[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/
                                 senate




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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.]
      

                                  
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