[Senate Hearing 111-279]
[From the U.S. Government Publishing Office]
S. Hrg. 111-279
FIELD HEARING ON THE CHALLENGES OF AN AGING VA MEDICAL CENTER
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
AUGUST 20, 2009
__________
Printed for the use of the Committee on Veterans' Affairs
Available via the World Wide Web: http://www.access.gpo.gov/congress/
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COMMITTEE ON VETERANS' AFFAIRS
Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West Richard Burr, North Carolina,
Virginia Ranking Member
Patty Murray, Washington Lindsey O. Graham, South Carolina
Bernard Sanders, (I) Vermont Johnny Isakson, Georgia
Sherrod Brown, Ohio Roger F. Wicker, Mississippi
Jim Webb, Virginia Mike Johanns, Nebraska
Jon Tester, Montana
Mark Begich, Alaska
Roland W. Burris, Illinois
Arlen Specter, Pennsylvania
William E. Brew, Staff Director
Lupe Wissel, Republican Staff Director
C O N T E N T S
----------
August 20, 2009
SENATORS
Page
Johanns, Hon. Mike, U.S. Senator from Nebraska................... 1
Photographs of the hospital.............................. 3
Prepared statement........................................... 12
WITNESSES
Orndoff, Donald H., AIA, Director, Office of Construction and
Facilities Management, U.S. Department of Veterans Affairs;
accompanied by Al Washko, Director, VA Nebraska-Western Iowa
Health Care System; Robert Yager, Chief of Facilities
Management, Omaha VA Medical Center; and Thomas Lynch, M.D.,
Acting Chief of Staff, VA Nebraska-Western Iowa Health Care.... 14
Prepared statement........................................... 15
Terry, Hon. Lee, a Representative in Congress from the State of
Nebraska....................................................... 28
Prepared statement........................................... 31
Maurer, Harold M., M.D., Chancellor, University of Nebraska
Medical Center................................................. 32
Prepared statement........................................... 33
Zetterman, Rowen K., M.D., Dean, Creighton University School of
Medicine....................................................... 34
Prepared statement........................................... 35
Brown, David G., President and Chief Executive Officer, Greater
Omaha Chamber of Commerce...................................... 37
Prepared statement........................................... 38
Vazquez, Amanda, Government Relations Director, Great Plains
Paralyzed Veterans of America.................................. 41
Prepared statement........................................... 43
FIELD HEARING ON THE CHALLENGES OF
AN AGING VA MEDICAL CENTER
----------
THURSDAY, AUGUST 20, 2009
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 1:06 p.m., in the
Education Conference Room, Omaha VA Medical Center, 4101
Woolworth Avenue, Omaha, Nebraska, Hon. Mike Johanns,
presiding.
Present: Senator Johanns.
OPENING STATEMENT OF HON. MIKE JOHANNS,
U.S. SENATOR FROM NEBRASKA
Senator Johanns. Ladies and gentlemen, let us come to
order. I do appreciate everybody being here today. I have some
introductions that I would like to make to get us started. I
will make an opening statement, and then, as you know, we have
two panels. We will work our way through those panels of
witnesses and I will move on to that after I have made my
opening statement.
But let me, if I might, introduce some really fine people
who have come from Washington to help me put this hearing
together. I will start with Lupe Wissel. Lupe, if you could
stand. I said I wanted to give these good people the proper
welcome to our great State of Nebraska. Lupe is the Minority
Staff Director, and my Senate office is right across the hall
from the Veterans' Affairs Committee, so we run into each other
a lot and she does great work. John Towers, who is the Minority
Staff Senior Advisor. John, we are very, very happy to have you
here. Nancy Hogan, who is with the Majority Staff, welcome. And
then you can see that we are recording and taping. Matt
Lawrence is with the administrative staff and we so appreciate
that. So I want to say welcome to all of those folks.
The gentleman behind me is Andrew Peek. He is with my
office, and Andrew is the individual who takes care of veterans
affairs and military affairs in the Johanns Senate office.
I want to start also appropriately today by remembering my
manners and thanking those who have really made this hearing
possible here in Nebraska. Chairman Akaka, I want to recognize
him. I want to recognize Ranking Member Burr. With their
support and their encouragement, we are here today to learn
more about this veterans' facility. They are two very good men.
They work together in a very bipartisan way. You sometimes hear
about all of the partisanship in Washington. That is what makes
the front page. It is interesting to read about. What you don't
often get to read about is the good hard work that is going on
at the committee level between Ranking Members and Chairmen,
and we have two really fine men there who I enjoy working with
and I enjoy being on this Committee. So I wanted the record to
reflect my appreciation for their support.
I also want to say to our first panel of witnesses,
welcome. We are very glad to have you here. I know that there
are many pressing commitments as you work with veterans and
their needs and I am so grateful that you have set aside time
to be with us on what I consider to be an enormously important
topic.
Mr. Orndoff, I do appreciate you coming all this way to our
great State. I hope that you have been able to enjoy some
Nebraska beef. You can't leave until you have. It is kind of a
rule of our State. [Laughter.]
August is a time where oftentimes D.C. folks do take a
little bit of a break, if they can, because the House and the
Senate are not in session. The health care debate has got all
of the Members working very hard, but this is as important as
anything that I will talk about during the August recess, and
that is health care for our veterans in this part of the world.
I would further like to express my thanks again to the
staff.
I would also like to say, if I could move on to my opening
statement, that we now have a study that has been done. It was
released on Monday, and that study has done a thorough analysis
of some of the needs and challenges and issues that we face
here.
The study was kicked off before I was in the Senate. It was
kicked off in 2008. I thank Lee Terry. I know you were a person
calling for that. We appreciate our Congressman's effort here.
I also acknowledged at an event this morning the good work of
the senior Senator of Nebraska, Ben Nelson, who has also worked
to try to get the study done.
After describing the problems, the authors of this report
presented recommendations in terms of the best way to move
forward. I do not doubt that a new way is very much needed. I
do want to say that I was here earlier in the week. I have
pictures that I am going to ask now to be made a part of the
record. I will ask somebody if we can just hand them to the
witnesses in case they want to refer to any of these pictures.
We all have heard the old saying that pictures do tell the
story, and believe me, these do.
[The nine photographs from Senator Johanns follow:]
Senator Johanns. The people that are here at the VA
hospital are doing great work. I don't care if it is the
doctors or the nurses or the professional staff or the
maintenance people, they are working against some rather
remarkably difficult conditions in delivering good patient
care. I read in preparation for this hearing a report that was
issued on patient care, and I will tell you that this area
ranks as well as really any area in the country. But they are
doing it in a facility that really is worn out. It was built a
long time ago.
Now, the first thing I noticed when I came here is the
paint on the walls, carpet on the floors--the people here have
done everything they could to make this as presentable to the
veterans as they possibly could. But when you start looking
into the facility, you really begin to see some of the
challenges that they are facing.
Because of HVAC deficiencies, this hospital may not be able
to deal with a major flu pandemic, for example. We sure hope
they can. I know the employees here would do everything they
could to deal with that issue if it does arise, and it is a
concern.
There is also, quite frankly, insufficient emergency power.
Should the electric power fail, the AC, most heating systems,
and the facility's surgery capacity would be lost, as well as
all equipment that requires any emergency power to operate. We
would basically be doing what we have to do to make sure that
we are dealing with the emergency of the situation, but beyond
that, we would just have to wait for power to come back on.
I looked at the water and oxygen pipes that are corroded.
They are 50 years old. They fail periodically. In my discussion
with the really great staff in the maintenance department, they
told me that one of the challenges that they have, if there is
a break in a pipe, is trying to find pipe somewhere that they
can attach onto for repair, because it just kind of crumbles as
they move down the foot-by-foot piece of that pipe to try to
get a firm piece that they can grab onto to do the repairs.
I was amazed to find that there is a defunct nuclear
reactor in the basement. Though space is at a premium here,
this area is preserved. I don't want to try to scare anybody.
Don't ask for a geiger counter or anything. They are down there
doing all of those things. As I was saying, I walked into a
room and somebody pointed out that this was a nuclear reactor
that had been decommissioned at some point.
In the surgical area--we have pictures of the surgical
area--I had an opportunity to visit with the staff there and
some of the doctors, and again, I am so impressed. There is
just tremendous commitment in mission, and they are going to
get the job done. It is patient care that is first. You know,
you just walk out of there feeling so good about what they are
doing for our veterans. But again, I will tell you, they are
working within a very, very difficult situation.
In the surgical area, there really aren't separate
corridors for clean and dirty equipment. Of course, they are
going to worry about contamination, and we are, too. Surgical
monitors cannot be affixed to the ceiling, like they are in
modern facilities. Actually, they can't put much more in those
ceilings because the ceilings are already low and if they did
much more there somebody who had any height to them, would be
bent over as you go down the hall.
So, there are so many things about the facility that
probably made sense, probably would have even been described as
state-of-the-art when the facility was built. But today the
facility is old. It is worn. In some respects, it is just
completely worn out.
I am encouraged by the feasibility study on the conditions
at the Omaha facility, which was completed by the VA through
their consultant group. As I said, the study was begun in 2008.
It was presented to the VA in May 2009. It was intended to try
to help the Omaha facility best meet the growing health care
demands of the local veterans community in the face of the
facility's really, really significant issues.
As Governor of Nebraska, we worked with veterans. In fact,
my veterans affairs person from those days, from my previous
position, is here, John Hilgert. I am so appreciative of him
being here. One of the things that we looked at was our
veterans homes. We realized that we either had to build new or
we had to rehabilitate, or we were not going to be providing
the kind of care we wanted for veterans. So literally, starting
with Senator Nelson, then having me join in, we headed out to
do that; and our four veterans hospitals, in many respects,
really reflect the commitment of the funding that is necessary.
Let me say today that what we are really going to try to do
is look at this facility. We are going to try to, if you can
picture this, turn it upside down and look at it from all
different directions. We are going to try to lay a very, very
sound record as to what we see here and what is needed. We are
going to confirm some problems that exist and we are going to
talk about some problems that we might anticipate if nothing is
done. I don't think there is a person in this hearing room that
wants to argue that nothing is going to be done. We are going
to get some things done here, but we are all going to have to
work together to get it done.
The report does offer some possible solutions, and in the
testimony today, I do want to analyze these approaches and
maybe get an idea, again, to have a very, very complete record
as to what these approaches might indicate.
Ultimately, the report recommended a concept called Concept
D, the option with the most new construction and the greatest
amount of money spent at the Omaha facility. It would construct
about 754,000 building gross square feet of new construction,
with about 72,000 square feet undergoing renovation and 47,000
being sent offsite.
Now, anytime you go to build a hospital, you know that you
are going to spend some money. I would argue that this
investment is a wise investment for our veterans. The estimate
for this option is about $550 million.
In outlining this concept, the study recognized the severe
limitations of Building 1, which is the main facility that we
are in right now; and it just simply calls for replacing most
of it. There are just so many fiscal limitations. There are
just so many things about this facility that the study
indicates really are not salvageable.
So, I am anxious, again, to kind of dig into that and see
what that concept is about.
Now, one of the things--I ran into somebody today who
wanted to talk to me about parking----
[Laughter.]
Senator Johanns [continuing]. Who was maybe suggesting that
I was the cause of some of the parking challenges today. I
plead guilty. All I want to say about that is we can't forget
that it is the facility that we want to focus on. It is patient
care. Yet, we have also got to pay attention to parking needs
and that sort of thing. I am going to be anxious to build a
record as to what is necessary and what needs to be done so we
can meet those needs.
Now, I am a realist. I have had the wonderful honor of
serving Nebraskans at all levels of government, and it has been
an honor. I have had the honor of working with veterans and
trying to do everything we can to meet their needs. I am a
realist. I appreciate that you don't build a facility
overnight. You don't do a complex construction project
overnight. You don't do the planning necessary overnight. I
also appreciate that we fit in the order of VA construction
priorities. We are probably not the only need in the country.
We are not. I sit on the Veterans' Affairs Committee, and I am
honored to be there, and we hear about challenges across the
country. But I am going to guess, once we have laid the
appropriate record, no one will argue that this isn't really a
critical need.
At the end of the day, Concept D recommended by the
facility study does not have to be precisely the project I
would suggest that is constructed. I think it is a good plan. I
think it is a great place for us to start the discussion.
The critical point, I believe, is that the report
recommends Concept D because it implicitly recognizes that
patch-me-up solutions are likely to have very diminishing
returns. I hope that this facility has all the potential to be
someday described, when it is built, as state-of-the-art,
anticipating the needs of the veterans not only today, but into
the future.
I will say this, which will show a little bias before we
even get started. I don't believe it makes sense for us to
approach this from the standpoint that a little bit of
jiggering here and a little bit of twisting and turning here
and maybe a little bit of this and that and the next thing gets
us to where we want to be. I do not believe that that is the
case. I believe the issues are too significant and I believe
the report establishes that, in fact, we are at a point where
we have to build.
Well, I am going to end my opening comments there, and
just, again, to all of you who have been a part of that--to our
hard-working Chairman and Ranking Member--thank you for giving
me the opportunity to conduct this field hearing here today.
[The prepared statement of Senator Johanns follows:]
Prepared Statement of Hon. Mike Johanns,
U.S. Senator from Nebraska
I want to thank our first panel of witnesses for appearing before
this field hearing. I know that you face pressing commitments in your
work here at the Nebraska-Western Iowa Health Care System, and I'm
grateful you took the time to testify today.
Mr. Orndoff, I appreciate your coming all the way out here to our
great state to discuss conditions in this facility. August, as I know,
is a time when DC folks would probably like to relax a bit. But the
health care debate has got us all moving, and veterans' health care is
a critical part of that discussion.
I'd further like to express my thanks to all the staff here, who
work under difficult conditions to make sure our veterans get the
health care they are entitled to. I'd like to thank the veterans who
are putting up with us and all of our commotion today in their
hospital. And I'd particularly like to thank the director of this
Health Care System, Al Washko, for interrupting his vacation and flying
back just for this.
As I'm sure you are aware by now, the VA released a study late on
Monday afternoon about the state of the Omaha VAMC. This study was
initiated in 2008 in response to a number of long-standing complaints
about the facility. After describing the problems, the authors of this
report made their recommendations to the VA in May about the best way
forward.
I do not doubt that a new way is very much needed. Though the staff
and affiliates here do a heroic job, I hear a great deal of complaints
about conditions in the Omaha facility from patients and other people.
Perhaps foremost among these concerns is the Heating, Ventilation, and
Air Conditioning (HVAC) system, which has been rated F in VA
assessments going back to 1999. Dust, contaminants, and potential
infections are distributed throughout the hospital by the HVAC system.
Because of HVAC deficiencies, the Omaha hospital may not be able to
support a major pandemic flu outbreak--which, in emergencies, is one of
its functions. In these days of the H1N1 flu virus, that should be a
concern not just for veterans and the VA, but for the greater Omaha
community.
There is also insufficient emergency power. Should the electrical
power fail, the AC, most heating systems, and the facility's surgery
capacity would be lost, as well as all equipment that requires
emergency power to operate. In this state, tornados and other storms
come through the area often, and we are dependent on emergency
facilities. Additionally, the water and oxygen pipes are corroded and
over 50 years old, and fail periodically.
Space is at an absolute premium to us, because if there's one thing
I hear a lot about from folks at Omaha, it's the lack of space. In the
surgery unit, they are absolutely on top of each other. There is no
separate corridor for clean and dirty equipment, increasing the risk of
contamination. Surgical monitors cannot be affixed to the ceiling, as
they are in modern facilities, because the ceilings are too low. And
doctors are forced to discuss their upcoming procedures with patients
in almost a group setting. There is no privacy.
I don't hear these complaints just from one source, but from many.
And unfortunately, this need will only increase. The surgical unit is
doing about 18 surgeries a day, up from 6-7 only a few years ago. I
raised some of these issues at a hearing on the VA construction process
held by the Senate Committee on Veteran's Affairs on June 10th in
Washington. I'm pleased now to be able to discuss them with you again,
Mr. Orndoff.
I am also highly encouraged that a feasibility study on conditions
at the Omaha facility has been completed for the VA by a consultant
group. This study was begun in 2008 and completed in April 2009. It was
intended to help the Omaha facility best meet the growing health care
demands of the local veterans' community, in the face of the facility's
severe space, functional, and technical problems.
As a former Governor, I have made many trips here, and am deeply
aware of the community's need for a modern and highly effective VAMC.
In fact, as a freshman Senator, I asked to be on the Veterans' Affairs
Committee largely in order to help this facility make it clear to VA
that it needed some help. I know other folks like Congressman Terry and
Senator Nelson have also been concerned with this VAMC, but I felt it
was so critical to have a Nebraska presence on the Veteran's Committee
to really focus VA on some of the deficiencies here, and work toward a
solution.
So I was very interested in what the feasibility study would
recommend. It was not an easy report to lay hands on, apparently. I
sent two letters to Secretary Shinseki--one on June 11th and one on
July 17th--asking for an estimation of when the study would be
released. I have to say that I am displeased that neither of these
letters was ever answered. The study was finally delivered to me Monday
evening, which is not much time for me to review it before this
hearing--which, as VA knew, would focus on the Omaha facility. However,
we have it now. I am disturbed that the study seems to confirm most of
the fears we have about the state of the Omaha VAMC.
Among the concerns I talked about earlier, the report says that 42
of 52 medical departments have a space deficiency, and in over half the
deficiency is greater than 4,000 Department Gross Square Feet (DGSF).
``The most significant deficiencies''--I am quoting the report now--
``are in the direct patient care area,'' such as surgery and ambulatory
care.
These departments are also particularly hurt by functional
deficiencies, where the poor layout and other problems simply mean they
do not work very well. Other problems were confirmed as well. The
``Site water and sewer systems'' said the study, ``are aging and due
for replacement.'' The report also discussed possible solutions to the
parking situation, which--as any visitor knows, particularly in the
morning--can be dire.
To remedy some of these issues, the report evaluated five
corrective construction ideas. Each of them were different remedies of
renovation, reconstruction, and working with affiliate locations. It
ultimately recommended Concept D, the option with the most new
construction and the greatest amount of money spent at the Omaha
facility. It would build 754,000 Building Gross Square Feet (BGSF) of
new construction, with 72,000 (BGSF) undergoing renovation and 47,000
BGSF being sent offsite. In total, it would cost $550 million.
In outlining this concept, the study recognized the severe
limitations of Building 1--the main facility we are in right now--and
called for replacing most of it. It stated that ``Due to the physical
limitations of this structure and its location on the site, its
retention would exacerbate the difficulty of every future planning
endeavor at this facility.'' Instead, two major facilities will be
constructed on the Omaha campus: a Surgical Addition overlaying the
current Outpatient Addition, directly adjacent to the existing ICU, and
a much larger Clinical Addition.
The study's authors also found that Concept D provides an
appropriate solution for parking. Ten aboveground acres and an
additional three-level garage would be needed to supply the estimated
need of more than 1700 parking spaces.
This study envisions that the construction could begin in FY12, and
the whole process could be completed by mid-FY18--provided we get
rolling on this in the next budget cycle, and VA prioritizes it high
enough, and allocates enough funding to keep us on schedule.
Now, I am a realist. I know we are not going to get a major
construction job approved overnight, and I know VA's network of
hospitals and facilities is aging in other places, as well. I am also
deeply aware of the many stakeholders who have contributed so much to
providing veterans' health care in Omaha, particularly my friends at
UNMC and Creighton University, some of whom will be testifying later. I
will be eager to hear what some of our affiliates think of this idea.
And at the end of the day, Concept D--the feasibility study's
recommendation--does not have to be precisely the project that is
constructed, though I think it is a good plan, and makes sensible
recommendations about the limitations of the current facilities here.
The critical point, I believe, is that the report recommends Concept D
because it implicitly recognizes that patch-me-up solutions are likely
to provide diminishing returns.
I know that this facility has an HVAC project in the pipeline.
However, I don't believe it makes sense for VA to try and fix Omaha
projects piecemeal over the next forty or fifty years. I believe
choosing the best solutions to problems--not the easiest. So I will be
very interested to hear what VA intends to do with this study. Will it
follow the report's recommendation, and consider a major replacement
construction project for the Omaha VAMC? Or will it put this study on a
shelf? Where do we go from here?
Gentlemen, thank you again for your time today. I would like to
start with Mr. Orndoff's statement, and then hope that you all will
answer some questions for me.
Senator Johanns. We are ready to start with our first panel
of witnesses. I know, Mr. Orndoff, that I think you have some
statement that you would like to offer. I think it is
appropriate we start with you. I want to keep this very, very
informal. This is an informal setting. I think we will start
with the statement. We will go through some questions for you,
and then I am going to turn to the other members of the panel
and try to flesh this out to build a good record. So take us
away.
STATEMENT OF DONALD H. ORNDOFF, AIA, DIRECTOR, OFFICE OF
CONSTRUCTION AND FACILITIES MANAGEMENT, U.S. DEPARTMENT OF
VETERANS AFFAIRS; ACCOMPANIED BY AL WASHKO, DIRECTOR, VA
NEBRASKA-WESTERN IOWA HEALTH CARE SYSTEM; ROBERT YAGER, CHIEF
OF FACILITIES MANAGEMENT, OMAHA VA MEDICAL CENTER; AND THOMAS
LYNCH, M.D., ACTING CHIEF OF STAFF, VA NEBRASKA-WESTERN IOWA
HEALTH CARE SYSTEM
Mr. Orndoff. Thank you, Mr. Chairman, and thank you for the
opportunity to appear before you today to discuss the
Department of Veterans Affairs health care and facility issues
in Nebraska. I will provide a brief oral statement and request
that my full written statement be included in the record.
I am accompanied today by Mr. Al Washko, Director of VA
Nebraska-Western Iowa Health Care System; Mr. Robert Yager,
Chief, Facilities Management, Omaha VA Medical Center, to my
far right; and Dr. Thomas Lynch, Acting Chief of Staff, VA
Nebraska-Western Iowa Health Care System, to my left.
The VA Midwest Health Care Network, VISN 23, is one of 21
integrated health care networks in the Veterans Health
Administration, or VHA. The VA Midwest Network provides
services to veterans residing in Minnesota, North Dakota, South
Dakota, Nebraska, and Iowa, and portions of Wyoming, Kansas,
Wisconsin, Illinois, and Missouri. There were an estimated one
million veterans living within the boundaries of VISN 23 in
fiscal year 2008.
The VA Nebraska-Western Iowa Health Care System in Omaha
proudly serves veterans in Nebraska, Western Iowa, and portions
of Kansas and Missouri. The Omaha facility is an inpatient
facility and also has a large outpatient clinic for primary and
specialty care. The Omaha facility maintains strong
affiliations with Creighton University and the University of
Nebraska Medical Schools. The Omaha facility employs 1,635
full-time employees and serves 47,479 unique patients, 3,071 of
whom are women veterans. The Omaha facility provided more than
660,000 outpatient visits during fiscal year 2008 and operated
on a budget of just under $300 million.
Through the third quarter of fiscal year 2009, the Omaha
facility completed 100 percent of patient appointments within
30 days of the requested time for primary care. The facility
completed 98 percent of specialty care appointments within the
same standard.
The Omaha facility was originally constructed in 1950, and
the aging facility presents some challenges, including a 35-
year-old heating, ventilation, and air conditioning system and
insufficient emergency power. The correction of these and other
space and functional deficiencies is made more difficult by the
low floor-to-ceiling height typical of hospitals constructed in
that era.
In June 2008, then-Secretary Peake visited the Omaha
facility at the request of Senator Ben Nelson. Three months
later, VA contracted with GLHN Architects and Engineers to
conduct a feasibility study to assess the infrastructure space
and functional deficiency corrections. By April 2009, the
contractor had completed the feasibility study and proposed
five alternatives. The following month, the facility and
division forwarded the study to VA's central office and
recommended a large clinical expansion, one of the options
identified by GLHN. In June 2009, at the request of Senator
Nelson, VA Chief of Staff John Gingrich visited Omaha with
staff of VISN 23 and the Office of Construction and Facilities
Management.
VA is moving forward with plans to improve our ability to
meet the needs of veterans in Nebraska. We thank Senator
Johanns and Senator Nelson and the Nebraska Congressional
delegation for your support in moving forward.
Again, Mr. Chairman, thank you for the opportunity to
testify at this hearing. My colleagues and I stand ready to
answer your questions.
[The prepared statement of Mr. Orndoff follows:]
Prepared Statement of Donald H. Orndoff, AIA, Director, Office of
Construction and Facilities Management, U.S. Department of Veterans
Affairs
Mr. Chairman and Members of the Committee, thank you for the
opportunity to appear before you today to discuss the Department of
Veterans Affairs' (VA) health care and facility issues in Nebraska. I
am accompanied today by Mr. Al Washko, Director, VA Nebraska-Western
Iowa Health Care System; Mr. Robert Yager, Chief of Facilities
Management, Omaha VA Medical Center (VAMC); and Dr. Thomas Lynch,
Acting Chief of Staff, VA Nebraska-Western Iowa Health Care System.
Today, I will briefly review the operations of VISN 23, which
includes Nebraska; provide an overview of our facilities in the State;
and describe VA's response to the recently completed feasibility study.
va midwest health care network (visn 23)
The VA Midwest Health Care Network (VISN 23) is one of 21
integrated health care networks in the Veterans Health Administration
(VHA). The VA Midwest Network provides services to Veterans residing in
Minnesota, North Dakota, South Dakota, Nebraska and Iowa, and portions
of Wyoming, Kansas, Wisconsin, Illinois and Missouri. There were an
estimated 1.0 million Veterans living within the boundaries of VISN 23
in Fiscal Year (FY) 2008.
VISN 23 includes eight VA medical centers or health care systems
based in Fargo, ND; Iowa City, IA; Minneapolis, MN; St. Cloud, MN:
Sioux Falls, SD; Fort Meade and Hot Springs, SD (VA Black Hills Health
Care System); Des Moines and Knoxville, IA (VA Central Iowa Health Care
System); and Omaha, NE (VA Nebraska-Western Iowa Health Care System).
In FY 2008, the Network provided services to 290,485 out of 384,225
enrolled Veterans. Additionally, there were about 2.5 million
outpatient visits and 30,722 inpatient discharges. The cumulative full-
time employee level was 11,196, and the operating budget was about $2.0
billion.
Seven of our VAMCs or health care systems are affiliated with local
medical schools, and VISN 23, and the Brain Sciences Center at the
Minneapolis VAMC is conducting research on neurological diseases,
disorders, and addictions. The VISN also has established 25 sharing
agreements with the Department of Defense (DOD). Given the large
geographic footprint of VISN 23, access to care is a priority. Between
2009 and 2010, 14 new locations are planned to open in the VISN,
including an Outreach Clinic in O'Neill, NE. VISN 23 is also home to
one of four Polytrauma Rehabilitation Centers in VHA dedicated to
addressing the clinical needs of the most severely injured Veterans and
military servicemembers.
nebraska health care facilities
The VA Nebraska-Western Iowa Health Care System in Omaha, NE
proudly serves Veterans in Nebraska, Western Iowa and portions of
Kansas and Missouri. The Omaha, Nebraska, facility is an inpatient
facility and also has a large outpatient clinic for primary and
specialty care. There is a Community Living Center located in Grand
Island, and Community-Based Outpatient Clinics (CBOCs) in Lincoln,
Grand Island, North Platte, Holdrege, Norfolk, Bellevue, Gordon,
Alliance, Scottsbluff, and Shenandoah (Iowa). The Omaha facility
employs 1,635 full-time employees and serves 47,479 unique patients,
3,071 of whom are women Veterans. The Omaha facility provided more than
660,000 outpatient visits during FY 2008 and operated on a budget of
just under $300 million. It maintains strong affiliations with
Creighton University and the University of Nebraska Medical Schools.
Through the third quarter of FY 2009, 100 percent of patient
appointments were completed within 30 days of the requested time for
primary care and 98 percent of specialty care appointments were
completed by the same standard. Specialty services available include
audiology and speech pathology, dental, extended care and
rehabilitation services, cardiology, infectious disease, geriatrics,
neurology, mental health and behavioral health sciences, nuclear
medicine, pathology, pharmacy, prosthetics, radiology, surgery, and a
Visually Impaired Support team, among others.
The Omaha facility was originally constructed in 1950, and the
aging facility presents some challenges. The challenges include a
Heating Ventilation Air Conditioning system which was installed in the
1970's and lack of sufficient emergency power. The correction of these
and other space and functional deficiencies is made more difficult by
the very low floor-to-ceiling height, typical of hospitals constructed
at that time.
In June 2008, then-Secretary Peake visited the Omaha facility at
the request of Senator Ben Nelson; three months later, GLHN Architects
and Engineers received a contract to conduct a feasibility study to
assess infrastructure, space, and functional deficiency corrections. By
April 2009, the contractor had completed a feasibility study and
proposed five alternatives. The following month, the facility and VISN
forwarded the study to VA Central Office and recommended a large
clinical expansion, one of the options identified by GLHN. In June
2009, at the request of Senator Nelson, VA Chief of Staff John Gingrich
visited Omaha with staff from VISN 23 and the Office of Construction
and Facility Management (OCFM).
conclusion
In summary, VA is moving forward with plans to improve our ability
to meet the needs of the Veterans in both Nebraska and the VISN. This
is being accomplished with the support of Senator Johanns as a Member
of the Senate Committee on Veterans' Affairs and the rest of Nebraska
Congressional delegation. Under the leadership of Senator Ben Nelson,
who requested a Feasibility Study in the FY 2009 MilCon-VA
Appropriations Senate Report, VA has information to guide the
Department to the right solution. Again, Mr. Chairman, thank you for
the opportunity to testify at this hearing. My colleagues and I would
be delighted to address any questions you may have for us.
Senator Johanns. Great. Maybe, since you have just made
your statement, if I could just turn to you right away and ask
you about something I am getting asked about already. I know at
the conclusion of this hearing, the media will be very
interested in this. Now that the report is out and needs are
being established and the condition of the premise is known, I
will be asked, what happens next? After this hearing and after
we have put this record together, how would a request like this
make its way through this process to a point where we would get
a thumbs up, break ground, and start heading off in a direction
of dealing with the issues the report identifies? Talk us
through that.
Mr. Orndoff. Yes, sir. The report gives us a much greater
depth of analysis than we have had before, and we will
translate that analysis into a project description and
definition. We call it a concept paper that will move forward.
We know that this is an extremely high priority. The Secretary
is very supportive of moving forward with this project. This
project, with all the other competing demands, as you alluded
to before, will be evaluated in upcoming budget cycles, but we
are confident that this project will be very high on that
priority list and have a great opportunity to move forward
quickly. That process will happen as part--the first cycle, of
course, would be the 2011 budget and it would be considered in
that process.
Senator Johanns. Now, when you say that, again for the
record and for the people who are here, when you say the 2011
budget, it conjures up in my mind somewhere late in 2011 this
might get approved. But when is that budget submitted?
Mr. Orndoff. The budget process for 2011 is the Department
of Veterans Affairs would pass its budget recommendation to the
administration, to the Office of Management and Budget, and
that then would be delivered to the Hill at some point. I am
not sure exactly the month that that is delivered, but
sometime, I believe, in the----
Senator Johanns. February?
Mr. Orndoff. February timeframe, thank you.
Senator Johanns. Mm-hmm.
Mr. Orndoff. That would be at the point where you would see
what is in the administration's budget request and whether this
project is in the budget request. So in that timeframe,
February of next year, 2010, we would see if this budget is, in
fact--or if this project is, in fact, in the 2011 budget
request.
The Secretary, as I mentioned, is very supportive of--very
much understanding the need for this project and supportive of
it moving forward, and we anticipate that, depending on where
we are in the budget process, that this project would certainly
have a good opportunity to move forward. We, of course, cannot
say today----
Senator Johanns. Sure.
Mr. Orndoff [continuing]. Exactly what would be in the
budget moving forward from the administration. But all
indications are this is a very strong project in terms of the
prioritization process. Clearly, it is a well-documented need
and it should move forward well.
Senator Johanns. So, ultimately, through your efforts and
then through the Secretary, it goes to the Office of Management
and Budget. When I was on the cabinet, we described that office
as the most powerful office in all of Washington. From there,
they work with the President's staff and then, ultimately, the
President submits a budget request.
Mr. Orndoff. Yes, sir.
Senator Johanns. Now let me ask you, this is an important
need. I think you and I agree on that. We certainly don't want
to be overbearing, but we certainly want to make our case. How
can we be helpful in terms of doing that? What would your
advice be to the Congressional delegation, Senator Nelson,
myself, and for that matter, to the Veterans' Affairs
Committee?
Mr. Orndoff. Well, I would say that you have done that.
Certainly today is part of that action. Inspiration for the
additional analysis that was done through the study was
certainly helpful. I think where we are today is we do have a
well-defined requirement, and at this point going forward, it
is really a matter of what is the funding that the
administration will put forward for capital projects for VA.
And certainly that is an ongoing discussion and will continue
to be until the President puts forward his budget.
But my sense is that the support we have been getting for
capital projects for the Department has been very robust and
hopefully will continue to be so, because we do have a great
need. Within that relatively robust budget, the opportunity for
this project to move forward is already there. So, I don't know
of any specifics that you could do at this point to bring more
attention or emphasis to this. We will see where we are with
the budget submission.
Senator Johanns. OK. If I could turn to Mr. Washko here. I
know you have been doing everything you can to deal with the
issues and challenges that you face. I know this is so
important to you that I think we even interrupted some much-
needed R&R; and we appreciate that. I don't know what you were
doing--it doesn't really matter--and we do appreciate you
coming to the hearing today.
You have been here a while now. Give us a historical
perspective of kind of what has brought us to where we are at
today.
Mr. Washko. I arrived here in 2003, late in the summer, and
as we began to survey the facility, it was apparent that there
were some serious issues with the aging of the facility. We
talk about the facility opening in 1950. I think that was in
Don's remarks. It reminds me very much of my first car. It was
a 1950 Chevrolet.
Senator Johanns. Beautiful car, right?
Mr. Washko. I loved it.
Senator Johanns. Yes.
Mr. Washko. It was one of my favorite cars ever, but you
know what? You don't see very many of them on the road anymore,
because they have outlived their usefulness.
So, as I began to look into the infrastructure of the
facility, I saw that there was a close resemblance to my 1950
Chevy: that we would run into lots of difficulties adding new
innovations to our 1950 Chevy. It is hard to add air
conditioning. You have rusty--1950s Chevrolets didn't have
galvanized steel and so they rust easily and it is difficult to
add some of the new innovations. And that very much is the case
with this facility. It has lived its useful life as we looked
into this.
So, we began to submit project proposals in the
neighborhood, I would say, of 2005 or so. Gary Krupa was our
Chief Engineer at the time, and as we began to study the
facility, we began to see that renovation was not a good
option, that--and a lot of the limitations of renovating this
current facility had to do with the floor-to-ceiling
limitations that Don brought up. When we bring in these new
technologies--we have a state-of-the-art radiology suite, for
example. It competes favorably with any hospital in Nebraska.
But we have got it squeezed into this little pancake that makes
it difficult to maintain, difficult to install, and difficult
to repair. And in some cases, our radiology suite doesn't have
emergency power because of the limitations of this old place.
So, our early project proposals dealt with renovation of
the existing facility, and as we learned more about the
infrastructure, we began suggesting that that was not a good
option. So, we have submitted three or four project proposals.
As Don said, the VA has a robust and objective set of
criteria that it evaluates projects by. And what we have seen
is that our projects have been rising to the top. I am actually
quite confident now that we are right close to the top. I take
Don Orndoff at his word. Secretary Shinseki sent his Chief of
Staff, Mr. Gingrich, out here to look at things and he
indicated that he was persuaded that we had serious need. So I
personally am confident that we have climbed the ladder of the
priority list and that we are waiting for budgetary authority
to address our needs.
Senator Johanns. I don't know if it is a question for Mr.
Orndoff or, for you Al, but how are these ranked? I hope that
is not inside information. We would love to fix every facility
all at once. The budget just simply does not allow that to
occur; so somewhere, ranking has to be done. How would you
describe that process and what are the things here that are
driving our rise to the top, which would concern the Secretary,
concern you, and concern all of us?
Mr. Orndoff. Yes, sir. The ranking process is communicated
in the budget itself and it shows the criteria that were used
to evaluate our projects. All of the projects are submitted on
an annual basis for review and are scored by a Capital
Improvement Panel, which is a cross-section of folks in the VA
organization that try to objectively look at each budget
submission and rank it against that criteria, score it, and
give it a number, for lack of a better way to talk about it.
Those are then ranked, racked and stacked against each other
and a list comes out. That list goes through a very significant
senior management review and is ultimately validated by the
Secretary.
Then in the budget deliberation process, there is a
determination of how much money can be allowed in the capital
budget as part of the overall VA budget going forward. So,
working from the top of that list down, we would be adding
projects--new start projects to the budget.
There is a competing piece for the capital budget and that
is projects that have previously received some funding. They
were a new start in a prior year, but yet not fully funded.
Typically, on a large budget, we will ask for 10 percent of the
total project value to begin the design process. That is when
authorization of the project would typically happen and we have
begun to move forward with the budget. But some of these
budgets are very large dollar figures, some approaching a
billion dollars at this point. So, we look at a multi-year
strategy for funding the projects.
On any given year, there is a competition between putting
more money against existing projects to keep them moving
forward toward completion and delivery or creating additional
new starts. The Department strategy is to do a combination, and
so typically we are able to add some new starts to the program.
We like to do that. We need to keep moving forward on the
priority list and to help Mr. Washko's project keep coming to
the top and ultimately get funded.
So, that is generally how it works. It is an annual cycle.
It is a very objective scoring process. The criteria is
established and approved by the Secretary before the process
begins, so it is very transparent to our stakeholders.
Senator Johanns. OK, great.
I am going to turn now, if I could, to Mr. Yager. You were
with me on the tour that I took a little earlier in the week.
As best as possible--and feel free to use the photos there if
they are helpful in explaining your testimony--kind of walk us
through the challenges that you are facing in terms of keeping
the hospital working and the air handling and the air
conditioning and all of that.
I, again, would like to put some special emphasis on the
fact that I think your people are doing a great job. I think
the maintenance people are doing a great job. Certainly, the
care here ranks very, very well. But what occurred to me when I
was touring with you was that the most minor of problem can
become a very big crisis just simply because it isn't easy
maintenance anymore. There is nothing easy about trying to
maintain the systems in this building and I would like to hear
from you about that.
So, if you could, kind of take those thoughts and tell me
what you are dealing with and where you think things are at
today.
Mr. Yager. Sure. Let me first talk about the people side,
just briefly. I have a boss who is hopefully leading us to a
better day. I have an immediate boss, the Associate Director,
who is tenaciously in the here and now. We are going to keep
everything fixed and running and she keeps on top of me to make
sure. And then I have a maintenance staff below me who are
primarily veterans and they take keeping this hospital running
personally. I am a veteran, also. My organization is primarily
veteran-staffed and we take it personally to keep this place
going.
With that said, there is no doubt that something of a major
action needs to take place to correct the long-term
deficiencies. Day-to-day operations--there are some challenges.
This HVAC system--there are times my maintenance staff have to
go out and shovel snow during a blizzard to keep the fresh air
intakes from plugging up and shutting off or diminishing the
air flow to the hospital. I have been on the roof in a blizzard
and it is not a comfortable place to be, yet they are out there
with shovels.
Senator Johanns. Yes.
Mr. Yager. If you have ever lived in a 50-year-old house--
you mentioned this exactly--you start a plumbing project and
you almost always end up--if starting on the second floor
bathroom, you almost always end up in the basement and you have
replaced every pipe all the way down.
The challenge is we have patients in our hospital and we
have to keep these utilities going. Long disruptions are just
not an option in our book. So shutting the water off for a week
to replace all the pipes just is not possible. Work is done at
night, work is done over the weekends, all in order to minimize
the construction activities in this patient care area. And that
is always the trick: maintaining patient safety while doing
construction; and it is not necessarily easy to do with both.
The electrical system poses some challenges. We are doing
upgrades to maintain as much as we can right now, but it is
frustrating that every small job--there is always the potential
for each job to become a lot more. And sometimes we just have
to say, this is how much we can get done in this period of time
and now we have to get the place cleaned back up and back to a
safe operation again; to give it back to the medical staff to
use. So, it is very difficult with the space deficiencies that
we have, trying to move people around. It just always gets
complicated.
Senator Johanns. Doctor, you have kind of done a number of
different jobs here. You were with me on the tour and we went
into the emergency ward--not emergency ward--but the surgical
ward, I should say. Again, we have pictures of this, with
equipment kind of in the hallways and the ceilings are very,
very low. There isn't much you can do with those ceilings. My
observation, more than about any other place, was the 1950s
construction I was observing because of the challenges of
shutting down surgery while you rehabilitate a piece of that
emergency area.
I would like to have you talk to us about what your doctors
are dealing with. You have been over there. What are the day-
to-day challenges of that area of the hospital?
Dr. Lynch. Let me begin by saying that I think the
physicians as well as the clinical staff are the beneficiaries
of the hard work that engineering does and innovative concepts
that they come up with to correct some of the deficiencies and
challenges that are associated with this infrastructure. So,
part of my answer is oftentimes we don't notice the
infrastructure because there are people working very hard to
make sure we don't notice the problems and the deficiencies.
That said, I think the biggest challenge that we face is
space. I have been here 21 years now. I suspect that space was
not an issue until approximately 5 years ago. From a surgical
standpoint, that is when we really began to see the growth in
technology, the introduction of laparoscopic surgery, the
introduction of endovascular surgery. The operating room was no
longer shared by a surgeon, an anesthesiologist, and a patient.
We were joined by three or four or five support towers with
electronic equipment. We were joined by radiology equipment.
All of these crowded into the space in the operating room.
Our operating rooms are, on average, about 300 or 400
square feet. Our largest operating rooms are about 500 square
feet. The newest operating rooms are at a minimum 600 square
feet, which are currently being built. So, we are now faced
with the challenge of trying to provide innovative,
technologically-advanced, and cutting-edge therapy in operating
rooms that were built in 1950. I think that we have succeeded
to this point. I think that we can continue to move forward,
but we are going to be limited very quickly by an inability to
match technology and space, and I think that is the biggest
challenge that we are facing.
I think it is not only shared by surgery, I think it is
also shared by medicine, because we are unable to renovate the
facilities to match the changing demographic of our veteran
population. We are treating a younger population and we are
treating a female population. Yet we don't have the swing space
or the extra space to use to begin to renovate the clinics and
to introduce innovative technology in medicine--telemedicine
technologies. So, we are going to be limited very quickly
because we don't have space and we don't have the ability to
adapt as quickly as other institutions might.
Senator Johanns. Because every construction project has
dirt and dust where you are tearing things up to put them back
together again, hopefully better than they were. Has that been
an impediment to getting things done? The other thing I would
ask you, even if there was a mountain of money to be put into
that space, it just occurred to me that the physical
limitations of the building would make it impossible to improve
it very much.
Dr. Lynch. The way the building is currently constructed,
it was not constructed to allow expansion or easy adaptation to
current technology. To simply replace the heating, ventilation,
and air conditioning system would require a 6-month shut-down
of the operating room. I think Mr. Yager allowed me half of the
operating room for 3-4 months and the other half for another 3-
4 months. That limits our capacity to deliver care. Any time
you begin modifying or renovating an operating room, there is
always the risk of infection because of the degree and the
materials that are around the operating room.
So, the short answer to your question is, I don't think we
have a facility that we can remodel into anything that would be
nothing more than an old hospital that had been remodeled
within the constraints imposed by 1950s construction.
Senator Johanns. Mr. Yager, do you have any thoughts on
that? Is that what we are dealing with, just----
Mr. Yager. You know, going back to Al's 1950 Chevy, you
could restore it back to factory original condition and you
have still got a car without seat belts, anti-lock brakes, or
an airbag. So it still doesn't have the engineered safety
features. You can drive it as safely as possible. You can stay
off the interstate. The reality is you do not have a car that
has the engineering safety issues built in.
That is part of what we are dealing within our facility
here, that there are some limitations. To put a modern HVAC
system in, you might have ceilings as low as six-foot-six in
the hospital, or you end up with a lot of pipes running
outside, almost like an octopus that is swallowing this
building. Those are the type of challenges we face.
Bringing the electrical system up to code, again, in an
occupied building with patients, is almost impossible to do
because we cannot compromise patient safety. So, what gets
compromised is the scope and breadth of what we can do for
construction and that limits us. It does.
Senator Johanns. You talked to me as we were doing the tour
about air handling. I know there was one area of the hospital
where you had to aggressively pull on the door just to get it
open because of the air handling issues. I would like to
establish a little bit of a record, because air handling, I
think, in a hospital, everyone would agree is a critical
feature. What is going on there and what are the difficulties?
Mr. Yager. We believe that the building is out of balance.
We don't have enough air flow coming into the building, and so
the building--and we are exhausting a lot. Surgery alone has a
100 percent outside air requirement, so we exhaust everything
we bring in. And I believe that we are exhausting more air than
we bring in. Buildings, any commercial building or health care
facility should be overall positive so you keep the outside air
out and the inside air generally--we have some anecdotal
evidence of sometimes when you open doors to the outside, the
air just comes rushing in, and so----
Senator Johanns. Yes, you can feel it.
Mr. Yager. We believe that the building is overall negative
and it should be overall positive. That is a challenge--to try
to fix an HVAC system that is, you know, patched together and
it is not one contiguous system, which we can just go turn a
dial and fix this. It would take tearing the thing up all
throughout the hospital to probably get it to where it was
operating exactly the way it needs to be.
Senator Johanns. As I understand it, it is not just the
equipment in the basement, it is the pipes that run through; in
expanding the capacity there lies another challenge, that you
just don't have the room to put a bigger pipe in.
Mr. Yager. That is correct.
Senator Johanns. Doctor, when you think about the air
handling and you think about just the issue of sanitation, et
cetera, talk me through that. What concerns you about the air
handling?
Dr. Lynch. I think probably the primary concern is patient
safety and infection. I would just like to state that the VA
has probably been a leader in health care and in the area of
quality, quality management, and quality measurement. We
monitor on a regular basis the incidence of infections. We
monitor our surgical mortality or death rate. We monitor a wide
range of surgical complications. We have been within acceptable
limits, at benchmark or below, for as long as I have been here.
And I think that while these are difficult situations in an
aging infrastructure, we have been able to maintain quality. I
think we have the measures that show that we are continuing to
maintain quality.
The VA has a composite measure that came out for the third
quarter. There are 12 elements on that measure. They extend
from access to patient management to prevention, and we are
ranking either at a benchmark or in the upper quarter of 10 of
those 12 measures. So, I think we have adequate monitors on
us--on our patient care--to assure that at the present time the
infrastructure is not adversely impacting patient safety or the
quality of care.
Senator Johanns. Thinking ahead to the future, and I am not
exactly sure who is best equipped to answer this question, have
you done an analysis of future patient needs and the impact on
this facility? If you have, I would like you to talk a little
bit about that and talk about how this facility meets those
future needs.
Mr. Washko. Maybe this is a time to talk a little bit about
complicated surgeries and some of the limitations we have, Tom,
with our existing facility.
Dr. Lynch. I can certainly address that. I think as
surgical technology advances, we are going to have an
increasingly difficult time keeping up with that technology
when we look at our current operating rooms. We don't have the
space to incorporate equipment and we don't have the ability to
remodel.
So, we are going to reach one of two conditions at some
point in the future. Either we can't deliver some state-of-the-
art technology, and at present, I think we have been very proud
of the fact that with our university affiliates, we have been
able to involve a large number of specialists and allowed them
to practice their specialty and their surgical care here
because of the technology we have. But we will reach a point
very quickly, because surgical technology advances very
quickly, where we will not have the room to incorporate that
equipment. It will become difficult, but not impossible, for us
to incorporate a robot because of the size.
As the technology advances, eventually, we are going to
reach a point where we won't be able to incorporate that
technology because it will require renovations in the ceiling
or in the wall to bring in new conduits and new equipment and
we won't be able to do that; or we may be able to do it, but we
would only be able to do it on a limited scale. So we would
reach a situation where we would have to develop backlogs in
order to get patients in for innovative technology.
I think the other big area that will be developing over the
next 10 to 15 years is going to be telehealth. We don't have
the space or the ability to incorporate that technology as
rapidly and as well as we could because of the current
infrastructure.
So, I think from a surgical standpoint and from a medical
standpoint, those are going to be our major constraints. As we
see advancing technology and advancing techniques, at some
point, we are going to hit the wall. I don't think we have hit
the wall yet. I think we have been able to keep up and we have
been able to be innovative and to continue to move forward. But
at some point, the facility and the infrastructure is going to
say, enough.
Senator Johanns. Yes?
Mr. Washko. I would like to give another example. The study
that you referenced shows that we are 40 percent deficient from
current VA standards. That is a very large deficiency. That
means we have only roughly 60 percent of the space that we
need. And where that begins to crimp patient care is when new
programs are necessary to add--for instance, combat veterans
programs. We have made a major commitment to treating combat
veterans here where we have over 5,000 returning combat
veterans signed up here. We have been trying to create clinics
so that combat veterans' care is concentrated among the same
primary care providers and that we also have psychiatric
presence and mental health presence in the same area----
Senator Johanns. Post Traumatic Stress Syndrome?
Mr. Washko. Exactly. So we have been trying to create
clinics for combat veterans that have a number of services
immediately available. Well, in a facility that only has 60
percent of its space, something has to give when you do that.
Now, we have created these clinics here, but in the process, we
have suboptimized other parts of patient care.
So, when we created these clinics, we no longer had two
exam rooms per doctor, which is what you need for an efficient
clinic. We now have compromises in the necessary exam rooms per
practicing doctor. So that is an example of a compromise that
limited space makes to our operations.
Senator Johanns. Yes. Yes. You know, this gives me such an
interesting perspective, because sitting on the Veterans'
Affairs Committee, we sit there and we pressure the Veterans
Administration, to get Post Traumatic Stress Syndrome
treatments in place. You have got to do this. Our veterans need
it, and there is tons of evidence to support that. But then you
begin to realize the limitations. You want that as badly as we
want it, but you are limited by this and it is very, very hard
to pull that off when you just simply don't have the adequate
tools to get that accomplished. So, that is just an important
perspective to have.
I am going to take a step--and I am just about done here
with the first panel--but I want to take another step. Of
course, there are all kinds of community discussions about what
is the best approach. Is it D? And I will guess that will only
increase. I would just like to hear again some description of
the process by which a final decision arrived at is that this
is the way we think we need to go here. Maybe it is Option D.
Maybe it is a hybrid of Option D. Maybe it is something else.
And I especially would like to hear any thoughts on
community input, because on our next panel, we will have
somebody from the University of Nebraska Medical Center, and
Creighton University Medical Center. I am a Creighton alum. I
love what these folks do at Creighton and at the University of
Nebraska. I would love to hear about potential for partnership.
I know you are doing some really exciting things now. I just
really believe that that is one way of providing really great
services and kind of utilizing the resources of each.
So, if you could help me and everybody else here
understand, how does that come about and what would be the
potential for community input?
Mr. Orndoff. Sir, I will take a shot at that, and Mr.
Washko can help me out as necessary. First of all, from a
project point of view, we have a project. We have a concept
that has been promoted by the study and our analysis of this is
we believe this is the way to go. Option D is the right answer
for all of the things that we have been talking about here
today. That is major new construction with some renovation. The
exact project is still a work in progress, but we are fully
committed to moving forward with a project that is similar in
scale and scope as Option D recommended by the
report.
Now, in our discussions, we know that there is another step
of planning that needs to be done before we really start to
design the project, and this is where the opportunity for
community input lies. I know the Medical Center Director is
very much interested in
pursuing that input. The central office will fund that effort,
the facilitation of that effort, through our advance planning
funds. We have already committed to do that. So that process
should happen
quickly.
On track two, my office will begin the process of designing
the project. We will begin the process of soliciting and hiring
a design firm to begin the actual design effort. We will do
this beginning very soon. So, those two things will be running
in parallel: the final lockdown of exactly what project we are
going to do; and the bringing aboard a design firm that will
actually decide the final solution.
Of course, depending on when the project is funded is when
we will actually move forward with execution of that design.
But we are not going to wait for that. We are going to begin
that initial design step very soon. And again, in parallel with
community input.
Did you want to----
Mr. Washko. I would say we are very grateful for Mr.
Orndoff's suggestion about how we can take the next steps in
the way he just described. That is why I am so optimistic that
Secretary Shinseki is supportive of the project proposal that
has been made. So we are looking forward to getting started on
this quite soon.
Senator Johanns. Great. Nothing I say, should be taken as
wanting to hold this up or gum it up. Boy, nobody in this room
wants to do that. Nobody in this area, this service area, wants
to do that. And I think we will hear that there are some great
community resources and they are ready to do anything they can
to help veterans, and that is kind of the philosophy that we
bring to this--partnerships work great in the State. People
know each other; and so, however you can reach out to us and
bring us into the process, I think will be beneficial to all
concerned, including the veterans.
I will wrap up with just one question directed at each of
you; and it is just a general question.
Is there anything that you came prepared to tell me at
today's hearing that you haven't yet told me or I haven't
elicited in my questioning? If you were laying awake last night
thinking about this hearing and thinking, boy, I just need to
make this point, I hope he understands it, I hope the Veterans'
Affairs Committee understands it, now is your chance. Doctor?
Dr. Lynch. I think the one aspect that has not come out so
far in this hearing is the educational value of this
institution. Not only are we providing care to veterans, but
this is a critical piece of the teaching programs at both
Creighton University as well as the University of Nebraska
Medical Center. So, I think as we look at the future of this
institution, we need to also look at it as a resource for
Nebraska, as well, because a number of the physicians that
practice and stay in Nebraska are those that are trained both
at the University and at Creighton.
Senator Johanns. That is such an excellent point. And
needless to say, we would love to see some of those future
physicians decide that this is exactly what they would like to
do with their career.
Mr. Orndoff. Sir, the only thing I would like to reiterate
is the fact that we have a big challenge at VA in terms of
doing the reinvestment in our infrastructure that is necessary
to continue to support world-class health care into the future
for veterans. Certainly, everybody is focused on how to do
that. It takes a great deal of resources to push this forward.
Over 63 percent of all VA facilities are over 50 years old.
That makes--the situation is, we have quite a few Omaha Medical
Centers out there in similar kinds of situations. But with the
level of analysis that we have and the support that we have
from the delegation, this project will move forward and the
solution for Omaha will be near-term.
Senator Johanns. I will tell you, I don't know the
Secretary yet. I look forward to getting to know him better. If
you would, take back to him how much we appreciate his
attention. Everything I know about him, he is a man that gets
it and really wants to do the right thing for veterans. So we
appreciate that and we especially appreciate the attention he
has given.
Mr. Orndoff. Yes, sir. I will do that.
Senator Johanns. Thank you.
Al, do you have anything you want to offer?
Mr. Washko. I do. In addition to replacing our 1950 Chevy
with the next model----
[Laughter.]
Mr. Washko [continuing]. We would like to make a new
facility a Center of Excellence in telemedicine. Nebraska is a
rural State and telemedicine, we think, plays a very major role
in reaching out to rural areas. We have an interest in using
this project to follow up some of your interests, Senator
Johanns, in the mental health area. We think that some of the
funds in this project will allow us to construct mental health
facilities that we can work in partnership with Creighton and
the University of Nebraska. The State legislature recently
passed bill No. 603 that focuses on rural mental health care,
so, we intend to put a major base here for telemedicine. We are
already moving in a number of areas fairly aggressively.
The second thing I would like to say is we intend to put
major effort into energy efficiency and building a green
facility. We would like to use every technology available and
maybe even experiment with one or two to be an example of how a
medical center can have drastic reductions in energy usage. We
look forward to that.
Senator Johanns. Great. Two great areas. You know of my
personal interest in mental health services. We all know that
when you move out to more rural areas--less densely-populated
areas--these veterans need these services as much as anyone. It
is very hard to get the services to them. Telemedicine is a
piece of the answer to that very challenging puzzle, so I
really applaud that.
Mr. Yager, you get one last shot here.
Mr. Yager. Senator, I will admit I did lose sleep last
night----
[Laughter.]
Mr. Yager [continuing]. As an architect, this is a very
exciting time. And I just look at all of the things that have
lined up in a positive manner--all the support that we have
gotten from our Congressional delegations, from central office,
our network, my leadership, from the guy at the bottom of the
food chain on this--everything is lined up in such a positive
way. I can't wait for the next few years.
Senator Johanns. Great.
Mr. Yager. It is going to be very exciting times for us.
Senator Johanns. Great. And you can hold it together until
we can----
Mr. Yager. I can.
[Laughter.]
Senator Johanns [continuing]. Get through this process?
Mr. Yager. Yes.
Senator Johanns. If I could ask you all to express to the
people here--whether they are working down on the HVAC system
or they are working in the emergency ward--how much we
appreciate their dedication. I was so impressed with that when
I was here and I walked out with such a great feeling about
that and even more committed to try to get them a facility that
meets the needs of the veterans and allows them to continue to
bring that first-class care.
I thank the panel. I want to tell you that if you do have
to move on, please feel free to do that. If there is something
that you think of--I am thinking I will keep the record open
here for probably a week, so if there is something that you
think of that you want to submit in writing, we would be happy
to receive that. Thanks.
Mr. Orndoff. Thank you.
Senator Johanns. We will get things reset here and then we
will invite our next panel to come up.
[Recess.]
Senator Johanns. I will go ahead and continue the hearing
here. Our second panel is seated. I just noticed that I forgot
to introduce somebody who really has just been a great piece of
the Johanns team dating back a long time, and that is Roger
Lempke. He is the former Adjutant General. When I became a
United States Senator a few months ago, I was wondering who
could be my Director of Military Affairs--all things military.
And it just so happened that Roger was thinking about doing
some other things in his life, so I convinced him that really
what he needed to do was to come back so we could work together
again; so, Roger, good to have you here.
Roger is another one of these guys that gets it and cares
about the veterans very, very deeply. Probably not a lot of
people in this country with the title ``General'' that do case
work for veterans. [Laughter.]
And he loves doing it.
We have an outstanding second panel, and Congressman, you
have been so very patiently waiting. I want to start the second
panel by acknowledging you. I said today at an event, this
hearing wouldn't be happening but for you. Senator Nelson, you
guys laid the groundwork. This has been a dream of yours for a
long time. I know what August recess is about--or at least I
know a little bit about it at this point--every minute is
booked. Yet here you are giving us a number of hours of your
time and we can't tell you how much we appreciate it.
The protocol is that you go first here, and I don't think I
even get to question you, so----
[Laughter.]
Senator Johanns [continuing]. You just jump in.
Mr. Terry. Nor I, you.
Senator Johanns. Yes, that is right. [Laughter.]
Mr. Terry. You are new. You may not have read that.
Senator Johanns. That is right. I didn't see that in the
rules, but I am very junior, so go ahead. Congressman, welcome.
STATEMENT OF HON. LEE TERRY, A REPRESENTATIVE IN CONGRESS FROM
THE STATE OF NEBRASKA
Mr. Terry. Thank you, Senator Johanns. I appreciate you
holding this field hearing. You and I certainly have a passion
to make sure that our veterans are properly respected and taken
care of, and we are able to work as a delegation to make sure
that happens for our Omaha, Nebraska-Western Iowa veterans.
Your staff mentioned that they probably did hear a little
bit of the history. We heard it from the VA perspective. Now I
get to give the outside-of-the-VA perspective.
Senator Johanns. Great.
Mr. Terry. When I was first elected 11 years ago, if a
veteran came into my office about the VA, it was usually to
complain--complain about, well, the facility, the quality of
the medical care here, the attitude of the employees here, or
employee morale that was projected onto the patients. And in
fact, we would have groups ask us to file complaints. In fact,
Bob Kerrey did, on behalf of some of the patients treated here,
file a complaint.
Leadership was changed. After an interim director, Al
Washko took over as the new Director of the VA Medical Center,
and he instantly grasped the depths of the issues here with the
quality of the health care and set up a system to elevate it.
Within about a year of Al Washko taking place, when we got
calls or would run into veterans, we would hear about how great
the facility is.
Now, Al Washko, I think, single-handedly raised the quality
of health care provided here to the point where it is second to
none in the city and treats the patients here with the respect
that they deserve. The reality is the quality of this building
has not been, at least in a highly-technical term, the bowels
of the building have not changed. Al just doesn't have the
power to fix those.
In his tenure, he has added, departments, ICU, and surgical
rooms, a new facade on the front that makes it look inviting
and open. But in a way, that is just eating away at the fringes
here. The quality of the care has probably peaked because of
the poor quality of the building itself.
So, one day, probably around 2005, I was talking to Al
Washko during one of my quarterly meetings with him--just him
and me talking--and we were talking about the facility, the
upkeep, and the repairs that were necessary. I just casually
asked him, I said, well, do you need a new hospital here? And I
think he said--I am paraphrasing from a couple years of memory
past here--but he said, well, I am not asking, but if you can
get one, yes. [Laughter.]
He wasn't going to turn that down, right?
He wasn't going to turn that down. So, I started kind of
poking around; wrote letters to VA and our Committee leader
saying, what can we do? Can we take a look at the Omaha
facility and see what options are available to us? I talked to
a couple of different Secretaries--Jim Nicholson at the time--
and, also about that time, went over and talked to Hal Maurer
over here. I said, hey, you guys are going to get a bunch of
land and I think the VA is kind of landlocked. If they got a
new hospital, could they put it on your land? We started
brainstorming about maybe some synergies that could be created
from that, and that is when I saw and listened to Hal; and
thought, OK, this is really doable. This is something we can
work on.
So, we then took it to the VA and that is when heads
started hitting against the wall here. We were told that there
are a lot of hospitals out there that need it, too. So, what I
started to do was work with our community, meet with the
veterans organizations here, and what we found out is--or I
found out in meeting with the veterans organizations here is--
that they had the same thoughts that I had. It is a great
facility, or the quality of care is great here. The employees
are great here. But, dang, that building is old and needs to be
replaced.
So, we started to get the community support from the
veterans. We also started to get the community support from the
fathers of our city, which is when I knew we really were
building up the dynamics. In fact, our fathers of the city
became intricately involved. Ben Nelson became intricately
involved. In fact, using Ben's position on Armed Services and
Appropriations, we all kind of asked Ben to take the lead on
this to see how far we could push it.
Calls were made. Finally, after meeting with various
Secretaries, Jim Nicholson got Secretary Peake to the building.
Finally, we had someone from the inside of the VA to take a
look at this place--besides the VISN 23 level--and then things
started to happen. They realized that this building is in as
bad as shape as we told them about. Secretary Petzel was able
to meet with the community fathers, and brainstormed with them
here. We need a study. Let us see a need, see the options. We
will work with you. There may be some financing ways that we
can help it so you don't have to go through the CARES program
or worry about what Congress will put up yet.
So, what we had is a total buy-in from our community at all
levels, Mr. Mike.
Senator Johanns. Great.
Mr. Terry. So that started, then we got Secretary Peake
here, who gave the commitment to follow through with the study
that brings us here today about what the options are. So now we
have a study that shows that this facility does need to be
replaced. And I think that that type of backing by the VA is
important. Now, let us make it happen.
I don't know what the timing will be. For me, this has been
3, probably about 4 years in the making, a lot of pushing and
yelling and screaming and tantrums, figuratively, with the VA.
Now we have gotten to the point where I see the light at the
end of the
tunnel.
Now, Option 4--to anticipate your question--I like Option
4. I think absolutely a new tower is necessary. I don't know
what utility there is left in this building, if any, so I don't
know if any renovations for other purposes is possible. But if
there is, I think we need to look at that.
One thing that we have to commit to, I think, is a new
tower. Where it is placed, I think, could still be left open
for discussion within the community and the VA, but I am glad
we have committed to the new tower.
One other thing I skipped over in that paragraph which I
think is important, I think it was just about 2 or 3 years ago,
while all these discussions about a new facility came up, where
I was asked to put an earmark in for 150--well, it was
suggested--but for $156 million for the replacement of the
HVAC. And at that point, I started thinking, what does a new
hospital cost, and talked to Leo Daly, because they build
hospitals, and they said, basically, they can replicate this
and just did down in Florida for about $210 million.
Senator Johanns. Yes.
Mr. Terry. I think that was a critical point where we
finally reached the point where now it is being documented that
the costs are outweighing the value of the building. So that
was an important tipping point. I put in that earmark, and
didn't get it. We didn't put it in last year because I wanted
to make sure we weren't confusing the path here.
Senator Johanns. Yes.
Mr. Terry. So, Mike, thanks for doing this. I think this
hearing is very helpful in moving this project down the road.
Hopefully, we will get the absolute commitment for the funding
and the planning now within months instead of years.
[The prepared statement of Mr. Terry follows:]
Prepared Statement of Hon. Lee Terry, U.S. Representative in Congress,
Second District of Nebraska
When I was first elected to Congress, nearly 11 years ago I toured
the Omaha VA medical facility. The tour was a quick look at the
building that cares for our veterans. At the same time my congressional
office was receiving complaints about the quality of care, the run down
nature of the facility and the poor attitude of the employees.
In 2003 Al Washko took over as new director for the Omaha VA
Medical Center. From day one Mr. Washko realized the vast problems at
the facility. He identified and quantified the problems and put the VA
on a path to increased quality of health care improved attitude of the
employees. Since Mr. Washko has been in charge my office has received
very little complaints about the Omaha VA.
I am proud to help with funding to make much needed repairs to the
facility. Some of those improvements include: new ICU, new MRI, updated
surgery suites and renovated ER.
Later I requested monies for the millions of dollars it would have
cost just to upgrade the HVAC system. When I toured the facility it
became very apparent that we were using ``duct tape'' to try and fix
major problems.
When I then met with Mr. Washko I wanted his opinion on whether
building a new VA hospital was needed. His response was overwhelmingly
yes!
In July 2005 I wrote a letter to the Chairman of the House
Committee on Veterans Affairs asking for assistance in initiating a
feasibility study to improve the veterans health care in Omaha.
In 2007 I met with then Secretary Jim Nicholson about the current
troubling facilities at the Omaha VA. I partnered with my Nebraska
colleague in the Senate, Ben Nelson. Senator Nelson sits on the
Appropriations and Armed Services Committee, so it was logical we would
partner and Nelson will be the lead. I have remained intricately
involved in the process.
Last year I again toured the Omaha VA with then Secretary Peake.
Again, the problems that were indicated years before were still there
or had gotten worse.
It is clear to me that the Omaha VA is great at providing care for
our veterans. But the facility, being 59 years old is in great need of
replacement. The rooms are too small, the ventilation system is not up
to code, the HVAC system needs immediate repair and the piping and
sewer system is so old that repairs just don't make sense.
A new facility is critical to the future care of those who so
proudly served our country. I really believe the nature of the building
inhibits the further growth of that exact site. I do want to commend
the UNMC and Creighton doctors and students who do their very best
every single day to care for our vets. Your work does not go unnoticed
and I commend you for it.
The VA and Congress must make a choice--a new building or partner
with the private sector. Most veterans I speak with are in full support
of a new hospital. There is, however, some resistance to eliminating
the hospital all together. If a merger does occur the VA must retain
its identity.
Building new or collaborating with an existing hospital has the buy
in from veterans in Omaha, we also have buy-in from the business
community--some have offered to build the new building and lease it
back to us. We also have buy-in from our Congressman Steve King in
Iowa. We also have 100 percent support from Congressmen Jeff
Fortenberry and Adrian Smith. So, the entire Nebraska delegation
supports this important endeavor.
I want what is best for our veterans, so if that means a new
facility or if it means combining efforts with an existing hospital, I
am on board. And I would even like to see the Omaha VA strive to be one
of the Centers of Excellence.
The men and women serving our country are making tremendous
sacrifices to protect our country. I would like to say thank you to all
our veterans for their service and sacrifice. It is time for us to do
the right thing for our veterans, we must have a new facility for
health care in Omaha, we can't wait, we must do it now.
Senator Johanns. Great. Well, let me just say, we thank you
for your efforts, appreciate it so much, and, are glad to be a
partner now. I thank the voters for their support in November
so I could be a partner in this effort. These are the kinds of
things that really do make a huge difference.
I also want to say that I look forward to working with you
in the future on this, together with the rest of the
delegation. We are very fortunate to have a good working
relationship, as you know, with everybody.
Mr. Terry. And to follow up on that, I wanted to make sure
it was a part of the testimony: Jeff Fortenberry, Adrian Smith,
and even Steve King from Western Iowa are fully on board with
this and equally as committed.
Senator Johanns. Great. Great. I know what your schedule is
because I have been watching it and you don't have serious bags
under your eyes yet, but they are close. If you do have to
leave to go on to another event----
Mr. Terry. I do, but I want to hear David Brown.
Senator Johanns. OK----
[Laughter.]
Senator Johanns. Then I will----
Mr. Brown. You heard me already once today.
[Laughter.]
Senator Johanns. Yes, we have heard him once. Actually,
what I am going to do--I don't wish to disappoint you, but we
do have the medical schools here today represented. Dr.
Zetterman, it is good to see you here, and Mr. Maurer. I
thought I would turn to them next because I think you are a key
piece of the present and the future in terms of our veterans.
I would like to start with you, Dr. Maurer, but I am really
going to ask you to focus on some of the same things. What
resources can be brought to bear here? How does this facility
help in terms of the teaching mission for the University of
Nebraska Medical Center and for Creighton University Medical
Center? Walk us through that, because my hope is that someone
reading this record or looking at this record would understand
there is tremendous community support here, but there is
tremendous community resources available. So, Doctor, take it
away.
STATEMENT OF HAROLD M. MAURER, M.D., CHANCELLOR, UNIVERSITY OF
NEBRASKA MEDICAL CENTER
Dr. Maurer. Thank you very much, Senator Johanns. I would
like to thank you for the support that you have given over the
years as Governor and as Secretary to health care issues in the
State of Nebraska. You mentioned mental health, but you have
also been interested in research----
Senator Johanns. Yes.
Dr. Maurer [continuing]. Which has been very important to
both medical centers in the State of Nebraska and others.
I believe that a new facility here could be
transformational in terms of the care of veterans. It could
bring new programs to this new facility. It could take some of
the existing programs and substantially expand them into
Centers of Excellence. It could broaden the research
activities, which has not been mentioned thus far by any of the
speakers so far. It could certainly enhance the educational
activities of both the residents, the resident physician, as
well as the students that take rotations at this facility.
There is also an opportunity here to allow nursing and
allied health, pharmacy, public health, and other areas to
become integrated into the veterans hospital--Omaha VA
Hospital--and also serve the veterans of the State of Nebraska,
and I think it is critical. So a new hospital here, which I
believe is desperately needed, would be absolutely essential.
I think there are limitations now. Having spoken to
residents and physicians today in orthopedics about this, they
could do a lot more if, for example, the OR had more space to
do that in. So, I think there is a real opportunity and we are
particularly excited for the VA and excited for the residents
to do all we can to support their health care needs in
Nebraska.
Senator Johanns. Great.
Dr. Maurer. I will stop there.
[The prepared statement of Dr. Maurer follows:]
Prepared Statement of Harold M. Maurer, M.D., Chancellor, University of
Nebraska Medical Center at Senator Johanns' Field Hearing on the Omaha
VA
I am Dr. Harold M. Maurer, Chancellor of the University of Nebraska
Medical Center. Prior to being Chancellor, I was Dean of the College of
Medicine and a regular member of the Dean's Committee of the Omaha VA.
The Omaha VA is an integral component of our education, patient
care and research program. Many of our faculty spend a considerable
portion of their effort at the VA. Our resident physicians and students
spend rotations in their training on both in-patient and out-patient
services of the VA. We have combined funded research projects,
particularly on alcoholism. Thus, the Omaha VA is essential to the
programs of the University of Nebraska Medical Center.
Our faculty are involved in general medicine, diabetes, surgery,
cancer diagnosis and care, vascular medicine, critical care,
gastroenterology, geriatrics and many other services that are provided
by the VA to the veterans. We see women's health as a new service for
the Omaha VA as well as for other VA's across the country. We are
working collaboratively on telemedicine, particularly telepsychiatry
for veterans who live in rural Nebraska. UNMC can do even more in the
future, but the existing facilities are tired and pose limitations on
our ability to serve the veterans to their best advantage.
The Omaha VA, as do all other VA's, provides UNMC with the best
electronic medical record example in the Nation. It also provides us
with educational opportunities that are irreplaceable. It provides the
best system for patient safety, outcome and performance measures. We
believe that a new VA facility will enhance the current services and
grow the synergism between UNMC and the Omaha VA to better serve the
veterans.
Thank you for your attention.
Senator Johanns. Doctor, thank you.
STATEMENT OF ROWEN K. ZETTERMAN, M.D., DEAN, CREIGHTON
UNIVERSITY SCHOOL OF MEDICINE
Dr. Zetterman. Thank you, Senator Johanns, for all that you
are doing and also for what you have done. I thought I would
just tell you briefly that, as Dean of the Medical School at
Creighton, I want to talk a little bit about what Creighton's
involvement has been here and a little bit about what we think
for the future.
I might say, if I have a conflict of interest, it is that I
have been on the medical staff here for 33 years--was the Chief
of Staff for 6 years until January 3 of this year--so I have
enormous numbers of very positive memories of working here.
All of Creighton's Health Sciences Schools of Medicine,
Nursing, Dentistry, and Pharmacy have mutually beneficial
programs here at the Omaha VA and actually at other sites
throughout Nebraska and Western Iowa, so we are intimately
involved. Our School of Medicine currently supplies about 50
percent of the medical staff here at the Omaha site. We have
about 55 full-time medical, surgical, psychiatry residents, and
pathology residents, that are on duty here at this site every
day and virtually all of our residents receive some of their
training here. Third- and fourth-year medical students also
receive a portion of their work here as they are being
supervised by the Creighton faculty.
The VA provides a crucial component of the education of
students in medicine, neurology, psychiatry, and surgery, and
introduces them to the diseases and the issues of America's
returning combat heroes. Creighton faculty engage in research
at the Omaha VA and expand our knowledge in common diseases
that affect veterans, including infectious diseases, diabetes,
obesity, smoking and substance use disorders, and a variety of
mental health disorders.
As I hope is apparent from what I am saying, these
interactions offer great reciprocal value to both Creighton
University School of Medicine and to Nebraska-Western Iowa VA
Health Care System. While Creighton faculty members serve a
vital role in the care of the veterans and the research into
their diseases, the VA provides the environment for education
and research that benefits our medical students, residents, and
faculty. Creighton faculty bring the latest expertise in
patient care and procedures to the VA which benefits the
veterans; and the interaction of our faculty at the VA has led
to improvements in patient safety and quality of care along
with that delivered by the other physicians, nurses, et cetera,
that are here.
While the Nebraska-Western Iowa VA Health Care System has
been remarkable in improving patient access both locally and
regionally through the use of telemedicine, testing the concept
of medical home in its primary care clinics, and proactively
reducing costs of care while at the same time enhancing patient
safety and quality, there are clinical areas that can be
greatly improved by additional funding.
The current physical plant was built at a time that it was
all inpatient care. Today's outpatient care needs much more
space, and I won't reiterate further the issues of the facility
because you have heard those in detail, and as I mentioned, I
have very intimate knowledge of those needs.
Nebraska-Western Iowa covers a geographic area that is 400
by 200 miles. Additional funding would permit the development
of more rural primary care clinics, further assessment of
innovative health care delivery models, such as the medical
home, enhanced mental health and counseling services, and the
greater use of telemedicine to reach veterans who would
otherwise be required to travel long distances for their care.
Our aging veterans populations will require greater access
to services in their later years. They will need assisted
living facilities, nursing home facilities, day care centers
for senior veterans, enhanced home care and assistance, and not
simply in the larger populated cities, but in our rural areas,
as well, and added personnel and services will help them stay
within their own homes in later life, while eventually more
hospice care sites for those that develop diseases bringing
them to their final months will also be needed.
Additional monies coupled with the health care engineering
activities currently being carried out at Nebraska-Western Iowa
should permit it to be the incubator to test new health care
delivery techniques for veterans that increase access, control
costs, and improve patient function. Funding can also bring the
VA the tools needed for screening and prevention of disease. If
we can deliver the care and preventive services that our OEF
and OIF war heroes deserve throughout their life and not just
when they become sick, we can maintain their current health and
will prevent the eventual chronic diseases that some of them
might develop.
So, these are but a few of the opportunities that I think
we can do with additional funding, and it covers more than just
the physical attributes of this facility.
I am grateful for the opportunity to speak on behalf of an
area that has an enormous passion in my life and I thank you
for bringing this to our attention.
[The prepared statement of Dr. Zetterman follows:]
Prepared Statement of Rowen Zetterman, MD, MACP, MACG, Dean,
School of Medicine, Creighton University
Creighton University is a liberal arts university established in
Omaha, NE, in 1870. Creighton provides comprehensive education in arts
and sciences, law, and the health sciences of medicine, nursing,
pharmacy and dentistry. All of Creighton's health science schools have
mutually beneficial training and clinical care relationships with the
Nebraska-Western Iowa VA Health Care System.
Creighton University School of Medicine has been associated with
the Veterans Affairs Medical Center in Omaha essentially since its
inception 60 years ago and is currently providing approximately 50% of
the physician medical staffing at the Omaha VA site. These Creighton
School of Medicine faculty are full-time, part-time or contracted
physicians at the VA and provide direct patient care in VA clinics, the
inpatient hospital, or procedural areas and operating rooms coupled
with administration of clinical services and the supervision and
education of VA personnel. Approximately 55 full-time medical,
pathology, psychiatry, and surgery residents sponsored by Creighton and
the VA are on duty in the Omaha VA every day and virtually all
Creighton University residents receive at least a portion of their
training at the VA.
Third and fourth year Creighton medical students also receive a
portion of their education at the Omaha VA. These students are
supervised by the faculty and residents with whom they work. In the VA
Emergency Room, students have access to modern educational equipment
and utilize simulation mannequins to learn in a controlled system how
to respond to emergencies they may face in their future. The VA
provides a crucial component of the education of students in medicine,
neurology, psychiatry and surgery and also introduces them to the
diseases and issues of America's returning combat heroes. These
invaluable lessons prepare them for the future care of all types of
patients.
Creighton faculty engage in research at the Omaha VA Research
facility and work to expand our knowledge of common diseases that
affect Veterans including infectious diseases, diabetes mellitus,
obesity, smoking and substance use diseases, and mental health
disorders.
As I hope is readily apparent, these interactions offer great
reciprocal value to both Creighton University School of Medicine and to
the Nebraska-Western Iowa VA Health Care System. While Creighton
faculty members serve a vital role in the care of Veterans and research
into their diseases, the VA provides the environment for education and
research that benefits our medical students, residents, and faculty.
Creighton faculty bring the latest expertise in patient care and
procedures to the VA to the benefit of the Veterans.
The interaction of Creighton faculty at the VA has led to
improvements in patient safety and quality of care. As an example, a
Creighton faculty member is the lead physician for patient safety and
ensures that identified safety problems are thoughtfully and promptly
handled. This includes weekly safety rounds in clinical areas to
proactively identify potential problems and provide solutions in
advance of unsafe events.
I had the opportunity to serve as the Chief of Staff of Nebraska-
Western Iowa VA Health Care System for 8 years until January 3rd of
this year. While Nebraska-Western Iowa VA Health Care System has been
remarkable in improving patient access both locally and regionally
through the use of telemedicine, testing the concept of the medical
home in its primary care clinics, and proactively reducing costs of
care while at the same time enhancing patient safety and quality, there
are clinical areas that can be further improved by additional funding.
The current physical plant was built at a time that inpatient care was
essentially all that was provided and a much larger physical plant is
needed today to deliver health care to our Veterans. Larger operating
rooms, more space for the services of pathology, radiology and mental
health, a new heating and air handling system, additional educational
facilities for both patient and student/resident education, and larger
clinics and group rooms are needed. These issues have been included in
a proposal to the Department of Veteran Affairs to replace or enhance
the current structure and the results of this request should be
available soon.
Nebraska-Western Iowa Health Care System provides the care for our
Veterans in a geographic area that measures 400 by 200 miles.
Additional funding should permit the development of more rural primary
care clinics, further assessment of innovative healthcare delivery
models such as the medical home, enhanced mental health and counseling
services, and greater use of telemedicine to reach Veterans who would
otherwise be required to travel long distances for their care. Our
aging Veterans population will require greater access to services in
their later years such as assisted living and nursing home facilities,
day care centers for senior Veterans, enhanced home care and assistance
and not simply in the larger populated cities, added personnel and
services to help them stay within their own homes in later life, and
more hospice care sites for those who develop diseases that bring them
to their final months. Additional monies coupled with the health care
engineering activities being carried out at Nebraska-Western Iowa
should permit it to be the incubator to test new health care delivery
techniques for Veterans that increase access, controls costs, and
improves patient satisfaction. Funding can also bring the VA the tools
needed for screening and prevention of disease. If we can continue to
deliver the care and preventive services that our OEF/OIF war heroes
deserve throughout their life and not just when they become sick, we
will not only maintain their current health, we will prevent their
chronic diseases and reduce the cost of care as they continue to age.
These are but a few opportunities as we continue to increase funding
for Veteran's care in Nebraska-Western Iowa.
I am grateful for the opportunity to speak to the importance of the
VA to Creighton and of Creighton to the Omaha VA. Thank you for your
attention.
Senator Johanns. Great. I will ask each of you, starting
with you, Dr. Zetterman, you have had experience with the
facility. Your students have. It just appears to me that there
is just no doubt about the need to replace what is here. Do you
have any question in your mind about that?
Dr. Zetterman. Absolutely none. I struggled along with Tom
Lynch, Al Washko, Bob Yager, Nancy Gregory, all of us looking
at these things, looking at the various issues that are there.
I think it is remarkable what the staff here has done with an
aging facility that is undersized. We can do better with a new
facility in large measure because of many of the problems that
you have heard.
Senator Johanns. Yes. Thank you for that.
Dr. Maurer, any doubts in your mind?
Dr. Maurer. There are absolutely no doubts in my mind. I
would say that it is a very tired facility and I think it is
doing a great job with what it has, but it is very limited in
what it could do at this particular juncture.
Senator Johanns. Yes. I am going to turn to David Brown,
who is of course, the President of the Omaha Chamber of
Commerce. In your position, David, you probably are as good a
gauge of community support and opposition as anyone out there.
You work with the business community, from the very, very
smallest to the very largest. I would like you to give us some
thoughts about the community and its support for what is
happening here and the potential support for a new facility.
STATEMENT OF DAVID G. BROWN, PRESIDENT AND CHIEF
EXECUTIVE OFFICER, GREATER OMAHA CHAMBER OF
COMMERCE
Mr. Brown. Thank you, Senator. I appreciate the opportunity
to be here today. We just left a gathering of 750 of your
closest friends as they were pulling off in Nebraska with our
Legislator's Day down at the Air and Space Museum, and one of
the key issues being discussed was health care reform. I think
each of the delegations spoke to it in some form or fashion
during the day, and then our keynote speaker at lunch, the U.S.
Chamber President, Tom Donohue, focused on health care reform
and really the state of health care in our country, which was
certainly timely as we talk about the VA facilities that we are
sitting in today and the potential for growing those facilities
into something we can all be more proud of in the future.
I contend that the local community that supports this
facility needs to be as robust as we anticipate the new
facility to be. We want the community to be able to grow. We
want the community to be able to support this facility with
additional partnerships and facilities and resources over time.
So, I have been asked, I think, to touch a bit on the
economy and whether or not we are in a position as a community
to support not only a new facility, but how do we enhance that
facility's success in time.
Omaha has been highlighted over and over and over again as
this significant marvel in today's economic times. The Governor
likes to call us the happiest State in the Nation. That is from
a fiscal sense, of course, and I think he has good reason to
be. We have the second-lowest unemployment rate in the country
as a State and we are among the lowest four or five communities
in the country when it comes to unemployment rate. We continue
to be ranked in the top ten in virtually every rank you can
find as a place to do business, as a place to start over, as a
place to retire, as a place to get medical care, and the list
goes on and on. The number of times that we have been ranked as
really kind of a unique island in this country when the economy
is tanking in so many places suggests we have found a way to be
very resilient.
We are not isolated from what is going on in the rest of
the country and the rest of the world. But because of our
structure, we are much more insulated from it. We have a very
diverse economy here. The military presence here is one of our
largest employers, numbering somewhere in the range of 12,000
people, either directly employed by the military or the VA, or
companies that support the military here. That is about a $4
billion a year impact on our State economy. That is $4 billion.
It is such a dominant industry that we need to make sure we are
paying attention to all the resources that we have here,
whether it be in the base or the VA.
We believe that the kinds of companies that we have here
and the economic structure we have here lend ourselves to a
much healthier economic outlook in the future than many cities
of our size can perceive. Four Fortune 500 companies are
headquartered here. Many other corporate headquarters are
here--like Mutual of Omaha, Ameritrade--companies that people
just don't think about when they think about the Midwest or
Omaha. But the fact of the matter is, they are all here and
they are all growing and they continue to commit to new job
growth.
Over the past 5 years, we have seen more than 15,000 new
jobs being created in this region. The Chamber alone, through
our projects, has dealt with almost 200 projects which totals
about
$2.6 billion in capital investment. That is just part of the
$11 billion in capital investment that has happened in this
region in the last 5 or 6 years; and there is really no reason
to think that it can't continue.
I think, frankly, that is an attribute to why we ought to
be thinking about a reinvestment in a VA facility. We do
partnerships here like nobody else does. That $11 billion in
capital investment was followed by about $2 billion in private
contributions to make those facilities happen and secure and
endow over the long term. We anticipate the same level of
support for this kind of facility.
The partnerships that they have already talked about here
with Creighton University and with University of Nebraska
Medical Center, frankly, are sort of expected. It didn't
surprise me at all the two gentlemen were up here saying we do
things together, because that is the way we do things here in
Omaha. The collection of those three entities working together
should make this facility even more successful in the future.
So, while this is sort of a no-brainer when you sit down
and ask, do we really need this here. What we have heard about
the facility already clearly says that from a physical plant
perspective, we have wrung just about every ounce of efficiency
and success out of this facility we can in the short term and
it is time for us to be thinking about something new so that we
can be even better at providing our veterans the services that
they need.
[The prepared statement of Mr. Brown follows:]
Prepared Statement of David G. Brown, President and CEO,
Greater Omaha Chamber of Commerce
Good afternoon, I'm David G. Brown, president and CEO of the
Greater Omaha Chamber. The Chamber is proud that the VA Nebraska-
Western Iowa Hospital is one of the top 10 VA hospitals in the country.
It is a leader in the ``ambient experience for patients'' and in
``state-of-the-art'' technology. Even with these positive attributes,
significant capital improvements are essential to maintaining the high
quality health care currently being delivered by the hospital.
We are proud to say that the Greater Omaha community continues to
support the VA Hospital--it is another example of the public-private
partnerships that are typical of the Greater Omaha community.
greater omaha's economy
Greater Omaha is an excellent city in which to do business. Omaha
is ranked #10 by the Brookings institute among ``America's Most
Recession-Resistant Cites'' and among the top 25 ``Best Places to Live
and Launch a Business'' by Forbes Small Business. In fact, this
favorable climate extends throughout the state of Nebraska, where
according to the Miliken Institute, the cost of doing business is 18
percent lower than the national average.
Omaha is home to four Fortune 500 Headquarters: Berkshire Hathaway;
Union Pacific; ConAgra Foods; Peter Kiewit and Sons. (Mutual of Omaha
is close at 525.)
Greater Omaha is also home to a broad range of corporate
headquarters. Companies from all industry sectors find Omaha an
excellent place to conduct business--Mutual of Omaha, Werner, TD
AMERITRADE, HDR, Inc., infoGROUP, Omaha Steaks and Valmont, to name
just a few.
Also, Greater Omaha is fortunate to maintain numerous large
employers, the top being Offutt Air Force Base in Bellevue, which
employs approximately 12,000 military and civilian workers; Second is
The Nebraska Medical Center, with approximately 8,350 employees. Major
private employers include Alegent Health, First Data, First National
Bank, ConAgra Foods, Union Pacific, Mutual of Omaha and PayPal. Major
employers are committed to community investment and growth. The
diversified economy is not reliant on any one industry. Greater Omaha's
economy benefits from solid population and labor force growth with a
relatively diverse industry mix.
The eight counties of Greater Omaha have a labor force totaling
more than 456,000, of which approximately 440,000 are employed. Since
1990, the area has added over 84,000 people to its labor force.
Greater Omaha has a higher concentration of its employment in
financial activities (Omaha--8.5 percent vs. U.S.--5.9 percent); trade,
transportation and utilities (21.3 percent vs. 19.2 percent);
information (2.6 percent vs. 2.2 percent) than the U.S.
It is worth mentioning that our financial sector has held up well
compared to the national level and, despite the turmoil in the
financial markets set in motion last year, employment in Omaha's
financial sector remains essentially unchanged. The high concentration
of insurance carriers helps to provide stability to our local economy.
There are also more than two dozen insurance companies domiciled in
Greater Omaha.
The strength of Greater Omaha's economy can also be seen in its
unemployment rate, which is consistently lower than the national
unemployment rate. (5.2% in June compared to 9.5% for the Nation in
June.)
Forbes magazine ranked Omaha eighth among the ``Best Cities for
Jobs in 2008'' and Nebraska as the 10th most favorable state for
business.
Kiplinger's Personal Finance ranked Omaha third among the ``Top 10
Best Cities in 2008.''
Greater Omaha has a history of strong business-government
partnerships in area development projects. In the past decade, this
cooperative redevelopment has resulted in more than $11 billion in new
investment metro-wide with $2 billion in downtown alone.
va impact on the economy
Currently, the annual economic impact of the operations of the VA
hospital is significant--contributing $68.5 million to the regional
economy (direct, indirect and induced). Employment at the hospital
supports an additional 545 jobs in our local labor market. From an
economic development standpoint, and considering the capital
improvements under discussion, this investment has the potential for
expanding services and the creation of additional jobs for Greater
Omaha. The medical sector has been, and will continue to be, an
extremely important contributor to the economic growth in our
community. Investment that results in jobs--especially jobs at this
level--helps keep our economy stable.
Omaha is one of the few communities in the US that has two
university medical research facilities and the Chamber often uses this
fact when recruiting businesses and people to Greater Omaha.
The VA Hospital also plays a major role in medical research in our
community through partnership affiliations with UNMC and Creighton
Medical Center essence, creating a third medical research facility in
Omaha.
This research impacts the wider medical community in ways we often
don't consider such as:
The VA provides employment opportunities for students in
residency from the two medical schools.
Keeping these skilled physicians in our community for
residency training is a huge benefit for our community and our local
economy.
Ultimately the goal is, keep many of these physicians
employed in Omaha full time.
impact on the community
The VA hospital provides specialty care to veterans in our
community. The VA plays an important role in rural health in our
region. The VA continues to incorporate leading-edge technology in
their specialty care programs.
VA performs an important role in taking care of 1 out of 3 vets in
the area--alleviating pressure/case load on other hospitals and medical
facilities. Enhancement of the existing facility is essential in
ensuring continued, on-going ``state-of-the-art'' care for veterans.
involvement with business community
As our guard and reserve personnel return from war zones, the VA
plays an important role in the re-assimilation into society and
returning them to being productive contributors in the community.
VA is an important resource to the business community in learning
how to assist the returning employees
In fact, this is an area that the Chamber intends to be more
involved in--(our role is to provide our members with the services they
need and this is an area we are considering; David--they asked us
yesterday if we could add ways to help businesses in this area--
reminded me of the personal conversation you had with a returning
National Guardsman).
conclusion
On behalf of the Greater Omaha Chamber, I ask for your careful
consideration of the request before you.
Thank you for your time.
Senator Johanns. Hopefully, there will be a day where we
are out there digging ground and the construction has started.
David, talk just briefly about the capacity of the community--
the surrounding area, for that matter--to meet the construction
needs of something this complicated. I mean, building a
hospital of this size is no easy undertaking.
Mr. Brown. You know, I would say in a lot of cities, you
might be able to make that statement. But if you look at the
companies that make their living designing hospitals and
medical facilities and building hospitals and medical
facilities, several of them are located right here in Omaha,
Nebraska. We have at least one of the largest construction
companies in the world is located here, Peter Kiewit and Sons;
and several of the largest design firms that specialize in
hospitals, both Leo Daly and HTR. There is no doubt in my mind
that we have not only the technical capacity to construct-
design something and then build it on time and on or under
budget, but we have the people here that can do that work, as
well.
Drive around town today and see how many sky cranes are
still operating, how many buildings are currently under
construction, and you can see that even in a time like this, we
can handle--we can put forward a lot of projects. We didn't
slow down when the economy was booming, either. Construction
happened here and we can certainly handle another project of
this magnitude.
Senator Johanns. Great. Amanda, the pressure is really on
you----
[Laughter.]
Senator Johanns [continuing]. Because there are many, many
veterans groups who stand by their veterans, and you are one of
them. I would be very, very interested in hearing the
perspective of some of the good people that you work with and
how they feel about how things are going here and what their
hopes and dreams for the future are.
STATEMENT OF AMANDA VAZQUEZ, GOVERNMENT RELATIONS DIRECTOR,
GREAT PLAINS CHAPTER, PARALYZED VETERANS OF AMERICA
Ms. Vazquez. OK. Thank you, Senator. On behalf of Great
Plains Paralyzed Veterans of America, I would like to thank you
for the opportunity to present our views to you today on the VA
facility in Omaha.
The VA Nebraska-Western Iowa Health Care System, while it
has improved immensely over the last 25 years, needs to be
examined and enhanced. We believe that there are options that
would improve the functionality of the Omaha VA and improve
overall quality of care for our veterans.
PVA would like to focus our discussion on the need for a
new VA facility that would address two very important issues
that our members face when visiting the current facility: the
need for increased parking; and for Spinal Cord Injury, or SCI,
services to be available in Omaha. We would like to impress
upon you the importance of addressing these challenges in order
to improve the care that Nebraska veterans receive.
Among our membership, parking has been identified as the
number 1 challenge with the Omaha VA. One of our members
commented, ``You have to get there 2 hours early for an
appointment just to find a parking space.'' Another member
commented that ``it is like a kamikaze run.''
All of our members are qualified to park in handicapped
parking spaces. However, these spaces are rarely unoccupied.
Most of our members use wheelchairs and drive vans with ramps.
Therefore, they require the van-accessible spaces which allow
for the ramp to be lowered into an access aisle. There are even
fewer van-accessible spaces than handicapped parking spaces,
making it virtually impossible for our members to utilize these
spaces when they visit the VA. If they park their van in a
regular parking space, there is no room for the ramp to unfold,
leaving no way for the individual to exit the van.
This leaves only two options: A, drive around for hours
waiting for a van-accessible space to open up; or B, have
someone drop the veteran off at the front of the hospital and
then park the van in a regular space. Option A is less than
ideal, since there is no way of knowing when someone will
return to their van to leave a parking space available. This
option is completely unreliable and could potentially cause the
veteran to miss his or her appointment. Option B is only an
option if the person needing the use of the ramp is not
driving, making it possible for the driver to drop them off and
park the vehicle. Many of our members are very independent and
drive themselves to appointments and anywhere else they may
need to go. Thus, this forces the veteran to rely on someone
else to take the time to transport them to and from their
appointment.
The second challenge I would like to bring to your
attention is space limitations that affect care for spinal cord
injured patients. Veterans with spinal cord injuries require
specialized care from the VA that should come from doctors and
nurses who have been trained specifically in SCI. It is
extremely important that SCI veterans meet with these doctors
and nurses to ensure that they receive the best care possible.
That being said, the only SCI clinic and doctor in Nebraska
are located 50-plus miles away from the main acute care
hospital in Omaha. With the majority of the veteran population
in Nebraska living within a 50-mile radius of Omaha, it does
not make sense to have this clinic based out of Lincoln.
Dr. Judge, who runs the SCI clinic in Lincoln, has tried
for years without avail to get approval to come to Omaha. He
has not been successful because there is not any available
space in Omaha to hold such a clinic. This situation puts
extreme limitations and hardships on PVA members. Therefore,
they have simply stopped making the trip. Our members are then
forced to meet with doctors and nurses who are untrained in SCI
and do not understand their specific disabilities. This can
cause misdiagnosis of certain conditions and could potentially
be life-threatening.
One member, Randy Squier, said he had never even heard of
the SCI clinic in Lincoln. Randy said, ``I don't know that the
Omaha VA staff fully understand SCI. Every time I go, I have to
tell them my story all over again.'' One staff person couldn't
believe Randy couldn't move his arms because his chart had him
classified as a quadriplegic. This lack of knowledge by
untrained staff that are treating SCI patients is deeply
concerning and does not measure up to the quality of care that
should be given in any VA hospital, let alone in Nebraska.
None of the staff in Omaha has attended any SCI training,
according to our National Service Officer, John Gogan. He says
that staff may have SCI assigned as their specialty area, but
it may be their third or fourth priority. When asked about the
nurses and doctors in Omaha relating to SCI, PVA member Tamara
Lawter said, ``They don't know anything about SCI. One nurse
actually said to me, `Oh, my God, that is gross,' '' when Ms.
Lawter was explaining a method of care related to her injury.
Many of these concerns could have been eliminated if there
were space for an SCI clinic to be housed in Omaha. Having
trained medical professionals to treat SCI patients is
essential in providing a higher standard of care, which the VA
prides itself on. These concerns must be addressed.
We believe part of the answer is a new facility. If space
becomes available in Omaha for the SCI clinic to be relocated
and for adequate parking, Omaha will then have the ability to
employ trained skilled nurses and doctors to care for SCI
patients and veterans will have a more positive experience at
VA.
Senator Johanns, Great Plains PVA would like to thank the
Committee for looking into this situation. We all agree that VA
is the best source of care for our Nation's veterans,
especially when it comes to specialized care, such as SCI. We
look forward to working with the Committee to address these
challenges and hope that we can find a much-needed solution.
I would be happy to answer any questions.
[The prepared statement of Ms. Vazquez follows:]
Prepared Statement of Amanda Vazquez, Government Relations Director,
Great Plains Chapter, Paralyzed Veterans of America
Senator Johanns, on behalf of Great Plains Paralyzed Veterans of
America, I would like to thank you for the opportunity to present our
views today on the VA facility in Omaha. We appreciate the effort of
this Committee to look into the situation in Omaha to see whether the
current hospital is sufficient to meet the needs of Nebraska's
veterans. The VA Nebraska-Western Iowa Health Care System, while it has
improved immensely over the last 25 years, needs to be examined and
enhanced related to available space for an SCI Clinic and parking. We
believe that there are options that would improve the functionality of
the Omaha VA and improve overall quality of care for our veterans.
PVA would like to focus much of our discussion on the issues that
our members face when visiting the VA facility in Omaha, and how these
issues affect their overall care. We will then outline the SCI services
that are provided at the Lincoln and Grand Island locations that would
be better implemented from Omaha. We would like to impress upon you the
importance of addressing these challenges in order to improve the care
that Nebraska veterans receive.
identifying challenges with the facility
Among our membership, parking has been identified as the number one
problem with the Omaha VA. One of our PVA members commented, ``you have
to get there two hours early [for an appointment] just to find a
parking space.'' Another member commented ``it's like a kamikaze run''
because you become so desperate to find an available parking space, you
are willing to risk collision and even hitting people who are walking
to and from their vehicles. Veterans do not want to, and often cannot,
spend their day driving around a parking lot to try to find an
available space, especially when they have had to wait a week or more
to get their appointment. Veterans know that a missed appointment could
result in another lengthy wait before their doctor would be able to see
them again. Going to a doctor's appointment should not be an all-day
event, especially if the individual is only actually in the hospital
for a couple of hours. You and I would never stand for that if we were
visiting our doctor's office. There is no reason why this should be an
acceptable practice for our veterans.
Further, handicapped parking is an even greater challenge. All of
our members are qualified to park in handicapped parking spaces;
however, these spaces are rarely unoccupied and so veterans must
venture out into the main parking lot where spaces are extremely tight.
Most of our members use wheelchairs and drive vans with ramps.
Therefore, they require the van accessible spaces which allow for the
ramp to be lowered into an access aisle. There are even fewer van
accessible spaces than handicapped parking spaces, making it virtually
impossible for our members to utilize these spaces when they visit the
VA. If they park their van in a ``regular'' parking space, there is no
room for the ramp to unfold, leaving no way for the individual to exit
the van. This leaves only two options:
a. Drive around for hours waiting for a van accessible space to
open up
b. Have someone drop the veteran off at the front of the hospital
and then park the van in a regular parking space.
Option a is less than ideal since there is no way of knowing when
someone will return to their van to leave the parking lot and free up
the van accessible space. This option is completely unreliable and
could potentially cause the veteran to miss his/her appointment. Option
b is only an option if the person needing the use of the ramp is not
driving, making it possible for the driver to drop them off and park
the vehicle. Many of our members are very independent, and drive
themselves to appointments and anywhere else they may need to go; thus,
forcing the veteran to rely on someone else to take the time to
transport them to and from their appointment.
Since the Omaha VA is situated on uneven ground, there is a very
steep hill leading up to the hospital from the main parking lot. If PVA
members, or any other individual who uses a wheelchair, is forced to
park in this lot, they are then also forced to climb this steep hill to
get to the hospital. This hill is often referred to as ``the death
hill'' by many veterans, because of the incredible slope and the amount
of endurance and strength it takes for a person in a wheelchair to push
up the hill. It becomes even more of a challenge in the winter months
when there is ice and snow on the ground and the extreme cold air is
inhaled. Many of our members and other disabled veterans are of the
older generations, and do not have the physical capacity to climb this
hill without risking their health and safety.
delivery of care for sci/d patients
Veterans with Spinal Cord Injuries (SCI) require specialized care
from the VA that should come from doctors and nurses who have been
trained specifically in SCI. It is extremely important that SCI
veterans meet with these doctors and nurses to ensure that they receive
the best care possible. That being said, the VA in Nebraska has an SCI
Primary Care Team which is located in Lincoln where the SCI Clinic is
held. Therefore, the only SCI doctor in Nebraska is located 50+ miles
away from the main acute care hospital. With the majority of the
veteran population in Nebraska living within a 50 mile radius of Omaha,
it does not make sense to have this clinic based out of the Lincoln.
To my knowledge, Dr. Judge, who runs the SCI clinic in Lincoln, has
tried for years without avail to schedule a couple days a month to come
up to Omaha to meet with patients. He has not been successful because
there is not any available space in Omaha to hold such a clinic, even
for a day or two a month. This situation puts extreme limitations and
hardships on PVA members, and has caused them to stop utilizing the SCI
Clinic. It becomes very difficult for many of our members to travel to
and from Lincoln to meet with the medical staff at the Clinic;
therefore, they have simply stopped making the trip. Since Dr. Judge
has not been approved to travel to Omaha to meet with patients, our
members are forced to meet with doctors and nurses who are untrained in
SCI and do not understand their specific disabilities. This can cause
misdiagnosis of certain conditions, and could potentially be life-
threatening.
One PVA member, Randy Squier of Glenwood, Iowa, said he had never
even heard of an SCI Clinic in Lincoln. No one has ever told him about
the SCI Clinic, or even talked to him about visiting a nearby SCI
Center. He said, ``I don't know what I'm missing out on.'' In response
to whether or not the staff in Omaha (where he goes for a yearly
checkup) understands his situation, Randy said, ``I don't know that
they fully understand SCI. Every time I go, I have to tell them my
story all over again because it's always a different person.'' One
staff person couldn't believe Randy could move his arms because his
chart had him classified as a quadriplegic. This lack of knowledge by
staff that are treating SCI patients is deeply concerning and does not
measure up to the quality of care that should be given in any VA
hospital, let alone Nebraska.
The SCI Clinic doctor and nurse travel quarterly from Lincoln to
Grand Island to meet with patients for a day. PVA member, Tamara Lawter
from Kearney, expressed that the ``SCI Clinic should be in Omaha'' with
the other clinics, since it is the main VA facility in the state. With
the majority of veterans living in and around Omaha, it only makes
sense to have this specialized clinic in Omaha as well. Ed Keuter,
another PVA member who lives in Omaha, said ``I think it would be a
great thing for Omaha to have it'' because many veterans are unable to
use the Clinic since it is based in Lincoln. Mr. Keuter is one of these
veterans. He used to travel to Lincoln to see Dr. Judge; however, he is
no longer able to make that trip. He now uses the VA's community or
home-based care. Mr. Keuter spoke very highly of this new program
because it allows for a nurse to visit him in his house. He and his
wife are extremely happy with this option as it alleviates the hardship
of driving to the SCI Clinic. However, the nurses who visit him are not
as knowledgeable in SCI because they have never been trained in that
area.
None of the staff in Omaha has attended any SCI training, according
to our National Service Officer, John Gogan. He says the staff may have
SCI assigned as their specialty area, but it may be their 3rd or 4th
priority. When asked if he thought he would be well-cared for at the
Omaha hospital should he have to be admitted, Mr. Keuter said ``it
would make [him] nervous'' to rely on the staff in Omaha to handle his
care. He does not think the staff could adequately care for his
specific needs relating to SCI because they have never had any formal
training. When asked about the nurses and doctors in Omaha relating to
SCI, Ms. Lawter said ``They're horrible. They don't know anything about
SCI. One nurse actually said to me `Oh my god that's gross''' when Ms.
Lawter was explaining a method of care related to her injury. According
to Mr. Gogan, if a SCI patient is admitted at the Omaha hospital, the
medical staff is resistant to calling Dr. Judge to see the patient.
There seems to be a certain arrogance about these doctors that they
feel they know how to handle SCI patients regardless of the fact that
they have never been through SCI training.
Many of the concerns that I have outlined for you today could have
been eliminated if there were space for a SCI Clinic to be housed in
Omaha. Having trained medical professionals to treat spinal cord
injured patients is essential in providing a higher standard of care,
which the VA prides itself on. These concerns must be addressed. The
level of care that many of our members are receiving is unacceptable.
We believe part of the answer could be a new facility. If space becomes
available in Omaha for the SCI Clinic to be relocated, Omaha will then
have the ability to employ trained, skilled nurses and doctors to care
for SCI patients. However, Omaha must increase the number of staff who
are trained in SCI to ensure that all SCI patients are cared for by
knowledgeable, trained staff who can handle and best diagnose their
unique situations.
Senator Johanns, Great Plains PVA would like to thank the Committee
for looking into the situation with the Omaha VA. We all agree that the
VA is the best source of care for our Nation's veterans, especially
when it comes to specialized services such as SCI. We look forward to
working with the Committee to address these challenges and hope we can
find a much needed solution. I would be happy to answer any questions
that you might have.
Senator Johanns. Amanda, that was great. This is why we do
these hearings. I must admit, I did not realize that that was
an issue facing paralyzed veterans, and that is exactly why you
are here, to flesh that out for us.
Here is what I am going to suggest, because your testimony
was so good, I really don't have anything I want to ask you,
but I know that there will be a process looking at what the
facility is to do once it is built. I am confident in saying
that and I am going to be very insistent that you and Paralyzed
Veterans are heard on that, although I don't think I have to
insist on that at all. I am confident the folks here will take
your views and the views of all veterans into account in trying
to decide how this facility can serve the veterans of today and
in the future.
My observation, which I am guessing is true, is that
because of the remarkable care that is provided literally at
the battlefield, if you will, or at the scene of the injury,
veterans are coming home with more significant injuries than
maybe we have ever seen before and living; and in many cases
living lives where they are doing things, but they need medical
care maybe different than what was needed 20, 30, 40 years ago.
So, we have to make sure we are not just focused on today, that
we are focused on what those needs are going to be for your
members as they age, because they will. We all do. So, we will
make sure that veterans are part of that process.
Ms. Vazquez. Thank you. I appreciate that.
Senator Johanns. Thank you for being here.
I am going to do exactly what I did with the last panel. I
am going to ask each of you if there something that as you were
thinking about your testimony today that you were hoping I
would ask you that I have not asked, or was there a point that
you wanted to make that has just come to mind since you
testified.
Dr. Zetterman, I will start on your side of the table and
we will just make our way down through the panel.
Dr. Zetterman. Thank you very much, Senator Johanns. I
guess what I would reiterate more than anything else is the
important mutual benefit of both medical schools and the
Nebraska-Western Iowa VA Health Care System, as well as to our
other health science schools. That mutual benefit arrangement
is crucial, I think, to both of our futures. Thank you.
Senator Johanns. Great.
Amanda, anything to add to your testimony?
Ms. Vazquez. I would just say that PVA is open to any
suggestions, any ideas that the VA is looking at as far as
expanding or relocating, and we would be more than willing to
be a part of that process. In fact, we would like to be a part
of that process to make sure that all veterans receive the care
that they need.
Senator Johanns. Great. Outstanding.
Dr. Maurer. I would like to say two things. One is I think
all of our interests are to do the best we can in health care
for the veterans. Whatever that is, that is what it is going to
be. That is what it should be.
And second, what I would like to say is that the
educational component of the VA is irreplaceable. It is
extremely important for each of our programs.
Senator Johanns. You know, likewise to what I expressed to
Amanda. I definitely want the medical schools to be engaged in
whatever occurs in terms of a planning process because I just
think you are such a great resource. Although I am sure there
is some healthy competition, my experience as the Governor was
there was a healthy desire to work together to improve medical
circumstances and health care in our State, and in this region,
for that matter. You all serve a bigger area than just the
State. So, I am going to want to be very insistent about you
being a part of that and where this goes from here, because I
think you are a great asset.
David, I think you might be close to getting the last word,
at least from the witnesses' standpoint.
Mr. Brown. How unusual. [Laughter.]
Senator, the only thing I might add is that the current VA
already has a significant economic impact on this region. It is
estimated to be about $68.5 million a year, with 550 direct
jobs. So as an economic development practitioner, a facility
like this is really a rare opportunity to keep a strong part of
our economy even stronger and to provide a valuable service. So
thank you for your leadership on this.
Senator Johanns. Glad to do it.
Ladies and gentlemen, we have now been here just about 2
hours. We have had two great panels. I want to express my
appreciation for your attendance, your being a part of this. It
is so very important, and it is so important that we get this
right. We are going to have a generational chance to do just
that. This doesn't come around every few years. The facility
that is going to rise from the ground is something that will
probably be around another 50 or 60 years, or who knows how
long. So, we want to make sure that it is right, not only in
terms of the structure and the mechanics and the size of the
operating rooms in all of that, but that it is right for the
veterans, and that really is the bottom line.
That is why I am so thankful that I ended up on the
Veterans' Affairs Committee. I just think we can do some really
great things here. I love the partnership I am seeing.
So my last words today, really in closing the hearing, are
to say thank you to the veterans and their families. They have
been very, very patient as we have worked our way through this
process. We are going to have to call on their patience some
more. Even with a good start here, this doesn't happen
overnight.
Ideally, we are going to get in the budget pretty quickly
here. My hope is right away, as a matter of fact. That will get
this off and going. But even at that, you don't build a
hospital overnight. Even if we get through the budget process,
there are still a number of years ahead of us.
My role on the Veterans Committee will hopefully give me
the ability to oversee this and make sure all of the right
people are at the right tables at the right time, which I will
do everything I can to make that happen.
I am going to hold the record open here for a week, so if
there is something that you think of or if there is somebody
here today that really wants me to hear about something, I hope
you will send us a letter in care of the Veterans' Affairs
Committee.
I am going to also insert as a part of the record the study
that was done. We have got the photographs as a part of the
record.
[The study is held in Committee files.]
Senator Johanns. Anyone who had written testimony, if you
would, leave a copy of that with staff.
If you have any questions, I introduced everybody behind
me, both from Veterans Affairs and from the staff, don't
hesitate to pull them aside, offer your comments, questions,
contact information, whatever it is we can do to help.
I do want to thank those who have given up their personal
time, who have traveled from a distance to be here with us
today. I do appreciate that immensely and I just so appreciate
the work that is being done here, like I said, from the person
who runs the facility to the person who is making sure that the
air handling is working and everybody here. Thank you. I can't
tell you how appreciative we are for your care and commitment
of these great individuals who have served our Nation.
Thank you all, and with that, we will gavel it closed.
[Applause.]
[Whereupon, at 2:52 p.m., the Committee was adjourned.]