, in 
our view, is through honesty and truthfulness. You have to do 
that to make sure you have the trust, and in this case, I think 
we have to rebuild the trust with the public.
    How are we going to make sure that not only this doesn't 
happen again in terms of the actual cleaning of the 
instruments, but of the way the public was informed and treated 
with that information? Accountability is our bottom line here. 
We want to see who was at fault and what accountability 
measures will be taken to deal with that.
    We are going to hear from veterans who were treated at the 
clinic and who have received the letter that says they are at 
risk. We want to understand their situation, their fears, and 
their questions while they are dealing with this.
    Unfortunately, I have to tell the audience this is deja vu 
all over again. We've had this kind of problem in other places, 
and each time we are told it won't happen again. In December of 
2008, we had improper reprocessing of endoscopes, which put 
thousands of veterans in Tennessee and Florida at risk of 
hepatitis and HIV. In February of 2009, another 1,000 veterans 
in Augusta, Georgia, received notification that they were at 
risk for hepatitis and HIV because of ear, nose and throat 
endoscopes that were not cleaned properly. Just last week, Mr. 
Miller, in your State, another 80 or so veterans were notified 
that they were at risk. Clearly, we have some problems here and 
I don't think we've remedied them when they keep occurring.
    I just want to raise some issues, which my colleagues then 
will take up, with the timeline of this whole thing.
    Dr. Petzel, when you get here on your panel, I hope you 
will respond to this.
    When you look at the timeline for what occurred, apparently 
the procedures were not being followed for a whole year, 
between February of 2009 and March of 2010. They were 
discovered in a routine inspection but if your routine 
inspections find things that have been going on for a year, 
there is something wrong with that routine inspection. Why do 
we only find out after a year of this going on? It seems to me 
that this has to be an ongoing issue. But whatever you do, Dr. 
Petzel, in the VA there has to be more rigorous and more 
regular inspections. If they take place quarterly or bimonthly, 
we can't let things go on for a year.
    When they discovered this in March of this year it took 
until May for the VA to put together a Clinical Risk Assessment 
Advisory Board to look at the risk. That's 2 months after they 
first discovered this.
    I don't understand that at all. I think what should have 
happened when the risk was discovered was to announce it. Stand 
here with the Governor of the State, with the Members of 
Congress, with the Senators. Let's stand here and say, look, 
this has occurred and we are investigating it. All of the 
veterans who visited the dental clinic in the last year had 
better come in right away for some tests.
    Two months go by and they call a board, who decided, as I 
understand it, Dr. Petzel, that the risk was sufficiently 
high--it wasn't zero--and they said we ought to notify 
everybody who was there at that time. That took another 2 
months. On June 28th, the letters went out and they had their 
meeting on May 6th.
    This is a serious issue. To allow that kind of waiting 
period and I know there is a cautiousness, but you are dealing 
with potentially fatal diseases of hepatitis B and C. We know 
the horrific consequences of HIV. You had 4 months where people 
could have given blood to your blood bank because they didn't 
know it wasn't safe or potentially unsafe--not to mention any 
sexual behavior. People might have changed their behavior had 
they known there was a risk. They didn't even know about it. I 
think that's intolerable, that it took that 4 months before 
anybody was notified.
    As Congressman Carnahan points out, the letter that was 
sent out seemed a little cold. You have the option of being 
tested. Call up our 800 number. Now, I hope that 800 number is 
being staffed. They say 24 hours a day but we all know people 
who call 800 numbers and are on hold for hours, or somebody 
answers that doesn't even know what they are talking about.
    I was going to call the 800 number this morning but I 
didn't have time. I was flying here but I wanted to see how 
they would actually respond to somebody. I hope they are 
responding.
    I will tell you if you have 1,800 people with serious risk, 
I would have called in 1,800 VA employees--we have 250,000--and 
said, each of you is responsible for one of these veterans. 
Make sure you call them, counsel them, and give them the 
emotional support they need. Advise them of what the tests mean 
and when they are going to happen, and provide them with 
information about follow-up tests.
    If you can't have one-on-one, call in 600 VA employees and 
put three to one, or call in 300 and make it six to one. As far 
as I understand it, we sent out these letters and the veterans 
are supposed to call in. Maybe we are following up, but I doubt 
if we are following up the way a case worker would where they 
track down these veterans. Such as address changes, phone 
number changes, etc. You've got to track people down. You've 
got to find them, and you've got to hold their hands and make 
sure they understand what's going on. We are not doing that. We 
are just not doing it. They are not only American citizens, 
they are our veterans.
    It seems to me that we have to do a far better job not only 
in the transparency of a mistake, but then in counseling and 
helping people. I think we will have a panel on this. Even if 
you get a negative test for HIV, you are not always sure it's 
really negative. You've got to re-test 6 months later, but I'm 
sure somebody could testify to the exact process. We are going 
to have to stay with these people and be with them long term.
    We owe it to them. They have fought for our Nation and we 
cannot let them just wander around, call up an 800 number, 
figure out when a test is going to be, and then maybe they will 
hear about it in a few weeks. Somebody has to be responsible 
for each of those 1,812 people. That's how I'm looking at this.
    Mr. Miller, I appreciate, again, you coming from Florida to 
be with us to make this an official hearing as we need two 
Members of the Committee present, and I thank you for your 
commitment to our veterans that you have shown for all of your 
career in Congress.
    You are recognized.
    [The prepared statement of Chairman Filner appears on p. 
66.]

             OPENING STATEMENT OF HON. JEFF MILLER

    Mr. Miller. Thank you, Mr. Chairman.
    I, too, share the anger and the frustration that you hear 
in the Chairman's voice. He has already recognized those 
Members that are here.
    I do want to specifically mention one that could not be 
here because of a scheduling conflict, and that was 
Congresswoman Jo Ann Emerson. She does have a staff member here 
today.
    And I, too, want to say that when this first became public, 
Roy Blunt and I had a very serious conversation in our 
cloakroom and he has sent a letter to Secretary Shinseki asking 
very pertinent questions. And I hope that today we will get the 
answers to some of those questions without waiting on a 
response from the Secretary.
    But suffice it to say that we have had incidents like this 
all across the country. There are dedicated VA employees out 
there and we salute them, but mistakes like this have happened 
over and over and over again and as the Chairman said, Florida 
just had another incident that had been notified to the 
Congressional delegation in Miami.
    The problem I have is that every time we have a hearing on 
one of these incidents, the VA comes forward and says, ``We are 
putting in new procedures, new controls. It's not going to 
happen again.'' But it happens again and again and again. And 
unfortunately, I would have to say that promises from VA in 
issues such as this ring very hollow, and that is not something 
that we would expect from anybody in government, least of all, 
those from within the Department of Veterans Affairs.
    I've got a lengthy statement and I want to ask that it be 
entered into the record because there are so many of my 
colleagues here who have a vested interest. I represent the 
First Congressional District in Florida, which is Pensacola to 
Destin, and I have the most veterans of any Congressional 
district in the country in my Congressional district.
    I specifically asked to be on this Committee when I came to 
Washington in 2001 because I wanted to make sure that the 
veterans of our Nation were getting the care that we, as 
Americans, have promised to those who have borne the battle and 
worn the uniform of this country.
    But without further comment, I would like to ask again that 
my statement be entered into the record without objection.
    [The prepared statement of Congressman Miller appears on 
p. 67.]
    The Chairman. Thank you. Thank you, Mr. Miller.
    As I said, Congressman Carnahan from St. Louis has been on 
top of this from the beginning and has acted as our liaison for 
knowledge. We thank you for all the work you have done and you 
are recognized for an opening statement.

            OPENING STATEMENT OF HON. RUSS CARNAHAN

    Mr. Carnahan. Thank you, Mr. Chairman, and to Mr. Miller 
for being here traveling from Florida, as well. For my 
colleagues from both sides of the aisle and both sides of the 
river, we thank you for being here.
    Mr. Chairman, your prompt response to the request of myself 
and Congressman Clay to hold these field hearings in St. Louis 
and to formally begin this Congressional investigation into how 
our veterans were put at risk by the safety lapses at Cochran 
Medical Center.
    Since we learned early this month that veterans throughout 
St. Louis and Illinois could have been exposed to blood-borne 
pathogens such as hepatitis B, hepatitis C, and HIV while 
receiving dental care at Cochran, I've heard from many 
constituents, veterans and their families who are gravely 
concerned about this matter.
    After their service to our country, this is not a fight our 
veterans should face. They deserve answers to this dental 
debacle, and relevant quality personnel and management 
questions. They deserve the best care available in our country. 
On behalf of the veterans that I am honored to represent, I'm 
here to demand answers and action to make this right.
    From where I stand, there are five core issues that I would 
like to see addressed here today. First and foremost, those 
1,812 veterans who received that cold letter in the mail just a 
few weeks ago, to be sure they are getting the special care and 
follow-up they need.
    Second, we need clear answers on how this happened and how 
it could have gone on for so long uncovered.
    Third, I'm determined to get to the bottom of whether an 
employee of the medical center was terminated, in part, because 
she raised concerns about the sterilization procedures as far 
back as August of 2009. And I have to say any sign of 
retaliation or intimidation of employees throughout this 
process should not be tolerated and needs to be reported 
immediately.
    I want to know what concrete steps are being taken to reach 
out to current and former employees, to be sure they are 
providing the necessary information to be sure we get to the 
bottom of this. We must make sure employees who have 
information that is relevant to this matter or any other 
problem are not only aware of their rights, but are encouraged 
to come forward and cooperate.
    Fourth, I want to determine whether this latest incident at 
the dental clinic is limited to that incident or is part of a 
larger systemic problem at this facility. The VA Medical Center 
has been cited for serious infractions, which leads me to 
suspect there may be broader issues that need to be addressed. 
In April of 2010, the VA Office of Inspector General (OIG) 
conducted an inspection to, ``Determine the validity of 
allegations regarding ongoing issues with the Supply Processing 
and Distribution (SPD) departments related to reprocessing 
endoscopes. The inspectors found that the SPD department did 
not have defined clean and dirty areas and there was severe 
communication breakdowns between staff regarding proper 
reprocessing procedures.
    Moreover, in the 2009 Survey of Health Expectancies of 
Patients, the VA approved Patient Satisfaction Survey that 
tracks satisfaction responses from inpatient and outpatient 
veterans showed that Cochran scored the lowest score out of 128 
VA hospitals around the country in inpatient services. A score 
of 46 percent is unacceptable.
    And lastly, and most importantly, we need action. We need 
to determine what next steps need to be taken to restore and 
rebuild the faith of our veterans.
    Let me be clear. This should not be an exercise to paint 
with a broad brush in a negative way our Veterans 
Administration or our health care services. As was said 
earlier, there are many professional and committed people that 
work in the VA. They should be commended and there are some 
important quality measures that we should all be proud of. But 
there is broad acknowledgment that serious mistakes have been 
made and there is much work to be done.
    This past week I met with a group of 30 veterans, many on 
my Congressional District Veterans' Advisory Committee. There 
was a strong belief in the quality of care, but also a deep 
concern about these recent problems. At the end of the day it's 
critical the VA identify and rectify any existing problems, 
make sure this never happens again, and takes actions needed to 
rebuild our veterans' shaken confidence.
    To all the witnesses here before us today, thank you for 
being here to appear before us to get to the bottom of how this 
happened, to help us determine the answers, reforms and actions 
that honor our veterans with health care they earned and that 
they deserve and that is the best.
    Thank you, Mr. Chairman, and Mr. Miller.
    [The prepared statement of Congressman Carnahan appears on 
p. 68.]
    The Chairman. Thank you, Mr. Carnahan. Thank you for 
putting that so clearly before us.
    Mr. Blunt, you have shown your commitment to veterans here 
during your time in Congress. We thank you and thank you for 
being here.
    You are recognized.

              OPENING STATEMENT OF HON. ROY BLUNT

    Mr. Blunt. Well, thank you, Mr. Chairman, and thank you for 
being here. Thank you and Congressman Miller for taking time to 
call attention here in St. Louis where we have the most access 
to witnesses. And our staff, some of our staff was in the 
facility again yesterday to talk to people at the facility. I 
thank both of you for being here.
    You know, recently I've had a chance to speak at the annual 
meeting of both the Veterans of Foreign Wars (VFW) in Missouri 
and the American Legion, and at both of those meetings I told 
them that of all our obligations as a country, at the top of 
the list of obligations is our obligation to our veterans. It 
should be a priority for us. I know it's a priority, Mr. 
Chairman and Mr. Miller, for your Committee. And thanks for 
your good work on this Committee.
    Most of what needs to be said here we are going to hear 
from the witnesses, and I would just share my sense that one of 
the questions are, how could 1,800 people have been exposed to 
this risk over such a long period of time? How does this go 
undetected, or perhaps even detected and ignored? That's a 
possibility that's been raised here today.
    Secondly, as the Chairman pointed out, how can we wait from 
March until almost July to notify people?
    And then third, the callousness of that notification all 
were unacceptable. All were unacceptable.
    If, as the Chairman suggested, as Mr. Costello has told me 
about an event in his district in recent years, this is deja vu 
over again, it's unacceptable all over again. And Mr. Chairman, 
Yogi Berra, who is one of the most famous given credit for that 
comment, grew up just a few blocks from here. And he grew up in 
a country that understood its obligation to those who fight for 
freedom, and to those who are willing to fight for freedom. And 
that's what your Committee focuses on. That's why we are all so 
upset about this problem.
    And you know, I've heard even earlier today, that some 
unsophisticated person getting this notice would be scared by 
it. My view is the more you know, the more you would have been 
scared by it. And the notice was unacceptable the way it went 
out, and apparently it's the way the VA always deals with these 
issues. And this is at the top of our list of obligations.
    And Mr. Chairman, again, thank you for drawing attention to 
this in a way, hopefully, that will make the future problems 
like this dealt with in a better way, and make this problem 
dealt with in a better way from now until every single veteran, 
and their family who is affected by it, is beyond the impact of 
it and hopefully and prayerfully all beyond the impact of that 
in a positive way.
    And I give it back.
    The Chairman. Thank you, Mr. Blunt.
    Mr. Costello, you are our senior Member here today. We 
thank you for all of your years of service and commitment to 
veterans.
    You are recognized.

          OPENING STATEMENT OF HON. JERRY F. COSTELLO

    Mr. Costello. Mr. Chairman, thank you. And I want to thank 
you for calling this hearing here in St. Louis on very short 
notice.
    I thank Mr. Miller for traveling here today from Florida to 
participate in the hearing. And let me just say that I have a 
lengthy statement that I will enter into the record so that we 
can continue with our witnesses. We have three panels.
    But let me say that we are here to get answers. I think Mr. 
Carnahan outlined what some of the questions are. We have 1,812 
veterans who have been put at risk. Three-hundred seventy of 
those veterans live in the Congressional district that I'm 
privileged to represent.
    It's an absolute outrage that this happened, given that 
this is not the first time that this has happened. You outlined 
in your statement, and Mr. Miller made reference to, the fact 
that over 10,000 veterans were put at risk in Tennessee, 
Georgia and Florida. And as a result of that, these veterans 
now here in St. Louis know that they have been exposed but they 
do not know if they have life-threatening diseases as a result 
of this.
    This Committee held a hearing, at my request, in 2008 as a 
result of what happened at the Marion Veteran's Hospital in 
Marion, Illinois. In 2007, nine veterans died as a result of 
substandard care at the Marion Veterans' facility. How many 
veterans have to be exposed and put at risk? How many veterans 
have to die before the VA gets it right?
    Let me say that, finally, as Mr. Carnahan pointed out and 
others, the vast majority of the employees at the VA facility 
in Marion, Illinois, are outstanding, dedicated employees. It's 
the management that was at fault. It was the lack of aggressive 
oversight that was at fault.
    And finally, in addition to the questions that Mr. Carnahan 
and you raised, Mr. Chairman, I want to know if, in fact, 
anyone is going to be fired as a result of this, as opposed to 
reassigned or located somewhere else. That happened in Marion. 
As opposed to firing the Director, they just reassigned him to 
another facility.
    So I want to know what action is going to be taken to the 
people who are identified that, in fact, both in the 
Administration and the on-line employees, that are responsible, 
I want to know what's going to happen there. Are they going to 
be pushed to another facility or are they going to be fired?
    I think it's about time that agencies like the VA start 
firing individuals that do not do their job. And that may send 
a message out to everyone throughout the entire Department 
that, in fact, your job could be in jeopardy if you do not 
follow proper procedures.
    And with that, Mr. Chairman, I thank you and I look forward 
to asking questions of our witnesses.
    [The prepared statement of Congressman Costello appears on 
p. 69.]
    The Chairman. That you so much, Mr. Costello.
    Mr. Shimkus, you've joined us from across the river, too. 
Thank you for being here.

             OPENING STATEMENT OF HON. JOHN SHIMKUS

    Mr. Shimkus. Thank you, Mr. Chairman. And I appreciate my 
colleague Congressman Miller coming up from Florida, and of 
course my good friend, Jerry Costello, who has already weighed 
in on the issues that we dealt with at the Marion VA.
    And I'm sure the folks out in the audience are hearing 
these stories and they are saying, why are we continuing to put 
up with this stuff? And so I knew you would probably elaborate 
that.
    We need to know who knew what, and when, and then we need 
to do, as Jerry said, when are we going to hold someone 
accountable? When, in a big Federal agency, are we going to 
start holding people accountable for in essence dereliction of 
duties?
    There is a cultural issue here. There is a cultural issue 
that we've dealt with in Marion and we've dealt with in other 
States that has to be changed. I was on a major radio station 
this morning in the St. Louis area and I had a, one of the 
call-ins was a veteran named Jason and he said, you know, I 
visit Cochran and I can't get the Patient Advocate to talk to 
me. Now, here is a veteran who called in to a talk show to let 
me know that there is more of a problem than just this.
    I have a long-established relationship with Secretary 
Shinseki and I'm very biased in my high regard and my opinion 
of him, and my faith, and my trust. If he needs tools to 
separate the wheat from the chaff, then we need to help him get 
those tools. And it's unfortunate that we are here.
    I welcome my colleagues to the bi-State area and I 
apologize to the veterans who have been affected on not only 
this but on other issues. And I think you've heard from the 
voices of my colleagues that we are going to continue to stay 
on-focus on this and start demanding change from the Veterans 
Administration.
    Thank you, Mr. Chairman. I give it back.
    [The prepared statement of Congressman Shimkus appears on 
p. 69.]
    The Chairman. Thank you, Mr. Shimkus.
    Mr. Clay, again, you've been on top of this from the 
beginning. We appreciate your commitment to St. Louis and 
welcome.

            OPENING STATEMENT OF HON. WM. LACY CLAY

    Mr. Clay. Thank you, Chairman Filner and Ranking Member 
Miller, for holding hearing and for inviting me to join the 
investigation regarding John Cochran St. Louis VA Medical 
Center, which I represent in Congress.
    Today we will examine and hopefully learn the truth about 
the improper processing of dental instruments, including a 
failure to clean dental equipment with a special detergent 
before it's sterilized.
    It is unacceptable that procedures were conducted from 
February of 2009 to March of 2010 without proper safeguards in 
place to protect the health of veterans receiving treatments. 
Making matters worse, the VA knew about the possibility of 
exposure in March of 2010, yet veterans were not notified of 
the problem until June of 2010. That is shameful and there is 
no excuse for withholding that information. This Nation owes an 
enormous debt to the brave men and women who served our country 
with courage and honor.
    Mr. Chairman, this is about a failure to follow proper 
procedure, a failure of supervision, and a failure to keep 
faith with all the brave Americans who have defended our 
freedom.
    The truth about this incident will be revealed in this 
Committee hearing, but we certainly need honest answers to some 
critical questions. And one is, what is the chain of command 
that had primary responsibility to oversee procedures at the VA 
dental clinic at Cochran?
    Two, what was the supervisor in charge--who was the 
supervisor in charge and when did he or she first become aware 
of the failure to follow proper procedure? And how did the 
supervisor find out about the problem during the time that the 
information about the potential contamination was withheld and 
did anyone else know about it? Who made the decision not to 
disclose that information immediately?
    And finally, have the individuals involved been disciplined 
in any way, as my colleague Mr. Costello has asked?
    Mr. Chairman, I thank you for conducting this hearing, and 
I yield back the balance of my time.
    [The prepared statement of Congressman Clay appears on p. 
70.]
    The Chairman. Thank you.
    Mr. Akin, again, thank you for joining us and we welcome 
your participation.

             OPENING STATEMENT OF HON. W. TODD AKIN

    Mr. Akin. Well, thank you, Mr. Chairman. And I likewise 
have some notes that can be submitted for the record, but I 
just wanted to sort of digress a little bit and be a little 
more brief.
    First of all, as a Member of the Armed Services Committee, 
I'm familiar with our soldiers. I'm familiar with their 
commitment, I'm familiar with their service, and also with the 
sacrifices that they make. And I guess it's maybe more 
personal. I have three sons that have been serving as Marines, 
and I've served in the Army myself. So what's gone on here is 
unacceptable.
    My concern largely centers around what increasingly smells 
like a systems problem. I don't believe that what we've seen 
was a result of one or two people who failed to do their job. I 
believe, rather, that it is a broader organizational management 
kind of problem that we are dealing with, and it's also a 
culture that appears to be suffering from misdirected 
understanding of what their priorities need to be.
    Just as our sons and daughters serve us, this should be a 
service organization and service must come first. And it 
appears that at a number of levels organizationally, this is 
just not the culture. So, and if it were just limited to this 
one incident, we would say, well, okay, maybe there is one 
location where there has been some difficulties. Maybe some 
management problems or whatever.
    This appears to be a broader kind of problem, and so my 
questions are going to be particularly from a systems point of 
view and from a culture point of view. What are we going to do 
to make this time different? Because we will not, as Members of 
Congress, put up with lousy service when we are asking people 
to give even their lives, at times, for this country.
    Thank you, Mr. Chairman.
    The Chairman. I think you hit the nail on the head, Mr. 
Akin. Thank you so much.
    Mr. Luetkemeyer, we welcome you. This is your first term in 
Congress and you are getting a great introduction to what we 
do.

          OPENING STATEMENT OF HON. BLAINE LUETKEMEYER

    Mr. Luetkemeyer. Thank you, Mr. Chairman and Ranking Member 
Miller. Thank you, gentlemen, for your service in helping to 
set this Committee hearing up, and in coming all the way to our 
beautiful part of the Midwest here.
    I've got a very brief statement. I will keep it brief 
because I know we've got a lot to talk about today.
    Commitment to our Nation, to those who fought for it, is a 
solemn obligation. Providing safe, sanitary health care is the 
least we can do for them in light of their service and 
sacrifice. It is absolutely unacceptable that procedures were 
conducted between February 1st, 2009, and March 11th, 2010, 
with a lapse in the safeguards in place to protect the health 
of veterans receiving treatment.
    It is deplorable that any assistance less than the best 
health care available, along with possible exposure due to 
unsterile equipment, is the level of care being offered to our 
veterans. In this hearing today, we must determine what were 
the causes in the breach of standards and what the Department 
plans to do to remedy this situation to ensure that it does not 
happen again. Also, that we discern why, upon discovery of this 
problem, information was not distributed in a timely matter to 
impacted veterans and to other VA health facilities.
    While we are here in St. Louis today, this situation 
impacted veterans all over the bi-State region and a number of 
other States. Constituents of mine in at least 12 counties were 
put at risk.
    Finally, I will also point out that my colleague, Mr. Clay, 
and I are both Members of the House Committee on Oversight of 
Government Reform, the chief investigative Committee of the 
House of Representatives, and we requested that that Committee 
conduct a full investigation of the situation, as well. And we 
will look forward to that hearing and disclosure, as well.
    Mr. Chairman, with that, I thank you and look forward to 
today's testimony.
    The Chairman. Thank you.
    As the first panel begins to come forward, Mr. Carnahan is 
going to introduce you, but I would like to make one other 
comment.
    Panel one please come forward. Ms. Maddux?
    In a July 2nd issue of the St. Louis Post Dispatch, the 
Chief of Dental Services at the Cochran VA Medical Center is 
quoted as saying, ``Things are done to get votes, and that's a 
shame.'' That is, we are here today for show.
    We are not here for a show. We are a bipartisan group that 
wants to get to the bottom of this for the, as all of you have 
stated, our veterans. That's our only concern here. I think 
that by blaming politics, it just looks like you are trying to 
shift the attention away from the mistakes that were made. I 
challenge----
    Mr. Shimkus. Mr. Chairman, can you yield on that?
    The Chairman. Of course, I will yield to you.
    Mr. Shimkus. Just, with my colleague, Jerry Costello, so 
the public understands, when people die in hospital facilities 
like they did in the Marion VA, we have to take action. So I 
really find that egregious on the part of that employee to make 
that claim, because this is serious business. We don't take 
this lightly.
    Thank you.
    The Chairman. Thank you, Mr. Shimkus.
    I challenge the Chief of Dental Service, in fact, I 
challenge all of you who are here on behalf of the Department 
of Veterans Affairs, to take responsibility for this 
disgraceful incident and show all of America, not just St. 
Louis, but all of our veterans what they are doing to better 
understand the why and the how of this inexcusable lapse in 
procedure happened.
    I think the VA is already facing an uphill battle, but you 
must work harder and longer to improve training, implement 
standardized procedures and, most importantly, regain the trust 
of the veterans that you serve.
    I would--Mr. Shimkus, I share your high regard, as I think 
we all do, for Mr. Shinseki, former Chief of Staff of the 
United States Army, now the Secretary for the Department of 
Veterans Affairs. As far as I know--and we will ask our panel--
I don't think he was told about this until late in the process. 
And if that's true, they've got more problems than this little 
incident shows.
    Mr. Carnahan, again, I think these are your constituents. I 
ask you to introduce the panel.
    Mr. Carnahan. Thank you, Mr. Chairman.
    I would just echo that. I think you can tell from the 
statements here from all the panelists that all the folks up 
here, there couldn't be a more united and focused and 
bipartisan effort here. So I appreciate all those kind of 
comments.
    I'm honored to introduce two veterans, Susan Maddux, who is 
a Gulf War veteran, served in the United States Air Force. She 
is married to another service-connected disabled veteran; and 
also Terry Odom, also a disabled veteran, suffering from post-
traumatic stress disorder, who served in the Navy. Both of 
these veterans received one of those cold letters in the mail.
    I want to thank you first for your service, and I want to 
thank you for being here to share what happened to you and to 
help us find answers here today.
    The Chairman. You will be recognized for an oral statement 
and any written statement you have will be made part of our 
record.
    Susan, you are now recognized.

       STATEMENTS OF SUSAN MADDUX, FESTUS, MO (VETERAN);

     AND TERRI J. ODOM, IMPERIAL, MO (VETERAN)            

                   STATEMENT OF SUSAN MADDUX

    Ms. Maddux. Thank you for allowing me to speak today.
    The Chairman. And we know how difficult this is for you but 
we are very grateful that you are sharing your experiences.
    Ms. Maddux. My name is Susan Maddux. I'm a 40-year-old Gulf 
War era veteran. I served in the United States Air Force from 
1988 to 1998 as an Aerospace Propulsion Specialist. I'm married 
to another service-connected disabled veteran and we are the 
parents of four teenage boys.
    On June 29th I received a certified letter from the John 
Cochran VA Hospital stating I may have been exposed to 
hepatitis B, hepatitis C and HIV. I found this letter to be 
very impersonal. In fact, there was little difference in the 
contents of this letter than from any other communication from 
the VA. It may have read just like an appointment cancellation 
letter if not for the signature required to receive it.
    I was very angry with the Veterans Administration after 
reading this letter. For something as significant as this, it 
should have warranted a more delicate approach than a form 
letter. The VA has advised us that there is minimal chance of 
being affected by these diseases. However, I feel that any 
chance of instruments becoming contaminated is unacceptable 
within a modern medical facility.
    The veterans that are eligible to use dental services at 
the VA Hospital are not normal veterans. Rather, they are among 
a select population and are also the most susceptible to harm 
due to being previously compromised by other illnesses.
    Those of us that are privileged to use the dental service 
are 100-percent service-connected, service-connected for dental 
health, or POW's. Then there are some veterans that have been 
hospitalized for more than 120 days that also have access to 
this dental clinic.
    To hear that there are some who think that the reaction of 
this incident is solely political angers me significantly. 
Hospital employees are not political appointees but, rather, 
are employed to perform a job, and that is to care for our 
Nation's veterans. It is their directive to follow the policies 
and procedures of their respected profession to ensure they do 
no harm.
    As an Aerospace Propulsion Specialist it was necessary to 
perform tasks following procedures and policies. This allowed 
the air crews to have confidence that I had installed or 
repaired their aircraft engines properly. If I didn't follow 
those procedures accurately, I put their lives at risk.
    In the same sense, the VA employees should strive to 
instill our trust in that they are doing everything the 
appropriate way since our lives are in their hands. In this 
instance, instead of strengthening our trust, the St. Louis VA 
has weakened our confidence by potentially risking over 1,800 
veterans lives.
    On June 1st of 2005, I was admitted to the intensive care 
unit at the John Cochran VA Hospital with bacterial meningitis. 
This was several months after having neurosurgery at this VA 
facility. Two forms of bacteria were found in my cerebral 
fluid. One of these infections is normally found in the 
gastrointestinal tract. I nearly lost my life due to this 
infection. After recovering from meningitis, I was just happy 
to be alive and I didn't think to ask more questions as to how 
this happened.
    After the disclosure by the VA over sterilization at their 
dental clinic, it brought me concerns that the VA sterilization 
issues are not just confined to this one clinic. It also raises 
questions in my mind as to how long these failures in 
sterilization policies have truly been going on.
    I would also like to express my concern about the length of 
time for the VA to notify us about this incident. It makes me 
speculate if there was an attempt to conceal this from the 
veterans. It has also taken an extended amount of time to get 
the test results back to us. They need to realize that we have 
put our lives on hold while we wait for these results.
    I would ask that VA employees speak out about policies and 
procedures that are not being followed; that it should be their 
duty to ensure our safety, and the managers and administrators 
should be willing to listen when informed about these issues.
    I would also ask or request the VA administrators and 
managers to look beyond saving money and follow their own motto 
by ``Putting Veterans First.''
    Thank you for allowing me to testify today, not only for 
myself, but as a voice for all veterans that use the VA medical 
facilities.
    [The prepared statement of Ms. Maddux appears on p. 71.]
    The Chairman. Thank you, Ms. Maddux.
    Ms. Odom.

                   STATEMENT OF TERRI J. ODOM

    Ms. Odom. Yes, my name is Terri Odom. I am actually an Army 
and Navy Vet and proudly served.
    First of all, I just want to say that all of my care 
providers at both John Cochran and Jefferson Barracks, from the 
dentists, to the psychiatrists, to doctors, to therapists, 
nurses, et cetera, have always shown me professionalism, 
compassion, and I can't say anything more for that. That's just 
me personally.
    Now, in regards to the dental lapse, I obviously have some 
major concerns. On behalf of what happened, basically we just 
want answers. There are more questions coming out of there 
right now than answers. And I also have major concerns about 
why it took them so long to notify me and I was notified via 
certified mail in a very, very cold letter. Like this lady 
said, it basically might have said, Hey, the parking lot is 
being paved. Park on the left side. That's how it felt.
    I know this mistake by the VA has made my anxiety disorder 
even worse, for obvious reasons. Like she said, our life is on 
hold and it's horrifying to know how many more tests we are 
going to have to have. There has been conflicting reports that 
perhaps we won't know for 5, to 10, to 20, to 30 years if we 
have hepatitis C or HIV. And that's a long time to put your 
life on hold, especially if you already have some serious 
health issues. And anyone that's seeking dental care at John 
Cochran has some serious health issues that are normally 
service-connected.
    In the information number that was attached to the 
certified letter that I received, I must say, with all due 
respect to the panel, that the people answering the phone were 
rude, knew nothing more than I knew, and I realize they were 
thrown together last-minute.
    I even called to verify my blood test, which was scheduled 
for July 6, 2010, at Jefferson Barracks Hospital. I called on 
July 5th, 2010, and a nurse actually laughed at my concerns. 
She said there was such a low risk that I had absolutely 
nothing to worry about. I asked her if the blood test being 
offered was because of zero risk or risk.
    Looking back now, I realize something in the dental 
department was wrong. After my first oral surgery I did have 
severe pain for 28 straight days, and some must ask why did I 
not return to the dental clinic, or call.
    We were taught in the military to suck it up, keep going, 
and that stride and toughness is still embedded in us veterans 
today. I had another oral surgery later and some teeth filled. 
I did receive partial dentures from the VA, but after three 
visits they still do not fit and my speech is bad with them.
    I also, looking back now, remember when the dentist reached 
for the metal molding piece to make my impressions for my 
partial plates, that they appeared dirty and rusty. Having a 
severe anxiety disorder, my attention to detail is somewhat 
greater than others, and I will leave it at that.
    In February of 2010, I was scheduled for a colonoscopy at 
the St. Louis John Cochran division but had a severe panic 
attack on the table, with extreme heart rate and elevated blood 
pressure. I looked around the room and it was beyond filthy. I 
felt that I could not continue with the procedure. As a result, 
I did end up in the ER and the procedure was canceled, 
thankfully, to my benefit.
    Also, during a 2009 inpatient stay at the John Cochran 
division for over 5 days, I was unable to shower due to the 
mold and unsanitary conditions of my bathroom. The nurses on 
the ward were very nice and just said, No, honey, you don't 
want to dare use that nasty shower. They did offer me 
washcloths and things of such to bathe with. I did offer to 
clean it myself.
    There must be a change in the VA. What has recently 
happened in St. Louis with the exposure is third-world 
treatment, if not less. And yes, we are angry and we have every 
right to be. The VA put our health at great risk and there has 
to be some accountability. This issue must not just be swept 
away like it never happened.
    I already have major trust issues due to my disability, and 
now I feel that the very people who are supposed to have my 
back are trying to put me in harm's way, and I'm not sure why. 
We deserve better than this. We are not just veterans, but 
human beings. People make mistakes. I understand that. But when 
you are dealing with people's lives, there is no room for 
failure. And I'm outraged at the lack of seriousness the St. 
Louis VA seems to be putting on this horrible issue. How would 
any of them like to wait in horror for test results, and then 
have to wait again and again and again?
    I thank you all for being here.
    [Applause].
    [The prepared statement of Ms. Odom appears on p. 72.]
    The Chairman. Thank you both. You do have a right to be 
angry.
    Mr. Carnahan.
    Mr. Carnahan. Thank you both for your honest testimony and 
description here.
    As you said, Ms. Odom, obviously there has been a toughness 
instilled in you, and a commitment to service, and we recognize 
that and we do want to get to the bottom of this.
    I want to ask both of you, you have very well described the 
coldness of those letters that you received. I want to ask, did 
you make that first phone call to the VA to set up those 
appointments, or was there any other outreach to you beyond 
that letter?
    Ms. Odom. I made the call immediately, and the person that 
answered the phone was a young man and he did not know anything 
about it. He said he was just hired to answer the phone and 
that a nurse would call me in approximately 1 to 3 hours to 
discuss any further details about the possible risk.
    Mr. Carnahan. And Ms. Maddux?
    Ms. Maddux. I called the following day. I already had an 
appointment that day to go to John Cochran, so while I was 
there I went down to their clinic to get the testing, and I've 
received no other calls.
    Mr. Carnahan. And can you describe the process when you got 
to the clinic in terms of doing the test and any counseling 
that was provided to you? Any answers at that point that were 
provided?
    Ms. Maddux. Well, we were given a folder with materials to 
read. Since I already had an appointment, they kind of walked 
me through it. I didn't sit through their orientation but I sat 
down with a nurse and he asked if I had any questions at the 
time. And then I went across the hall for the blood testing.
    I found when I got to the VA facility, there was people 
stationed at every turn in the hallways and those people had 
smiles on their face, asking if you needed help finding 
anything, and that went all the way down to the basement and 
into the clinic. And I found that to be very fake. And you 
would never see that on a normal day. And it was just 
ridiculous.
    Mr. Carnahan. Let me ask you both, are you satisfied with 
the advice that you have been given in terms of what kind of 
follow-up care you are going to need?
    Ms. Odom. No. I was not, I had my blood test, as I 
mentioned earlier, drawn at Jefferson Barracks July 6th. And 
when I got to the blood draw clinic, I was told I could not 
have it drawn until I spoke with a Mrs. Bart Thompson on the 
second floor.
    I immediately went to the second floor. The personnel there 
said they knew of no such person. I called the 800 number 
again. The lady informed me that she was from out of Missouri, 
out-of-state. She knew of no Ms. Thompson on the list.
    So I went back to the staff on the second floor and said, 
I've called the number. What is it? And finally I come across a 
nurse, I believe she was a nurse that said she did know of a 
Mrs. Thompson who had been at the last minute thrown into it 
but went on leave, and that she would personally call back to 
the blood lab and say it was okay for me to be tested. But I 
had no counseling or anything like that, sir.
    Mr. Carnahan. And then have you been advised in terms of 
the length of time you are going to have to wait to get 
results?
    Ms. Odom. I was told that because of the incubation period, 
that I can possibly return in late August, but they are going 
to be doing some investigation on how long they may have to 
follow us. That it may be 2, 3, 10 to 20 years. I had different 
stories about it, sir.
    Mr. Carnahan. And Ms. Maddux?
    Ms. Maddux. I was called yesterday with my results and I 
was told since my dental treatment was at the beginning of 
March, I would have to be re-tested around September 2nd. And 
that's all I've gotten.
    Mr. Carnahan. But no advice about any testing beyond that?
    Ms. Maddux. No.
    Mr. Carnahan. I guess have you had an opportunity to talk 
to anyone about how this occurred or about improvements that 
are being made there to help rectify this?
    Ms. Maddux. No, I haven't.
    Ms. Odom. No, sir.
    Ms. Maddux. I find I take it upon myself, when told I was 
exposed to this, going on the Internet and researching it 
myself, as I do with any medication or any treatment that I 
have been given, to inform myself as best as possible.
    Mr. Carnahan. And I guess the last question for both of 
you. If you could, in brief, tell the Committee here, what 
would you like to be done to help you in terms of being sure 
you get the right care you need going forward?
    Ms. Odom. I would like just honest answers. And I would not 
always appreciate it always having to come from the media. No 
disrespect, but I think it should come from the VA. Honest 
answers. It seems like, you know, I've received ten different 
answers on one question. That's unacceptable.
    And I would like to know, how long do you plan on following 
this group of veterans and their families? I have a 19-year-old 
son. You know, I would like to know this. I have enough issues 
to deal with currently that I don't think I need extra anxiety 
to worry, do I get re-tested in August and then wait for 
results? And then again in December and so forth and so on? I 
would like somebody to let us just know the truth. We are not 
blaming anyone. We just want answers, that's all. The truth.
    Mr. Carnahan. And Ms. Maddux.
    Ms. Maddux. Yes, I would like to have someone appointed 
that we can call one person and not go through being directed 
or misdirected all different places to get the answers that we 
need.
    Mr. Carnahan. Thank you both.
    The Chairman. Mr. Blunt.
    Mr. Blunt. Thank you, Chairman. And thank you both for 
testifying. Let me ask a couple more questions.
    On the letter, Ms. Odom, you mentioned that you called. How 
long did you wait until you called?
    Ms. Odom. I fell down to my knees----
    Mr. Blunt. Uh-huh.
    Ms. Odom [continuing]. I'm just being honest, sir, in 
shock. It was the last thing I expected. You don't normally get 
certified letters from the VA Hospital. You might get them from 
the Veterans Benefits Administration (VBA) but never from the 
hospital.
    Mr. Blunt. Right.
    Ms. Odom. So I opened it, read it three times, let it sink 
in, fell down to my knees and said, you've got to get back up. 
I will call. It must not be that big of a deal because, you 
know, we are finding out by a certified letter.
    Mr. Blunt. Right.
    Ms. Odom. I called and, as I stated earlier, the young 
gentleman said he had just gotten hired for the 24-hour, 7-day 
a week manned thing. The Educational Department at John Cochran 
Division. He said, I'm sorry, ma'am. I can't help you. I don't 
know anything. But a nurse will be calling you in 1 to 3 hours, 
and he or she at that time will discuss any concern that you 
have.
    And I waited, literally looking at my phone for it to ring, 
and it did ring in about 2\1/2\ hours.
    Mr. Blunt. And when you talked to that person, what did 
they tell you?
    Ms. Odom. They told me that the risks were minimal. They 
told me not to have unprotected sex, use razors, fingernail 
clippers, share any bodily fluids with anyone else until I was 
tested. And they were so new into this, they were uncertain of 
what all had occurred. That we needed to wait until all of our 
blood tests were back.
    And they basically minimized it and stressed over and over 
again that the risk was very low, and even mathematically. We 
did the math. I did the math with them. That only one vet out 
of the 1,812 could be infected. But to me, one vet is 
deplorable and unacceptable----
    Mr. Blunt. Right.
    Ms. Odom [continuing]. And inexcusable. One person's life 
and maybe their spouses, et cetera? I don't have words for it.
    Mr. Blunt. And did you get--where did you get this 
information, or just give me a sense, that they might need to 
test you over a period of time? I think you said it could be 2 
years. It could be 20 years. Who told you that?
    Ms. Odom. I got that information, sir, from, I believe he 
called himself a physician from the VA this past Sunday that 
called me to tell me that, you know, because of the incubation 
period that I would be rescheduled to test again late August.
    He at that, at this time is not sure how they are going to 
track the vets that were affected and how long that we may have 
to be re-tested again. Sometimes strains of hepatitis C show up 
years later.
    And of course at that time, if you did test positive, they 
would have to go back to the 1,812, make sure that that strain 
actually came from this exposure.
    Mr. Blunt. Well, hopefully we will glean from later panels 
today, or follow-up with the Committee, Mr. Chairman, and get 
some more specific detail on that.
    I mean just the notice in July, for reasons we've 
mentioned, is bad enough. To wait that long. And then, you 
know, to have to worry from the first of July until sometime in 
August, that is an incredible amount of anxiety, particularly 
if you are already dealing with service-related anxiety, but 
even if you are not.
    And I'm going to be anxious to find out, for you and for me 
both, how long this really is going to take before you know 
that your life, as Ms. Maddux said in her testimony, is on 
hold. And hopefully we can get some answers there that are 
helpful for all of us to know. And I'm hopeful that the extent 
of time that this could take is--we can find out better answers 
than that.
    And the only other question I would have, Ms. Maddux, with 
Ms. Odom's testimony about other procedures at the facility, I 
notice you had some concerns in your testimony about earlier 
procedures. I assume those concerns are heightened now by this 
incident? You want to talk about that for just a second?
    Ms. Maddux. Yes. I have had numerous procedures since then. 
Just last month I had a cardiac catheterization done and I'm 
hoping everything from there was clean.
    And I'm concerned, like if I start feeling a fever or 
something, is that meningitis coming on again? And going 
through meningitis was the worst thing in my life. I guess I 
just have to wait and see.
    Mr. Blunt. And you now think that may have related to your 
care at the hospital? At the facility, rather?
    Ms. Maddux. Well, the meningitis was done after 
neurosurgery.
    Mr. Blunt. Uh-huh.
    Ms. Maddux. Leading up to it, I started getting fevers in 
the evenings and just all of a sudden a severe headache started 
that I wasn't used to. And in fact, that day I was 
hospitalized. And then----
    Mr. Blunt. They had surgery, these things happened, and 
then you were hospitalized again with meningitis?
    Ms. Maddux. Right.
    Mr. Blunt. Okay.
    Ms. Maddux. It was about 7 months since the neurosurgery 
that I was hospitalized again. And while in the hospital that 
time, I had to have another neurosurgery to remove the shunt 
and everything they had put in in the last surgery.
    Mr. Blunt. And you were scheduled for other care at the 
time you got the notice and so you were--you went to the 
facility pretty quickly after the notice because you were 
scheduled to go there, is that what you said?
    Ms. Maddux. Yes, I was scheduled 30th for a neurology 
appointment, so I knew I would be going there anyway, so I went 
through their process.
    Mr. Blunt. And you got your notice on June----
    Ms. Maddux. Twenty-eighth.
    Mr. Blunt [continuing]. Twenty-eighth?
    Thank you all for testifying. I know it's hard to talk 
about and I'm sure it's hard to live with the uncertainty of 
this. And one of our goals here would be to create whatever 
sense or whatever level of certainty and closure we can create, 
as quickly as we can help create that. But it helps to have the 
experience that you've gone through here.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Mr. Blunt.
    Mr. Costello.
    Mr. Costello. Thank you, Mr. Chairman.
    I thank both of you for your service to our Nation and I 
thank you for coming forward to testify before the Committee 
today.
    Ms. Odom, you mentioned seeing the dirty and rusty dental 
equipment. Did you report that to anyone when you saw it?
    Ms. Odom. No, sir, I did not.
    Mr. Costello. And I take it from your testimony, both you 
and Ms. Maddux, that the VA did not assign a caseworker or an 
individual to you, to either one of you to follow up, an 
individual that you could call at any time if you had 
questions?
    Ms. Odom. No, not at all.
    Ms. Maddux. [Shook her head.]
    Mr. Costello. You were just left on your own.
    And Ms. Maddux, as far as you know, you are going to be re-
tested in early September and there is not going to be any 
other contact with the VA?
    Ms. Maddux. Not for this situation, no.
    Mr. Costello. Okay. Again, I thank you for your testimony.
    Mr. Chairman, thank you. I give it back.
    The Chairman. Mr. Shimkus?
    Mr. Shimkus. Thank you, Mr. Chairman.
    I appreciate your testimony and thank you for your service. 
The quote of the VA comes from Abraham Lincoln and says, ``Care 
for him who shall have borne the battle and for his widow and 
orphan.''
    And obviously the VA failed in this aspect, and in their 
opening statements we, our concern is that this isn't an 
isolated case. And that's really telling.
    If it was an isolated case, as I think Chairman Filner and 
I talked about even prior to coming here, if it's isolated, 
then there are mistakes and we can move. But if it's endemic, I 
mean I would agree with my colleague, Mr. Akin, there is a 
systems problem here.
    So let me ask, your experience with Cochran on an--overall, 
not just this incident, on a zero-to-ten scale, 10 being great, 
where would you rate--because in the opening statement you 
especially, Ms. Odom, you mentioned the caregivers and people 
concerned. Overall, that facility, how would you rate them?
    Ms. Maddux first.
    Ms. Maddux. Before coming to St. Louis--I'm originally from 
St. Louis--I lived in Minnesota, so I had experience with their 
VAs and I would have to give John Cochran, at the very most, a 
four. And I find it really dirty, and knowing that there is 
other VAs out there that do a wonderful job.
    Mr. Shimkus. Ms. Odom?
    Ms. Odom. Are you talking specifically about the facility, 
sir? Or the personnel?
    Mr. Shimkus. Just the overall, if you've had service there 
and you walk away.
    Ms. Odom. I've had many services there, sir, and I would 
agree with this lady, that overall, a four at the highest. 
There is just things that we can do better. It's mainly the 
sanitation.
    Mr. Shimkus. And my colleagues have already asked questions 
about what you saw, when you notified. Have any of you ever 
used the Veteran Advocate in any process?
    Ms. Odom. They don't call you back, sir.
    Mr. Shimkus. They don't call you back.
    Ms. Maddux.
    Ms. Maddux. Yes, I have. It has been quite a few years ago, 
but I used that at Jefferson Barracks and I did get answers.
    Mr. Shimkus. Well, and that--one more follow-up. We have 
Cochran. But how would you rate the Jefferson Barracks 
component of care on a zero-to-ten scale?
    Ms. Odom. Ten.
    Mr. Shimkus. Ten. And as for Ms. Odom?
    Ms. Maddux. I would say a seven.
    Mr. Shimkus. Okay. That's all I have, Mr. Chairman. Thank 
you.
    I give it back.
    The Chairman. Thank you.
    Mr. Akin.
    Mr. Akin. Thank you, Mr. Chairman.
    Just to try to get a little bit more detail on what my 
friend Congressman Shimkus was getting at, if you were to take 
a look at the facility, first of all in terms of the people who 
are specifically medical doctors, how would you rate the people 
that you worked with? Did you feel like they were competent and 
did a good job, sort of one to ten, the doctors themselves?
    Ms. Maddux. As far as the doctors at John Cochran, I would 
give a seven because I find some that I'm not able to work 
with.
    Mr. Akin. So the doctors, about seven. Then how about the 
facility? Just the physical facility.
    Ms. Maddux. The facility is----
    Mr. Akin. I mean the buildings and, you know, the rooms and 
the bathrooms.
    Ms. Maddux. I find it really----
    Mr. Akin. What's that.
    Ms. Maddux [continuing]. Dirty. It's--you don't want to set 
your purse down on the floor. Holes in the wall. I know it 
takes time and money to get through it, but like the cleaning 
part could be done much better.
    Mr. Akin. How about the other medical personnel? Not the 
doctors but the other people who are physically doing medical 
kinds of things, like nurses and other aides?
    Ms. Maddux. Nursing care I would give a seven. But as far 
as clerks, I find almost every clerk I come in contact with is 
very rude. It's you are taking up their time.
    Mr. Akin. That was going to be my last question, was the 
administrative side. Just sort of the process of knowing who to 
call and getting the right information and having ease of 
access and being able to get answers quickly and that kind of 
thing.
    What would that be?
    Ms. Maddux. A five.
    Mr. Akin. Five.
    Ms. Maddux. I have to go through many people to get the 
right answer or to get the right clinic.
    Mr. Akin. Okay. Could I ask the same, Ms. Odom? The same 
kind of questions? First of all, doctors. You said you felt the 
doctors themselves were pretty good?
    Ms. Odom. The doctors and nurses and the medical staff that 
have treated me at John Cochran have been excellent.
    Mr. Akin. Okay. Then the actual facility itself, the 
buildings, the rooms, the bathrooms, all that kind of stuff?
    Ms. Odom. Everyone here that's toured the building, or any 
vet that's been to John Cochran sees that there is construction 
going on, improvements, but it's absolutely deplorable and 
unsanitary.
    I just happened to be there yesterday for a scheduled 
appointment and noticed a lot of housecleaning going on there.
    Mr. Akin. Okay. And then last of all, from the 
administrative side, just the ease of knowing how to get in, 
get your appointment scheduled, knowing who to talk to, just 
the interface, do you feel like you are a very important 
customer to them, or is it the opposite?
    Ms. Odom. I take up their time.
    Mr. Akin. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Mr. Luetkemeyer.
    Mr. Luetkemeyer. Thank you, Mr. Chairman.
    And thank you, ladies, for your service and your 
willingness to be here today. And I know it's difficult to be 
in your position. You are publicly talking about some very 
personal things and we appreciate your willingness to share, 
and are very sorry for your situation. Hopefully this hearing 
will rectify that and hopefully we can make amends for that.
    Just curious. I know that, Ms. Odom, you talked a number of 
times about the conditions there. Have you ever complained to 
any administrative people about the filthy conditions or unsafe 
or unsanitary things that you may have seen or experienced?
    Ms. Odom. Yes, I actually called the Patient Advocate 
because it's actually on a brochure when you are an inpatient. 
I left my name, number, last four, and I never got a response.
    And actually, I felt so horrible for the nurses that were 
on the floor that said that it's been like that for years that 
I didn't, I did not follow through with trying to keep 
contacting the Advocate over and over again.
    You know, I don't know, I don't know if it's lack of funds, 
lack of housekeeping, but I'm not talking about a bathroom, for 
instance, where I was supposed to take a shower that was just 
nasty or dirty or messed up, but someplace that was disease-
contaminated for obvious reasons. I mean you could not take a 
shower in there unless it was the last resort.
    Mr. Luetkemeyer. But they didn't respond to you once you 
called, is that what you are saying?
    Ms. Odom. No.
    Mr. Luetkemeyer. You complained, and there was no follow-up 
by them on your complaint, to you?
    Ms. Odom. No, sir.
    Mr. Luetkemeyer. Ms. Maddux, did you do that yet?
    Ms. Maddux. In 2003, after moving back to St. Louis and 
seeing the facilities, my husband and I both did complain about 
it. We received a call-back asking, well, what room did you see 
a hole in? Or--it was almost like I was bothering them by 
making a complaint.
    Mr. Luetkemeyer. Just to reframe what you have said here, 
it appears that when you were told, when you contacted the VA 
after you received your letter, you each one got a different 
explanation of what was going on.
    Am I reading that correctly? Or have you talked with each 
other? Or I mean----
    Ms. Odom. [Shook the head.]
    Mr. Luetkemeyer. Each one has a different explanation of 
what you were told at the time you called. Am I getting that 
correct from your testimony here today? It sounds like that.
    Ms. Odom. We've never met each other. I mean what I 
understand, sir, is I called, and she had a scheduled 
appointment anyway.
    I don't know if you called.
    Ms. Maddux. I called on the 30th, you know, right before I 
was going there that afternoon. And I believe my appointment 
time was 3:00 and they gave me an appointment to I guess go 
through their process for 4:00.
    Mr. Luetkemeyer. I guess the point I'm trying to get at 
here is, is there a plan or have you been explained--has a plan 
been explained to you on how to take care of yourself, or how 
you are going to be treated, or what they are going to do to 
take care of you over the next several months?
    Ms. Odom. No, sir.
    Mr. Luetkemeyer. No. Okay.
    Ms. Odom. Other than the nurse who did call me back in 2\1/
2\ hours to explain no unprotected sex, no fingernails sharing, 
no toothbrush sharing. You know, things like that.
    Mr. Luetkemeyer. No scheduled follow-ups for you on a 
regular basis?
    Ms. Odom. No, sir.
    Mr. Luetkemeyer. All right. Have either one of you gone to 
a private doctor or a private clinic and been checked out at 
all on your own?
    Ms. Maddux. With my service-connected condition I guess I 
have to sign a contract with my physician, because I'm 
receiving certain medications, that I do not go to other 
doctors.
    Mr. Luetkemeyer. Okay. We are talking today mainly about 
the dental portion of this. Have either of you been to the--had 
dental service more than just once over the last several 
months----
    Ms. Odom. I have.
    Mr. Luetkemeyer [continuing]. During this time period 
that's in question?
    Ms. Odom. I have, sir. Five times.
    Mr. Luetkemeyer. Five times.
    Ms. Odom. And I have a scheduled appointment for the 23rd 
of August, 2010, which I obviously plan to cancel.
    Mr. Luetkemeyer. Okay. So you actually could have been 
exposed or were exposed five separate times, is that what you 
are saying?
    Ms. Odom. Yes, sir.
    Mr. Luetkemeyer. Ms. Maddux? Were you----
    Ms. Maddux. Twice.
    Mr. Luetkemeyer. Twice? So you could have possibly two 
exposures, is that what you are saying?
    Ms. Maddux. Yes.
    Mr. Luetkemeyer. Okay. When you were--has anybody at this 
point given you an explanation, whenever you called or since 
then, given you an explanation of, number one, why this went on 
this long and what happened and why it took so long to get to 
you? Have they given you any explanation at all?
    Ms. Odom. They just keep stressing low risk. Don't worry 
about it.
    Mr. Luetkemeyer. So there has been no explanation to you of 
how this happened, why it happened, or sort of remedy why it 
took so long. You just, you got a letter that said, hey, you've 
got a problem perhaps, and it said, we will take a look at it? 
Okay.
    Ms. Maddux. I was told I guess the same story line as the 
media has gotten about, it was found in a routine inspection 
and that there is minimal risk. Everything should be fine.
    Mr. Luetkemeyer. Okay. Again, thank you very much for your 
service and being here today. And hopefully we can get to the 
bottom of this and prevent this from happening in the future. 
Thank you very much.
    Thank you, Mr. Chairman. I give it back to you.
    The Chairman. Thank you. Mr. Miller?
    Mr. Miller. I think most of the questions have already been 
asked, but first of all, thank you for your service. And as has 
already been said up here, thank you for your willingness to 
step forward.
    We hear you. And regardless of what people say, I didn't 
come from Florida trolling for news up here. I came here 
because I wanted to hear your story and we want to make sure 
that this doesn't happen again.
    If you could go to another medical facility in the 
community, would you go?
    Ms. Odom. Yes.
    Ms. Maddux. Yes.
    Mr. Miller. Prior to this happening, if you could have gone 
to another facility, would you go?
    Ms. Maddux. Yes.
    Ms. Odom. No.
    Mr. Miller. And why do you say no?
    Ms. Odom. Because it's taken me years to trust my 
therapists and doctors, and I finally have that trust with 
them, that I don't feel like I want to start from ground zero 
with new doctors. That's me personally, though.
    Mr. Miller. And you say yes.
    Ms. Maddux. Yes. I just received a new primary care 
physician that I don't care for, and I'm starting all over 
again getting all this testing and I guess having her trust me.
    Mr. Miller. What happened? You say you don't care for your 
primary care physician now.
    Ms. Maddux. Yes.
    Mr. Miller. How do you get another one? Can you?
    Ms. Maddux. Yes. Requesting a new primary care. The last 
one I had, I had for 7 years. But she moved to a different part 
of the facility and the new one is starting from zero. And with 
my conditions it's, she keeps questioning, well, do you have 
this condition?
    Mr. Miller. Thank you, Mr. Chairman. I yield back.
    The Chairman. I, again, thank you. Between your testimony, 
which is very searing, and the sensitive questions of my 
colleagues, I think we get a picture that is pretty shocking. 
All I wanted to say is that we are not going to forget it. We 
are going to act on it. We appreciate your testimony. Thank you 
very much.
    Ms. Maddux. Thank you.
    [Applause.]
    The Chairman. Now, panel two, will you come forward.
    We ordinarily don't do that, but this is a very emotional 
issue so I see a hand that, if you want to just come up and 
state your name and ask a question, that will be fine, while 
panel two is coming up.
    Voice. Hello. Can you hear me?
    The Chairman. Yes.
    Voice. I would just as soon not give you my name because I 
don't want to get the dentist in trouble that told me this. 
So--I've been to the dentist a couple times here and I think my 
first visit was in August. August/September. And I had missed 
a, I had missed the appointment and it took me months and 
months to get an appointment again.
    I asked him, why does it take so long? And of course he 
said, we are understaffed. We put in request after request to 
get dental, to get dentists, and maybe other staff people, I 
don't know, but it keeps getting denied. This is at John 
Cochran.
    And then a few more minutes I talked with the gentleman and 
he says, and the other thing is we have a requirement that if 
someone comes in for a dental check and we find something 
wrong, like a tooth decay, we have to see that patient again in 
maybe 2 or 3 weeks. Well, we can't do that because we are 
understaffed. We have so many people we've got to see.
    I said, well, what do you do about that? He said, well, we 
send up the paperwork saying that we didn't meet that 
requirement. But somewhere between the dentist and the VA, it 
gets changed to show that they are meeting their requirements. 
So they don't get, they don't have that staff. Additional 
staff.
    So the paperwork is getting doctored that, I don't know, 
maybe the Budget Committee is seeing. Maybe it goes to the 
administration here at John Cochran. Maybe it gets sent on 
further.
    The Chairman. Okay.
    Voice. So they are understaffed.
    The Chairman. Thank you very much. We will be looking into 
that.
    Our second panel consists of a former VA dental employee, 
Ms. Earlene Johnson, and Mr. Barry Searle--is that the 
pronunciation?
    Mr. Searle. That's right.
    The Chairman. The Director of the Veterans Affairs 
Rehabilitation Commission for the American Legion, I assume 
from Missouri or St. Louis.
    Mr. Searle. Actually, Washington, sir.
    The Chairman. I'm sorry. From Washington. Thank you for 
joining us here today.
    Ms. Johnson, we will put any written remarks you have in 
the record, and whatever you want to tell us, Earlene.

STATEMENTS OF EARLENE JOHNSON, ST. LOUIS, MO (FORMER VA DENTAL 
EMPLOYEE); AND BARRY A. SEARLE, DIRECTOR, VETERANS AFFAIRS AND 
           REHABILITATION COMMISSION, AMERICAN LEGION

                  STATEMENT OF EARLENE JOHNSON

    Ms. Johnson. First of all, thank you. Thank you very, very, 
very much for this opportunity to speak.
    The Chairman. If you will bring the microphone a little 
closer, ma'am? Thank you.
    Ms. Johnson. I did not work in the dental department. I 
worked in an area called Sterile Processing. Sterile Processing 
is an area where we do cleaning processing of instrumentation.
    I was terminated for trying to help the Vets Gateway 
Chapter of Paralyzed Veterans and my family members that go to 
John Cochran. I never worked for the VA Hospital nowhere else. 
In Oregon, I was a manager over Sterile Processing, in which we 
collected instruments throughout the hospital. I wasn't a lazy 
manager. I took that extra step.
    You find at John Cochran when you open your mouth about 
something, you are either retaliated on, or targeted, or you 
are just praying that the next day you walk in, you have a job. 
Unfortunately, I was on probation and didn't keep my mouth 
shut. I called Washington. I tried to warn people in 
Washington. I couldn't get through. I couldn't get through.
    I knew something was going to happen at John Cochran and I 
didn't give up, even when they terminated me. I still made 
calls. I have a father that's buried at Jefferson Barracks. He 
was a sergeant major. I have another father that goes to John 
Cochran that can barely walk. I have family members that go to 
John Cochran and it didn't matter to me if I was on probation. 
There is something wrong. There is something wrong.
    When you hire people in positions, you don't hire your 
friends. You don't hire people that are not qualified for that 
particular position. You want people that's going to, you know, 
take extra steps.
    What happened in the dental clinic shouldn't have ever 
happened. If people were taking their jobs seriously, not 
passing the buck and pointing the finger, none of this would 
have happened. And I apologize to the 1,800 veterans and I 
apologize to all of the veterans throughout the United States. 
Not just John Cochran.
    I didn't know what to do. I had to play strategic games 
around there. They start transferring me from one department to 
the next because I hurt my arm and had to have surgery. In 
fact, I tore my tendon. So I tell you what. Since they were 
transferring me to one department to the next department--and I 
do have experience in management, I do have experience in 
troubleshooting--I just took a look at the departments that 
they were transferring me to, okay?
    And out of I would say four departments, I found only two 
where the management were managers. And out of the two, the 
technician should have been the manager. I've seen so much 
mismanagement at John Cochran. I've seen employees talked to 
like they were kids. I've managed people and one thing I have 
learned in managing is that your employees make you. So if you 
are belittling them, intimidating them, what kind of service do 
you think you are going to get?
    If employees are intimidated, they are not going to speak 
to you. They need their job just like I needed mine. I needed 
my job. I had medical issues going. I wouldn't have ever done 
anything to jeopardize my job. I had medical issues going. Not 
just for my arm. I had medication that I have to take. If I 
don't take it every day, I will die.
    And then to top it all off, when Unemployment did their 
investigation, they found out this girl, what did you fire this 
girl for? You fired her for other reasons than misconduct. They 
had 30 days to appeal. They didn't appeal it.
    This isn't about me. It's about the veterans. Has anyone 
talked to the veterans about HIV and HIV on instruments? No. 
Well, first of all, if the procedures in the department was 
taking that extra step like I warned them when I was there--I 
told them that you are supposed to get up and check all of the 
auxiliary units. Auxiliary units are the units like your 
dental, your eye. Any instrument that needs to be processed 
needs to come to this department. I told them that.
    But see, at John Cochran, to me, in my opinion it's like, 
oh, that's their department. They do it. No. No. No. No. No. 
That's where a lot of people have a misconception. When you run 
a Sterile Processing department, that's your responsibility to 
take that extra step to walk around, to make sure no one is 
doing any kind of processing whatsoever, because you have the 
people who have gone to school who are supposed to know how to 
clean. They are certified.
    I mean if your heart was hurting, who would you go to? An 
orthopedic doctor or a heart specialist? A heart specialist. 
It's simple. If you need your instruments processed correctly, 
would you take them over here to dental, or would you take 
those instruments somewhere that's located inside the hospital 
to have them cleaned and processed by people who have gone to 
school, that are supposed to know how? That wasn't the case at 
John Cochran.
    [The prepared statement of Ms. Johnson appears on p. 72.]
    The Chairman. Ms. Johnson, we thank you.
    Ms. Johnson. Okay.
    The Chairman. We will have questions for you, so thank you 
so much for your testimony.
    Mr. Searle.

                  STATEMENT OF BARRY A. SEARLE

    Mr. Searle. Thank you, Mr. Chairman and Members of this 
Committee. Thank you for giving this opportunity to the 
American Legion to view this pressing issue brought to light 
recently by developments at the John Cochran VA Medical Center.
    The American Legion, from its inception, has been both a 
strong advocate for veterans and proponent for an effective 
Federal entity whose mission is to care for those veterans.
    Central to the American Legion's efforts is a program 
called ``A System Worth Saving.'' This Task Force, first 
established in 2003, annually conducts site visits at VA 
Medical Centers nationwide to assist the quality and the 
timeliness of VA health care. This Task Force we believe has 
identified some issues contributing to the issue at hand.
    In March of this year, during a routine inspection of the 
John Cochran Medical Center by VA's Infectious Disease Program 
Office, it was determined that dental instruments were not 
being cleaned in accordance with specifications of the 
manufacturers or in accordance with VA's own procedures for 
proper sanitation and sterilization. These instruments were 
being cleaned without proper detergent, potentially putting 
veterans at risk for blood-borne illnesses such as HIV and 
hepatitis.
    VA's Central Office convened a special Committee to 
determine an appropriate response. The Committee could not 
determine that risk to approximately 1,800 patients was zero, 
an absolute zero chance of infection, therefore, a decision was 
made to notify all affected veterans. These 1,812 veterans, 
notified through certified mail, were provided with free 
testing for HIV and B and C strains of hepatitis, and will be 
provided with whatever follow-up care is deemed necessary. As 
of this time, no veteran is known to have contracted any of 
these diseases through this exposure.
    The American Legion feels that VA took responsibility and 
demonstrated an act of faith to bring this issue to the 
attention of veterans and the public. Placing patient safety 
before good publicity deserves to be acknowledged.
    However, as the American Legion National Commander, 
Clarence Hill, recently stated, this is an extremely serious 
problem that has happened before, and will happen again unless 
VA ensures strict adherence to proper sanitation and 
sterilization protocols.
    To expose trusting veterans to blood-borne illness through 
routine medical treatment because of avoidable errors in 
sanitation of medical equipment is inexcusable. The problem 
exists not in the business process structure of this system, as 
the existing protocols were designed to prevent such exposures, 
but rather, in the failure of those operating the system to 
execute those protocols. This can only be overcome by diligent 
management, training and accountability.
    This event is not the only reported occurrence of failure 
to follow procedures within the Veterans Health Administration 
(VHA) system. The Department of Veterans Affairs Office of 
Inspector General Report from 21 April, 2010, concerning 
suspected issues in the Supply Processing and Distribution 
department related to endoscope reprocessing and communications 
to St. Louis facility substantiated alleged cleaning issues of 
equipment.
    In its findings, VA OIG identified turnover in several key 
staff positions as a serious issue. During the 2010 ``System 
Worth Saving'' Task Force visits to 32 VA Medical Centers 
across the country, a commonly repeated theme was the shortage 
of personnel, especially nurses and personnel with specialty 
training.
    It is the opinion of the American Legion that turnover of 
personnel and the shortage of personnel at most facilities 
requires renewed emphasis on standardized procedures, quality 
review, and individual training, as well as documentation of 
that training.
    If an emphasis on training is subverted to day-to-day 
operations, dedicated people will make mistakes. Further, the 
American Legion believes that Central Office must maintain 
proper oversight of medical care, utilization of facilities, 
and resources in order to ensure veterans receive the highest 
quality of care.
    On April 28th, 2010, in a Pittsburgh Tribune Review article 
concerning a reported incident at the Pittsburgh VAMC in 2007, 
it was noted that the Food and Drug Administration (FDA) had 
cited the VA facility for not doing a routine blood type 
certification test, a violation of standard procedure. This 
resulted in a patient receiving six units of the wrong blood 
before he died. It was reported that VA officials told the FDA 
the error stemmed from a heavier-than-usual workload in the 
blood bank.
    The American Legion understands that the policies developed 
at Central Office with the best of intentions are, for the most 
part, executed at the discretion of the Veterans Integrated 
Services Network (VISN) Director or Facility Director level, 
and therefore vary in local implementation.
    It was testified by the American Legion, during a 1 July 
Subcommittee hearing, we believe that there is a breakdown in 
follow-up and accountability by Central Office to ensure 
procedures are being followed. This autonomy of the facility 
directors is a function of an overly decentralized VA 
structure. It is no means unique to VHA. It is, we believe, 
systemic to VA's mode of operation.
    For example, in VBA we have seen and, in fact, been told by 
VA personnel themselves that when you see one regional office, 
you have seen one regional office. The implication is there is 
little standardization in VA.
    Again, one of the concerns of the American Legion, as 
stated in testimony over the last few months, has been that VA 
needs to do a better job in training its people, more 
effectively ensuring they understand and follow the correct 
protocols that have been established. There is also a need to 
enforce central oversight of the regional VISNs, thereby 
ensuring consistency and accountability nationwide.
    When a problem is identified, it is not enough to simply 
move people to different facilities doing the same job. 
Unfortunately, at times accountability means negative impact on 
the individual who is responsible. With correct and effective 
accountability, there is hope for continued faith in the 
veterans' health care system.
    The American Legion is committed to working with the 
Secretary to ensure that this situation is successfully 
resolved and that instances such as this do not become an 
ongoing issue with our otherwise excellent VA health care 
system.
    Mr. Chairman and Members of the Committee, thank you.
    [The prepared statement of Mr. Searle appears on p. 76.]
    The Chairman. Thank you, sir.
    Mr. Carnahan.
    Mr. Carnahan. Thank you again, Mr. Chairman.
    And I guess I want to first start with Mr. Searle. Thank 
you and the Legion for the work they do with VA. And I wanted 
to ask, with regard to any of the prior annual site visits that 
are done at Cochran, were there any red flags that appeared in 
those recent visits, and did they reflect any of the other 
issues that were raised by the Inspector General recently, or 
in the recent Patient Satisfaction Surveys?
    Mr. Searle. Well, actually, the Legion has not been to 
Cochran in several years. We do 32 facilities a year, so we 
have them done on a rotational basis, so we have not done a 
follow-up on this particular facility.
    Mr. Carnahan. So when was the last time that you had done a 
site visit at Cochran?
    Mr. Searle. I believe it was 2007. I can confirm that, sir.
    Mr. Carnahan. Okay. Thank you very much.
    And Ms. Johnson, we really appreciate you being here. From 
your background and your experience in Sterile Processing, I 
think you have some unique insights to share. So we especially 
appreciate your willingness to come forward.
    I want to first, I guess, ask you about the earliest time 
when you began raising concerns about any of the sterilization 
processes while you were at Cochran.
    Ms. Johnson. I brought this up before the supervisor. 
Walking and checking like the dental clinics and the eye, in 
March.
    Ms. Maddux. Of this year?
    Ms. Johnson. 2009.
    Mr. Carnahan. Of 2009. And I know that you had, I 
understand that you had previously provided copies of an e-mail 
as far back as August----
    Ms. Johnson. Yes.
    Mr. Carnahan [continuing]. Of 2009, where you outlined some 
improvements that needed to be done. Could you talk about that?
    Ms. Johnson. Well, when I was hired in, I saw a lot of 
things wrong with the Sterile Processing department. I saw how 
it was ran.
    After I had suggested to my boss that she should be walking 
around, you know, checking--in the old days we used to call it 
CYA. Excuse me, but that's what we called it, you know. And----
    Mr. Carnahan. And excuse me. Who was your boss at the time?
    Ms. Johnson. I can't answer that.
    Mr. Carnahan. Okay. What department were you in.
    Ms. Johnson. I was in a department called Processing and 
Distribution at John Cochran Hospital. And that's what made me 
start the improvement process. I sent an e-mail to her boss as 
far as improvements for the department.
    Mr. Carnahan. That was to your supervisor's boss?
    Ms. Johnson. Yes. They both had copies of it.
    Mr. Carnahan. And this was in March of 2009.
    Ms. Johnson. I don't have the dates with me, but I do have 
the e-mail as far as the improvements were concerned. And you 
know, nothing happened. Nothing. It was just like I was just 
there and they are going to do what they wanted to do. That's, 
they didn't--whatever improvements, they didn't want to.
    Mr. Carnahan. And you were raising these issues because of 
your prior experience in Sterile Processing?
    Ms. Johnson. Yes, sir. Yes, sir. I have 27 years experience 
in Sterile Processing. I started off as a technician. I grew 
into a supervisory position, and then I went on into management 
in Chicago and in Oregon.
    Mr. Carnahan. And so the earliest time you can recall 
raising this is March of 2009. Do you recall about how many 
times you raised these issues?
    Ms. Johnson. There was another time I brought the issue up 
because there was a problem in another clinic, which it didn't 
get to the public.
    I brought it up again and I, you know, I told this person 
that, you need to be walking around and, you know, talking to 
the supervisors or directors in these departments, making sure 
that no instruments are being sterilized in their department. 
All the instruments are supposed to come to our department.
    Mr. Carnahan. And that's the central sterilization 
facility?
    Ms. Johnson. Yes, which they call P&D.
    Mr. Carnahan. And that's the--you worked in the central 
facility?
    Ms. Johnson. I worked in Processing and Distribution, where 
they do the sterilization of instrumentation.
    Mr. Carnahan. How many employees worked there when you 
worked in that department?
    Ms. Johnson. Oh, I would say approximately 13, 13 or 14. It 
might have been more.
    Mr. Carnahan. And when you were terminated, what reason did 
they give you?
    Ms. Johnson. Unprofessional conduct.
    Mr. Carnahan. What do you think that meant?
    Ms. Johnson. I didn't know. I asked them, because I've 
always carried myself in a professional manner, always, no 
matter what they did, no matter what they said, no matter how 
they tried. I'm an Army brat and it's hard to really break me. 
So I always carried myself in a professional manner. My daddy 
taught me that.
    Mr. Carnahan. Do you still have a pending complaint or 
case, or has that been resolved?
    Ms. Johnson. Nothing has been resolved. It's still pending.
    Mr. Carnahan. Were there other people within your 
department that discussed these concerns, also, besides the 
supervisors?
    Ms. Johnson. I was the only one.
    Mr. Carnahan. We appreciate your service and especially 
being here to share your story. And again, we hope this is an 
important part of getting to the bottom of this, getting 
answers, so that we can care for those veterans impacted and be 
sure this doesn't happen again.
    Thank you all.
    The Chairman. Thank you.
    The Chairman. Mr. Blunt.
    Mr. Blunt. Thank you, Mr. Chairman.
    Ms. Johnson, when did you come to work at Cochran?
    Ms. Johnson. I left Chicago, Illinois, in December of 2008.
    Mr. Blunt. And when did you go to work here?
    Ms. Johnson. December the 22nd or the 23rd of 2008.
    Mr. Blunt. Of 2008? Of 2008? Now, did you ever work in the 
dental sterilization area at all?
    Ms. Johnson. No, sir.
    Mr. Blunt. And your view is, as I understand it, that all 
the sterilization should have been done in the Sterile 
Processing department?
    Ms. Johnson. Yes, sir.
    Mr. Blunt. And do you know how the dental sterilization was 
done before February 1, 2009?
    Ms. Johnson. Processing and Distribution was going to 
dental to pick up the dirty instruments. That's why I can't 
understand how this happened. They were going making rounds, 
picking up dirty dental instruments.
    Mr. Blunt. Even between February of 2009 and March of 2010, 
they were picking up some of the instruments or were not?
    Ms. Johnson. From the time I was hired in December of 2008 
until the time of my termination of November the 10th of 2009, 
the Sterile Processing department was picking up dental 
instruments that needed cleaning and processing.
    Mr. Blunt. And your impression would be, from what we now 
know, they weren't picking up all the instruments?
    Ms. Johnson. Yes, sir.
    Can I explain one thing?
    Mr. Blunt. Yes.
    Ms. Johnson. This is why I'm saying that when you hire 
people in, you need to really know they know their job. This 
dental clinic is located inside a hospital. It's not located 
outside somewhere in another building, where the dental 
hygienists have to know sterilization because they use smaller 
equipment, tabletop sterilizers and ultrasonic. This clinic is 
located inside the hospital. Anything that's located inside the 
hospital, you have a central area for cleaning, and that would 
be Sterile Processing.
    So all these instruments that come to Sterile Processing, 
they are processed. They are clean. You have people who do just 
that. They are supposed to know their jobs.
    Mr. Blunt. Right. And you are telling us that your 
impression is, or your full understanding is that some things, 
between the period we are talking about here, went to the 
Sterile Processing area?
    Ms. Johnson. Yes.
    Mr. Blunt. And we don't think the problem occurred, Mr. 
Chairman, in Sterile Processing. We think it occurred at the 
department level. And I see some agreement behind you that that 
is the case.
    I'll be interested--and I don't know that you would know 
this--but I would be interested to know what happened February 
1, 2009, that was different than January, 2009.
    And I'm surmising that maybe everything was going to 
Sterile Processing in January, and for some reason everything 
didn't go in February.
    But at some point I want to know what was different in 
January and what was different after February 1. And I assume 
maybe someone on the next panel will be able to tell us that.
    And I think those are the only questions I have here, Mr. 
Chairman.
    The Chairman. Thank you.
    Mr. Costello.
    Mr. Costello. Thank you, Mr. Chairman.
    Mr. Searle, you've stated in your written testimony that, 
``The problem exists not in the business process structure of 
the system, and the system protocols were designed to prevent 
such exposures, but rather, in the failure of those operating 
the system to execute those protocols. This can only be 
overcome by diligent and attentive management and training.''
    You heard earlier about the incidents, the veterans, over 
10,000 veterans that were exposed in the three States, 
Tennessee, Florida and Georgia. You heard me and Congressman 
Shimkus talk about what's happened at the VA facility, the 
hospital in Marion. Those deaths resulted in Marion because of 
substandard care. Failure to follow standard procedure.
    In your position, have you ever heard, either at the Marion 
facility or any VA facility where anyone was held accountable 
and actually terminated from employment? Either an 
administrator or employee?
    I can tell you in the case of Marion, as Mr. Shimkus can, 
the administrator who was in charge of the facility was 
transferred to be an administrator at another facility and, in 
fact, we got an Acting Administrator. This happened in 2007 and 
they just appointed a permanent administrator over at the 
Marion facility who started this week.
    So my question is, do we just shuffle chairs around, or do 
we hold people accountable?
    Mr. Searle. The information that the Task Force has brought 
back is that there is a shuffling of people going on. I've not 
been told anyone has ever actually gotten fired. I haven't 
substantiated that. But that people have just been moved.
    Mr. Costello. So basically the people that work for the VA, 
the message is that if you don't follow procedures, you will 
still have a job. They may transfer you to another facility, 
but no one really is held accountable.
    Mr. Searle. That's the trends that we are picking up, yes, 
sir.
    The Chairman. Good step, Mr. Costello, for a whistleblower.
    Mr. Costello. And I was going to get to that.
    Ms. Johnson, I can tell you, in your testimony where you 
state that they wanted you to keep your mouth shut, they did 
not want employees to give suggestions or to criticize 
procedures, that is exactly what we found from the employees at 
the VA facility in Marion.
    I have had, and Congressman Shimkus had many meetings with 
the employees, both at the facility and off the facility after-
hours, to hear their complaints and to investigate some of the 
issues that they raised, and we heard the exact same thing from 
those employees, that the administration did not want to hear 
suggestions or criticism and, in fact, there was retaliation 
and intimidation.
    So what you have testified to this Committee today, we have 
seen not only at this facility that you are testifying about, 
but we saw it in Marion.
    Finally, let me ask, Mr. Searle, examining what has 
happened here based upon what you know thus far, what should 
the VA have done as soon as they found out that 1,812 veterans 
were at risk?
    Mr. Searle. Well, we would agree that they could have moved 
faster and put the word out sooner. I think that it goes back 
to what I read in my original testimony is that rather than 
waiting until something happens, there has got to be more 
oversight on a quarterly basis, monthly basis, whatever is set 
up, rather than--we feel that there is not enough oversight 
from Central Office. There are many different issues. There are 
a lot of policies that are put out, documentation put together. 
But when it gets down to the autonomy at the facility division 
director, regional office level, there is just too much leeway, 
in our opinion, that they can manage it as they see fit. And 
that's where the issue has been, or it wouldn't have come up in 
the first place.
    Mr. Costello. Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Mr. Shimkus.
    Mr. Shimkus. Thank you, Mr. Chairman.
    As my friend Congressman Costello mentioned Marion, this is 
a, it's important to understand this stems two administrations. 
The Marion problem was in a previous administration and this is 
in the present administration. That's why a lot of us now are 
boring down on what is it about the Veterans Administration and 
the culture that's not focused on taking care of our veterans?
    And that's why, Mr. Searle, I'm going to be interested in 
following--I'm a Legionnaire myself and my post is right across 
the river, Post 365 in Collinsville--not just ``A System Worth 
Saving'' but a system worth reforming.
    Mr. Searle. [Nodded the head.]
    Mr. Shimkus. And I think we need other eyes on the system. 
Obviously the current eyes are not identifying things, or it's 
being squashed.
    Now, I know at Cochran when I visited a year or 2 ago, we 
had a Veteran's Advisory Committee made up of Legionnaires. 
Made up of VFW's. The only ones who complained to me at that 
time was the Paralyzed Veterans, based upon a spinal cord 
facility that we had been fighting and struggling and trying to 
get access to at Cochran.
    I think there must be an issue there, too. If we've got 
Veterans Advisory Committees and we've got these problems in 
veterans hospitals, then our Veterans Advisory Committees ought 
to be speaking up. They ought to be calling us. They ought to 
be calling the administration. They ought to be using the 1-800 
lines. And I would suggest that veterans here who know members 
on that Committee, that we all do a more diligent job.
    And Ms. Johnson--and my colleague Mr. Costello highlighted 
this--you believe you were fired for doing your job, you were 
punished, where we have a system that when people don't do 
their job, they are not punished?
    Ms. Johnson. Exactly. And that's the way it goes. You see 
it.
    Mr. Shimkus. And that's the way it has to change.
    Ms. Johnson. [Nodded the head.]
    Mr. Shimkus. That's the way it has to change.
    And my question was--and you answered it--this system seems 
like it's upside down?
    Ms. Johnson. Yes.
    Mr. Shimkus. You should be awarding people. When you work 
on a line, you are building a vehicle and there is a flaw in 
the vehicle, you pull the cord and you stop the process, 
because you don't want to sell faulty product. If you let it go 
on, then there is the whole, the whole system pays. So I 
apologize.
    Let me read something that came out of the St. Louis Post 
Dispatch on July 7th. And this is for Ms. Johnson. ``The 
cleaning of endoscopes was moved from the Supply Processing 
department to the gastrointestinal unit after problems surfaced 
with equipment not being properly cleaned.''
    Is that--would you view that as proper procedure, based 
upon your experience?
    Ms. Johnson. Did the article--I mean they moved the scopes 
from Processing to what area?
    Mr. Shimkus. Gastrointestinal.
    Ms. Johnson. When did they do that? Because Sterile 
Processing was doing the processing of scopes when I was there.
    Mr. Shimkus. I just have a snippet from, I know it's a Post 
Dispatch article. He's probably here, who wrote it.
    Ms. Johnson. Well, in my opinion, when I was there Sterile 
Processing was doing the scopes, processing the scopes, 
cleaning scopes, and they have a machine that do all of this.
    And GI, you know, they wanted those scopes and I thought it 
was proper that GI and their staff clean the scopes if they had 
well-educated employees in GI to clean the scopes.
    Mr. Shimkus. Okay. And the only reason why--the story goes 
on. It says, ``A month later, after receiving a complaint about 
endoscope sterilization, the Veterans Affairs inspectors 
visited the hospital and found several health and safety 
infractions. The temperature in the sterilization area was too 
high, rags and gloves were strewn about, decontamination area 
filters had not been changed, as required, a technician was not 
wearing protective gear, chemical test strips were left 
exposed, emergency exits were blocked, and employees were 
unsure whether an unattended endoscope was sterile, according 
to the Inspector Report issued in April by the VA's Office of 
the Inspector General.''
    Those would all be errors.
    Ms. Johnson. They kept me away from that area.
    Mr. Shimkus. Mr. Chairman, that's all I have. Thank you.
    The Chairman. Thank you.
    Mr. Akin.
    Mr. Akin. Thank you, Mr. Chairman. Just a couple of quick 
questions.
    First of all, Ms. Johnson, it sounds like you were in a way 
a whistleblower, but you really tried to reform things, get 
things changed from the inside. Of course, that's tricky to do 
if you don't have enough management support behind you, and 
sometimes they can isolate you.
    One thing, though. Did you write some letters making 
recommendations, specific recommendations, and saying, if we 
don't do this, we are going to have this problem? Did you leave 
any kind of a trail in that regard?
    Ms. Johnson. Yes, sir, I did.
    Mr. Akin. And could you make those letters available to the 
Committee?
    Ms. Johnson. Yes, I can.
    Mr. Akin. Thank you. Thank you for your testimony.
    The next question, is there any kind of--this is for the 
second witness, Mr. Searle. Is there any kind of a Customer 
Satisfaction Survey type of thing that people can fill out to 
say, how has your experience at the hospital been? Do they have 
any kind of procedures like that so there is a feedback loop 
that says, hey, we are missing something?
    Mr. Searle. That's part of our ``System Worth Saving.'' 
That's part of the investigations that we do. We go in and we 
look at the facilities, we talk to staff, and we do question 
patients to see what type of----
    Mr. Akin. And what sort of data do you get from that? Is 
there a pattern of people not being very happy with the 
services there, or is it no different than other places, or----
    Mr. Searle. Quite honestly, we find veterans are very 
pleased with the health care system overall.
    Mr. Akin. Overall.
    Mr. Searle. But we hear a significant, that they call it 
the best care anywhere. I'm sure you've heard that. There are 
very positive results.
    I am a veteran and obviously I'm a product of the Old 
Square VA in Pennsylvania, and I have nothing but positive 
things to say about it.
    Mr. Akin. Okay. So now we generalized the question, but are 
there certain specific facilities where you find that the 
ratings are low?
    Mr. Searle. I'm sure there are some that are lower than 
others. I don't have this year's ``System Worth Saving'' 
compiled yet. The team is still putting it together. It will be 
made available to you as soon as----
    Mr. Akin. Because from your testimony what I thought I 
heard, because I was interested in kind of the overall system 
and what's going on.
    I got the impression from you that the system is pretty 
independent. That one Veterans Center may work pretty much 
differently than another. There is a lot of autonomy.
    Mr. Searle. That's correct.
    Mr. Akin. Therefore, if that's the case, I would think 
there might be some that would be shining examples of good 
care, and some other ones--at least you'd think there would be 
good ones and bad ones in the system, and a lot of ones partly 
in between.
    Mr. Searle. Oh, yes, there are.
    Mr. Akin. If that's the case and you do have those sort of 
satisfaction surveys, is that the pattern that you see in 
general, do you think?
    Mr. Searle. I would think so, yes, sir.
    Mr. Akin. You would think so. But have you noticed that 
pattern specifically?
    Mr. Searle. Again, I haven't seen this year's report. I 
don't know.
    Mr. Akin. I'm not talking about this year's. I'm just 
talking about in general.
    Mr. Searle. In general? Yes, sir, we have seen some 
patterns.
    Mr. Akin. You do see that. And have you seen anything in 
terms of the data from the people that you have going through, 
has there been a problem with this particular facility?
    Mr. Searle. No, sir. As I mentioned before, the last time 
that we went through this facility was in 2007.
    Mr. Akin. And at that time was there difficulty there, or 
not particularly?
    Mr. Searle. No, sir.
    Mr. Akin. It didn't stand out as being worse than some 
other facilities or something like that?
    Mr. Searle. No, sir.
    Mr. Akin. Okay. Thank you very much.
    That's all the questions I have, Mr. Chairman.
    The Chairman. Thank you.
    Mr. Luetkemeyer.
    Mr. Luetkemeyer. Thank you, Mr. Chairman.
    For Mr. Searle, you are an advocate group for veterans with 
regards to VA treatment and benefits, the care that they get.
    How is your relationship normally with the VA? Do they 
accept your suggestions? Do you have a pretty good working 
relationship with them? Is it adversarial, or what would you 
say?
    Mr. Searle. I wouldn't say it's adversarial. I think we 
have a good working relationship. I'm sure that at some times 
we get under their skin, but that's part of the job of being an 
advocate.
    Mr. Luetkemeyer. You know, during your testimony you were 
talking they need some increased accountability. What were some 
areas? Can you define that or explain where you thought it 
would be? And specifically to this situation.
    Mr. Searle. Well, again, sir, what we are looking at is 
that the procedures have been set up for the sterilization and 
various specifically to that are going on, and we just are not 
seeing a feedback mechanism going to Central Office, where the 
facility directors can say, yes, we are following these 
procedures. This is the training that's being conducted. These 
are the specifically to that are being done. We are not seeing 
anything that shows Central Office.
    Again, going back to my military, I was a colonel. Retired 
colonel. The troops do best when the boss checks. And we are 
just not sure there is a significant feedback mechanism to make 
sure the troops are doing what they are supposed to be doing.
    Mr. Luetkemeyer. During your testimony I think you made the 
statement that you hadn't been in this facility for a while, is 
that correct?
    Mr. Searle. Yes, sir, that's correct.
    Mr. Luetkemeyer. How can you make accountability 
suggestions if you haven't been there?
    Mr. Searle. Again, I came from National Headquarters. We 
are using the VA system, VHA, in general, not specifically to 
this facility. It's what we have found across the board at VA, 
sir.
    Mr. Luetkemeyer. Okay. The suggestions that you have made, 
have you given those to the Cochran folks at this point?
    Mr. Searle. No, sir.
    Mr. Luetkemeyer. You have not. Have you had any discussions 
with them at this point about you are going to give them some 
suggestions? Or----
    Mr. Searle. No, sir, we have not.
    Mr. Luetkemeyer. Okay. At what point were you notified, or 
the American Legion? Or were you notified at all about this 
situation?
    Mr. Searle. We, similar to the Committee, we saw it in the 
newspapers in this case.
    Mr. Luetkemeyer. Okay. Is it normal procedure that you not 
be notified?
    Mr. Searle. By VA?
    Mr. Luetkemeyer. Yeah.
    Mr. Searle. VA would not, has not in the past brought 
anything in particular to our attention with regard to these 
kind of issues.
    Mr. Luetkemeyer. Okay. So sometimes they do, sometimes they 
don't. Generally they don't do it at all?
    Mr. Searle. I can say that generally they don't let us know 
these things.
    Mr. Luetkemeyer. Okay. All right. What is your organization 
doing to assist, or are they doing anything right now to assist 
the veterans who have gone through this dental program here and 
have some problems? Are you working with them at all? Do you 
have any programs in place for them as an individual group?
    Mr. Searle. No, sir.
    Mr. Luetkemeyer. Okay. Do you anticipate doing it?
    Mr. Searle. We certainly would look at it any time that we 
get comments or questions or requests for assistance from 
veterans. We do so on a daily basis. But in this particular 
case we haven't really thought about it.
    Mr. Luetkemeyer. Okay. All right. Very good.
    Thank you, Mr. Chairman. That's all I have.
    The Chairman. Thank you.
    Mr. Miller.
    Mr. Miller. Ms. Johnson, you said there are about 13 people 
that you worked with in Sterile Processing?
    Ms. Johnson. It could be a couple more. About 14 or 15.
    Mr. Miller. A dozen or so, thereabouts.
    Ms. Johnson. Yes.
    Mr. Miller. And I'm just trying to go back to your 
testimony. You were the only person in that group that had any 
type of problems or vocalized your issues? Nobody else would do 
that?
    Ms. Johnson. Well, they did behind the boss's back. But as 
far as, you know, changes and what was supposed to be done and 
suggestions, I was the one that came in and saw that the 
department weren't being up to par, as far as I'm concerned.
    Mr. Miller. Even if they didn't say anything negative, 
would you say they agreed with what your recommendations were?
    Ms. Johnson. Uh-huh. Yes, sir.
    Mr. Miller. Why do you think they wouldn't say anything?
    Ms. Johnson. Because they would be retaliated on. I mean 
everyone needs their job now. They wasn't going to say 
anything. The only difference is my family goes to John 
Cochran. My daddy goes there. Vets go there. I did everything 
out of concern for the veterans. I come from a military 
background. I opened my mouth.
    It was for the best. You see what happened. Eighteen 
hundred vets now have to go and get blood tested. All they had 
to do was listen.
    Mr. Miller. Did you say that--and again, I have no medical 
background--but that dental should have had all of their 
equipment processed by Sterile Processing, is that correct?
    Ms. Johnson. May I give you something? And that is correct.
    I wanted to give you something and Mr. Carnahan, so you 
have a better understanding about what I'm saying when you 
receive this and read it.
    And the other half comes from the Department of Veterans 
Affairs. It comes out of their book. So you will have a better 
understanding as to what I'm saying.
    Is that okay? It will just take a minute. It's right behind 
me.
    Mr. Miller. Please.
    The Chairman. Go ahead.
    This always gets us in trouble when I'm advised not to do 
it, but the gentleman in the back, did you want to add 
something to this?
    Mr. Huskey. Yes. There is a survey and----
    The Chairman. Would you identify yourself?
    Mr. Huskey. Yes. Bob Huskey. I'm with the Gateway Chapter 
of Paralyzed Veterans. And we had asked--we had to go to the 
Freedom of Information Act to get it--for a survey administered 
by the Veterans Administration of 124 hospitals. John Cochran 
scored the lowest in three different categories. I have that 
survey, if you would like to see it. I would be glad to give it 
to you.
    The Chairman. Okay. You can give it to our staff. We would 
be glad to look at it. Thanks.
    Mr. Costello. Mr. Chairman.
    The Chairman. Mr. Costello.
    Mr. Costello. I wonder, before we dismiss this panel, if I 
could ask two questions?
    The Chairman. Sure.
    Mr. Costello. We are not done yet.
    The Chairman. We are not done.
    Please, Ms. Johnson.
    Ms. Johnson. Yes, sir.
    Mr. Miller. Thank you for providing additional material. 
With your indulgence we will also make it available for all the 
Committee Members.
    [The supplemental information is attached to Ms. Johnson's 
prepared statement, which appears on p. 73.]
    Ms. Johnson. Thank you very much, because I didn't want to 
leave anyone out. No one.
    Mr. Miller. Thank you. I think I heard you say that dental 
should have had their equipment processed with Sterile 
Processing, but was okay for GI to sterilize the scopes. Why 
the difference?
    Ms. Johnson. The difference was because when I was there, 
GI had the most experienced person or personnel to clean their 
scopes.
    And another reason I said that was because once the scopes 
are down in Sterile Processing, it takes away the employees 
from doing instrumentation. In other words, you will have about 
three people over here doing scopes where we need these people 
over here to be assembling trays. So in the process, everybody 
is rushing because we are short on this side because they are 
over here doing the scopes.
    Now, we in Sterile Processing, I'm not saying that the 
people, the staff wasn't qualified to process the scopes. What 
I'm saying is that those scopes should have been sent to GI 
because they have the most experienced staff. And you know, it 
just takes away the work that Sterile Processing is supposed to 
be doing.
    Mr. Miller. My time has expired, but one other question. 
You are aware that you can file a complaint under the 
Whistleblower Protection Act, correct?
    Ms. Johnson. No, sir, because I don't consider myself a 
whistleblower. I consider myself someone trying to help the 
veterans in seeing things that weren't being done that should 
have been done. I didn't consider myself a whistleblower. I'm 
not. I just wanted things to----
    Mr. Miller. With all due respect, I would advise you to 
file.
    Ms. Johnson. Thank you.
    The Chairman. Thank you.
    Mr. Costello, please?
    Mr. Costello. Thank you, Mr. Chairman.
    And again, Ms. Johnson, I would concur with Mr. Miller. I 
would recommend that you file, as well.
    But you, when Mr. Carnahan asked you about your case, you 
said it was pending. You also said earlier that the VA had 30 
days to appeal but they did not appeal. Can you explain, one, 
what you meant by that, that they didn't appeal? Apparently 
there was a finding in your favor?
    Ms. Johnson. Yes, sir.
    Mr. Costello. And when that finding was issued, the VA had 
30 days to appeal but they did not?
    Ms. Johnson. No, they didn't.
    That was on my unemployment claim. VA had 30 days to appeal 
the decision that my termination was not for misconduct. They 
did not appeal that.
    Mr. Costello. But you said that your case is still pending. 
Can you explain what the status is?
    Ms. Johnson. I also filed an equal employment opportunity 
complaint against VA. So that's still pending.
    Mr. Costello. And how long has your case been pending?
    Ms. Johnson. I think I filed in, I guess about 7, 8 months.
    Mr. Costello. Thank you.
    Mr. Searle, a final question. I'm a little confused as to 
the American Legion. How often do you visit facilities? You 
mentioned that you had not been to John Cochran since 2007. Do 
you visit facilities on a regular basis, or just when you get 
complaints, or can you explain the procedure?
    Mr. Searle. No, sir. What we do is we--and again, this year 
we did 32 facilities. There are 153 different facilities, so we 
go on a rotation and we select them out of there. That's how 
they do that.
    Mr. Costello. And if you get a complaint, do you----
    Mr. Searle. Yes, sir.
    Mr. Costello. Very good. Thank you very much for your 
testimony, both of you.
    And I thank you, Mr. Chairman.
    The Chairman. Okay. I just want to compliment our visitors 
here today for their questions. Usually, we think that only 
those of us on the Committee know what's going on.
    But your talk, Mr. Shimkus and Mr. Akin, about the culture 
and the systems hits the mark. I think Ms. Johnson's testimony 
illustrates that.
    There is a well-known sociological theory that a 
bureaucracy, almost inevitably, begins to function for itself 
rather than for who it serves. I think we see that happening in 
many places. Not every place and not equally. There are still 
good managers and good people, but the sense of fear and 
intimidation seems to be an indication that something is wrong.
    I had high hopes, I still do, of Mr. Shinseki getting his 
arms around that. I don't think he has yet. But there are too 
many examples of the bureaucracy functioning for its own self 
rather than for the good of the veterans. This is only one 
example. If they had listened to Ms. Johnson, we might not have 
been here today.
    I could give you hundreds and hundreds of similar things 
and decisions being made, for example, because somebody will 
have a better bottom line on their budget, and then not want to 
spend the money on behalf of a patient so that they will get a 
promotion.
    If things like that happen, there is something going wrong. 
Again, the fear that people have is evidence itself that 
something is wrong.
    No matter how much you say, we have the best of this or the 
best of that, if there is fear, something bad is happening. I 
think you have given us a good illustration of that, Ms. 
Johnson. We appreciate it. Again we've got to get our arms 
around this system and this culture.
    I think you have to constantly revitalize staff from the 
top both in working conditions but more, in morale boosters. 
The Secretary should be seen around the country at the 
different hospitals inspiring and re-inspiring people.
    Almost everyone I have ever met in the VA has joined 
because they want to help veterans. But somehow that gets lost 
in order to keep a job and to not rattle the cages. So it's 
hard. I think, Mr. Blunt would agree that the hardest thing we 
have in the legislature is getting our arm around these issues, 
as a bureaucrat from here.
    Mr. Luetkemeyer.
    Mr. Luetkemeyer. Yeah. Mr. Chairman, if I may for just a 
moment.
    Not serving on the Veterans' Affairs Committee myself, the 
report that the gentleman mentioned a while ago, do you, as 
Members, get that report?
    The Chairman. I think so, yes.
    Mr. Luetkemeyer. Is it something that could be made public 
so that there is some accountability to the----
    The Chairman. Yes, they are public. And the OIG and others 
report on their reports.
    Mr. Luetkemeyer. Well, my point is----
    The Chairman. And, on whether or not the recommendations 
have been carried out.
    Mr. Miller. They are on the Web site.
    The Chairman. As Mr. Miller points out, they are on the Web 
site. They are public reports.
    Mr. Luetkemeyer. All right. So there could be some 
accountability for those institutions and those groups that are 
not providing good service and, therefore, they can be held 
accountable.
    The Chairman. Theoretically.
    Mr. Luetkemeyer. Okay.
    The Chairman. But as we heard from Mr. Searle and others, 
they always cloak it in legal matters. We can't talk about 
personnel decisions.
    We've got to figure out a way that we can talk about things 
that are public policy and that accountability is there. Unless 
people know they can be fired for withholding information, 
change doesn't occur.
    Mr. Luetkemeyer. Well, in the business world you go to an 
Executive Committee whenever you have an issue that you need to 
talk about personnel. And perhaps that's what needs to happen 
with this Committee, is at some point have an executive 
Committee so that they can discuss one-on-one and----
    The Chairman. I will be interested, when we get back to the 
Hill, to hear your impressions. You know, that would help----
    Mr. Luetkemeyer. Thanks.
    The Chairman [continuing]. This Committee do a better job. 
I think you are perfectly right.
    I thank you, and we will call the third panel. Most 
Committees have the Executive Branch testify first; however, 
they tend to leave the room after they testify and never hear 
what the other witnesses have to say.
    We have instituted a policy, under my Chairmanship, where 
the Administration testifies last. I like to ask them about 
what they've heard and what they are going to do about it. 
Usually, they don't have clearance from the Office of 
Management and Budget to answer my questions, but we try.
    Dr. Petzel, I think you are on now.
    Anyway, that's why they are third, so they can take into 
account the views of both the public and the stakeholders and 
hear things before they leave the premises.
    The Chairman. Our witnesses on the third panel are from the 
Department of Veterans Affairs. Dr. Robert Petzel is the Under 
Secretary of Health for the Veterans Health Administration. He 
is accompanied by Dr. George Arana, the Acting Clinical Quality 
Assurance Liaison for Field Operations in the VHA. Dr. Andrea 
Buck is the National Director of Medicine at the Veterans 
Health Administration. And RimaAnn Nelson is the Acting Medical 
Center Director at John Cochran. Acting because? How long have 
you been Acting?
    Ms. Nelson. Since October 2009.
    The Chairman. Then we haven't had a permanent director 
there since then? Is that----
    Dr. Petzel. We actually haven't had a permanent Director 
there since January of 2009. We are soon going to have a 
permanent director.
    The Chairman. Why is that, by the way? Why have you gone so 
long without a permanent Director?
    Dr. Petzel. Well, just briefly, Mr. Chairman, before I give 
my opening remarks----
    The Chairman. Do they have something to do with this?
    Dr. Petzel. We do not believe so. The previous Chairman--
the previous Director was detailed out and we are unable to 
fill a position if somebody is detailed out of it. Once he was, 
once he was permanently in his new position, we began the 
search and we are very close, Mr. Chairman, to filling it.
    The Chairman. What does that mean, you can't do something 
because he's detailed? Because, you mean he still has the job?
    Dr. Petzel. He still has that job, yes.
    The Chairman. Something is wrong. The average person 
listening in the back says, what in the hell does that mean? If 
you can't fill a job because someone left it, what are you 
administering back in Washington?
    Dr. Petzel. We would be happy if you could change that rule 
for us.
    The Chairman. What kind of rule is it?
    Dr. Petzel. It's a personnel rule.
    The Chairman. But that comes from you guys, not from us 
guys.
    Dr. Petzel. Well, it comes from the Office of Personnel 
Management.
    The Chairman. Well, that just doesn't make any sense. But 
go ahead.

STATEMENTS OF HON. ROBERT A. PETZEL, M.D., UNDER SECRETARY FOR 
  HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
VETERANS AFFAIRS; ACCOMPANIED BY GEORGE W. ARANA, M.D., ACTING 
 QUALITY ASSURANCE LIAISON, FIELD OPERATIONS, VETERANS HEALTH 
  ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; ANDREA 
   BUCK, M.D., J.D., NATIONAL DIRECTOR OF MEDICINE, VETERANS 
HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND 
 RIMAANN O. NELSON, ACTING MEDICAL CENTER DIRECTOR, ST. LOUIS 
    VETERANS AFFAIRS MEDICAL CENTER, JOHN COCHRAN DIVISION, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
                            AFFAIRS

    Dr. Petzel. Chairman Filner, Ranking Member Miller, and 
distinguished Members of the Committee, thank you for the 
opportunity to appear before you today.
    I am here to discuss our finding that there was a failure 
to clean dental hand pieces according to manufacturers 
instructions and VA standard operating procedures at the St. 
Louis Department of Veterans Affairs were not followed.
    I'm accompanied today by Dr. George Arana, VA's Acting 
Quality Assurance Liaison, Dr. Andrea Buck, VA's National 
Director of Medicine, and Ms. RimaAnn Nelson, the Acting 
Director at the St. Louis VA Medical Center.
    We appreciate the opportunity to address this issue in 
detail and on the record. Simply put, what happened at St. 
Louis was inexcusable and unacceptable. It's the first 
responsibility of every government agency to be open and honest 
to the public and its clients. In our place, those clients are 
the brave men and women who wore the uniform and promised to 
defend this Nation.
    We at VA have a great privilege and a solemn responsibility 
to provide quality health care and benefits to this population. 
That's why every day we constantly monitor and inspect our more 
than 1,000 hospitals and other clinical sites. That's why we 
check and re-check the safety and quality of the millions of 
procedures that we perform each year.
    When we discover our care does not meet the high standards 
we have set, as happened in St. Louis, we take immediate steps 
to set things right. We notify our veterans, arrange necessary 
care and hold our people accountable.
    Yet we understand that honesty and good intentions are not 
enough. The risk of infection to our veteran patients in this 
instance is extremely low, but nonetheless, we deeply regret 
the emotional and psychological burden, as testified to today--
--
    The Chairman. Let me--Mr. Petzel, it's not----
    Dr. Petzel [continuing]. That's been placed on our veteran 
patients----
    The Chairman [continuing]. It's not----
    Dr. Petzel [continuing]. And their loved ones.
    The Chairman. I'm being less than decorous to stop you in 
the middle of your testimony, but we've gone through this 
before. You've been there.
    You just made several sentences which conflict directly 
with the testimony you have heard today. Why don't you just 
stop for a second and either say that it might not have been 
fast enough for you but we have to do this, or, we didn't even 
do it right?
    You just said, we respond as rapidly as we can. You have 
heard 2\1/2\ hours of testimony where every one of us said it 
wasn't fast enough. You act as if we didn't say a word here.
    Dr. Petzel. We absolutely, I absolutely agree with you, Mr. 
Chairman. We did not respond quickly enough.
    The Chairman. But that's not what you just said in your 
sentence. You said, we acted as quickly as we could.
    Dr. Petzel. We took too long to investigate this.
    The Chairman. Well, you didn't say that.
    Dr. Petzel. Well, it comes later in my testimony. We took 
too long to investigate this and we took too long to notify. I 
absolutely agree with you on that, Mr. Chairman. Absolutely 
agree.
    The Chairman. Thank you.
    Dr. Petzel. The VA is grateful for the sustained confidence 
in our ability to provide world-class care and demonstrate by 
our veterans, their families, and the veteran service 
organizations. We believe our system of quality assurance and 
safety is second to none. It has been proven time and time 
again by a wide range of organizations who have testified to 
the general quality of care within the VA.
    My written testimony provides a chronology of the events, 
and documents our responses to this situation. In the time I 
have now, I would like to acknowledge that we recognize there 
were missed opportunities to uncover this issue sooner.
    Not only are we reviewing our experience and our responses 
to identify lessons learned, our policies for identifying these 
lessons, these issues earlier and notifying our veterans and 
stakeholders faster; I will submit a letter describing the 
improvements in our standards for ensuring compliance by 
facilities to the Committee on Veterans' Affairs on August 
15th. We have reviewed our processes and we have determined 
that these have to be shortened; that the 108 days that we took 
to bring this to public notice was far, far too long.
    The Chairman. And now you are going to take another 30 days 
to notify me by letter? That means you really learned your 
lesson?
    How can you say that? You just said, you are going to 
notify everybody as quick as you can. You just said, you 
learned your lesson, and then you say you are going to send a 
letter about that 30 days from now.
    Why not right now? What goes on in the thinking here? You 
know, you've heard, as I said, 2\1/2\ hours of testimony. 
Respond to it. Give us some sense that you get it. All I hear 
is the same justifications that ``we've been doing.'' I will 
let you complete your statement, sir, but we make you sit 
through the previous testimony so you can respond to it. The 
frustration, the anger, the hurt, and everything else that you 
heard--you are not responding to it. People will leave as 
frustrated as when they came if you continue this way.
    You are not showing that you understand the depth of the 
fear, the hurt, and the loss of trust--I mean all these things 
are there. You have a chance here to try to begin to build a 
bridge and are not taking that chance.
    Dr. Petzel. Mr. Chairman, we do recognize, as I said 
earlier, that this took far too long. That we must find a 
quicker way to investigate these incidents.
    The Chairman. Give me the letter tomorrow. Why on August 
15th?
    Dr. Petzel. To notify--we can certainly send the letter to 
you long before the 15th, sir.
    We are committed to implementing the high quality 
principles of the ISO 9001. We've talked about this before with 
you. Therefore, I'm not going to go into the details of it.
    But the critical part, the critical part, in my mind, of 
changing the incidence of events in the SPD is 
industrialization of the process, and ISO 9001 is that 
industrial standard by which we need to have our SPD's fully 
functional.
    To respond to veterans' concerns about this issue, the VA 
has set up a Call Center, beginning to operate 7 days a week, 
24 hours a day. Veterans and their families can call this 
number, 1-888----
    The Chairman. Did you hear what happened when someone 
called?
    Dr. Petzel [continuing]. Three seven four----
    The Chairman. Respond to that. Don't tell me you've got a 
24/7 hotline. You've got new people who don't understand a word 
of what they are doing. I just called this morning and I will 
tell you if I was a veteran, I would have just started crying. 
The person who answered the phone had no sense of what I was 
talking about. No sense of what I needed and you heard this 
earlier, Dr. Petzel. You've heard it and yet you still quote, 
``24/7, they are always there.''
    It doesn't work. Besides, they've had so much experience 
with the 1-800 numbers and nobody answering them that they 
don't even bother to call any more.
    We've tried this 800 number, and I don't know what you do 
there, but nobody seems to be there. You can wait for an hour 
before it gets to be your turn. So, they say, the hell with 
these 800 numbers. They don't have any confidence in this.
    You say it's working. We just heard everybody say it's not 
working. It's not an acknowledgment that we've got a problem. 
That's why we have the problem.
    You said industrialization is the answer. That's not the 
answer. The answer is caring people who understand the 
veterans, and who can make changes and recommend solutions to 
their supervisors without getting intimidated and somehow the 
bureaucracy responds to the real needs of people. All you keep 
telling me is that bureaucracy comes first. We've got the 
industrialization. We are working as hard as we can.
    It's not working.
    Dr. Petzel. Then we will go back and make it work, Mr. 
Chairman. It's appropriate to have a 24-hour, 7-day-a-week 
call----
    The Chairman. Not with 50 people who were hired yesterday.
    Dr. Petzel. No. I absolutely agree with you. They need to 
be answered by compassionate, understanding people who 
understand what the issues are and are able to talk and respond 
directly. If those aren't the kinds of people that are manning 
that call, then we will have those kinds of people there.
    The Chairman. You just heard that there weren't, and you 
didn't even acknowledge that there were those complaints.
    Mr. Miller. Mr. Chairman, will you yield?
    The Chairman. Mr. Miller.
    Mr. Miller. I think part of the problem is, Doctor, that 
you've got approved testimony that you have submitted that 
obviously has been reviewed by somebody, because you keep going 
back to it. And I understand with testimony that's the way that 
it normally works.
    I think the thing that bothers us is the fact that the 
Chairman does ask the administration officials to wait until 
the end so they can hear from those that are testifying before 
the Committee in hopes that you will deviate from your written 
remarks, go off-script, if you will, and show some compassion 
yourself; that you heard the people who poured out their hearts 
as best they could in a public forum.
    And I read this last night. I read it this morning. I read 
everybody's testimony. But my feelings for the testimony 
changed when I heard them actually give it personally. It would 
for any human being.
    But I'm not hearing your testimony change. And I would just 
ask if you could fold up your testimony and speak from the 
heart. Because we know that VA cares about their people but 
what you are showing is that VA cares more about the script 
that's been prepared for this hearing today.
    Dr. Petzel. Yes. I hear you, Congressman Miller.
    The Chairman. I thank the Ranking Member for making me more 
eloquent.
    Dr. Petzel. So let me review, if I may, if I could, then, 
before the questions begin.
    First of all, we are shocked, appalled at this unacceptable 
incident. I think I want to make that very clear that we do not 
condone what happened. We do not believe it was appropriate. 
And, number one, we are, I am personally embarrassed by the 
length of time that it took the organization to respond in two 
ways, one, to get the investigation done and, two, to notify 
the patients.
    And Mr. Chairman, as I said before, I promise you that we 
will outline for you a rapid procedure for both identification 
of the issues and problems, and notification and a new process 
for notifying families.
    As you heard before, we have traditionally used this letter 
phenomena. Clearly, in listening to what was going on today, 
that failed to meet the needs of these patients. Absolutely 
failed to meet the needs of these patients. It's clear that we 
need to do a personal, on-the-phone, qualified professional's 
initial call. There may be letters to follow up with at some 
future date, but it's clear that this was not the appropriate 
way to notify people.
    And it's also clear that we don't have the kinds of 
experienced people that we need to have answering our phone 
calls and leading our patients through the process. And those 
things, as we will outline in the letter to the Chairman, need 
to be changed. Absolutely need to be changed.
    The Chairman. Thank you.
    Dr. Petzel. This process did not demonstrate the kind of 
compassion that I know people at St. Louis feel for these 
patients, and we will change that process.
    [The prepared statement of Dr. Petzel appears on p. 78.]
    The Chairman. Thank you.
    Dr. Petzel. Yes, sir.
    The Chairman. Mr. Carnahan.
    Mr. Carnahan. Thank you, Mr. Chairman.
    My question is for Dr. Petzel. And first, with regard to 
this incident, you heard the description from Ms. Johnson about 
her being retaliated against and the culture of really 
suppressing people speaking out when they see problems, large 
or small.
    And I want to know, what is going to be done from the VA to 
affirmatively tell employees that they are not only able to 
speak up, but encouraged to in a safe way, without retaliation?
    Dr. Petzel. I promise you, Congressman Carnahan, that we 
will, at the John Cochran, have a program to do exactly as you 
implied. To encourage employees to come forward, tell us about 
issues, tell us about problems, or to set up a safe system 
whereby they can do that. Where they can anonymously, if you 
will, present their problems to the management.
    I don't, I don't condone retaliation.
    Mr. Shimkus. Will my colleague yield for a second on this 
point?
    Mr. Carnahan. Yes.
    Mr. Shimkus. This needs to be system-wide. This is the same 
problem we had at Marion. This has to be system-wide. See, the 
employees need to feel open to be able to air their concerns 
and their problems. And the patients need to be able to 
complain without fear of retribution.
    If there is fear of retribution, either by an employee or 
veterans, there is failure. So I would ask that you take back 
to the Secretary these comments and say, we've got to clean 
this up.
    Thanks to my colleague.
    Mr. Carnahan. No, I appreciate that.
    And that was my point, as well, that can we learn from this 
incident? Because this does not seem to be restricted to 
Cochran. And in any kind of an organization where you are 
striving for quality, you have to reward people. Not punish 
them. Reward them. You know, Ms. Johnson should have been 
promoted, not fired. And reward them for speaking up about 
quality and how to make those improvements.
    I don't think that exists, not at Cochran, and it doesn't 
seem to exist in the VA. And their needs to be a system in 
place to do that. That, to me, has to be the critical part of 
continuous improvement within an organization like the VA.
    Dr. Petzel. I absolutely agree with you, Congressman. We 
need to have a culture where, as you say, people are willing to 
speak up and become a part of a continuous improvement process 
in the hospitals. I absolutely agree with you.
    The Chairman. If you will yield for a minute, I want to get 
unanimous consent from my colleagues. I like the group here 
today.
    I want to come back in 6 months. Dr. Petzel, we appreciate 
your promises. We appreciate your effort. Let's see what's gone 
on in 6 months.
    Mr. Shimkus. No objection. No objection.
    The Chairman. I suggest that to my colleagues because of 
the frustration here as we see this again and again and the 
changes don't get made. I want to see some changes even if it's 
in one place. If it has to start here, fine.
    You have all shown a real sensitivity and a real empathy, 
so maybe VA can report back to us.
    Anyway, I'm sorry.
    Mr. Carnahan. No. Thank you, Mr. Chairman. I wholeheartedly 
concur.
    And the other question I had, Dr. Petzel, was the use of 
the Administrative Investigation Board versus the Inspector 
General of the VA, what's the rationale for that? What's the 
precedent for that?
    Dr. Petzel. For using an Administrative Investigative Board 
to look at the incident at Cochran?
    Mr. Carnahan. Yes.
    Dr. Petzel. Well, we wanted to get an unbiased, outside-of-
the-institution, outside-of-the-network view of why this 
happened.
    We know what happened and we want to be absolutely certain 
about why this happened. And when we are, then we can decide 
who was responsible for this and we can decide who needs to be 
disciplined and who needs to be held accountable. So that is 
our mechanism for gathering the information to find out who is 
accountable.
    Mr. Carnahan. And you got to my last point, and that is, 
how important it is at the end of the day, when we have 
discovered exactly what happened, who was responsible, that 
somebody is held accountable and we can begin to tell our 
veterans that any of their confidence that has been shaken in 
the system, that it's been taken seriously, that the shortfalls 
are being addressed, and in going forward, we are going to have 
a better system?
    Dr. Petzel. Absolutely agreed, Congressman. I absolutely 
agree.
    Mr. Carnahan. Thank you. I give it back.
    The Chairman. Thank you.
    Mr. Blunt.
    Mr. Blunt. Well, thank you, Chairman, and thank you for 
coming to Missouri today. You know, you and I have talked about 
these issues many times but I've never got to sit on a 
Committee on this topic with you. And the intensity and the 
commitment you bring to this issue is important.
    And Mr. Miller, you, as well. And you and I have talked 
about these veterans issues over the years.
    And I think what you can see, Doctor, is the frustration of 
hearing the same answers over and over again to the same 
problem. And so I'm--how long have you had your job?
    Dr. Petzel. I was sworn in in February, the middle of 
February, 2010.
    Mr. Blunt. And what did you do before that?
    Dr. Petzel. I was the Network Director in Minnesota, 
Minneapolis, Minnesota, for Network 23.
    Mr. Blunt. So how long have you been with the VA?
    Dr. Petzel. Approximately 37 years.
    Mr. Blunt. So you bring your career-long background to 
this. And I would hope that if anybody could figure out how to 
solve this, somebody who had been working in this for 37 years 
would be able to do it.
    Dr. Petzel. I do have many ideas that we are just beginning 
to implement, yes, sir.
    Mr. Blunt. Well, it will be interesting to see, 6 months 
from now, if you've implemented them or not.
    I will say that, you know, I have people from southwest 
Missouri, from my district, that are among these 1,800 and I 
believe 1,812 people. People from a significant number of 
States, because of the uniqueness of this particular facility, 
are among the 1,800 people. And on July the 1st, I sent a 
letter to the Secretary and, like others here, I have great 
hopes for his leadership of the VA. I was pleased to see, just 
a few weeks ago, that he had done some things long overdue to 
try to cut the paperwork, to try to cut all of the application 
process to get this done.
    But this is a time when we need to get to the bottom of 
some of these problems and use all of the new things available. 
You know, we've got a new Veterans Clinic in Branson that I 
walked through the other day. They have a doctor there just for 
traveling veterans. And that doctor for traveling veterans can 
pull up any veterans' health records because the VA is ahead in 
this.
    But we need to figure out, okay, we are ahead in that. What 
else can we, how can we use the time we used to spend looking 
for records--because all those records are on Health IT now--
how do we use the time we used to spend looking for records to 
get ahead somewhere else?
    And I would charge you to do that. And I would hope--you 
know, the six questions that I asked on July 1, the day after I 
heard about this problem, are the six questions we've been 
asking today. Now, if I can figure out these six questions 
within 24 hours, it is amazing to me that it would take, you 
know, months to decide how are we going to, are we going to 
notify people? And then even more months, up until today, to 
figure out that we've notified these people in the wrong way, 
the VA has.
    That when you get that letter, you know, we heard Ms. Odom 
say that she just fell to her knees. And I tell you, a lot of 
people would fall to their knees if they got that letter, 
wondering which of these things they might have and why they've 
got this letter that, as she described it, was like getting a 
notification that the parking lot was going to be repaved on 
the south side next week, instead of the reaching out. As the 
Chairman said the very first thing, why don't you find 1,800 
people that can be assigned to each of these people until the 
problem is solved?
    And you know, I've got several questions here. Look at the 
six questions I asked you, line one. And we've answered some of 
them today, but I would like an answer and I would like it 
before next July 1.
    And surely after this hearing somebody can sit down and 
just write a letter that answers these six questions so that I 
know that at least somebody there is responding to what we are 
asking.
    Now, what was different? I think the Acting Director of the 
hospital is here, or of this facility is here, is that right?
    Ms. Nelson. That's correct.
    Mr. Blunt. How long have you been the Acting Director?
    Ms. Nelson. Since October, 2009.
    Mr. Blunt. Of this? Now, are you the Acting Director of the 
John Cochran VA Medical Center?
    Ms. Nelson. Yes, I am.
    Mr. Blunt. And you've done that since October of 2009?
    Ms. Nelson. Yes.
    Mr. Blunt. Tell me what you were doing different in January 
of 2009 than they were in February of 2009. Why is this a 
problem that only goes back to February 1, and what changed 
between January 31 and February 1 that makes this problem start 
on February 1?
    Ms. Nelson. Well, and I started in October 2009. But what 
happened----
    Mr. Blunt. Well, surely you know the answer to that 
question. Surely this is a question you asked somebody when 
they said this started February 1. I don't care when you 
started. Surely you asked that question.
    What was the answer?
    Ms. Nelson. What happened prior to February 1, 2009, was 
that we had an inspection of the dental clinic area, which 
showed that we were following cleaning procedures per 
manufacturing guidelines.
    After February 1st, 2009, we are not sure that those 
procedures were followed and so we wanted to make sure that we 
took care of all veterans seen in the dental clinic, so we 
chose February 1st, 2009, as the date because we did not have 
any evidence after February 1, 2009, that the procedures were 
still being followed.
    Mr. Blunt. So are you telling me that this routine 
inspection that I asked about in the letter--according to 
information provided by VA staff, this situation was discovered 
during a routine inspection conducted by the National 
Infectious Diseases Program Office.
    Dr. Petzel. Congressman Blunt, let me explain. Prior to 
February of 2009, all of the instruments were going down to 
Sterile Processing and being both washed and sterilized in 
Central Processing.
    Mr. Blunt. All of the--okay.
    Dr. Petzel. All of the instruments.
    Mr. Blunt. Now, is that--do you agree with that answer? I 
don't know why you didn't say that.
    Dr. Petzel. I think she didn't quite understand the 
question.
    Then after February of 2009 the dental service, because 
they weren't getting back all of the instruments in the right 
packets that they wanted, said, we will do the washing. They 
didn't say it but they started doing the washing, they packaged 
the instrument packets, and then they went down to be 
sterilized.
    And our problem with that and everybody's problem with that 
is that they weren't doing the prewash in exactly the right 
fashion.
    Therefore, even though the instruments were pre-washed, in 
a way, and were indeed sterilized in the sterilizer, we cannot 
definitively say that they were sterile. That's the issue that 
was discovered, then, on March 10th of 2010.
    Mr. Blunt. All right. So now let me be sure I understand 
this. Did they change the process just because, right after an 
inspection, and they, why did they----
    Dr. Petzel. They changed the process, as I am led to 
believe----
    Mr. Blunt. Was there an inspection in January of 2009 or 
not?
    Dr. Petzel. No.
    Mr. Blunt. Now, I thought you just said there was an 
inspection in January of 2009 and it didn't come around again 
until--and that's why you picked the day, is that not right?
    Ms. Nelson. We did an internal audit where we walked 
through the dental clinic and saw that the procedure was being 
followed at the time of the audit. This was our own audit 
conducted by our Quality Management Department.
    Mr. Blunt. And the procedure at that time was everything 
was going somewhere else to get sterilized?
    Ms. Nelson. Yes. It was going down to the Sterilized 
Processing Area.
    Mr. Blunt. And you believe that changed, but it didn't 
change any earlier than February 1, 2009. Sometime after that 
they decided they weren't getting their equipment back in the 
order they wanted it in?
    Ms. Nelson. That's correct.
    Dr. Petzel. That's right.
    Mr. Blunt. All right. So that's why it starts on that date. 
And you are confident it couldn't have been earlier than that? 
I'm hearing maybe it might have been a few days later than 
that, but you are confident it couldn't have been earlier than 
that, is February 1, 2009?
    Ms. Nelson. Yes, we are confident that February 1, 2009, is 
the risk period and would capture all the patients that were 
seen in dental that would have potentially been exposed.
    Mr. Blunt. And the 1,812 of them, can somebody give me an 
idea how long these people--could it possibly be 20 years 
before you know whether this is still a problem or not?
    Dr. Petzel. I would like to turn to Dr. Arana, who is 
prepared to answer that question for you, Congressman.
    Dr. Arana. Mr. Blunt, in response to that question, the 
issue of the window of exposure, that is, if you get exposed to 
hepatitis B or hepatitis C or HIV on July 1st, you don't know 
whether you have those or you've essentially gotten infected 
until 6 months later. So that's a 6-month window of time that 
we have to wait and make certain that we've captured every 
single vulnerable vet in terms of infection.
    So the, right now we have notified all the veterans. We 
have tested approximately 950 of those. To date we have the 
number, the latest number from yesterday close of business is 
that 826 of those veterans were negative on all three 
illnesses: HIV, hepatitis B and hepatitis C. Up to yesterday's 
close of business, 261 of them were notified.
    Mr. Blunt. And then they are outside the 6-month window, 
the ones you are notifying?
    Dr. Arana. Some of them are. Some of them aren't.
    Mr. Blunt. All right. Well, once you get outside the 6-
month window, 6 months from the last person impacted here, 
which would be March the 10th, 6 months from then, if that last 
person that was seen on March 10th has a test and it comes back 
negative, do they have to worry for the next 20 years that it 
may not be negative or not?
    Dr. Arana. No, sir. They only have to worry until 
September, when they get re-tested at that time. The 10-year, 
20-year number that we heard somebody mention is usually the 
period of time that it takes for some of these illnesses to 
manifest. But in terms of testing and being certain that they 
have been infected, that is a 6-month period of time.
    Mr. Blunt. So, okay. Let me be sure. This is one point I 
want to make and I'm sure the people have other questions. And 
they will be questions I might have asked, but let's let them 
ask them.
    The one point I want to be sure I'm clear on here is 6 
months from the last time you were in this dental clinic, if 
you are not testing positive, you are not positive. And if you 
are testing positive, it could be a long, sometime in the 
future before hepatitis C or whatever manifests itself.
    But if you are not positive 6 months later, you don't have 
to worry about 10 years from now.
    Dr. Arana. You don't have to worry about--at 6 months if 
you are testing negative, you are finished worrying.
    Mr. Blunt. Okay. Susan and Julie, does that help? At least 
in 6 months.
    But then if you say, okay, you are testing positive for it, 
you've got the hepatitis C positive test----
    Dr. Arana. Right.
    Mr. Blunt [continuing]. At that point you do have to 
continue to be concerned, but only if you are told that at that 
point?
    Dr. Arana. Yes.
    Mr. Blunt. Is that right, Dr. Arana?
    Dr. Arana. That's true.
    Mr. Blunt. All right. That's helpful to me. And it's not, 
it's obviously not as good as if this didn't happen, and it's 
obviously not as good as if all of the people we hope test 
negatively.
    But whoever has the sense that you won't know for 20 years 
whether you've got this or not, that's not true. You won't know 
for 20 years, if you've got it, whether it might manifest 
itself or not.
    Dr. Arana. Correct.
    Mr. Blunt. Is what----
    Dr. Arana. That's a correct statement. That is that if you 
end up testing positive, then you can, over time, convert to 
having the illness. But at that point what you have is you have 
evidence in the blood of exposure, but you don't have the 
disease.
    Mr. Blunt. But 6 months from the last day you were in that 
dental situation, you should be able to know one way or another 
whether this is over for you, or you have to continue to worry, 
right?
    Dr. Arana. Yes.
    Mr. Blunt. And if the last day you were there was 6 months 
ago and you took the test tomorrow, you would know tomorrow----
    Dr. Arana. Yes.
    Mr. Blunt [continuing]. Or whenever the test is reported 
back, you would know one way or another that you have to worry 
about this or you don't?
    Dr. Petzel. That's correct.
    Mr. Blunt. All right. Did somebody else want to answer a 
question there? Any time I see somebody grab a microphone, I 
don't want to not let you ask a question, if you want to.
    Do you have anything else you want to say?
    Dr. Petzel. No. You've got this exactly right, Congressman 
Blunt.
    Mr. Blunt. Thank you. Thank you, Mr. Chairman.
    The Chairman. Has anybody in those latest tests, tested 
positive in anything?
    Dr. Arana. No.
    The Chairman. So far it's zero.
    Voice. That's not true.
    Dr. Arana. No. No. We have, what we have is we have some 
that have tested positive, but we have to go back and verify 
exactly when they were in the clinic in terms of the risk.
    So the evaluation is not complete until we have checked 
back when they were actually seen in the clinic. So although we 
have found some positives, we don't know that they are positive 
until we verify----
    The Chairman. Of course you wouldn't ``no'' treat them.
    Mr. Blunt. Mr. Chairman, there is somebody back there 
saying that's not true. Can you ask her what she means by that?
    The Chairman. Some people are yelling. Ma'am in the red.
    Ms. Henry. Yeah, my father was----
    The Chairman. Identify yourself, please.
    Ms. Henry. My name is a Lisa Henry. I wasn't planning on 
speaking today. I'm sorry.
    My father was in the dental clinic in May and several times 
after that, and he was in full liver failure at the VA in 
January, hepatitis B. They had to transfer him to Barnes for a 
workup for a liver transplant. He was seen in the VA dental 
clinic four times. He had normal liver function tests prior to 
being diagnosed with hepatitis B.
    So I don't know 100 percent this is where he got it, but a 
72-year-old man who doesn't have any other risk factors----
    The Chairman. By the way, they are going to argue that he 
was not tested in this program, so they don't still have any 
positives.
    But you had better understand what happened to that man.
    Dr. Arana. Absolutely.
    Ms. Henry. He almost died.
    The Chairman. Thank you. One or two more. We shouldn't do 
this but--in the back, please?
    Mr. Hart. Yes, my name is Richard Hart. And at the VA they 
overdosed me with botulism. You was talking about tests being 
run. Well, they gave me 1,000 units in 45 days. It almost 
killed me. They did a Doppler on my leg and they said I was 
fine for blockage, but later I go to the Social Security 
doctor----
    The Chairman. We need to look at that, sir, but that's a 
little bit different problem than what we are discussing.
    If you would let our staff know about your situation, we 
will look into that, please.
    Mr. Hart. What I'm saying, their test comes up different 
than what everybody else's test comes up.
    The Chairman. Okay.
    Mr. Hart. I had three different tests and it came up good 
for them. But when I went to a different facility, they found 
out something different.
    The Chairman. Okay. Thank you.
    Dr. Petzel. We will follow up with that, as well.
    The Chairman. One more question in the back. Go ahead, 
please, ma'am.
    Mrs. Shands. I've got one quick comment for the Committee.
    Please get a board certified hepatologist with experience 
in dealing with all the different forms of hepatitis, from A 
through G, who knows about C, who knows that, one, you cannot 
always find it that easily, and two, just because you test 6 
months later and you come up negative, it doesn't necessarily 
mean it's not there.
    For example, in the case of my husband, who died at John 
Cochran of hepatocellular carcinoma, which is hepatitis C 
related liver cancer, he tested negative in his serum until the 
day before his death.
    Dr. Chenowitz called me the day before, because VA doctors 
did not believe he had cellular carcinoma, he said, Mrs. 
Shands, please, may we do a biopsy and confirm it? I gave my 
permission. They found it, once the biopsy was done, in the 
tissue but it never showed up in the blood. So please, get a 
board certified hepatologist and get the facts.
    Thank you.
    The Chairman. Thank you.
    The Chairman. Mr. Costello, please.
    Mr. Costello. Mr. Chairman, thank you.
    Mr. Chairman, let me applaud your approach to Mr. Petzel's 
testimony. I almost said, take the testimony, turn it over, and 
tell us what you know and what you are going to do about it. 
What's the action that we are going to take from here on out.
    We realize you've only been in your position a very short 
period of time, your current position, and I'm sure that you 
have every intention of trying to make the changes that are 
necessary to be made here, but I've got to tell you, based upon 
my experience and the track record of the Agency, I'm very 
skeptical that the change will take place.
    You know, I talked about the Marion facility. That was in 
2007. We talked about what happened to veterans who were 
exposed in Tennessee, Georgia and Florida. And this Committee, 
at my request and Mr. Shimkus' request, held a hearing on the 
VA facility in Marion.
    And I've got to tell you that it was most troubling that 
after 2 years, we requested that the Inspector General take a 
look at the Marion facility to see what improvements were made. 
After 2 years of discovering the problem and nine veterans 
dying, that the Office of the Inspector General discovered in 
2009 that Marion had not improved on their procedures. That's 
the Inspector General, 2 years after it was discovered that 
nine veterans died because of substandard care.
    So I would just suggest, Mr. Chairman, as you have, that 
this, the only way that action is going to be taken and the 
only way the change will come about is if this Committee 
provides aggressive oversight to make certain that the VA is 
doing what they tell us they are going to do.
    It's my experience, in Chairing the Aviation Subcommittee, 
that the Federal Aviation Administration has all of the good 
intentions in the world, but unless the Subcommittee keeps 
pressure on them, they do not act. And that is my fear with 
John Cochran.
    So I'm pleased to hear you say that in 6 months or whatever 
the time period, there will be another hearing of this 
Committee, and I think that's an excellent suggestion. It puts 
the VA on notice that someone is looking over their shoulder 
and will continue to.
    I personally, and Congressman Shimkus and Senator Durbin, 
have met on a regular basis at the VA facility since the 
Inspector General's report came out in 2009. We are starting to 
see some improvements, but it's because they know that someone 
is looking over their shoulder and we will expose it if they 
are not taking proper action.
    Having said that, let me ask just two quick questions for 
Dr. Petzel.
    Dr. Petzel, my understanding is that on June 26th of 2009, 
the VHA directed, has a directive that states that VHA policy 
requires each facility to have standardization and oversight 
plans for reprocessing reusable medical equipment according to 
the manufacturer's instructions.
    Number one, who approves those plans and ensures that they 
are followed?
    Dr. Petzel. There are several mechanisms, Congressman 
Costello. One is that each one of the networks has an oversight 
board for Supply Processing and Distribution. And that board is 
responsible for doing both announced and unannounced 
inspections of each one of the facilities within that network 
to ensure that they are indeed following those processes.
    Number two is that we ask the facility directors to certify 
to the effect that they are indeed following all of those 
processes and procedures.
    Does that catch this every time? Does that mean that I can 
say definitively that we are never going to have another 
incident in another Supply Processing and Distribution area or 
in another dental clinic? It doesn't. Unless we've got good 
surveillance and good oversight, as you were about to point 
out, to ensure that these things are being done, we can't make 
those kinds of assurances.
    Mr. Costello. If, in fact, the second part of your 
procedure that you explained--did, in fact, the Acting Director 
at this facility sign a certification that those procedures 
were followed?
    Dr. Petzel. I believe so, they were signed just before she 
became the Acting.
    Ms. Nelson. They were signed prior to my arriving.
    Mr. Costello. And when would that have been?
    Ms. Nelson. This would have been prior to October 2009.
    Mr. Costello. I would request, Mr. Chairman, that that 
documentation, not only the certification that was signed 
before you became the Acting Director, I would like to see if 
in fact a certification was signed, and the dates for the last 
few years. The last 2 years.
    Dr. Petzel. We will do that, sir.
    The Chairman. And how often do you have to sign one? Every 
year or every 2 years?
    Dr. Petzel. This was a result of the----
    The Chairman. No? When did she have to sign one?
    Dr. Petzel. She would have been signing as a result of--she 
wouldn't have to sign one independently, Mr. Chairman. She 
would, someone had to sign the certification at the time that 
we sent that out.
    Now, if we have to find out, I don't know who was the 
Acting here or whether the previous Director was here, but 
that's the individual that would have certified that.
    Mr. Costello. Well, what does the, what is the procedure? 
Does the procedure say that a certification has to be signed 
every month, every 6 months, every year? What's the----
    Dr. Petzel. That was just a one-time event associated with 
the publication of that new directive, as I remember it.
    Mr. Costello. So if I understand you correctly, the Acting 
Director had to do the certification one time and that's it?
    Dr. Petzel. The certification was a one-time that they have 
looked at, inspected all of the facilities and we, then, are 
indeed following all those procedures that was in that 
directive. That was just a one-time event associated with the 
issuance of that directive.
    Now, there are a number of inspection groups that go and 
look at our Supply Processing and Distribution centers. Some of 
them come out of the network, some of them come out of Central 
Office, Infection Control. There is also a national group, now, 
of Supply Processing and Distribution that reviews and inspects 
our procedures in each one of the medical centers. That's the 
external methods for accounting.
    In addition to that, the Joint Commission every 3 years 
comes in and looks at these things. The Inspector General, in 
their Combined Assessment Program visits, comes in and looks at 
our Supply Processing and Distribution and we have Systematic 
Ongoing Assessment and Review Strategy, an internal group that 
also looks at it.
    Mr. Costello. My understanding is that the letters that 
were sent out to the 1,812 veterans, that in the letter that 
the Center says between February 1, 2009, and March 10, 2010.
    Why did it take this long to go undetected?
    Dr. Petzel. I don't know the answer to that, Congressman, 
to be honest with you. That's part of what we are trying to 
find out with the Administrative Investigative Board. Who 
should have known that this was not proper and appropriate? Why 
didn't they know and why didn't we know?
    Mr. Costello. Are there procedures in place now? I mean for 
a year this went on. Are there procedures in place now that 
inspections have to take place or a review has to take place on 
a regular basis?
    Dr. Petzel. What we've done first to assure that this 
doesn't happen with dental is that we now require, and we have 
certification from every one of the medical centers, we require 
that all processing of dental equipment, the prewash and the 
sterilization, must occur in the Supply Processing and 
Distribution central center. That's our mechanism for being 
certain that we are not doing what happened before.
    In addition to that, there should be walking rounds that 
occur in a medical center to ensure periodically that indeed 
that process is being followed.
    Finally, the Supply Processing and Distribution people are 
alert now to the fact that they are supposed to be receiving 
the unwrapped dental instruments. If that should not happen, if 
they should be coming down wrapped, then that's a red flag to 
say this is not happening correctly.
    Mr. Costello. Finally--the last question because I'm out of 
time here--what did the Agency learn from the incidents that 
happened in Tennessee, Georgia and Florida that should have 
happened here with the notification of the 1,812 veterans? I 
mean surely the Agency learned something from those incidents.
    Dr. Petzel. I think we did. It's very interesting, 
Congressman. We notified by letter all of the people, and we 
received absolutely no feedback or pushback about the way that 
happened. So clearly, we didn't learn from that that the method 
of notifying was not sensitive to the patients' needs and was 
not, didn't recognize the seriousness of this event in the 
lives and minds of the patients. So that's a lesson we didn't 
learn.
    We did learn how to go about organizing ourselves for an 
event like this. We did learn that we need to have counseling 
available. We did learn that we need to have professionals 
available.
    The things that we did not learn were, number one, the time 
and the implications that it was going to have on both Congress 
and the public in terms of the time it took us to discover 
this, and the reaction that the patients would have to the 
letters that we sent out. In retrospect, it's obvious.
    Mr. Costello. Would you agree with the Chairman's statement 
earlier that all 1,812 should have a caseworker or someone 
assigned to them so that they can have a contact, and ask the 
caseworker questions throughout this process?
    Dr. Petzel. Yes. I believe that each one of those people 
should have a contact person that they can go to, that they 
know will answer their questions, that they know is available, 
and help them with whatever issues they might have.
    It's interesting, though. Most--not most. Some of the 
people are going to reject that. When we called after we sent 
the letters out, there are numbers of people who don't want to 
be tested, don't want to be involved.
    Mr. Costello. How soon do you intend to implement that so 
each one who wants a caseworker has a name and a phone number 
of an individual to call?
    Dr. Petzel. We can start that tomorrow.
    Mr. Costello. We can or we are going to?
    Dr. Petzel. We will start that tomorrow.
    Mr. Costello. Thank you, Mr. Chairman.
    The Chairman. As long as every one of the 1,812 doesn't 
have the same caseworker.
    You have to figure out how to ask these questions with 
these guys.
    Mr. Akin.
    Mr. Akin. Thank you, Mr. Chairman.
    First of all, Secretary Petzel, you are not, you haven't 
been assigned specifically to your job but you've been in this 
business a long time, so just first of all, do you have, across 
the Nation, do you have any sort of a feedback loop, first from 
the employees, if they want to talk to you about something? If 
somebody is going to be a whistleblower, are they a legitimate 
whistleblower and do they have legitimate concerns? And do you 
have some sort of a feedback loop from your own employees?
    And second of all, do you have a feedback loop from the 
veterans that are getting service, so that you have any way of 
knowing or monitoring whether you've got problems in certain 
locations? Is there anything like that?
    Dr. Petzel. Well, there is a system within the VA of what 
we call incident reporting. Every medical center has suggestion 
boxes, which are places that people can put complaints, where 
people can put suggestions that they have for making 
improvements.
    I think we have some work to do in terms of providing a 
mechanism for employees to provide us with feedback, to provide 
us with information in a completely and totally, an atmosphere 
that's free of reprisal or intimidation.
    We are--and I have been in a medical center as a chief of 
staff. I was a network director. And I can tell you that in 
those positions, you are a victim of what you don't know. And 
these people can provide you with valuable information about 
events that may lead you to an incident, say, such as what 
happened at Cochran.
    So I think we have work to do. I have not got a specific 
idea of how it should be done, but I think it's something that 
needs to be addressed.
    Mr. Akin. Probably, I would think, after the last couple of 
hours you would probably have gotten sensitized to the fact 
that the people here, that are just to some degree outside 
observers, have a sense of frustration.
    And part of the sense of frustration is not so much that we 
don't trust that you would like to make things better, or that 
you, if we put pressure on you, will say, it will be better. 
The question is, can you make it better? And do you have a plan 
to make it better, and are you going to be able to execute that 
plan?
    It seems like, to me, the front end of that plan might be 
that, better than suggestion box, you have an organized system 
that works across your veterans' hospitals to give you feedback 
to let you know if you've got problems.
    And it would seem like that one of the things that you are 
desperate for is feedback from veterans as to what kind of 
quality service do they think they have. If you really care 
about the service you are providing, then you are going to need 
to have that sort of feedback loop. And also, you need to have 
it better than a suggestion box. Obviously that's not a very 
reliable system. So it would seem like that might be the front 
end.
    I'm an engineer by training. I don't mind being critical, 
but I always want to say, hey, here are some ideas. The first 
thing is you'd better get some feedback as to where you are 
going to go. If you don't have that loop in place, you are not 
going to convince any of us that you are going to change 
anything. First of all, you have to be collecting some data.
    It seems--and second of all, I wanted to ask this question 
in a general sense. You put your hat on and go to work each 
day. There have to be some--what are a couple of the biggest 
challenges you have in your job? All of a sudden you've got 
this new job. You are in charge of all these things and you are 
going to be there for some period of time. What are some of the 
challenges that you face?
    We have heard several things that sound to me like they 
would be really serious challenges. The first is we have a lot 
of trouble with turnover. The second one is we don't have 
enough staffing. Are those two things that keep you up at 
night? Are those things that you are worried about? If those 
things are true and I were in your position, I would be worried 
about that. Are those the sort of things you are worried about?
    And the, part of where I'm going with this question is do 
you have the capability of changing it even if you wanted to? 
Do you have--the authority that you've been granted, can you 
deal with the cost of how much it costs? Because my 
understanding--I don't serve with the Chairman. He seems like a 
pretty good Chairman, by the way.
    But my understanding of veterans stuff is there is 
tremendous demand for your services and fairly limited 
resources to try to provide those services. So just like a lot 
of medical places, it costs a lot of money and it's hard to try 
to provide that level of service for the funds and the people. 
Is that something that you struggle with?
    Dr. Petzel. Well, first of all, let me address the turnover 
issue that you mentioned. That is something that I feel I have 
control over. I can control. I can do the things, or I can help 
the organization do the things that contribute to less 
turnover. A more satisfying working environment, things such as 
that. So I do.
    In terms of resources, I believe that across the country 
this organization has the resources that it needs. I believe, 
also, that there probably are places where those resources are 
being used better than there are places, than at some other 
places. And if----
    Mr. Akin. Do you have a mechanism to know?
    Dr. Petzel. I do. I do. We do have a way of looking at the 
efficiency, the effectiveness, et cetera, of the money that's 
being spent. We have very detailed ways of looking at, again, 
how the money is being spent. Changing that may take a lot more 
effort, et cetera, but knowing what's going on, yes, we do. 
Yes, we do.
    Mr. Akin. I would think that--I won't speak for everybody 
on the Committee, but I would be skeptical if you are telling 
me that you are going to change some of the patterns that we've 
seen, particularly what appears to be a pretty casual attitude 
towards the veterans you are supposed to be serving on the part 
of many staff people. I would be skeptical.
    You would say, we are going to change it tomorrow, 
Congressman Akin, but I would be skeptical that you could do 
that unless you have some plan in place, which is going to take 
a look at the overall situation and figure out what you've got 
to change, and analyze it, and how you are going to solve the 
problem.
    And I would think that some type of report back to the 
Members of this meeting today, and the Committee, would make a 
lot of sense and would give us a sense of, hey, they've got 10 
things they are going to do. And we've got three of them done. 
We are working on the fourth. That type of thing would give us 
the sense that there is some, some forward progress.
    Dr. Petzel. I hear you.
    Mr. Akin. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Mr. Luetkemeyer.
    Mr. Luetkemeyer. Thank you, Mr. Chairman.
    I've got a constituent or two of my district here today who 
is listening to the testimony, and one of the questions that 
they've got is what recourse/restitution does the veteran who 
has been diagnosed as positive or had positive tests done, what 
do they have? What kind of restitution do they have?
    Dr. Petzel. Well, it's my understanding, first of all, we 
would provide them with whatever medical care they need.
    Secondly, they can file a tort claim and if we are held to 
be responsible for having created that condition, let's say 
hepatitis C or HIV infection, they can be compensated for that 
through the tort claim process.
    Mr. Luetkemeyer. What about the individual that were to 
find out who this person is, or this group who are responsible 
for doing this? Are they being held liable at all? Personally 
liable?
    Dr. Petzel. Financially liable?
    Mr. Luetkemeyer. Well, either you are financially liable or 
you go to jail. One or both of them.
    Dr. Petzel. Well, the Federal Tort Claim Act would protect 
them from financial liability if they were acting within the 
scope of their job, but they certainly can be disciplined, 
punished.
    Mr. Luetkemeyer. Yeah, but if it's negligence on their 
part, just simply criminal negligence, are they protected by 
Federal law then? I would think not.
    Dr. Petzel. If it's criminal negligence, they would not be 
protected. But if they were acting within the scope of their 
job, then they would be protected.
    Mr. Luetkemeyer. Okay. Are you looking at other procedures? 
I mean we will talk today about this, about the dental 
situation, but obviously if this is going on, there may or may 
not be other things.
    Are you looking at all at other procedures that are going 
on in this particular facility that may be improper----
    Dr. Petzel. We are not only looking at all the procedures 
in this particular facility, we are looking across the country.
    As I said, we brought all the dental processing into our 
Central Processing Unit. And we are bringing everything into, 
eventually, the Central Processing Unit so that we don't have 
any reprocessing or processing of reusable medical equipment 
occurring anyplace but in our Central SPD units. So yes, we 
are.
    Mr. Luetkemeyer. What are you doing for the folks, or do 
you have a program in place if somebody tests positive? What 
about their spouse, or their partner, or other people who they 
come in contact with? What are your plans to take care of those 
people?
    Dr. Petzel. Certainly we would provide them with 
counseling. We would provide them with testing. And quite 
frankly, Congressman, I cannot answer your question about what 
our legal responsibility is, but I will get back to you.
    [The VA subsequently provided the following information:]

        During the oversight hearing on July 13, Dr. Petzel was asked 
        if VA had in place a program for the spouse or partner of an 
        affected veteran. Unless the spouse is eligible for CHAMPVA 
        care (38 U.S.C. 1781), VA has no legal authority to extend such 
        an offer to the spouse of a veteran. If the intimate partner of 
        a patient who has been newly diagnosed with a viral infection 
        is also found to have positive test results, the intimate 
        partner could file a tort claim with the Regional Counsel 
        seeking damages, including the cost of past and future medical 
        care. The decision on whether such a claim would be payable 
        would depend on whether the supporting evidence showed that the 
        patient's infection was more likely than not associated with 
        the dental equipment and not other possible causes.

    Mr. Luetkemeyer. Okay. Well, I just want to close with just 
a remark. I mean as we have said here today, and I think you've 
heard the Chairman and all of the individuals, the Congressmen 
here that testified.
    You know, I think that as I listened to your testimony--and 
this doesn't apply, it applies not only to you, Dr. Petzel, but 
to other members of the panel. I don't hear the concern for the 
veterans. I don't hear the angst over what happened. I don't 
hear the empathy for the people who have been harmed by this.
    In my world, as a former businessman and now as a 
Congressman, I always try and put myself in the place of the 
person across the table from me and try and say, how do they 
feel? How can I help them? What are their real concerns? I 
don't see that from this group today and that concerns me, 
because that's exactly what you should be doing.
    Yours is not a job. Yours is a responsibility of care. And 
we don't see that, the understanding that there is a 
responsibility on your part to take care.
    And if you look at what happened, it took a year to find 
it, 13 months to find it. It took 90 days to notify the people, 
or more. One hundred eight days to notify the people. That is, 
that shows there is nothing there of concern, or that the 
process and programs in place are not working, the bureaucracy 
is not working, and that can't happen because you are in a 
people business. You have to understand that.
    With that, Mr. Chairman, I give it back.
    The Chairman. Thank you, Mr. Luetkemeyer.
    Let me make a suggestion along those lines. I think you hit 
the nail on the head. You said you would try to get some case 
managers by tomorrow?
    Dr. Petzel. Yes.
    The Chairman. May I suggest, in a very humble way, that the 
Acting Director take a dozen, you take a dozen, the Secretary 
of Veterans Affairs take a dozen.
    Let's show that we care by talking to these people 
directly. Don't leave it to the person that was hired 
yesterday. Find out what's going on with these people. Just 
call six of them up. See how they are doing. What don't you 
understand? If you were affected you would want someone to show 
compassion. You are administrators and you have someone else 
making these calls when you ought to be doing it.
    Dr. Petzel. Good idea.
    The Chairman. I just make a modest proposal. If the 
Secretary says, ``let the Chairman do it,'' I will be happy to. 
Just give me some names and phone numbers.
    I think we ended when Mr. Carnahan asked you some quick 
questions.
    You may not be able to answer this, but do you know when 
the Secretary was notified about this incident?
    Dr. Petzel. I don't.
    The Chairman. That bothers me. I didn't understand this 
Administrative Investigative Board. Who are they and why isn't 
the OIG brought in?
    Dr. Petzel. Why wasn't the OIG brought in? Because we 
wanted to do an administrative evaluation that we can use for 
disciplinary actions if need be, and the OIG's business is not 
available for that purpose.
    The Chairman. That's the first time I've ever heard it.
    Dr. Petzel. These are people from across the country, a 
team of about four people.
    The Chairman. Is it private and you hire them?
    Dr. Petzel. No. These are VA employees.
    The Chairman. VA employees?
    Dr. Petzel. VA employees who are going in and looking at 
what happened there.
    The Chairman. And why would they be independent?
    Dr. Petzel. Well, because----
    The Chairman. We just heard is Ms. Johnson still here?
    Ms. Johnson. Yeah, I'm here. I'm here. I'm listening to 
everything you are saying, Mr. Chairman.
    The Chairman. I want you to----
    Ms. Johnson. It's my business.
    The Chairman. I want you in court, to use what Dr. Petzel 
said about what should happen at all the Central Offices. He 
said exactly what you said, exactly. Except you had premature 
sensibility to this, so you were fired.
    But he said it exactly the way--that all the cleaning and 
the sterilization should take part in----
    Ms. Johnson. In your department.
    The Chairman [continuing]. In your, in that department.
    Ms. Johnson. May I say something?
    The Chairman. I just don't understand. How is it 
independent with employees? Don't they care? Aren't they 
worried about their next job and everything else?
    Dr. Petzel. Well, don't you think that they are able to 
rise above that? They are concerned about what happened?
    The Chairman. They are able to rise above it if you guys 
are able to rise above it. I mean we've had people fired for 
saying stuff, so how can they rise above it?
    Dr. Petzel. I do believe that they are capable, they are 
capable of looking independently and without bias at what the 
circumstances were in this incident.
    The Chairman. Well, I would hire some people from the 
Congress rather than from the VA, then. I would trust any one 
of our offices to do that better. We are sitting here for 2\1/
2\ hours talking about intimidation and fear, and now you are 
telling me you are going to have the independent investigation 
from the very employees who fear for their jobs? That doesn't 
make any sense to me.
    Dr. Petzel. I don't think these employees fear for their 
jobs, that are going to be doing this investigation.
    The Chairman. Oh, so it's just the ones that are already up 
there. So why should I trust them, then?
    Dr. Petzel. Well, Mr. Chairman, are you implying that we 
can't do an unbiased investigation?
    The Chairman. I'm not implying. I'm saying it. You said you 
wanted an independent investigation. Now I find out that it's 
VA employees that are going to do it.
    Even if they could rise above it, the perception is that 
they can't. Now you are telling me that the Inspector General 
is not independent or something. I don't know what you are 
telling me about that, but that's been our traditional 
approach. I've got to look into what the Administrative 
Investigative Board is.
    One last question. Why, from your perspective--and I'm sure 
you have a justification for it--why did it take 2 months for 
this Board to be set up to investigate this? And why did it 
take 2 months, after they decided that people should be 
notified, to be notified? What is going on with the bureaucracy 
that puts the process above the people?
    Dr. Petzel. I have absolutely no justification for that, 
Mr. Chairman.
    The Chairman. What's going on? They couldn't find a date 
for a meeting so they kept putting it off and they all got 
together or somebody was on vacation so they couldn't meet 
then? I mean what's going on there?
    Dr. Petzel. I think there were probably a number of 
different things, all of which were inappropriate.
    The Chairman. All right. You will get that in your letter 
to me.
    Mr. Carnahan, you have been on top of this from day one. 
You get the concluding questions.
    Mr. Carnahan. Thank you. I just have a couple of quick 
follow-ups.
    Specifically, Dr. Petzel, how is the VA going to advise 
employees that they are not only encouraged to step up and 
speak out about this specific case, but cases and any problems 
going forward? How are they going to be advised of that to sort 
of break this culture of real or perceived retaliation?
    Dr. Petzel. I can't tell you, Congressman Carnahan, exactly 
what we are going to do, but it needs to be in the nature of a 
campaign. It needs to be written notification to employees. It 
needs to be setting up--just as was pointed out by another 
Congressman, that we need to set up a mechanism for them to 
bring their concerns forward in a completely un-intimidating, 
no-fear-of-reprisal kind of atmosphere.
    And I'm not, I'm not prepared to say exactly how that can 
be done. I do know what needs to be done but I don't know 
exactly how we are going to do it.
    Mr. Carnahan. Well, we are going to need, we are going to 
need to know exactly how that's going to be done.
    Dr. Petzel. I can appreciate that.
    Mr. Carnahan. Because I think that's going to be critical 
to going forward. And I'm assuming the process of evaluating 
those kind of concerns that have come up at Cochran before.
    Is there a process in place if--and I direct this to Ms. 
Nelson. Prior to this incident, was there a process in place at 
Cochran to take complaints or suggestions and be evaluated for 
implementing them?
    Ms. Nelson. Yes, there is a process in place. Employees are 
notified through New Employee Orientation exactly what it is 
that they can do if they discover problems. We also have an 
annual reminder for employees to remind them of what they can 
do.
    We have informed them that they can contact the Joint 
Commission or the Inspector General at any time if they feel 
that the quality and safety of the patients, the veterans in 
the hospital isn't up to the standard. And that's exactly what 
happened in the OIG report.
    Mr. Carnahan. And based on what you've heard here today and 
other conversations, do you think that system is sufficient?
    Ms. Nelson. It sounds like we need to do some more work to 
improve it, based on what we've heard today.
    Mr. Carnahan. Okay. Now, and then lastly I want to ask, we 
heard Ms. Johnson here today and her reference to conversations 
she had, but also a copy of an e-mail from August 24th of 2009 
and the title, ``Here is an outline of improvements for Sterile 
Processing.'' This is from August of 2009.
    Was this brought to anybody's attention, that you are aware 
of?
    Ms. Nelson. No, I'm not aware of that.
    Dr. Petzel. We've looked, we've looked for e-mails in both 
of our e-mail systems from Ms. Johnson to anybody in the 
organization during her employment, and we cannot find but one. 
That was not one of them.
    Mr. Carnahan. Well, we will want to hear more about that, 
as well.
    Mr. Chairman, thank you.
    The Chairman. Thank you. I want to thank my colleagues. I 
have not served on a Committee with most of these gentlemen, 
but I think you helped us get to some really important things 
here.
    I want to assure those of you in attendance, especially 
those who are veterans who are affected, this is not just a 
hearing for show. We are going to look at all 1,812 and take 
care of you until you are assured there is no problem. We want 
to make sure you know that.
    You heard me and Dr. Petzel have some, or me, at least, 
have some exchange. He knows, and I've said in public how much 
I respect him. I feel like I'm talking to someone who can 
understand it.
    We are going to come back with the same group in 5 or 6 
months. We may have a different Chair or we may not have a 
different Chair. I don't know yet. But we are all committed to 
seeing that some of the issues that came up today have real 
follow-through. We may find out Dr. Petzel was fired because he 
raised too many questions, and the next guy will say, I don't 
know what he promised, so we are going to start over again. I 
hope that doesn't happen, but I've seen it too often.
    We take this hearing very seriously. We have every word 
written down and we are going to hold people accountable. And I 
think we have found both a Republican and Democrat community of 
interest here and that is going to ensure we continue our 
follow-up. I assure all of you we are going to do that.
    I especially thank the Missouri delegates for joining us.
    Dr. Petzel you look like you want the last word. I will 
give it to you.
    Dr. Petzel. Thank you, Mr. Chairman.
    I look forward to joining you back here in 6 months to 
demonstrate some progress on the issues we've discussed today.
    The Chairman. Fantastic.
    This hearing is adjourned.
    [Whereupon, at 4:33 p.m., the Committee was adjourned.]



                            A P P E N D I X

                              ----------                              

                 Prepared Statement of Hon. Bob Filner,
             Chairman, Full Committee on Veterans' Affairs

    This hearing will now come to order.
    I would like to thank everyone for attending, especially the 
veterans who are with us today. I would like to thank the staff of 
Thomas F. Eagleton U.S. Courthouse for their generosity in providing a 
space for today's hearing.
    Today, I join my colleagues Mr. Miller, Mr. Carnahan, Mr. Costello, 
Mr. Blunt, Mr. Shimkus, Mr. Akin, Mr. Clay, and Mr. Luetkemeyer in 
examining an incident involving reusable dental equipment at the John 
Cochran VA Medical Center. As a result of the lapse in the protocol for 
cleaning dental equipment, more than 1,800 veterans have been put at 
risk-possibly having been exposed to hepatitis B, hepatitis C, and HIV.
    The purpose of today's hearing is to get to the bottom of the 
events leading up to the lapse in protocol for cleaning dental 
equipment. We need to examine the steps that VA officials took once 
they learned of this incident, and evaluate whether they were effective 
in providing timely information to veterans. I am also concerned with 
VA's lack of transparency. Members of Congress did not receive 
appropriate information to allow them to relay information to their 
constituents in a timely way. When mistakes are made, honesty and 
truthfulness are the only way to begin to rebuild trust with the 
public.
    We need to explore how best to deal with the aftermath of this 
shameful incident. First, we must affirm that VA properly identified 
all potentially affected veterans and that these veterans get tested 
for hepatitis and HIV. Most assuredly we must deal with the issues of 
accountability when standardized procedures are not followed and 
veterans are put at risk, along with again reviewing VA's oversight 
policies to ensure that mistakes like these will not happen again. 
Finally, today's meeting presents us with the opportunity to hear 
directly from veterans and better understand the questions and fears 
they face while dealing with this incident.
    My biggest concern is that we've been here before. In December 
2008, I was notified of improper reprocessing of endoscopes which put 
thousands of veterans in Murfreesboro, Tennessee, and Miami, Florida, 
at possible risk of hepatitis and HIV. And in February 2009, another 
one thousand veterans in Augusta, Georgia, received notifications that 
they were at risk for hepatitis and HIV because of improper processing 
of ear, nose, and throat endoscopes. And just last week, the Department 
notified 79 additional veterans in Florida, whom they failed to notify 
previously, that they were also at risk. Clearly, VA has had issues 
with ensuring the sterility of reusable medical equipment in the past 
and clearly they have yet to resolve these problems, as evidenced by 
the most recent incidents in St. Louis and Miami.
    Most veterans-and Members of Congress--are getting their 
information from news outlets. These are just some of the headlines 
that we have been reading in the last couple of weeks:

          Washington Post, ``HIV Scare Causing New Problems for 
        Veterans Affairs'';
          New York Times, ``Veterans at St. Louis Center Are 
        Told of Exposure Risk'';
          CNN, ``VA Hospital May Have Infected 1,800 Veterans 
        with HIV'';
          St. Louis Post-Dispatch, ``Faulty Dental 
        Sterilization in St. Louis.''

    In the July 2 issue of the St. Louis Post-Dispatch, the Chief of 
Dental Services at the John Cochran VA Medical Center is quoted as 
saying that, ``Things are done to get votes, and that's a shame''--
implying that this hearing here today is for show. Frankly, I am 
angered by this comment. By blaming politics, this is simply an attempt 
to shift the attention away from the incident and minimize the mistakes 
that were made.
    Instead, I challenge the Chief of Dental Services--in fact, I 
challenge the entire leadership of the Department of Veterans' 
Affairs--to take responsibility for this disgraceful incident and show 
America and our veterans what they are doing to better understand why 
and how this inexcusable lapse in dental sterilization occurred. 
Already facing an uphill battle, VA now must work harder and longer to 
improve training, implement standardized procedures, and regain the 
trust of the veterans it serves.
    I look forward to hearing today's testimonies.

                                 
                 Prepared Statement of Hon. Jeff Miller

    Thank you, Mr. Chairman. And, thank you for calling this important 
hearing.
    I want to thank my fellow Members of Congress from the neighboring 
states of Missouri and Illinois for joining us today--my good friend 
Roy Blunt--John Shimkus--Todd Akin--Blaine Luetkemeyer, and--from the 
other side of the aisle--Lacy Clay, Russ Carnahan, and Jerry Costello. 
I know Congressman Blunt has already sent a letter to Secretary 
Shinseki on July 1st with some very specific questions that need to be 
answered, and I hope this hearing will answer at least some of those 
questions. I also know other Members also wanted to be with us today, 
but were unable to attend. In particular, Congresswoman Jo Ann Emerson 
asked me to give you her best regard and express her regret that she 
could not attend. JoAnn has sent a member of her staff to listen and 
participate and many of the Missouri and Illinois delegations have done 
the same.
    We are all here because we share a deep concern for our veterans 
and the quality of care they receive in VA facilities.
    The problem that has come to light with the cleaning of dental 
equipment at the medical center in St. Louis is unfortunately a 
disturbing symptom of a system-wide breakdown in patient safety.
    Over the past 2 years, we have been confronted with the discovery 
of the improper cleaning of various types of reusable medical equipment 
in locations such as Murfreesboro, Tennessee; Miami, Florida; Augusta, 
Georgia; and San Juan, Puerto Rico. After each incident, Congress and 
the country were assured that VA was addressing these serious threats 
to patient safety and that our veteran's trust would not again be 
compromised. After each incident, the VA assurances proved hollow.
    Today, we are here because it is clear that VA does not have 
effective processes in place to ensure proper reprocessing of reusable 
medical and dental equipment.
    It is well and good for VA to talk about changes that are taking 
place to address these problems, but these are repeated failures of 
senior leadership and management. I am going to ask today what is being 
done at the highest levels in VA to hold Veterans Health Administration 
leadership and management accountable. And, what is it going to take to 
get actual results?
    Time is past due for VA leadership to take charge to eliminate 
ongoing quality care issues and adopt an aggressive and effective 
action plan to monitor compliance with device-specific standard 
operating procedures for sterilizing medical equipment. At risk is no 
less than the health and well-being of our most revered citizens.
    Patient safety is and should continue to be our very highest 
priority. The 1,812 men and women who may have been exposed to any 
infection as a result of improper cleaning at the John Cochran VA 
medical center served our country honorably. The very least that we can 
offer them in exchange for their bravery and sacrifice is health care 
that is safe and effective.
    With that said, I want to thank all of our dedicated VA health care 
workers for the care they provide our veterans. It is your compassion, 
experience, and expertise that is bettering the VA health care system 
each and every day. However, as with everything in life there is always 
a need to continue to strive for improvement in every aspect of chosen 
work. And, I hope today's hearing will encourage staff to be diligent 
and always report any and all concerns they feel should be addressed. 
You will be heard.
    It is the obligation of Congress to oversee the quality of health 
care VA provides to our veterans and to ensure that they and their 
families can have the utmost confidence that VA really is the ``best 
and safest care anywhere.''
    In closing, and most importantly, I want to thank every veteran 
present for their service. I want you to know that I will not rest 
until situations like the one that brought us here today are fully 
resolved. You have earned and deserve the best and safest care our 
Nation can provide. And you can be certain that I will continue to do 
all I can to bring it to you.
    Mr. Chairman, I yield back my time.

                                 
                Prepared Statement of Hon. Russ Carnahan

    Mr. Chairman, thank you for holding this necessary meeting to 
discuss the risk created by a breach of standard operating procedures 
in the John Cochran VA Medical Center's dental clinic and other non-
compliance issues.
    Since we learned earlier this month that veterans throughout the 
St. Louis and Illinois area could have been exposed to blood borne 
pathogens such as Hepatitis B, Hepatitis C, and HIV while receiving 
dental care at John Cochran VA Medical Center, I have heard from many 
constituents, veterans, and their families who are gravely concerned 
about this matter.
    From where I stand, there are five issues that need to be addressed 
here today:

        1.  We need to make sure that the 1,821 veterans who have been 
        directly impacted by this--and their families--are getting the 
        special care they need, including any mental health care.
        2.  We need clear answers as to exactly what happened, how it 
        could have gone on for as long as it did and how it was 
        uncovered.
        3.  I am determined to get to the bottom of whether an employee 
        of the Medical Center was terminated in part because she raised 
        concerns about the sanitization procedure. In addition, I want 
        to know what concrete steps the Cochran Center and the VA are 
        taking to proactively reach out to current and former employees 
        in order to seek information that may be relevant to this 
        investigation. When employees see coworkers who speak up lose 
        their jobs, it can have a chilling effect, and a thorough 
        investigation depends upon witnesses who feel safe and secure 
        in their ability to be candid and forthright, without fear of 
        retaliation from supervisors. We must make sure employees who 
        have information that is relevant to this matter are aware of 
        their rights and feel comfortable coming forward.
        4.  I want to determine whether this latest incident in the 
        dental clinic--in conjunction with prior safety and 
        sanitization problems at Cochran--represent a larger systemic 
        problem at this facility. This is not the first time John 
        Cochran VA Medical Center has been cited for serious 
        infractions, which leads me to suspect that there may be 
        broader issues that need to be addressed at this facility. In 
        April 2010, the Veteran Affairs' Office of Inspector General 
        conducted an inspection to ``determine the validity of 
        allegations regarding ongoing issues with the Supply, 
        Processing and Distribution departments related to reprocessing 
        gastrointestinal endoscopes.'' The inspectors found that the 
        SPD department did not have defined clean and dirty areas and 
        there were severe communication breakdowns between staff 
        regarding proper reprocessing procedures. Moreover, in 2009 
        Survey of Health Expectancies of Patients--a VA approved 
        patient satisfaction survey that tracks satisfaction responses 
        from inpatient and outpatient veterans--showed that John 
        Cochran VA Medical Center scored the lowest score out of the 
        128 VA hospitals around the country in inpatient services. A 
        score of 46 percent is unacceptable in when it comes to 
        providing much needed health care services to our veterans.
        5.  And most importantly--we need to determine what next steps 
        must be taken in order to restore and rebuild the faith of our 
        veterans--and the public--in the quality of care being 
        delivered by the VA Health System generally and Cochran VA Med 
        Center specifically.

    Let me be clear--this is not and should not be an excise that 
broadly paints a negative picture of our VA Health Care system.
    The fact is, I have been encouraged by the VA's response to our 
inquiries, and I have no doubt that the leadership at the VA and 
Cochran care as deeply as I do about providing the best quality care 
possible for our veterans.
    And certainly, many of the vets I have met and spoken with tell me 
that they have been extremely pleased with the care they have received 
through the VA--even veterans who received the letter advising them of 
their risk from the Dental Clinic.
    In fact, just last Thursday, I met with a group of about 30 
veterans from throughout the area after touring the Cochran facility. 
TELL INDIVIDUAL STORY FROM VETS MEETING
    But at the end of the day, it is critical that the VA identify and 
rectify any existing problems, make sure this never happens again, and 
take whatever steps are needed to rebuild our veteran's confidence in 
the VA health care system.
    To all the witnesses before us today--thank you for taking time out 
of your busy schedules to appear before us. I look forward to hearing 
your testimony.

                                 
              Prepared Statement of Hon. Jerry F. Costello

    First, I would like to thank Chairman Filner for responding to our 
request on short notice to hold today's field hearing to examine the 
U.S. Department of Veterans Affairs (VA) actions in failing to comply 
with standard operating procedures and the possible risks our veterans 
were exposed to from inadequately cleaned and sterilized dental 
equipment at the John A. Cochran Veterans Medical Center (VAMC).
    As we now know, 1,812 veterans were notified on June 28, 2010 that 
they were at risk, the same day Congress was made aware of this 
situation. Of the 1,812, 370 of these veterans reside in the 
congressional district I am privileged to represent. I am outraged at 
what happened, which is particularly egregious as it is not the first 
time the VA has jeopardized the health of veterans by improperly 
cleaning medical equipment. In 2009, an investigation by the Office of 
Inspector General discovered that 10,320 veterans were exposed to 
Hepatitis B and C, or HIV because VA hospitals were not properly 
cleaning endoscopic equipment in Murfreesboro, Tennessee; Augusta, 
Georgia; and Miami, Florida.
    In my Congressional district in Southern Illinois, we are dealing 
with similar inabilities to follow basic, routine procedures and 
quality management standards at the Marion VAMC. These events led to 
the unfortunate deaths of nine veterans in 2007 and caused a lack of 
confidence in patients receiving care from the Marion Veterans Medical 
Center.
    Equally troubling, this committee has previously investigated 
failures in VA procedures, including basic sterilization processes, and 
assured these problems were resolved. The evident inability of the VA 
to ensure these procedures are implemented is shocking. I am eager to 
hear from the VA if our existing Veterans Integrated Service Network 
(VISN)--which is charged with maintaining oversight at the facilities--
and its review processes are capable of addressing inefficiencies in a 
timely and effective manner. Simply issuing guidelines is not 
sufficient and the VISN and facility leadership are responsible for 
ensuring those guidelines are successfully followed. It is fair to ask 
if the VA can effectively institute system-wide standards--and provide 
the necessary oversight to make certain that the standards are being 
followed.
    Hopefully, none of the 1,812 veterans contracted a disease because 
of this breakdown in procedure. The VA must explain how they will 
handle the matter if any veteran does contract a disease. At the same 
time, the VA will not be vindicated if all remain healthy--the key 
question here is the VA's ability to follow their own routine 
procedures. I want to know why such a time lapse occurred between the 
breakdown in procedure and when veterans were notified. I also want to 
know the exact dates of when regional and Washington D.C. officials 
were notified of this breakdown. I think we must follow this timeline 
closely to determine if the VA's reaction to this situation was slow 
and ineffective.
    For everything that our veterans have sacrificed for us, we must 
ensure that the health care they receive at VA facilities is of the 
highest quality care. I look forward to hearing from our witnesses 
regarding these questions and how the VA will assure patient safety 
moving forward.

                                 
                Prepared Statement of Hon. John Shimkus

    Thank you, Mr. Chairman. We are all appalled that dental 
instruments were not properly sterilized at the Cochran VA Dental 
Clinic here in St. Louis. Unfortunately, this is a sign that serious 
problems affecting the health of our Nation's veterans have not been 
corrected--even after the recent tragedies at the Marion VA Medical 
Center in my state and the temporary closing of the supply processing 
department here just months ago.
    This is quite an egregious situation, given that it was more than 1 
year before it was determined that the proper procedures were not being 
followed. And the proposed solution--turning over sterilization to the 
supply processing department--raises even more questions. According to 
the July 7, 2010, St. Louis Post-Dispatch, ``the cleaning of endoscopes 
was moved from the supply processing department to the gastrointestinal 
unit after problems surfaced with equipment not being properly cleaned.
    ``Hospital leaders closed the department for two weeks in December 
and January to train staff and to sterilize all endoscopes, which are 
used in colonoscopies and other procedures.
    ``A month later, after receiving a complaint about endoscope 
sterilization, Veterans Affairs inspectors visited the hospital and 
found several health and safety infractions. The temperature in the 
sterilization area was too high, rags and gloves were `strewn about' in 
the decontamination areas, filters had not been changed as required, a 
technician was not wearing protective gear, chemical test strips were 
left exposed, emergency exits were blocked, and employees were unsure 
whether an unattended endoscope was sterile, according to an inspection 
report issued in April by the VA's Office of Inspector General.''
    I hope that the precautionary tests being given to veterans who 
were treated during the time in question reveal no adverse health 
conditions. This is certainly traumatic for those men and women who had 
dental work done at the clinic.
    My colleagues and I are asking Secretary Shinseki to follow through 
on investigating the actions that led to this critical safety lapse and 
to take steps to ensure patient safety standards are upheld at all VA 
facilities, including dealing with infected patients. We urge Secretary 
Shinseki to make sure promises are kept to strengthen VA oversight of 
sterilization practices and enhance regulations to protect veterans 
from infection and reduce the chance of such a lapse happening in the 
future.
    As we have learned from the situation at Marion, problems such as 
these do not occur overnight and are not solved overnight. This is a 
corporate culture issue that must be solved. And without follow-up, 
they will continue to occur. While we are now fired up to show our 
concern, let us not leave here and forget our veterans one more time. I 
have a long, established relationship with Secretary Shinseki and am 
biased in my belief in and support of him. He has a big job, and if he 
needs help separating the wheat from the chaff, let us give him the 
tools to do so.
    I welcome my colleagues to the bi-State area and thank you for 
taking the time to come to St. Louis for this important discussion.

                                 
                Prepared Statement of Hon. Wm. Lacy Clay

    Thank you Mr. Chairman, Ranking Member Buyer and members for 
holding this timely hearing and for inviting me to take part in this 
field hearing regarding the John Cochran St. Louis VA Medical Center 
which I represent in Congress.
    We will examine, and hopefully, learn the truth about the improper 
processing of dental instruments, including a failure to clean dental 
equipment with a special detergent before it is sterilized.
    According to reports, on June 28, 2010, the St. Louis VA Medical 
Center distributed a disclosure letter by certified mail to thousands 
of Veterans which notified them of the possible exposure of Hepatitis 
B, C and HIV.
    Those exposed to this potential risk received dental treatment from 
February 1, 2009 to March 11, 2010.
    It is unacceptable that procedures were conducted from February 1, 
2009 to March 11, 2010 without proper safeguards in place to protect 
the health of veterans receiving treatment.
    Making matters worse, the VA knew about the possibility of exposure 
in March 2010, yet veterans were not notified of the problem until June 
2010.
    That is shameful, and there is no excuse for withholding that 
information.
    This country owes an enormous debt to the brave men and women who 
served our country with courage and honor.
    The care and treatment of military veterans has always been one of 
my top priorities, and President Obama and this Congress shares that 
essential commitment.
    On July 10, 2009, the House of Representatives passed H.R. 3082, 
which provided a total of $45.1 billion for the Veterans Health 
Administration (VHA).
    That bill also provided $48.2 billion in advance appropriations for 
VHA to be available in FY 2011.
    The $48.2 billion advance appropriation is for medical services, 
medical support and compliance, and medical facilities accounts, to be 
available in FY 2011.
    Mr. Chairman, I outline that legislative history to point out that 
this situation is not about a shortage of money.
    This is about a failure to follow proper procedure;
    A failure of supervision;
    And a failure to keep faith with all the brave Americans who have 
defended freedom.
    Thank you for your attention, and I look forward to today's 
testimony.

                                 
        Prepared Statement of Susan Maddux, Festus, MO (Veteran)

    My name is Susan Maddux. I am a 40-year-old Gulf War era veteran. I 
served in the United States Air Force from 1988 to 1998 as an Aerospace 
Propulsion Specialist. I am married to another service-connected 
disabled veteran and we are the parents of 4 teenage boys.
    On June 29th I received a certified letter from the John Cochran VA 
Hospital stating I may have been exposed to Hepatitis B, Hepatitis C 
and HIV. I found this letter to be very impersonal. In fact there was 
little difference in the contents of this letter than from any other 
communication from the VA. It just may have read like an appointment 
cancellation letter if not for the signature required to receive it.
    I was very angry with the Veterans Administration after reading 
this letter. For something as significant as this it should have 
warranted a more delicate approach than a form letter. The VA has 
advised us that there is a minimal chance of being infected by these 
diseases, however I feel that any chance of instruments becoming 
contaminated is unacceptable within a modern medical facility.
    The veterans that are eligible to use the dental services at the VA 
hospital are not normal veterans, rather they are among a select 
population and are also the most susceptible to harm due to being 
previously compromised by other illnesses. Those of us that are 
approved to use the dental service are 100% service-connected, service 
connected for dental health or are P.O.W's. Then there are some 
veterans that have been hospitalized for more than 120 days that also 
have access to the dental clinic.
    To hear that there are some who think that the reaction to this 
incident is solely political angers me significantly. Hospital 
employees are not political appointees, but rather are employed to 
perform a job and that is to care for our nations veterans. It is their 
directive to follow the policies and procedures of their respective 
profession to ensure they do no harm.
    As an aerospace propulsion specialist it was necessary to perform 
tasks following procedures and policies. This allowed the aircrew to 
have confidence that I had installed or repaired their aircraft engines 
properly. If I didn't follow those procedures accurately I put their 
lives at risk. In the same sense, the VA employees should strive to 
instill our trust in that they are doing everything the appropriate way 
since our lives are in their hands. In this instance, instead of 
strengthening our trust, the St Louis VA has weakened our confidence by 
potentially risking over 1800 veterans lives.
    On June 1st, 2005 I was admitted to the intensive Care Unit at the 
John Cochran VA Hospital with bacterial meningitis. This was several 
months after having neuro-surgery at this VA facility. Two forms of 
bacteria were found in my cerebral fluid. One of the infections is 
normally found in the gastro-intestinal tract. I nearly lost my life 
due to this infection. After recovering from meningitis I was just 
happy to be alive and I didn't think to ask more questions as to how 
this happened. After the disclosure by the VA over the sterilization 
failures at the Dental Clinic, it brought me concerns that the VA's 
sterilization issues are not just confined to this one clinic. It also 
raises questions in my mind as to how long these failures in 
sterilization policies have been truly going on. I would also like to 
express my concerns about the length of time it took for the VA to 
notify us about this incident. It makes me speculate if there was an 
attempt to conceal this from the veterans. It is also taking an 
extended amount of time to get the testing results back to us. They 
need to realize that we have put our lives on hold while we wait for 
these results.
    I would ask that VA employees speak out about policies and 
procedures that are not being followed. That it should be their duty to 
ensure our safety first and the managers and administrators should be 
willing to listen when informed about these issues. I would request 
that VA administrators and managers look beyond saving money and follow 
your own motto by ``Putting Veterans First''.
    I would like to express my thanks to Miss Earlene Johnson for 
attempting to advocate for the safety of the veterans even at the risk 
of her own livelihood. By her saving all of the communications with 
management in regards to this issue, she has exposed the grave 
injustice that the St Louis VA was knowingly allowing to happen. If 
only there were more VA employees that had the same courage and 
conviction of Miss Johnson to stand up for what is right.
    Thank you for allowing me to testify today, not only for myself but 
also as a voice for all veterans that use VA Medical Centers.

                                 
      Prepared Statement of Terri J. Odom, Imperial, MO (Veteran)

    My name is Terri J. Odom. I am a disabled veteran and am one of the 
1,812 veterans that were exposed to Hepatitis B, Hepatitis C, and HIV 
at the St. Louis VA Hospital Dental Clinic, John Cochran Division. I 
was informed via certified letter of the error on behalf of the VA. I 
suffer from severe chronic Post Traumatic Stress Disorder from Military 
Sexual Trauma while serving in the Navy. So with my panic attacks and 
anxiety level already on over-drive, this terrible mistake by the VA 
has made me even more anxious.
    The phone number attached to the certified letter was a joke. The 
people answering the telephone were rude and knew nothing more than I 
did. I even called to verify my blood test, which was scheduled for 
July 6, 2010 at Jefferson Barracks VA hospital. I called the 24/7 
manned phone line on July 5, 2010 and the nurse actually laughed at my 
concerns. She said it was such a ``low risk,'' and that I had nothing 
to worry about. I asked her if the blood test being offered was because 
of''zero risk'' or ``risk.''
    Looking back, now I realize something in the dental department was 
wrong. After my first oral surgery, I had severe pain for 28 days 
straight. We were taught in the military to suck it up and keep going. 
That strive and toughness is still embedded in us veterans today. I had 
another oral surgery later and some teeth filled. I did receive partial 
dentures from the VA, but after three visits they still do not fit, and 
my speech is bad with them. I also remember when the dentist reached 
for the metal molding piece to make impressions for my partial plates; 
they appeared dirty and rusty.
    In February of 2010, I was scheduled for a colonoscopy at the St. 
Louis VA JC division, but had a severe panic attack on the table with 
extreme rapid heart rate and elevated blood pressure. I looked around 
the room, and it was beyond filthy. I didn't want the equipment being 
used on me. Thankfully I was taken to the Emergency Room, and the 
procedure was canceled.
    While on a hospital stay at the St. Louis VA John Cochran division 
in 2009, I was unable to shower due to the moldy and unsanitary 
condition of my bathroom. The nurses were very nice and just said, ``No 
honey, you don't want to dare use the dirty nasty shower.'' I did offer 
to clean it.
    There must be a change in the VA. What has recently happened in St. 
Louis with the exposure is third world treatment, if not less. And yes, 
we are angry and have every right to be. The VA put our health at great 
risk! There has to be some accountability! This issue must not be just 
swept away like it never happened!
    I already have major trust issues due to my disability, and now I 
feel that the very people who are supposed to have my back are trying 
to put me in harms way. WHY? We deserve better than this. We are not 
just veterans but human beings. People make mistakes; I understand 
that. But when you are dealing with lives, there is no room for 
failure. I am outraged at the lack of seriousness the St. Louis VA 
seems to want to put on this horrible issue. How would any of them like 
to wait in horror for test results and then again in 6 months to do it 
all over again?

                                 
          Prepared Statement of Earlene Johnson, St. Louis, MO
                       (Former VA Dental Employee)

    My name is Earlene Johnson. I left Chicago, Illinois, to take care 
of my mom and dad who are veterans and live on the outskirts of St. 
Louis, Missouri. I took a medical technician position at John Cochran 
VA Hospital. I have almost 30 years of experience in my field of 
Processing and Distribution (P&D), in which the private sector calls 
this department Sterile Processing (SPD). I am also an operating room 
scrub technician, obstetrician technician, and I am also a 
Phlebotomist. I was a manager in Oregon and supervised in Chicago, 
Illinois. I was called by CEO's when they were having situations with 
Sterile Processing. In some cases, when employees were trying to form a 
union, sometimes I would find management at fault due to poor 
management skills.
    The supervisor of P&D at John Cochran knew I was a supervisor of 
SPD and a manager, but what she didn't know was that I was a trouble 
shooter for hospitals. I have always carried myself in a professional 
manner and her staff had a problem with this; even the supervisor and 
her boss had a problem with my professionalism.
    I saw a lot, and I knew the department was not being run by an 
experienced supervisor. In fact, I believe she is a lead technician, 
and everyone called her a supervisor.
    Sterile processing is a very important area in every hospital. The 
staff goes to school or takes a home study course to become certified 
in cleaning, decontamination, infection control, disinfectants, etc.
    I warned management that they needed to go to every auxiliary 
department to ensure no one was sterilizing any instrument or anything 
that pertains to Sterile Processing. I was told that it was her 
department, and that she can do what she wants. I left that situation 
alone until she did something to me, and I set an appointment up to see 
a higher boss. I was told the same thing by her boss. Her boss asked me 
if I have other issues, and I sent her an e-mail of some of the 
improvements needed for the department.
    Afterwards I started being harassed and intimidated because of my 
warning. I was told I was not coming back to her department with a 
disability and all sorts of harassment. She fired me while I was under 
doctor care for a torn tendon that occurred on the job.

                               __________
         SUPPLEMENTAL MATERIAL PROVIDED DURING THE HEARING BY 
                              MS. JOHNSON

[Notes made by Ms. Johnson of submitted documents are bracketed. Bold-
italics text indicated highlighted text by Ms. Johnson.]

   Excerpt from the ``Central Service Technical Manual,'' 6th Edition
   International Association of Health care Central Service Materiel 
                               Management
              Chapter 1--The Profession of Central Service
THE IMPORTANCE OF CENTRAL SERVICE
    One can think of the central processing area as a manufacturing and 
production unit within the health care facility. The functions of 
recycling, decontamination, processing, inspection, assembly, packaging 
and sterilization are production activities. In essence Central Service 
is a manufacturer of sterile products. While these production and 
sterilization activities are usually considered its primary 
responsibility, Central Service is also responsible for other 
associated materiel management functions such as procurement, inventory 
control and distribution.
    The term Service is key. Central Service personnel must always 
remember that they are an integral part of a service entity. These 
vital services contribute greatly to the quality of patient care. Due 
to the impact Central Service has on operational functions, it is often 
referred to as the hub around which other departments revolve. 
Virtually all areas of the facility that require processed sterile 
supplies, equipment and materials depend upon Central Service (see 
Figure 1.1).
Figure 1.1: Central Service: Hub of the Health care Facility
[GRAPHIC] [TIFF OMITTED] T8057A.001


    The term Central implies that the services are centralized. 
Activities of reprocessing soiled goods and sterilization are conducted 
in one centralized location under the direction and management of one 
individual. Many facilities find an increased demand for reprocessing 
services partially as a result of a growing trend: the use of more 
reusable products. In addition, many facilities have expanded to 
clinics, surgical centers, professional offices and the like, some of 
which may be remote from the main site of the facility. In response to 
the growing demand for reprocessing services, many institutions have 
established satellite processing units with centralized management. 
Others have consolidated (centralized) services for an entire 
integrated system (IDN-integrated delivery networks). Still other 
organizations outsource required services to specialized businesses. 
Regardless of where reprocessing activities are conducted, quality 
practices must be standardized in compliance with Central Service 
policies and procedures. (The standards of practice and resulting care 
must be consistent!)
    Centralized management helps assure uniform standards of practice 
and provides for maximum utilization of human and material resources. 
This eliminates the costly duplication of utilities, processing 
equipment personnel efforts and space. Educated and skilled technicians 
must be knowledgeable about the complexities, precautions and 
techniques of their job. They must carry out tasks in a manner that 
protects the welfare and safety of the patients, workers and the 
community. Proven material handling techniques are employed to provide 
high levels of efficiency.
    Today, greater volumes of materials can be processed in less time 
by fewer people. This helps to address the problem of increased 
workload in today's health care operations.

                               __________
    [The Supervisor of P&D gives this Test to the Employees of P&D.]
                  U.S. Department of Veterans Affairs
        ''Supply, Processing and Distribution Training Manual''
                           Level One Training
                                Page 2-1
                             [VA Test Book]
Section Two: Microbiology


    This module covers:




Estimated                          The basics of microbiology
Contact Time:                      and why it is important in the SPD
40-45 minutes                      environment
                                   the threat of disease,
                                   infection, and cross contamination in
                                   the medical center environment
                                   preventative infection
                                   control measures



------------------------------------------------------------------------

------------------------------------------------------------------------
Following instruction, you should be able to perform the following:

                                   3   Identify and define terms
                                    associated with
                                   microbiology.




------------------------------------------------------------------------


    Why is Microbiology Important?

    It is imperative that SPD technicians understand what microorganisms are and how they spread so they can be
     effectively controlled, contained, and killed. SPD's objectives are to provide centralized supply support
     of the medical center's patient care programs, while assuring appropriate aseptic conditions, economy of
     operation, and consistency in processing, storing, and distribution, all under strictly controlled
     conditions. In order to accomplish these objectives, SPD must control the number of . . .



                               __________
                            VA HANDBOOK 7176
                            August 16, 2002

        1.  Open Drawers.
        2.  Sharps and Needle Sticks.
        3.  Carelessly Stacked Washer/Sterilizer Baskets.
        4.  Automatic Cart Washer Doors.
        5.  Lifting Heavy Objects.
        6.  Slick/Wet Floors.
        7.  Automatic Loaders/Unloaders and Doors of Washer 
        Sterilizers.
        8.  Hot Items.
        9.  Improper Use of Chemicals.
     10. Operating Equipment Noise.

6. 606 SOILED SUPPLY COLLECTION PROCEDURES

    a.  One of SPD's primary functions is the collection of 
contaminated supplies and equipment. All contaminated supplies and 
equipment will be collected in covered conveyances or containers, such 
as waterproof plastic bags, tote-boxes with lids, or closed or covered 
carts. Collection containers for holding soiled reusable supplies 
should be made of material that can be properly decontaminated or 
discarded. Care must also be taken to protect the environment when 
transporting contaminated items to SPD. All nursing units and clinic 
areas will have a dedicated soiled utility or ``dirty'' room. Enclosed 
carts or containers should be provided in these rooms, and all ward 
procedure trays and reusable equipment should be placed in them. These 
containers will be exchanged at each pickup location. Containers will 
be cleaned between each use. It is the user's responsibility to dispose 
of sharps appropriately and to remove or dispose of gross soil from 
items being returned to SPD.

    b.  The decontamination attire for picking up contaminated items 
from soiled pickup areas will consist of:

          1.  Cover Gown--may be used to protect the uniform and must 
        be removed after completion of pickup.
          2.  Exam Gloves--will be changed after each pickup. Gloves 
        should not be worn when transporting items back to the 
        decontamination area. This prevents the contamination of 
        elevator buttons, light switches, doorknobs, etc. Changing to 
        clean gloves for transporting items back to the decontamination 
        area is not required and should not be a practice that 
        technicians use. If the technician feels that the items being 
        picked up are soiled, e.g., IV pump & poles, commode chairs, 
        then they should be covered and transported to the 
        decontamination area.

                                 
            Prepared Statement of Barry A. Searle, Director,
    Veterans Affairs and Rehabilitation Commission, American Legion

    Mr. Chairman and Members of the Subcommittee:
    Thank you for this opportunity to submit The American Legion's 
views on this pressing issue brought to light by recent developments at 
the John Cochran VA Medical Center (VAMC).
    The American Legion from its inception has been both a strong 
advocate for veterans and a proponent for an effective federal entity 
whose mission is to care for those veterans. In fact, it was following 
a recommendation from The American Legion's 1920 National Convention 
that the Dawes Committee with The American Legion representation, 
advocated for and was instrumental in the development of the 
predecessor of today's Department of Veterans' Affairs. Throughout this 
long history with The Department of Veterans' Affairs The American 
Legion has worked hard to develop a relationship of trust and mutual 
respect.
    Central to The American Legion's efforts is a program called ``A 
System Worth Saving.'' This Task Force, first established in 2003, 
annually conducts site visits at VA Medical Centers nationwide to 
assess the quality and timeliness of VA health care. In preparing for 
these visits, The American Legion team researches General 
Accountability Office (GAO) reports, VA's Office of Inspector General 
(VAOIG) reports, and news articles relating to potential breakdowns in 
a system that we consider, ``The Best Care Anywhere.'' This task force, 
we believe, has identified some issues contributing to the issue at 
hand.
    In March of this year, during a routine inspection of the John 
Cochran VAMC by VA's Infectious Disease Program Office, it was 
determined that dental instruments were not being cleaned in accordance 
with specifications of the manufacturers, or in accordance with VA's 
own procedures for proper sanitations and sterilization. These 
instruments were being cleaned without proper detergent, potentially 
putting veterans at risk for blood borne illnesses such as HIV and 
Hepatitis. VA Central Office (VACO) convened a special committee to 
determine an appropriate response. The Committee could not determine 
that the risk to the approximately 1,800 patients treated during this 
period could be assessed as an absolute zero chance of infection; 
therefore the decision was made to notify all affected veterans.
    These 1,812 veterans, notified through certified mail, will be 
provided with free testing for HIV and the B and C strains of 
Hepatitis, and they will be provided with whatever follow up care is 
deemed necessary. As of this time, no veteran is known to have 
contracted any of these diseases through this exposure.
    The American Legion feels that VA showed great responsibility and 
demonstrated an act of good faith to bring this issue to the attention 
of the veterans and the public. Placing patient safety before ``good 
publicity,'' deserves to be acknowledged.
    Nevertheless, The American Legion National Commander Clarence Hill 
recently stated, ``This is an extremely serious problem that has 
happened before and will happen again unless VA ensures strict 
adherence to proper sanitation and sterilization protocols.'' To expose 
trusting veterans to blood borne illness through routine medical 
treatment because of avoidable errors in sanitization of medical 
equipment is inexcusable.
    The medical protocols to prevent such occurrences were already in 
place; however a lack of compliance with those protocols has led to a 
situation where veterans' confidence in their health care system is 
being eroded. Simply put, a veteran should never have to fight 
misgivings about seeking health care from what is overall an excellent 
system for the delivery of their earned health care benefits. The 
problem exists not in the business process structure of the system, as 
the existing protocols were designed to prevent such exposures, but 
rather in the failure of those operating the system to execute those 
protocols. This can only be overcome by diligent and attentive 
management and training.
    This event is not the only reported occurrence of failure to follow 
procedures within the VHA system. A Department of Veterans Affairs 
Office of Inspector General (VAOIG) report from 21 April 2010, 
concerning suspected issues in the Supply, Processing, and Distribution 
(SPD) department relating to endoscope reprocessing and communications 
at the St. Louis facility, substantiated alleged cleaning issues of 
equipment. In its findings the VAOIG identified turnover in several key 
staff positions. The American Legion believes that turnover and 
shortages in staffing are contributing factors in these serious events.
    During the 2010 ``System Worth Saving'' Task Force visits to 32 VA 
Medical Centers across the country, a commonly repeated theme was the 
shortage of personnel, especially nurses and personnel with specialty 
training. It is the opinion of the American Legion that turnover of 
personnel and the shortage of personnel at most facilities require 
renewed emphasis on standardized procedures, quality review and 
individual training, as well as documentation of that training. If an 
emphasis on training is subverted to day to day operations, dedicated 
people will make mistakes. Further, The American Legion believes that 
VACO must maintain proper oversight of medical care, utilization of 
facilities and resources in order to ensure veterans receive the 
highest quality of care.
    In a May 2010, VAOIG report concerning the review of Brachytherapy 
Treatment of Prostate Cancer at Philadelphia, PA and other VA Medical 
Centers, a recommendation was made for VHA to ``standardize to a 
practical extent, the privileging, delivery of care, and quality 
controls for the procedures required to provide treatment.'' As 
technologies continue to change and treatments and procedures continue 
to develop, it is critical that VA staff delivering care be properly 
trained and held accountable. The American Legion supports training and 
the accountability highlighted and also the standardization of all 
patient care delivered across the VHA system.
    In an April 28, 2010, PITTSBURGH TRIBUNE-REVIEW article, after a 
reported incident at the Pittsburgh VAMC in 2007, it was noted that the 
Food and Drug Administration had cited the VA facility for not doing a 
routine blood type confirmation test, a violation of standard 
procedure. This resulted ``in the patient receiving 6 units of the 
wrong blood before he died.'' It was reported that, ``VA officials told 
the FDA the error stemmed from ``a heavier than usual workload in the 
blood bank.''
    We believe, and it has been supported by our visits, that the VA 
Health care system does in fact have SOP's and procedures in place. 
However, The American Legion understands that policies developed at VA 
Central Office, with the best of intentions, are for the most part 
executed at the discretion of the Veterans Integrated Service Network 
(VISN) Director or even Facility Director level and therefore, vary in 
local implementation. As was testified by The American Legion during a 
1 July Subcommittee hearing, we believe there is a breakdown in the 
lack of follow-up and accountability by Central Office to insure 
procedures are being followed. This autonomy of the facility directors 
is a function of the over decentralization of the VA structure. It is 
in no means unique to VHA. It is, we believe, systemic to VA's mode of 
operation. For example, in VBA we have seen and, in fact, been told by 
VA personnel themselves that, ``When you see one Regional Office, you 
have seen One Regional Office.'' The implication is that there is no 
standardization in VA.
    It appears that only when a significant issue is identified such as 
this unfortunate breakdown in what appears to be cleaning procedure 
training is action taken on the part of VACO to rectify the lack of 
follow-up.
    Again, one of the rising concerns of The American Legion, as stated 
in testimony over the last few months, has been that VA needs to do a 
better job in training its people more effectively and making sure they 
understand and follow the correct protocols that have already been 
established. There is also a need to enforce central oversight of the 
regional Veterans Integrated Service Networks (VISNs) thereby insuring 
consistency and accountability nationwide. It is not enough to simply 
move people to different facilities doing the same job. Unfortunately, 
at times accountability means negative impact on the individual who is 
responsible. VA has undoubtedly turned their attention to addressing 
this matter, and is treating it with the seriousness it deserves. With 
the correct and effective accountability, there is hope for continued 
faith in the veterans' health care system. However, we must always be 
mindful of the fact that this has happened before, and unfortunately, 
it has happened again.
    The American Legion is committed to working with the Secretary to 
ensure that this situation is successfully resolved and that incidents 
such as this do not become an ongoing issue with the otherwise 
excellent VA Health Care System.
    Mr. Chairman and Members of the Committee that concludes my 
testimony.

                                 
           Prepared Statement of Hon. Robert A. Petzel, M.D.,
      Under Secretary for Health, Veterans Health Administration,
                  U.S. Department of Veterans Affairs
    Chairman Filner, and distinguished Members of the Committee: thank 
you for the opportunity to discuss our finding that there was a failure 
to clean dental handpieces according to manufacturer instructions and 
VA standard operating procedures at the St. Louis Department of 
Veterans Affairs (VA) Medical Center. We understand our Veterans, the 
public, and Congress are deeply concerned about this revelation, and we 
appreciate the opportunity to address this issue in detail and on the 
record. Simply put, what happened at St. Louis was unacceptable.
    It is the first responsibility of every government agency to be 
open and honest with the public and its clients--in our case, the brave 
men and women who wore the uniform and promised to defend this Nation. 
We at VA have the great privilege and solemn responsibility to provide 
health care and benefits to this population. We strive every day to 
improve the quality of health care for our Veterans. We constantly 
monitor and inspect more than 1,000 VA clinical sites performing 
millions of procedures each year. We are dedicated to taking immediate 
steps to set things right whenever we discover problems.
    We understand that honesty and good intentions are not enough; 
public confidence in government is equally important in delivering 
quality health care to our Veterans. Every employee of the Department 
of Veterans Affairs understands that incidents like what happened in 
St. Louis can lead Veterans and their families to question the care we 
provide, delay needed health care or seek it from another source. We 
deeply regret the emotional and psychological burden that we have 
placed on our Veteran patients and their loved ones. Even though the 
risk of infection to our Veteran patients is in this instance 
statistically low, the psychological consequence of the error is a high 
price to pay for those men and women who have already paid so much on 
behalf of this Nation.
    VA is grateful for the sustained confidence in our ability to 
provide world class care demonstrated by our Veterans, their family 
members and the Veteran Service Organizations. We believe we have a 
system of quality assurance and safety that is second to none. This 
belief is buttressed by the findings of a range of independent 
investigations that have reported health outcomes are better for 
Veterans seen in VA facilities than those seen in other settings. We 
know that public confidence is a resource not to be esteemed lightly or 
taken for granted. Following setbacks in the quality of care we 
delivered in several of our endoscopy programs, and now this issue in 
St. Louis, we have to demonstrate with actions and not words that we 
continue the care and safety of our Veterans as a priority. When our 
care does not meet the high standards we have set, we notify our 
Veterans and arrange the necessary care to alleviate their concerns and 
restore their confidence. But we also must hold our people accountable. 
I have always believed that accountability is a two-way street: leaders 
must provide clear expectations and the resources necessary to meet 
them, and employees must use those resources carefully to achieve our 
objectives. Accountability can take many forms. In some cases, errors 
are made because of a lack of training or information, and in these 
cases, it is our duty to provide our front line staff with what they 
need. In other cases, disciplinary action is warranted. We have 
convened an Administrative Investigation Board to review the issues we 
identified in St. Louis to determine what further action we need to 
take as an organization to ensure the protection of our Veterans, and 
we will keep Congress informed as this Board makes its recommendations. 
In the rest of my testimony, I will outline the chronology of events at 
St. Louis and our response to this incident, and provide information 
that every potentially affected Veteran needs to know.
Chronology
    In March 2010, the National Infectious Diseases Program Office 
(IDPO) conducted an announced site visit of the St. Louis VA Medical 
Center. During this inspection several issues concerning the proper 
processing of dental instruments were identified, including a failure 
to clean dental handpieces according to manufacturer instructions and 
VA standard operating procedures. VA procedures call for the instrument 
to be cleaned with a detergent before it is sterilized, and the 
facility was not doing this. It is important to note these instruments 
received additional cleaning prior to use, but VA cannot establish 
conclusively their sterility because of the pre-cleaning deficiency. 
Upon learning of these findings the Acting Medical Center Director 
immediately suspended Dental Services until the identified issues could 
be fully addressed and resolved.
    Coinciding with the IDPO inspection findings, VA officials 
immediately initiated and completed an in-depth review of the program, 
including staff training and direct observation, ultimately resulting 
in a redesign of dental equipment cleaning processes. On March 18, 
2010, the Oral Surgery and Dental Hygienist Clinics reopened with 
corrected procedures in place, and on March 26, 2010, the General 
Dentistry Clinic was reopened.
    On May 6, 2010, VA convened a Clinical Risk Assessment Advisory 
Board (Board) at VA Central Office. This Board's membership is 
comprised of many VA national program leaders representing both 
clinical and non-clinical expertise. The Board thoroughly reviewed the 
findings related to the dental issues. While the Clinical Risk 
Assessment Advisory Board identified the risk of infection to be 
extremely low, in keeping with VA's commitment to informing Veterans 
about issues related to their care, the Board recommended notification 
of 1,812 St. Louis patients receiving dental care between February 1, 
2009 and March 10, 2010 of the possible risk through disclosure 
information letters and that serology testing for hepatitis B, 
hepatitis C and HIV be offered. Between May 10 and 12, 2010, the 
National Director of Medicine and the Acting Executive Manager of the 
Supply, Processing and Distribution Program with a team from VA Central 
Office conducted a new site visit of St. Louis and found that all 
issues at the dental clinic had been resolved. VA sent disclosure 
letters to 1,812 affected Veterans, offering testing for hepatitis B, 
hepatitis C and HIV on Monday, June 28, 2010.
    Response
    Upon learning of the identified issues, the Acting Medical Center 
Director took immediate action to temporarily suspend St. Louis Dental 
Services until the issues identified could be fully assessed and 
resolved. All Veterans with appointments were given the option to 
reschedule at the St. Louis dental clinic, or to receive care in the 
community at VA expense during the suspension.
    St. Louis VAMC is contacting all potentially affected Veterans 
through certified mail. Additionally, VA staff members are working with 
local Congressional offices and Veteran Service Organizations to ensure 
Veterans know of this issue and receive the care they have earned. We 
appreciate the opportunity to participate in a forum like this where 
Veterans can see our commitment to their care and can hear directly 
from us what we are doing to address this issue. More importantly, this 
forum offers us an opportunity to hear from our Veterans, to address 
their concerns directly and to answer their questions honestly.
    We recognize there were missed opportunities to uncover this issue 
sooner. We have implemented safeguards system-wide to prevent a similar 
situation from happening again. We are reviewing our experience at St. 
Louis and our response to it to identify lessons learned, and I can 
promise you that our policies for identifying these issues early and 
notifying our Veterans and stakeholders promptly will change to create 
a faster response system. We hear too often that VA is too big a ship 
to respond quickly, but I will not accept this as an excuse. I will 
submit a letter describing the improvements and our standards for 
ensuring compliance by our facilities to the Committees on Veterans' 
Affairs by August 15, 2010.
    One of the safeguards we have already identified involved elevating 
the Supply, Processing and Distribution program to the level of a 
stand-alone national program. This alignment will allow for improved 
oversight of the program and specific dedication of additional 
resources. Supply, Processing and Distribution Boards are being created 
at all 21 VA Networks to review local facilities and their compliance 
with VA policies and procedures.
    VA also is in the process of standardizing the operating procedures 
for the cleaning of all reusable medical equipment to reduce variation 
and errors. VA has committed to implementing industry principles (in 
the form of International Organization of Standardization, or ISO 9001 
standards) system-wide, in its ongoing efforts to reduce variation. No 
other health care system in the country has adopted the industrial 
practices that ISO requires, and VA will lead the way in this area as 
we have in so many others before. Moreover, VA has arranged for the 
International Association of Healthcare Central Service Material 
Management, a nationally recognized organization promoting excellence 
in the sterile processing of reusable medical equipment, to intensively 
train all VA Chiefs of Sterile Processing and Distribution in state-of-
the-art techniques for sterile processing.
    VA has set up a St. Louis Dental Review Call Center that is being 
operated 7 days a week, 24 hours a day. Veterans and family members 
with questions or concerns can call 1-888-374-3046 to speak to our 
health care staff who will be available to answer any questions and to 
assist with scheduling an appointment and obtaining the necessary blood 
tests. A Dental Review walk-in clinic opened on June 29, 2010 at the 
John Cochran Division at the St. Louis VA Medical Center (hours of 
operation Monday through Friday 8:00 am to 6:00 pm and Saturdays 8:00 
am to 4:00 pm). Blood tests can be obtained at the Jefferson Barracks 
Division, St. Louis Community-Based Outpatient Clinic (CBOC), 
Belleville CBOC or St. Charles CBOC (a full list of addresses and 
contact information is available at the end of this statement). For 
Veterans and family members located outside the St. Louis area, the St. 
Louis VA Medical Center will arrange for them to receive service at the 
most conveniently located VA facility. Wherever Veterans receive 
services related to this issue, there will be no co-payments associated 
with the necessary appointment or testing. Through July 7, 2010, 778 
Veterans had accepted testing, and 615 have scheduled appointments in 
the St. Louis Dental Review Clinic.
    Finally, we are strengthening our system of accountability for 
compliance with national directives. These directives are developed and 
promulgated after careful review by clinicians with years of 
experience, and it is essential that they be followed. We have a 
rigorous system of monitoring in place to determine if these directives 
are being implemented, and employee performance is assessed based upon 
success in attaining the standards we set. We will reinforce the 
importance of these principles so that new policies and procedures are 
adhered to when they are issued.
What Veterans Need to Know
    It is important for our Veterans and their families to know that VA 
has attempted to contact every Veteran seen and possibly exposed to a 
blood-borne disease between February 1, 2009 and March 10, 2010. If you 
are a Veteran and you were seen in the St. Louis VA Medical Center 
Dental Clinic during this time and you have not received a letter from 
the Department, or if you know a Veteran who was seen during this time 
who has not received a letter, please call 1-888-374-3046 to notify us 
so we can arrange testing and monitoring.
    It is also important to know that while the risk of exposure is 
extremely low, it does exist. It is imperative that our Veterans be 
tested, both for their health and for the health of their loved ones. 
For Veterans who are worried about being seen in a VA facility, we will 
arrange for these tests to be done by another party at no cost to the 
Veteran.
    VA has long had staff members known as patient advocates who are 
available in each of our major medical facilities who can help Veterans 
with whatever concerns they have. If Veterans need counseling or advice 
or have any concerns with the quality of care or the nature of our 
response, VA strongly encourages them to please contact the patient 
advocate at the facility and discuss these issues with that person.
Conclusion
    In the past 18 months, VA has implemented more stringent oversight 
of the existing safety guidelines for reprocessing of reusable medical 
equipment in all of its medical facilities. It is this more rigorous 
standard that directly led VA to identify and address problems at the 
St. Louis VA Medical Center. The St. Louis VA Medical Center provides 
quality health care services to more than 50,000 Veterans a year, and 
employs more than 2,600 individuals from the community. The Veterans 
potentially affected are their neighbors and friends.
    VA, from the Secretary to the staff at the St. Louis VA Medical 
Center and in every VA facility, has expressed a deep commitment to 
preventing this, or any similar situation, from happening again, and 
has taken steps to accomplish that goal.
    We deeply regret that this situation occurred and VA is taking all 
the necessary steps to make certain that testing is offered quickly and 
that results are communicated in a timely manner. We understand the 
responsibility and trust Veterans place in us and we want Veterans and 
our stakeholders to know that the staff at the St. Louis VA Medical 
Center is doing everything possible to address this situation and 
prevent it from occurring again.
    Thank you again for the opportunity to appear before you today. My 
colleagues and I are prepared to answer any questions you may have.
List of Facilities in the St. Louis Area
VA Medical Centers
John Cochran Division
915 North Grand Blvd.
St. Louis, MO 63106
Phone: 314-652-4100 or 1-800-228-5459

Jefferson Barracks Division
1 Jefferson Barracks Dr.
St. Louis, MO 63125
Phone: 314-652-4100 or 1-800-228-5459
VA Clinics
Belleville Clinic
6500 W Main St
Belleville, IL 62223
Phone: 618-398-2100 or 800-228-5459 ext. 56988

Salem Clinic
Hwy 72 North
Salem, MO 65560
Phone: 573-729-6626 or 1-888-557-8262

St. Charles Clinic
7 Jason Ct.
St. Charles, MO 63304
Phone: 636-498-1113 or 1-800-228-5459 ext. 56988

St. Louis Clinic
Missouri Veterans Home--VA Clinic
10600 Lewis and Clark Blvd.
St. Louis, MO 63136
Phone: 314-286-6988 or 1-800-228-5459 ext. 56988

                                 
                      Statement of Hon. Phil Hare,
        a Representative in Congress from the State of Illinois

    I would like to thank Chairman Filner and Ranking Member Buyer for 
calling this important hearing to investigate the failure to comply 
with sterilization procedures at the John Cochran VA Medical Center in 
St. Louis, MO.
    People in the armed services routinely risk their lives so that we 
do not have to live in fear, and yet because of medical negligence at 
the St. Louis VA Medical Center, many veterans are currently doing just 
that. There are over 55,000 veterans living in my district, and it 
pains me to think that any one of them received a letter warning them 
that they may be infected with HIV, the Hepatitis B and C viruses or 
other blood-borne diseases from potentially contaminated equipment used 
during dental treatment.
    According to best practices for infection control, sterilization, 
disinfection and cleaning of medical equipment and instruments, also 
known as reprocessing, should be performed in a centralized area. 
However, over the course of a year, employees at the St. Louis center 
disregarded these guidelines. And seemingly, no supervision was taking 
place to ensure the medical guidelines for centralized sterilization of 
medical instruments were being followed by the dental staff at John 
Cochran.
    On July 1st, I sent a letter to Secretary Shinseki expressing my 
sincere concern and frustration about the mismanagement at John Cochran 
and the risk of potential exposure to hundreds of veterans in my 
district. In this letter, I asked the Secretary to immediately 
investigate and take steps to ensure that patient safety standards are 
upheld. I also urged the VA Secretary to strengthen oversight of 
sterilization procedures and enhance regulations to protect our vets 
from infection.
    I am pleased that the Secretary acted quickly to ensure health care 
workers are complying with effective sterilization processes. Secretary 
of Health Robert Petzel's call for an independent, national 
Administrative Investigation Board to see what went wrong here is a 
step in the right direction. Re-training all hospital personnel and 
standardizing washing procedures is a step in the right direction. 
Placing the Chief of Dental Services on administrative leave until the 
outcome of the investigation is determined is, again, a step in the 
right direction.
    But our efforts must not stop there. The VA must also take steps to 
implement these changes agency-wide and restore our veterans confidence 
in the VHA. I am sure we all remember the failure to sanitize 
colonoscopy equipment just a little over a year ago. In addition, 
audits conducted by the Office of Inspector General in the past year 
have often found issues with sterile processing areas at other VA 
facilities. The frequency of contaminated instruments cited in OIG 
reviews suggests an ongoing problem with equipment sterilization within 
the VA system. Let us once and for all standardize cleaning practices 
throughout all medical departments and enforce compliance with regular 
audits at all VA Medical centers to take human error out of the 
equation.
    After all our veterans have done for us, it is our responsibility 
to do all that is necessary to prevent this kind of occurrence from 
happening again.
    Again, I thank the Chairman for his leadership on this issue and 
hope that today's testimonies will help us provide our veterans with 
the best care possible.

                                 
                  Statement of Hon. Claire McCaskill,
           a United States Senator from the State of Missouri

    Chairman Filner, Members of the House Committee on Veterans' 
Affairs and panelists, I applaud you for holding a hearing to review 
the vitally important issue before the Committee today--the 
consequences to the health and safety of our Nation's veterans 
following revelations of safety non-compliance at the John Cochran 
Veterans Administration Medical Center (VAMC) in St. Louis, Missouri. I 
am sorry that I could not appear before you in person today because of 
the Senate voting schedule, and I appreciate your accepting my written 
statement.
    As we all now know, approximately 1,812 St. Louis-area veterans 
were potentially exposed to blood-borne pathogens, including hepatitis 
B and C and HIV, as a result of possibly being treated with improperly 
cleaned dental devices at the John Cochran VAMC dental clinic between 
February 2009 and March 2010. I know that I--and I would venture to say 
all Americans--were deeply saddened and disappointed by this 
revelation. My colleagues Senators Bond and Durbin and I made that 
clear in our June 30, 2010 letter to Veterans Affairs (VA) Secretary 
Eric Shinseki, which I am providing today and request that you include 
in the record of this hearing. Veterans are our Nation's heroes--men 
and women who risked their health and safety for our freedom--and it is 
disturbing to learn that their health and safety could have been 
endangered in any way, even if by accident. As we all know, such 
mistakes simply cannot be allowed to happen.
    In addition, our veterans' trust and confidence in the VA medical 
system and, particularly in the John Cochran VAMC, is badly damaged by 
incidents like this one. It is going to take time to get that trust 
back, but I believe the VA can and must do so, and I know today's 
hearing will be part of that process.
    We all agree that veterans receiving treatment at John Cochran 
deserve the best quality care available, including absolute assuredness 
that the hospital is meeting the most basic and critical professional 
standards of cleanliness and conduct. This one incident is disturbing 
enough, but unfortunately John Cochran VAMC has been the source of 
other violations and low customer service ratings in the past. In April 
2010, the VA Inspector General released a report outlining reprocessing 
problems with endoscopes used at John Cochran VAMC. Prior to that, John 
Cochran received some of the lowest customer service satisfaction 
ratings of any VAMC in the country. I know that efforts have been made 
to address these problems by the VA, but the latest revelations about 
the improper dental device sterilization pose a significant setback to 
progress.
    Further, many veterans groups have expressed concern to me about 
John Cochran VAMC, including the Paralyzed Veterans of America Gateway 
Chapter, which has strongly opposed a move of the spinal cord treatment 
unit to John Cochran VAMC. I have written to Secretary Shinseki about 
this move because I understand their concerns. I ask that the letter to 
Secretary Shinseki also be included in the record of this hearing.
    I am also deeply concerned that the VA took 4 months (from March 
until the end of June 2010) to notify veterans who may have been 
endangered by the flawed procedures at John Cochran VAMC, as well as to 
notify the area Congressional delegation so that we might assist our 
constituents, many of whom have called my office worried and outraged 
about this incident. I appreciate that the VA acted quickly to remedy 
the flawed cleaning procedures, but the failure to share information in 
a timely fashion about the situation is unacceptable. In addition, a 
follow up visit to John Cochran VAMC by VA Headquarters staff was not 
conducted until May 2010, some 2 months after the initial inspection 
revealed problems with the cleaning of the dental devices. When a 
significant failure in procedures occurs, like those discovered at the 
John Cochran VAMC dental clinic, I would expect a more timely response 
and more aggressive oversight. There must be an evident and palpable 
sense of urgency from the VA. It is clear the VA now has such a sense 
of urgency and it must continue.
    The VA has decided to dedicate $5 million in funding to make 
infrastructure and other improvements at the John Cochran VAMC in light 
of this troubling incident. While I applaud the VA's efforts to address 
aggressively underlying problems, including infrastructure problems 
that could have contributed to the failures in the dental clinic, I and 
the other members of the Missouri and Illinois delegations want to be 
kept closely apprised of how the $5 million in renovations will be 
prioritized and spent. I ask today that the VA keep me, the rest of the 
congressional delegation and all interested veterans and veteran 
service organizations, regularly informed about any follow up actions 
that the VA takes to train staff and improve standard operating 
procedures in the dental clinic and elsewhere in the hospital.
    As John Cochran VAMC staff go about the task of evaluating each of 
the 1,812 veterans who have received letters from the VA about 
potential exposure from improperly handled dental devices, I ask for a 
full and complete accounting by the VA of any health irregularities 
identified and attributed to the exposure--I cannot stress enough how 
any exposure would be a truly tragic outcome to this case. I know that 
Secretary Shinseki and the staff at John Cochran VAMC value the health 
and safety of each and every veteran, and I strongly urge him and the 
John Cochran VAMC leadership to make sure that no veteran's health goes 
unchecked in this exposure case.
    The incident at John Cochran VAMC is a sad chapter that leaves a 
stain on the VA system. I abhor that it happened, and I join the 
Committee and all Americans in demanding a full accounting and 
assurance that such an incident will not happen again. Because of the 
challenges John Cochran VAMC has continued to face, I also call for a 
redoubling of efforts to make improvements at the facility.
    I am committed to working with the VA to provide veterans with the 
resources they need to heal--resources that they have earned through 
their great service to this country. There is much to be proud of in 
the work the VA does for America's veterans and there are many skilled, 
patriotic, selfless employees on the VA team caring for our veterans. I 
want to thank the VA and its staff for all it does to honor and care 
for America's veterans and urge everyone who is part of the VA to 
persevere through challenges like that which this incident poses. The 
men and women who receive care at the VA know a thing or two about 
hardship and about perseverance. They will carry on and the VA will, as 
well.
    Thank you, once again, Mr. Chairman for accepting my statement for 
the record today and for holding this hearing on this important matter.

                               __________
                                               United States Senate
                                                    Washington, DC.
                                                      June 30, 2010
General Eric Shinseki
Secretary of Veterans Affairs
Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Dear Secretary Shinseki:

    Please note our deep disappointment and concern that 1,812 St. 
Louis area veterans were potentially exposed between February 2009 and 
March 2010 to dangerous blood-borne diseases, including Hepatitis B and 
C and HIV, through possible contact with improperly cleaned dental 
devices at the John Cochran VA Medical Center (VAMC) in St. Louis, 
Missouri. In light of other recent revelations by the VA Inspector 
General regarding problems with reprocessing of endoscopes at John 
Cochran and frequent customer service satisfaction problems reported at 
John Cochran, we are concerned about VA management of the facility. 
Veterans receiving care at John Cochran deserve the best quality care 
available, including absolute assuredness that the hospital is meeting 
the most basic and critical professional standards of cleanliness and 
conduct.
    We are also deeply concerned that the VA took 4 months to notify 
veterans who may have been endangered by the flawed procedures at the 
John Cochran VAMC, as well as to notify the area Congressional 
delegation so that we might assist our constituents. We appreciate that 
the VA acted quickly to remedy the flawed cleaning procedures but the 
failure to share information in a timely fashion about the situation is 
unacceptable. In addition, a follow up visit to John Cochran by VA 
Headquarters staff was not conducted until May, some 2 months after the 
initial inspection revealed problems with the cleaning of the dental 
devices. When a significant failure in procedures occurs, like that 
discovered at the John Cochran VAMC dental clinic, we would expect a 
more timely response and more aggressive oversight.
    The VA has decided to dedicate $5 million in funding to make 
infrastructure and other improvements at the John Cochran VAMC in light 
of the troubling incident. While we applaud the VA's efforts to address 
aggressively underlying problems, including infrastructure problems 
that could have contributed to the failures in the dental clinic, we 
must be kept apprised of how the $5 million in renovations will be 
spent and prioritized. Please keep us informed about any follow up 
actions that the VA takes to train staff and improve standard operating 
procedures in the dental clinic and elsewhere in the hospital.
    In closing, as you evaluate each of the 1,812 veterans who have 
received letters from the VA about potential exposure from improperly 
handled dental devices, we ask for an accounting of any health 
irregularities identified and attributed to the exposure. We know you 
value the health and safety of each and every veteran and strongly urge 
you to make sure that no veteran's health goes unchecked in this case. 
We are committed to working with you, Mr. Secretary, to provide 
veterans with the resources they need to heal-resources they earned 
through their great service. The repeated failures to follow simple 
rules and regulations, however, is wholly unacceptable, and we want to 
know the measures you plan to implement in order to ensure this 
catastrophe never happens again.
    We thank you for your immediate attention to this matter and look 
forward to your reply.
    Should you have additional questions please feel free to contact us 
directly or to have your staff contact Tressa Guenov in Senator 
McCaskill's office, Bo Prosch in Senator Bond's office or Gabe Chavez 
in Senator Durbin's office.

            Sincerely,

                                                   Claire McCaskill
                                              United States Senator

                                                   Christopher Bond
                                              United States Senator

                                                     Richard Durbin
                                              United States Senator
                   MATERIAL SUBMITTED FOR THE RECORD

                                     Committee on Veterans' Affairs
                                                    Washington, DC.
                                                      July 29, 2010

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 ``Veterans at 
Risk: The Consequences of VA Medical Center Non-Compliance'' on July 
13, 2010, I would appreciate it if you could answer the enclosed 
hearing questions by the close of business on September 10, 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
                                  and
                      The Honorable Wm. Lacy Clay
     ``Veterans at Risk: The Consequences of VA Medical Center Non-
                              Compliance''
                             July 13, 2010
    Question 1: As of today, what is the total number of Veterans 
identified by the Veterans Health Administration as being at risk of 
exposure to Hepatitis B, C, and HIV/AIDS virus?

    Response: The data below reflects the most current notifications, 
testing, and results and can be found at: http://www.va.gov/HEALTH/rme/
stlouis.asp.

------------------------------------------------------------------------
    Numbers of Potentially Affected Patients as of September 7, 2010*
-------------------------------------------------------------------------
                   Number of Patients                       St. Louis
------------------------------------------------------------------------
Potentially Affected Risk Pool)                                   1,812
------------------------------------------------------------------------
Notified                                                          1,769
------------------------------------------------------------------------
Responded to Disclosure Letter or Called VAMC for                 1,750
 Appointment
------------------------------------------------------------------------
Declined Testing or Appointment                                      74
------------------------------------------------------------------------
Notified of Test Results                                           1400
------------------------------------------------------------------------
Total Calls to Toll Free Hotline or Call Center                   2,523
------------------------------------------------------------------------
  *These numbers are based on the most current analysis of test results
  and notifications as of the date stated above. While every effort is
 made to provide exact numbers, the nature of medical science may result
 in shifts of this data as new results are determined. Note: 43 Veterans
were deceased at the time of initial notification. VA does not routinely
             send notification letters to deceased Veterans.
------------------------------------------------------------------------


------------------------------------------------------------------------
                Newly Diagnosed and Have Been Notified**
-------------------------------------------------------------------------
                          Test                              St. Louis
------------------------------------------------------------------------
Hepatitis B Virus                                                     2
------------------------------------------------------------------------
Hepatitis C Virus                                                     2
------------------------------------------------------------------------
HIV                                                                   0
------------------------------------------------------------------------
   **These results are not necessarily linked to any reusable medical
 equipment issues. VA is performing extensive epidemiological testing to
  determine the time period and to the extent possible, source of known
 infections. Regardless of time period or source of known infections, VA
will provide all related health care at no cost to infected Veterans. We
   are continuing to notify individuals and are working with homeless
       coordinators to reach Veterans with no known home address.
------------------------------------------------------------------------


    Question 2: How can the Veterans Health Administration be assured 
that no health risks existed at the St. Louis VA Medical Center before 
February 1, 2009?

    Response: The St. Louis VAMC Quality Management office reviewed the 
process in the Dental Service in February 2009. That review did not 
indicate any failures to follow proper procedures for handling reusable 
medical dental equipment. During the time period from February 2009 to 
March 2010, there were no indications that pre-cleaning of reusable 
dental equipment was occurring in the dental service. Additionally all 
instruments were being sterilized in central Supply Processing and 
Distribution (SPD). On May 6, 2010, the Clinical Review Board (CRB) met 
to review the information from the St. Louis VAMC to determine the risk 
to patients and identify if disclosure was needed. The Board is 
comprised of experts in infectious disease, public health, specialty 
care services, patient safety, and quality management. Based on the 
review of clinical information presented to the Board, it was 
determined that the risk to Veterans was from February 1, 2009 to March 
12, 2010. The Administrative Investigation Board (AIB) is reviewing all 
facts and circumstances surrounding the case, and will provide an 
additional check on the validity of this information. Based on 
additional review, the Under Secretary has requested that the CRB 
revalidate this information.

    Question 3: How many Veterans, who are residents of the First 
Congressional District of Missouri, are at risk of exposure to 
Hepatitis B, C, and HIV?

    Response: There is no ongoing risk of exposure; 545 Veterans who 
were identified as residents of the First Congressional District (FCD) 
were treated at the Dental Clinic during the period identified and may 
have been exposed prior to the shutdown of the service.

    Question 4: How many of these Veterans have been tested? Also, are 
there any plans to do to compensate victims for this error?

    Response: As of September 7, 2010, 477 of the 545 Veterans who 
reside in the FCD of Missouri have been tested. Testing and care 
associated with this event is provided at no-cost to the Veteran. 
Regarding compensation, Veterans have been provided with education, 
written materials and contact information regarding claims they may 
file with VA Regional Offices for Veterans' disability benefits 
designed to compensate persons injured by medical care, and regarding 
claims under the Federal Tort Claims Act that they may file with VA 
Regional Counsel Offices.

    Question 5: Considering that it took a full year to discover the 
error that put Veterans at risk, what changes would you suggest in 
improving the inspection process to ensure any future problems are 
discovered and reported earlier?

    Response: Nationally, the Supply, Processing and Distribution (SPD) 
Program function has been realigned within VHA with the goal of 
providing enhanced leadership, oversight and resources. Each Veterans 
Integrated Network (VISN) has established an SPD Management Board, 
which has prescriptive changes and comprises multidisciplinary subject 
matter experts. The Boards are responsible for policy enforcement and 
oversight. Various tools, including announced and unannounced 
inspections of SPD areas are used to accomplish their duties. The 
standards developed for each SPD area are exacting, down to the 
citation of applicable codes, and self-diagnostic tools are designed 
with specificity against those standards.
    The Veterans Health Administration (VHA) acknowledges that it took 
excessively long to notify the affected patients in this case. We have 
directed targeted improvements to streamline the CRB process by 
involving the clinical experts initially. Also, the communication 
process has been redesigned to be able to alert Veterans much more 
rapidly. By shortening this time, we will improve our ability to 
discuss these issues, consistent with Federal privacy laws, with 
Members of Congress so that they have the information they need to 
perform oversight responsibilities and explain events to their 
constituents and offer assistance. VHA officials are committed to 
ensuring that this SPD realignment and additional actions discussed 
will make VA responsive across all VISNs.

    Question 6: What measures have the Veterans Health Administration 
established to ensure that such errors will not occur again?

    Response: St. Louis VAMC has removed all packaging supplies in the 
dental clinic so instruments can no longer be packaged prior to being 
sent to Processing and Distribution for sterilization. The Acting 
Medical Center Director established an Executive Action Telephone Line 
so employees can report to the Director's Office concerns or issues 
related to patient care, quality and safety. The facility reassessed 
staff competencies and provided re-training. Additionally, facility 
leadership reviewed and standardized procedures to comply with 
manufacturers' guidelines and to prohibit the cleaning of equipment 
outside of the SPD. Ongoing staff education and competency assessments 
are in place, and ongoing quality reviews and inspections continue. The 
medical center activities are reported to the VISN SPD Review Board 
quarterly, who conduct unannounced reusable medical equipment (RME) 
review inspections on an annual basis or as needed.
    Several National VA Teams and the Quality Management staff at the 
VAMC have reviewed areas in the facility where RME is used as part of 
the clinical care. Their goal is to assure that proper procedures are 
in place for both pre-cleaning and sterilization.
    Additionally, VA has taken the following actions to improve 
oversight and reduce variation:

      VA elevated the SPD program to the level of a stand-alone 
National program (from under the infectious disease program office) 
that reports directly to the National Director of Medicine. This 
realignment will allow for improved oversight of the program, and 
dedication of additional resources.
      All 21 VISNs created SPD Review Boards to review local 
facility compliance with VA SPD policies and procedures.
      VA is in the process of standardizing SPD processes 
related to all RME to reduce variation and errors.
      VA has committed to implementing industry principles (in 
the form of International Organization of Standardization, or ISO 9001 
standards) system-wide, in its ongoing efforts to reduce variation.
      VA has arranged for the International Association of 
Health care Central Service Material Management, a nationally 
recognized organization promoting excellence in the sterile processing 
of reusable medical equipment, to supplement existing training of all 
VA Chiefs of SPD in state-of-the-art techniques for sterile processing.

                                 
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