[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]




 
               FAILURES AT MIAMI VETERANS AFFAIRS MEDICAL
                  CENTER: WINDOW TO A NATIONAL PROBLEM

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

                                HEARING

                               before the

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

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

                            OCTOBER 12, 2011

                               __________

                           Serial No. 112-31

                               __________

       Printed for the use of the Committee on Veterans' Affairs




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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

CLIFF STEARNS, Florida               BOB FILNER, California, Ranking
DOUG LAMBORN, Colorado               CORRINE BROWN, Florida
GUS M. BILIRAKIS, Florida            SILVESTRE REYES, Texas
DAVID P. ROE, Tennessee              MICHAEL H. MICHAUD, Maine
MARLIN A. STUTZMAN, Indiana          LINDA T. SANCHEZ, California
BILL FLORES, Texas                   BRUCE L. BRALEY, Iowa
BILL JOHNSON, Ohio                   JERRY McNERNEY, California
JEFF DENHAM, California              JOE DONNELLY, Indiana
JON RUNYAN, New Jersey               TIMOTHY J. WALZ, Minnesota
DAN BENISHEK, Michigan               JOHN BARROW, Georgia
ANN MARIE BUERKLE, New York          RUSS CARNAHAN, Missouri
TIM HUELSKAMP, Kansas
MARK E. AMODEI, Nevada
ROBERT L. TURNER, New York

            Helen W. Tolar, Staff Director and Chief Counsel

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


                            C O N T E N T S

                               __________

                            October 12, 2011

                                                                   Page
Failures at Miami Veterans Affairs Medical Center: Window to a 
  National Problem...............................................     1

                           OPENING STATEMENTS

Chairman Jeff Miller.............................................     2
    Prepared statement of Chairman Miller........................    51
Hon. Robert L. Turner............................................     1
Hon. Mark E. Amodei..............................................     2
Hon. Joe Donnelly................................................     4
Hon. Ileana Ros-Lehtinen, prepared statement only................    52

                               WITNESSES

William Schoenhard, FACHE, Deputy Under Secretary for Health for 
  Operations and Management, Veterans Health Administration, U.S. 
  Department of Veterans Affairs.................................     5
    Prepared statement of Mr. Schoenhard.........................    53

Accompanied by:

  Nevin M. Weaver, FACHE, Network Director, Veterans Affairs 
    Sunshine Health Care Network/Veterans Integrated Services 
    Network 8, Veterans Health Administration, U.S. Department of 
    Veterans Affairs.............................................     5
  Mary D. Berrocal, MBA, Director, Miami Veterans Affairs Health 
    Care System, Veterans Health Administration, U.S. Department 
    of Veterans Affairs..........................................     5

                   MATERIAL SUBMITTED FOR THE RECORD

Prepared Statement of Hon. Bob Filner, Ranking Democratic Member.    57
Prepared Statement of Hon. Russ Carnahan, Democratic Member......    57

Post-Hearing Questions and Responses for the Record:

  Letter from Hon. Bob Filner to Hon. Eric K. Shinseki...........    57
  Post Hearing Questions from Hon. Bob Filner for Deputy Under 
    Secretary Schoenhard.........................................    59
  Post Hearing Questions from Hon. Bob Filner for VISN 8 
    Director, Nevin Weaver.......................................    61
  Post Hearing Questions from Hon. Bob Filner for Miami VAMC 
    Director, Mary Berrocal......................................    63
  Department of Veterans Affairs Final Responses to Hon. Filner's 
    Post Hearing Questions.......................................    59


                   FAILURES AT MIAMI VETERANS AFFAIRS
                      MEDICAL CENTER: WINDOW TO A
                            NATIONAL PROBLEM

                              ----------                              


                      WEDNESDAY, OCTOBER 12, 2011

                     U.S. House of Representatives,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:05 a.m., in 
Room 334, Cannon House Office Building, Hon. Jeff Miller 
[Chairman of the Committee] presiding.
    Present: Representatives Miller, Lamborn, Bilirakis, Roe, 
Stutzman, Flores, Johnson, Denham, Runyan, Benishek, Huelskamp, 
Amodei, Turner, McNerney, Donnelly, Walz, and Barrow.
    The Chairman. Good morning. I want to thank everybody for 
coming to the hearing this morning.
    We were going to do a business meeting first, we do not 
have the necessary requisite number of Members of the Committee 
in order to conduct the business, and one of our new members 
has got to leave to go to a markup in Homeland Security, but I 
would like to have an opportunity to welcome Bob Turner from 
the 9th District of New York where he has been a lifelong 
resident. Forty years in the television industry, leader in 
large and small businesses, and a veteran, and we welcome you 
to this Committee.
    And Mr. Turner, you are recognized for any remarks you may 
wish to make.
    [The prepared statement of Jeff Miller appears on p. 51.]

                OPENING STATEMENT OF MR. TURNER

    Mr. Turner. Thank you, Mr. Chairman.
    It is a delight to be here. I am very proud to serve on the 
Veterans' Committee as a veteran, lo those many years ago, but 
there is a lot I haven't forgotten and I will discharge these 
responsibilities with enthusiasm.
    And thank you, I yield.
    The Chairman. Thank you, Mr. Turner.
    Mr. Donnelly.
    Mr. Donnelly. On behalf of all the Democratic members I 
want to welcome you to the Committee and thank you for your 
service to our country, we are in your debt for that and look 
forward to having you as part of the team here.
    The Chairman. We have another new member, or will, once we 
do hold our business meeting, but Mark Amodei, who is from the 
2nd District of Nevada, which actually covers most of the 
entire state, but he is also a veteran, a Jag officer in the 
United States Army. He was a state senator in Nevada before he 
came here in a special election, so without question we welcome 
another veteran to this Committee.
    And I would yield to Mr. Donnelly also.
    Mr. Donnelly. And we welcome you as well. I want to thank 
you for your service to the country, we are proud to have you 
here, and you will find this is a committee where people don't 
really even think about politics, it is how can we serve our 
veterans, and so we look forward to having you as a great part 
of the team.
    The Chairman. Mr. Amodei, do you have any comments you 
would like to make to the Committee? You are recognized.

                OPENING STATEMENT OF MR. AMODEI

    Mr. Amodei. Thank you, Mr. Chairman, and I will follow in 
the lead of my co-classmate from New York, I would just say 
that I am actually proudest of being the father of a Gulf War 
veteran, my daughter who served in the Navy for 4 years, so 
look forward to working with everybody on the Committee, and I 
yield back. Thank you, Mr. Chairman.
    The Chairman. Thank you very much. And at a time when we 
have enough members we will go ahead and make the assignments 
to your committees. We understand that people are having to go 
in and out. We do appreciate you being here this morning.
    I would like to go ahead and ask the witnesses if they 
would go ahead and come forward to the table.
    Because of some of the detail that we are going to be 
covering in this hearing today I gave great thought, thought 
long and hard about deviating from a standard practice of this 
Committee, and that was requiring that you be sworn in as 
witnesses. I do not think that is going to be necessary this 
morning. I trust that each of you would and will provide 
nothing but truthful and complete answers to us.
    That being said, we are going to be listening, and I 
reserve the right to swear you in at any time in the 
deliberations this morning. Is everybody clear?

              OPENING STATEMENT OF CHAIRMAN MILLER

    Some of the issues plaguing the VA Medical Center in Miami 
are not new to this Committee.
    Members of the Miami delegation, including the chairman of 
the House of Foreign Affairs Committee, Ms. Ros-Lehtinen, have 
been talking with me on a regular basis about the medical 
center in Miami, but it came into the spotlight in 2009 when it 
was discovered and reported that endoscopes were not being 
reprocessed correctly, placing over two thousand veterans at 
risk of exposure to disease.
    Nearly 2 years later, after the initial round of 
notifications, 12 additional veterans have been identified as 
being at risk of exposure, and I think all of us would agree 
that putting any veteran at risk is not acceptable, but failure 
to identify and notify everybody at risk because patient 
logbooks were locked away in a safe is almost impossible to 
believe. I only say nearly impossible because that is in fact 
what occurred.
    The issues we are going to discuss today extend well beyond 
sterilizing reusable medical equipment. At the heart of this 
issue is leadership at VA at all levels and in all parts of 
this great country.
    It is my belief that the failures in leadership and patient 
safety that were brought to light in 2009 are still occurring 
today.
    Multiple investigations have taken place, disciplinary 
recommendations have been put forth, new processes and 
procedures developed, new policies established, yet problems 
still exist and have not been fixed.
    Earlier this year VA told this Committee in a briefing that 
things were running smoothly in Miami; however, the VA 
Inspector General released a report in August detailing how in 
one case 50 percent of the facility employees still failed to 
properly sterilize reusable equipment.
    Recent news reports are also troubling. For example, This 
summer we read about an Air Force veteran was brought to the 
Miami Medical Center from a neighboring hospital, Jackson 
Memorial. The veteran had been admitted to the hospital earlier 
by a friend after threatening suicide. Once it was realized 
that she was a veteran she was transferred to the Miami VA 
Medical Center. The veteran then escaped and committed suicide 
by cop just one day after she had been admitted to a system 
that should have protected her in her clearly fragile state of 
mind.
    In another troubling story released last month the Miami 
Herald reported on its findings contained within one of several 
administrative investigation boards. This board was conducted 
in the wake of the colonoscopy equipment cleaning problems and 
subsequent notification of veterans. And as the Herald noted, 
disciplinary action was recommended for a lack of oversight by 
hospital leadership.
    The article also noted that the hospital's director, who 
was reinstated less than 2 months after the report's 
recommendations were completed, and that VA declined to comment 
on what actions were taken based on the recommendations.
    It is this Committee's desire that today's witnesses 
outline a clear process for VA's leaders in preventing and 
fixing failures that compromise the safety of veterans.
    The Committee also needs to hear about how a stricter and 
comprehensive process can be put into place so that necessary 
information flows to all levels at VA from the local level to 
the network level to central office.
    We know that currently there is much that goes unreported, 
and given the public, repeat offenses, a solution from VA is 
overdue.
    VA must also outline how compliance with department 
policies is enforced. If employees are circumventing patient 
safety procedures they have to be held accountable. If policies 
made by central office can easily be circumvented, then policy 
makers at VA must be held accountable, and meaningful, 
enforceable policies put forth.
    A related expectation by the Committee is that existing VA 
policies in place can and will be followed by all employees. If 
policies are disregarded or will fully ignored there should be 
enforcement mechanisms in place and the right people held 
accountable, otherwise policies become words on paper and 
little more.
    An important point to keep in mind throughout today's 
hearing and moving forward is that the problems we are 
discussing are not limited to Miami or even to VISN 8. The 
Committee is well aware of similar problems at medical centers 
all across this country.
    More than once VA has come before us and said problems at 
its facilities are fixed and all is well. More than once that 
has been shown not to be the case.
    The Miami facility is one glaring example of this national 
occurrence. Just as it should not be acceptable to Secretary 
Shinseki to be told one thing about how VA facilities are 
faring only to be subsequently told otherwise, it is beyond 
unacceptable for that to occur before this Congressional 
Oversight Committee.
    All of us must be vigilant in rooting out misleading or 
incomplete information that only serves to keep the truth from 
full view and ultimately harms those who all serve in a common 
mission, the veterans of this country.
    I appreciate everyone's attendance this morning, I now 
yield to the Ranking Member--a stand in, I like you--for an 
opening statement.
    [The prepared statement of Jeff Miller appears on p. 51.]

               OPENING STATEMENT OF MR. DONNELLY

    Mr. Donnelly. Thank you, Mr. Chairman, I like you too.
    Patient safety should always be the VA's top concern. Our 
veterans go to our hospitals because they are one of the best 
in this country. In obtaining optimal health care should not 
come at the cost of veterans health.
    Veterans trust their doctors, but what they might not trust 
is the system, and when they get the news that there has been a 
data breach and their personal information might have been 
stolen or the news that they are at risk of contracting 
diseases because staff did not properly sterilize reusable 
medical equipment veterans rightly lose trust and start to have 
concerns.
    Even when these or other incidents come the light we often 
find out that they could have been prevented if hospital 
administrative officials would have implemented proper guidance 
or enforced protocols to avoid significant breakdowns of 
patient safety.
    Many questions come to light with the many recent issues at 
the Miami VAMC, particularly the veteran suicide 2 months ago 
after that veteran was not held the mandatory 72-hour VA 
required evaluation period.
    Taxpayers are also curious to hear why this fault is 
running under a $30 million budget deficit.
    While the Committee has examined these issues in both the 
111th and 112th Congresses today we have the opportunity to 
hear from the hospital director who has witnessed this 
firsthand.
    I hope that we will be able to receive insight into the 
experiences at the Miami VA Medical Center with the delays that 
occurred in notifying individuals of contamination, what lead 
to these delays and the notification to 79 veterans, and what 
the Miami VAMC is doing to correct previous deficiencies and 
improve patient safety.
    Mr. Chairman, I look forward to this morning's testimony 
and I yield back the balance of my time.
    The Chairman. Thank you very much.
    Our first and only panel that we are going to hear 
testimony from today is William Schoenhard, Deputy Under 
Secretary for Health and Operations and Management in the 
Veterans Health Administration.
    In this position he is responsible for VA's 21 veterans 
integrated service networks, or VISNs, including their 
operation and their administration.
    Mr. Schoenhard is accompanied by Mr. Nevin Weaver, the 
director of VISN 8, which encompasses much of the part of 
Florida and parts of southern Georgia.
    Also accompanying Mr. Schoenhard is Ms. Mary Berrocal, 
director of the Miami VA Healthcare System within VISN 8.
    Mr. Schoenhard, your complete statement will be entered 
into the record as a part of this hearing and you are 
recognized for five memberships.

STATEMENT OF WILLIAM SCHOENHARD, FACHE, DEPUTY UNDER SECRETARY 
   FOR HEALTH FOR OPERATIONS AND MANAGEMENT, VETERANS HEALTH 
     ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS, 
   ACCOMPANIED BY NEVIN M. WEAVER, FACHE, NETWORK DIRECTOR, 
    VETERANS AFFAIRS SUNSHINE HEALTH CARE NETWORK/VETERANS 
INTEGRATED SERVICES NETWORK 8, VETERANS HEALTH ADMINISTRATION, 
  U.S. DEPARTMENT OF VETERANS AFFAIRS; MARY D. BERROCAL, MBA, 
 DIRECTOR, MIAMI VETERANS AFFAIRS HEALTHCARE SYSTEM, VETERANS 
   HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

                STATEMENT OF WILLIAM SCHOENHARD

    Mr. Schoenhard. Thank you, Mr. Chairman and Members of the 
Committee, good morning, and thank you for the opportunity to 
appear here to speak to care regarding the Bruce W. Carter VAMC 
in Miami, Florida.
    As Congressman Donnelly and the chairman emphasized, 
patient safety is our first priority, what is in the best 
interest of our patients in any hospital, certainly in a VA 
hospital is to provide a safe and effective treatment for all 
of our veterans, and as a veteran myself I take this 
responsibility very seriously.
    The written statement that we have submitted speaks to a 
lot of detail regarding the actions and events at Miami, and I 
would like in these few brief minutes to back away from that a 
little bit and speak from a national perspective regarding the 
issues that particularly the chairman rose.
    We really find in patient safety both in the private sector 
where I had 35 years of experience before coming to VA, as well 
as in the public sector, that there are three essential 
elements to providing safe patient care in a hospital.
    First is to do all we can do prevent harm. Second to 
develop a culture of safety, psychological safety where people 
can raise concerns. And finally to hold leaders accountable to 
ensure a safe environment.
    Let me just speak a little bit to each of those. First and 
foremost we have an obligation to do all we can on a continuous 
basis every day to prevent harm in our Nation's hospitals and 
particularly those that serve our veterans through systems, 
processes, training, equipment, all that we know in health care 
can be applied to ensure safe and consistent care, we have an 
obligation to do that.
    This is a job of continuous improvement. You will never 
hear me say we have arrived and the destination has arrived. 
This is a journey that requires continuous improvement as new 
technology, new process, new insight both from practice within 
VA as well as outside of VA are brought forward. That is why 
root cause analysis, RCAs of serious events, training our issue 
briefs, the development of administrative investigative boards 
to do fact finding when we have breakdowns in care are so 
important, and that is what we are obligated to do as first and 
foremost ensure that we provide preventative care and safe care 
to our patients.
    This has been facilitated in recent months by a realignment 
within the VACO, the VA Central Office organization where we 
now have in operations the SPD, or Sterile Processing 
Department, operation directly in our line, and I will speak to 
that a little bit more.
    The second major issue is a culture of safety, and I would 
suggest to you that culture trumps strategy in everything we 
do. By that I mean open lines of communication to ensure that 
people who come forward with concerns, suggestions for 
improvement, concerns about patient care are heard by 
leadership and that follow-up action is taken in a timely and 
vigorous manner.
    Also as has happened in recent months in our hospitals, to 
empower the staff to stop the line when it is necessary in the 
interest of care for our veterans. That is to say when we see 
something that doesn't look right to have the courage to stop 
the line and make sure before any veteran is put at risk that 
we understand completely what may be in the case of a breakdown 
and process that needs further study before any patients are 
put at risk, and leadership needs to support that and that is 
certainly a big part of what we need to do as we go forward. 
And as you see in a number of our hospitals is being fully 
accounted for.
    Finally as the chairman and Ranking Member have described, 
holding our leaders accountable. And I would just say most 
importantly for those first two things that is doing all we can 
to prevent harm in the first place through full implementation 
of everything we know both in and without VA to prevent harm 
and develop a culture of safety, and secondly to ensure that 
culture of safety is evident throughout our organization.
    Secretary Shinseki, Dr. Petzel and all of us are committed 
to accountability, transparency, and full disclosure of all 
that we do on behalf of our veterans. That is probably no more 
evident than in our ASPIRE program where we put out those 
indicators of quality, which I don't of know of any system in 
the Nation does, that are indicators of care that we aspire to 
perfection, and that is an effort that we will continue to 
focus.
    So finally, Mr. Chairman, out of our values, integrity, 
commitment, advocacy, respect, and excellence we are committed 
to providing the best possible care to our patients and we will 
do this on a continuous basis every day to ensure those who 
have served our country receive the best possible care in the 
United States.
    And we are happy, sir, to answer your questions.
    [The prepared statement of William Schoenhard appears on p. 
53.]
    The Chairman.. Thank you very much for your testimony and 
providing a global view of VA and the health care that it 
provides. Obviously we are focusing specifically today on 
Miami, so I first would just like to ask Mr. Weaver as the VISN 
8 director, are you satisfied with where Miami is? And can you 
tell me where you would recommend improvements?
    Check your mic too, please, Mr. Weaver. Thank you.
    Mr. Weaver. There we go. Thank you, Mr. Chairman.
    First I am pleased with the direction that Miami is headed. 
We have been through a lot of challenges over the last couple 
years. I think that we have made some of the necessary changes 
that we needed to do.
    Having the national leadership develop new programs to 
provide oversight, our establishing oversight at the network 
level, including a SPD board that oversees all of the 
activities at the medical centers, and also having a number of 
unannounced visits during the year from my office, and then at 
the medical center level the same kind of activity is going on.
    They have a team that goes in and does unannounced visits 
and ensures that the training is accomplished, that policies 
are up to date, and that the work is being done correctly.
    In looking at the Miami performance. First of all at the 
network level we have a performance improvement council that 
reviews performance of all medical centers on a monthly basis. 
We look at the performance measures that are the standard for 
VA and we have the leadership present to us, along with our 
program managers in our office, talking about any areas that 
need to be improved.
    Miami has continued to move in a positive direction. We 
have relied on Miami to work with other medical centers within 
our network. We had surgeries that are referred by West Palm 
Beach to Miami, to Orlando to Miami, and from Bay Pines to 
Miami. We continue to look at other kinds of opportunities to 
send referrals to Miami.
    And areas that need to be worked on are areas that continue 
to look at administrative processes to ensure that we are 
working as efficiently and effectively as possible.
    The three drivers in our network are quality. That is 
number one. We will not do anything to compromise quality. We 
look at those quality measures and performance.
    The second driver is our satisfaction. We look at patient 
satisfaction which has been high. We have looked at employee 
satisfaction which continues to be at the higher level.
    And then the third driver is our cost effectiveness, and we 
try to do this in a very cost effective way.
    And then finally with Miami on a real positive note is that 
even though we had a lot of negative publicity over the last 
couple years the workload at Miami continues to grow. We 
continue to reach out to our veterans and our veterans continue 
to come to the VA, and those numbers have continued to 
increase. In fact they are above the national average.
    The Chairman. Thank you very much. I would like to recess 
the hearing for just a moment procedurally. We do have a quorum 
present to take care of Committee business. Mr. Donnelly, if 
that is okay with you.
    Mr. Donnelly. Yes.
    [Whereupon, Committee broke for Business Meeting.]
    The Chairman. Ms. Berrocal, would you like to comment on--
since it is your facility--how you feel things are going in 
Miami?
    Ms. Berrocal. Thank you, Mr. Chairman. Things in Miami, as 
mentioned before, are steadily improving.
    I will note that upon my arrival at Miami, shortly after my 
rival, a year almost exactly, the AIB pointed out a number of 
areas that had been--or irregularities that had been going on 
for a number of years. Upon realizing, that what the AIB did is 
it provided me the opportunity to address those areas with the 
proper degree of urgency to ensure that we were addressing with 
specificity the area of the RME.
    I will mention that in the RME area in the Sterile 
Processing Department we have done a number of changes. We have 
changed the organizational structure. We have the department 
reporting directly to the Nurse Executive. Previously it 
reported to the administrative arm of the Medical Center. We 
have ensured that the staff that is in that section has high 
credentials to be in that area and that they have a clear 
understanding of the things that go on in that area.
    In addition to that, the individual that leads that area as 
well as the Nurse Educator for the sterile processing area are 
certified in instrument sterilization. And we steadily replaced 
staff as appropriate to ensure that we are hiring operating 
health technicians to people who are much more sensitive to 
those areas.
    There are a number of other things that we have done in the 
area including physical restructuring. We have bought all new 
equipment that is of the same kind of vendor so that it reduces 
variability in the number of processes that the individuals 
have to remember.
    We have provided extensive training. We do competency 
reviews on annual basis on these individuals.
    We have set up an RME committee that reviews the processes. 
We have the RME committee reporting to the Medical Executive 
Board who then reports to the Patient Center Executive 
Leadership Board.
    I will indicate that my mantra has always been to be 
patient centered, and I made that clear to the staff from day 
one that my decisions would always be patient centered.
    My father is a Veteran like several of you and my father is 
a physician so health care is something--and my mother a 
nurse--so health care is something that I have been--that has 
always been in my DNA, if you wish.
    I am keenly cognizant of the impact anything that would be 
less than perfect, could have in particular for our Veterans.
    I have worked serving the Veterans for other 30 years and 
am honored to have the opportunity to do that and I take that 
job very seriously.
    Our performance measures, in particular our outcomes, would 
show that we have worked steadily to improve the confidence of 
our patients in the care that we deliver at the Miami VA, and 
evidence of that is the fact that we have, as Mr. Weaver 
indicated, increased the number of patients that are coming to 
our medical centers. I work very hard to ensure that we are 
reaching the Veteran population so that we can provide proper 
care to them.
    In addition to that to restore some of the confidence that 
we have in the processes that we are providing to our 
Veterans--the number of colonoscopies that are being done at 
the Miami VA since 2009 have increased by approximately 20 
percent, so I think that we have put the necessary oversight 
systems in place to ensure that we are not placing our Veterans 
at risk.
    In addition to that I try to receive feedback from the 
stakeholders, so I meet often with the veteran service 
organization members, with members of the veterans--the PVA, 
Paralyzed Veterans of America, I am in communication, I have 
also tried to develop partnerships with the community so that 
we can ensure that we are strengthening our relationships with 
the ability to provide the best care anywhere.
    We in addition, because some of the questions have arisen 
about whether or not we hold staff accountable, and I believe 
that we do hold staff accountable when there are areas that 
have not been properly addressed or addressed as we would 
expect.
    We have set policies in place, and when members of our 
staff deviate from those policies we have a variety of areas 
that we--systems that we have put in place to review each 
instance to ensure that--to understand what happened.
    So we have the root cause analysis system, as has been 
mentioned previously, we also have the administrative 
investigation boards.
    It is my policy to always start by looking at the process, 
because I believe that if we are able to--if there is something 
wrong with the process and we can fix the process we will be 
able to standardize the care that we provide and in doing so, 
diminish the number of errors that might happen.
    In addition to that, whenever during the process of a root 
cause analysis we determine that there has been some degree of 
negligence or something that reflects poorly on the conduct of 
an employee, we establish either an administrative board of 
investigation or if the facts are fairly clear we might do a 
fact finding. In conclusion of that we would then take the 
necessary actions to discipline employees or to train employees 
or whatever it may call for.
    In terms of patient safety let me tell you that the Miami 
VA in the last 3 years has been recognized by the National 
Patient Safety Center for the completion and thoroughness of 
their RCAs. We received the bronze award in 2008, the bronze 
award in 2009, and the gold award in 2010.
    We have also been recognized by external bodies. We hold 
ourselves accountable for the type of work we do and as such we 
get oversighted not only by this Committee, but by many 
internal and external bodies. We received probably on the 
average of I believe it was over 30 visits in the past year, 
and in each of those visits there might be some findings.
    The Chairman. If I could, and thank you. We will have an 
opportunity to discuss more.
    Ms. Berrocal. Okay.
    The Chairman. And my time has pretty much expired, but 
since you brought up the issue of root cause analysis, in my 
opening statement you heard me talk about the suicide by cop. 
Are you familiar with the issue that I am referring to?
    Ms. Berrocal. Yes, sir.
    The Chairman. Okay. It is my understanding that this 
individual was an Air Force veteran, had in fact told her 
family and friends that she was going to commit suicide by cop, 
and was acting very irrationally, was taken to Jackson and 
Baker Acted; is that correct?
    Ms. Berrocal. That is correct.
    The Chairman. And from that point once Jackson heard that 
she was a veteran she was transferred to Miami; is that 
correct?
    Ms. Berrocal. That is correct.
    The Chairman. So this individual was involuntarily 
committed through the Baker Act, correct?
    Ms. Berrocal. There was some confusion as to whether it was 
involuntary or voluntary.
    The Chairman. But she was Baker Acted into Jackson, 
correct?
    Ms. Berrocal. Correct.
    The Chairman. That is involuntary, correct?
    Ms. Berrocal. Correct.
    The Chairman. Okay. Where was the confusion?
    Ms. Berrocal. In the communication between Jackson and the 
VA. There was initially some miscommunication about whether she 
was being transferred on a voluntary or involuntary.
    A full root cause analysis has been done on the case and 
they had found several things, in addition to the root cause 
analysis, there are some areas that we have conducted a fact 
finding. As you know the root cause analysis is--basically 
focuses on processes and doesn't allow us to utilize that 
information to take the necessary action on individuals, so we 
have----
    The Chairman. So it is your recollection that Jackson did 
not inform you that she had been involuntarily committed?
    Ms. Berrocal. My recollection was that there was some 
verbal communication which was not clear, but that upon----
    The Chairman. Is that normal that it is done verbally on 
somebody that has been committed to another facility?
    Ms. Berrocal. I cannot speak that if it is normal. I know 
that upon arrival of the individual the papers indicated that 
it was involuntary.
    The Chairman. Jackson's papers indicated that it was 
voluntary or VA's papers indicated it was voluntary?
    Ms. Berrocal. Jackson's papers when they came in indicated 
that it was involuntary. So the verbal communication was that 
it was involuntary, the paperwork upon receipt was that it was 
voluntary. That was my recollection.
    The Chairman. So she was Baker Acted, Jackson informed she 
was Baker Acted and involuntarily committed, and then she 
walked out the front door, shot a cop, and was killed.
    Ms. Berrocal. The resident that was at the ER at the time 
interviewed the veteran extensively and----
    The Chairman. It doesn't matter at that point because there 
was paperwork saying that she had been involuntarily committed; 
is that correct?
    Ms. Berrocal. That is my understanding.
    The Chairman. Okay.
    Ms. Berrocal. And the resident then spoke to the patient 
and at that time determined that they would--that it was going 
to be a voluntary--she felt comfortable after interview that it 
would be a voluntary admission.
    The Chairman. Oh, so she can be Baker Acted and then 
Unbaker Acted and then can walk out the door and be killed?
    Ms. Berrocal. You know, I cannot----
    The Chairman. Let me ask you this. What would be the 
difference--and I will ask Mr. Weaver--reporting requirements 
from the hospital to you at the VISN. And I apologize to my 
colleagues for the lengthy question.
    If this person had been involuntarily committed and it had 
been communicated as such and this person eloped or escaped or 
walked out from your facility, was killed by a cop after saying 
that she was going to commit suicide by a cop, would that be 
something that would be reported to you, and how was it brought 
to your attention? How did the hospital handle the 
communication?
    Mr. Weaver. Okay. Mr. Chairman, we were notified 
immediately of the situation and----
    The Chairman. What did they say had occurred? This person 
had voluntarily committed themselves and walked out?
    Mr. Weaver. The person had I believe involuntarily 
committed themselves, and as Ms. Berrocal mentioned, mistakes 
were made. The response by the staff was not appropriate.
    The issue is, is that we looked at an RCA looking at the 
process, but we also looked at individuals who were responsible 
for and we held them accountable.
    I think that any time a patient is admitted we have to do 
our due diligence and make sure that the patient remains with 
us and is safe and secure and that we respond appropriately by 
having the person placed in the facility--in the medical 
center.
    The Chairman. So was this a failure or not a failure?
    Mr. Weaver. I think the event was a--it was I think a 
failure.
    The Chairman. And somebody has in fact been reprimanded for 
the failure?
    Mr. Weaver. Go ahead.
    Ms. Berrocal. We have done a series of things. We recognize 
that there were some process failures through the RCA, in 
addition to that we recognize that there were some failures of 
individuals to follow the policy, to conduct their job 
appropriately.
    What we have done is we have addressed the process issues. 
One of the main things that they----
    The Chairman. Has anybody been disciplined for this veteran 
being allowed to walk out of a hospital after saying they were 
going to commit suicide by cop, allowing her to pull a gun on a 
police officer, shoot the police officer, and being killed by 
that police officer? Has anybody been disciplined at your 
facility?
    Ms. Berrocal. I have taken the people out of the position 
and the fact finding is being----
    The Chairman. So they still have a job.
    Ms. Berrocal [continuing]. The fact finding is being 
finalized.
    The Chairman. They still have a job.
    Ms. Berrocal. Sir?
    The Chairman. They still have a job.
    Ms. Berrocal. As of today they do. They are not in that 
position and the actions have not been finalized, but because I 
am in the middle of the deliberations with the fact finding I--
there are strong actions being taken.
    The Chairman. Mr. Donnelly.
    Mr. Donnelly. Thank you, Mr. Chairman.
    I have a question regarding Dr. Vera and the green notebook 
with 79 names in it. Are you familiar with the 79 veterans who 
were not contacted that that information had been put in a 
safe?
    Ms. Berrocal. The----
    Mr. Donnelly. Ms. Berrocal, I am sorry.
    Ms. Berrocal. Sorry. Okay. The logbooks had been reviewed 
in the initial review of the endoscopy in trying to make 
identification of the veterans, and when they reviewed the logs 
the logs were determined to be inconclusive, it didn't have 
complete information, and because it didn't have complete 
information it was determined by clinicians that it wasn't a 
reliable source of information.
    Mr. Donnelly. Well, what was Dr. Vara's explanation for 
those 79 folks not being contacted and their names being in a 
safe?
    Ms. Berrocal. So what we did with it was that as soon as we 
learned about it, and I think that this is an important piece 
to note----
    Mr. Donnelly. But what I asked you was what was his 
explanation as to why that happened?
    Ms. Berrocal. Because at the beginning when they reviewed 
the logs they determined them to be an unreliable source of 
information to determine which individuals were affected by the 
endoscopy issue--event. And it was determined to be an 
unreliable source because it was incomplete, these were 
handwritten, names were incomplete.
    Mr. Donnelly. So did he not believe those 79 people had 
suffered possible contamination?
    Ms. Berrocal. No. At the time the 79 individuals had not 
been identified.
    Mr. Donnelly. But their names were in this book.
    Ms. Berrocal. What had happened was--actually there is 
two--the 79 is--it was the result of a patient coming up with a 
letter.
    Mr. Weaver. There are two different events that happened. 
One with a logbook and others were already in the system. The 
logbook was identified--there was a decision made in 
combination with the medical center, the network, and central 
office that the logbooks were an unreliable source. The 
logbooks were composed--were in various clinics--and by the 
way, the logbooks are no longer--new logbooks do not exist 
anymore because they are not allowed to use them.
    Mr. Donnelly. Did you feel you had any reliable source if 
the logbooks are not a reliable source?
    Mr. Weaver. Yes. The computerized patient record was a 
reliable source, and that is where most of the--that is where 
the data was mined to get the first list. The logbooks came on 
like the third stage.
    The second part was the 79 individuals that were 
identified, they came when the clinicians went back and started 
looking at data again.
    What prompted that was a patient came in, said he was not 
identified, so they went back and they started to look. And Ms. 
Berrocal can explain that process.
    Ms. Berrocal. Yeah.
    Mr. Donnelly. So the source though--the source that you 
had, the computerized patient records that you said was the 
reliable source didn't even include these 79 people, is that 
what you are saying?
    Mr. Weaver. No, it did. What----
    Mr. Donnelly. Well, if it did how did you not have these 79 
people?
    Ms. Berrocal. What has happened in that process, if you 
would allow me to walk you through the process, when we 
originally looked at trying to identify all the patients we had 
contacted central office and we had received the look back 
manual which gave some guidelines as to how we go about a look 
back, so we identified as many individuals as we could by 
utilizing a series of methods, which in fact even enhanced the 
methods that were in the previous look back, and that allowed 
us to identify the bigger cohort of people that were at 
potential risk.
    Subsequent----
    Mr. Donnelly. But what were the holes that you couldn't 
find those 79 people to start with? I mean here they are 
walking around at possible risk.
    Ms. Berrocal. So we continued to enhance our methodology by 
bringing additional experts to enhance the methodology further 
and further and further so we continued to refine the 
methodology. We thought we were completed in that process and 
one of my residents received a letter from a veteran indicating 
that he had not been identified and he had had a colonoscopy 
during that period of time.
    So that letter--and I think this is important to note 
because it speaks to the culture that I have worked so hard to 
establish in Miami--and that is one that where people will 
stand up whenever they find that there is a problem and we will 
stand up and take responsibility for it and do the right thing 
on behalf of our Veterans.
    So the 79----
    Mr. Donnelly. But how did we miss those 79 to start with?
    Ms. Berrocal. The 79 individuals--as a result of the letter 
that we received----
    Mr. Donnelly. Okay, I understand the letter, my question 
is, how did we do all these enhanced methodologies that you are 
talking about and we still didn't even know we had 79 folks we 
missed?
    Mr. Weaver. What happened was when they went through the 
process of going to the computerized patient record there were 
pages that were behind pages that they were looking at and they 
found that they had not drilled down far enough and that is 
when they started to look at that process and started to drill 
down further and found out that there were 79 additional.
    Mr. Donnelly. So I guess the question comes down to were 
they in the records but we missed them or were they not in the 
records? Were the pages stuck together, is that what you are 
saying?
    Ms. Berrocal. The particular patient had had more than one 
procedure at that time.
    Mr. Weaver. Yes. The answer is yes, it was in the record.
    Mr. Donnelly. And we missed it.
    Mr. Weaver. It was in there but they had not drilled down 
far enough because of the way the record is set up to identify 
those 79 individuals.
    Mr. Donnelly. Mr. Chairman, my time is up. Thank you, sir.
    The Chairman. Thank you.
    Mr. Johnson.
    Mr. Johnson. Thank you, Mr. Chairman.
    You know I have reviewed the materials that have been 
compiled for this hearing and I can tell you that as a veteran 
I am extremely concerned. And I can tell you that as the 
Chairman of the Oversight Investigation Subcommittee I am not 
going to let loose of this one. There is some accountability 
that must result, and I am looking forward to working with the 
Chairman and the full Committee to make sure that that happens.
    Mr. Schoenhard, am I pronouncing your name correctly? You 
talked about holding the leaders accountable.
    Mr. Schoenhard. Yes, sir.
    Mr. Johnson. I have already heard enough testimony to want 
to ask you, what is your definition of holding leadership 
accountable?
    We got veterans that are escaping the facility and 
committing suicide, what is your idea of holding leadership 
accountable?
    And I know in my military days I know what holding 
leadership accountable means. What is yours?
    Mr. Schoenhard. Our definition of holding leaders 
accountable is creating what I said before, the process for 
ensuring safe effective----
    Mr. Johnson. No, no, no, no, no, that is holding 
leadership--that is making leadership responsible----
    Mr. Schoenhard. Okay.
    Mr. Johnson [continuing]. Creating processes.
    Mr. Schoenhard. Yes.
    Mr. Johnson. What happens when the process fails and 
veterans die? How do you hold leadership accountable?
    Mr. Schoenhard. In this case, sir, as we are here doing 
complete fact finding to determine what went wrong.
    Mr. Johnson. Okay, thank you.
    Mr. Weaver in your testimony you talked at being pleased 
with the direction that the Miami facility is going. I can 
assure you, sir, I am not, and I want to make sure you 
understand that as we get into these questions.
    Ms. Berrocal and Mr. Weaver you have explained your efforts 
to continually provide and improve environment and care.
    VA provided this Committee with a document identifying an 
eventual mock Joint Commission survey from your facility. Ms. 
Berrocal, are you familiar with this document?
    Ms. Berrocal. Yes, sir, I am familiar with the fact that 
they did a mock survey.
    Mr. Johnson. When there you schedule a mock Joint 
Commission survey?
    Ms. Berrocal. What we do is----
    Mr. Johnson. When? Not how, when? When will you be 
scheduling that survey?
    Ms. Berrocal. We schedule it, you know, in----
    Mr. Johnson. When? Is there a date for the survey?
    Ms. Berrocal. It is not a particular date. We schedule the 
survey as we----
    Mr. Johnson. So you haven't done one yet?
    Ms. Berrocal. We had a mock survey, we were anticipating 
the joint commission to come in last year, and they did and we 
were fully accredited at that time.
    Mr. Johnson. So you have already conducted the mock survey?
    Ms. Berrocal. We conducted a mock survey.
    Mr. Johnson. When was that conducted?
    Ms. Berrocal. I don't recall the exact date, sir.
    Mr. Johnson. Okay. Well then if that survey was conducted, 
Ms. Berrocal, how is it that radio--that a radio isotope could 
be left out in the open and unattended?
    Ms. Berrocal. You know, the idea of--again, we are an 
organization of continuous improvement, and what we are trying 
to do is identify issues so that we can correct them on the 
spot. So we are trying to be in a position of continuous 
readiness, and that means that we set different processes in 
place to try to identify issues so that we can correct them.
    Mr. Johnson. Why is preventive maintenance not being 
documented?
    Ms. Berrocal. So we do EOC, which are environment rounds, 
we are doing those now on a weekly basis, and I have one of my 
executives attend those so that we can be on top of all the 
different issues to determine what is happening.
    Mr. Johnson. Well, you know, the results of the mock survey 
that we have been--that has been made available to us was 
conducted on August 2nd and it indicates that preventive 
maintenance is still not being documented. So I am confused 
about how your process on continuous improvement is working, 
because I don't think it is producing the results that 
America's veterans expect or the American taxpayers expect.
    Why is your emergency management program not conducting 
drills and reports?
    Ms. Berrocal. We have had a turnover on the emergency 
management.
    Mr. Johnson. Since October 2nd?
    Ms. Berrocal. No, sir.
    Mr. Johnson. Okay. All right.
    Mr. Weaver, these issues are not new and you talk about 
being pleased, and Mr. Schoenhard you talk about holding 
leadership accountable. They appear on report after report in 
one form of another, what are you doing to hold leadership 
accountable for these kinds of failures?
    Mr. Weaver. I will take the first response.
    Sir, at the network level we have individuals that have 
responsibility to go out and do surveying and audits, and we 
review the performance, we review surveys, we do crosswalks 
with the environmental----
    Mr. Johnson. Mr. Weaver, I don't mean to cut you off. I am 
not talking about how your process works. Your process and the 
surveys that have been conducted and the results of veterans 
going out and committing suicide after escaping the facility in 
Miami are evidential.
    I am looking for accountability. You have both talked about 
leadership accountability and I have not heard either one of 
you say yet what leadership accountability is being enforced.
    Mr. Weaver. Okay, I am sorry, I didn't answer your 
question, sir.
    My approach to this is looking at performance.
    Mr. Johnson. Who has been disciplined? You got any 
disciplinary records as a result of these things that the 
surveys say still are not being conducted? Who has been 
counseled? Can you give me a name?
    Mr. Weaver. On those specific issues we have not worked 
through those yet. A lot of this is going to deal with the 
performance appraisal process.
    Mr. Johnson. I am familiar with the civil service 
performance appraisal progress, Mr. Weaver, that is not going 
to get it, that is not accountability, not when patients are 
leaving your facility and dying.
    Mr. Chairman, I think I have extended my--I hope we are 
coming around for another round of questions, because I am not 
finished.
    The Chairman. We may have five rounds.
    Mr. Johnson. Okay, thank you. I yield back.
    The Chairman. Mr. McNerney.
    Mr. McNerney. Thank you, Mr. Chairman.
    Mr. Schoenhard, do you agree that there is still a problem 
within the Veterans Health Administration with compliance of 
established patient safety protocols, policies, and procedures? 
And if so, what is being done about this?
    Mr. Schoenhard. Sir, we are continually inspecting both at 
the VISN level and at the medical center level for compliance. 
And as I said in my opening statement, this is an area that 
requires ongoing vigilance.
    And I if might just say earlier in terms of accountability, 
it is important that our leaders are ensuring that steps are 
taken to correct deficiencies that occur in joint commission 
mock reviews, that occur in CAP reviews and the rest. We invite 
those kinds of inspections. We know they will find things.
    Where we hold leadership accountable is not necessarily for 
finding areas for improvement because we want areas for 
improvement. What we hold leaders accountable for is ensuring 
full implementation of those recommendations, and that would 
extend to this effort as it relates to patient safety.
    Mr. McNerney. Well good. Then what specific actions are 
being taken to investigate and fix the reported problems at the 
Miami Medical Center?
    Mr. Schoenhard. Well, let me just go back and say at my 
level as the Committee I am sure is well aware, a national AIB 
was convened in the second iteration where the veteran called 
and indicated that he had not been notified as part of the 
initial review.
    We wanted at that time to understand what happened, because 
we obviously missed a veteran, we wanted to understand what 
more veterans might be at risk that were missed, and we wanted 
to understand not just for Miami, but nationwide, what we would 
learn from this experience. Because if we had a glitch in the 
initial review, we missed a veteran in Miami, we could have 
done that elsewhere.
    Part of also what I wanted done were recommendations 
regarding whatever corrective action might be taken, and there 
were as a result of this AIB disciplinary actions taken with 
regard to local leadership.
    I might just add that when the initial report came back 
from the board it was moot on the subject of whether at the 
VISN level or at VACO level, at our level, there was a lack of 
leadership and accountability with that first disclosure, and I 
charged them to come back with information.
    Mr. McNerney. I am surprised that we are here again today. 
I mean the problem is in my mind that there are specific issues 
at the Miami Center.
    Mr. Schoenhard. Right.
    Mr. McNerney. But how does that reflect across to the other 
centers in the country? Are we just looking at the tip of an 
iceberg here or are we really talking about an isolated set of 
cases that involves specific performance at that facility?
    Mr. Schoenhard. Well, I think that every facility varies in 
its level of performance, and the reason that we are here 
supporting Mary Berrocal and her leadership is that she is 
turning this ship around. It takes time to change the culture, 
it takes time to be able to ensure that people are held 
accountable at the local level and that we really are a patient 
center, and if I did not believe, if our leadership did not 
believe Mary Berrocal was making improvements we would not be 
supporting her leadership in place there.
    Mr. McNerney. Well, I mean I have been to many hearings of 
this nature--not many, but I have been to hearings of this 
nature--and there are times when you get the feeling that yes, 
things are moving in the direction they need to move in, I 
think there are times when you don't get that feeling and that 
is the case we are in right now. I just don't get the feeling 
we are moving in the right direction. But it worries me because 
I want to make sure that this isn't something that is more 
broad and that could have bigger implications for our Nation's 
veterans than the bad enough case that we are seeing in Miami.
    Mr. Schoenhard. Well, sir, I can assure you that at the 
VISN level and at the central office level we continually 
monitor the operation of our facilities, and I know there has 
been some question about whether we get ground truth, and part 
of what we are working very hard to ensure is timely reporting 
and accurate reporting. We are making great strides in that 
respect, and that again comes back to the culture, it comes 
back to an accountability to ensure first and foremost that the 
Mary Berrocal calls of our system, the medical center directors 
have full visibility of issues. You cannot solve what you don't 
see, and that is what Mary is turning around in Miami.
    Mr. McNerney. So you are saying that Mary didn't see these 
problems from her position?
    Mr. Schoenhard. I think frankly there has been a culture in 
Miami. This varies from institution to institution both in VA 
as well as it does in the private sector of a culture that did 
not have the psychological safety that Mary is bringing to it.
    That there would be--typically when we have problems in 
health care, whether it is in the private or the public sector 
it can be sometimes the case that people bring forward concerns 
and leadership doesn't act. That is back to the congressman's 
question, what I hold people accountable for.
    I don't fault that there is opportunity to improvement, 
what I fault and hold accountable are leaders who don't act on 
that information and improve care for veterans and don't create 
the conditions whereby people can freely come forward without 
recrimination and be heard and supported on behalf of our 
veterans.
    Mr. McNerney. And so have people come forward and have 
there been recriminations?
    Mr. Schoenhard. Excuse me, sir?
    Mr. McNerney. Have people come forward and have there been 
recriminations for that activity in Miami?
    Mr. Schoenhard. No, but that can happen or rather it can be 
perceived. And one thing that I have learned after the last 2 
years in VA is that there has been considerable concern in the 
past regarding whether people can freely come forward without 
recrimination. I have had a number of members express concern 
to me about that.
    We are working very hard in keeping with our values to 
ensure accountability and transparency, and the first thing I 
would hold a leader accountable for is creating a culture where 
we know what is going on and that we act on. Because there is 
always opportunity for improvement in any hospital that serves 
patients.
    Mr. McNerney. Okay, thank you. I yield back.
    The Chairman. Before I recognize Dr. Benishek for the next 
question I just find it troubling that you have said that the 
Miami VA Medical Center is moving in the right direction.
    We extrapolated some of the numbers, and I apologize this 
may be a little difficult, but I think you kind of get the 
gist, in fact here it is, they are showing it up on the screen. 
Senior management satisfaction down. I mean the ship may be 
going in the right direction, but I think it is sinking. 
Psychological safety down. These are your numbers. Customer 
service down. Overall satisfaction down. I mean that is not the 
direction that any of us want to see our medical centers 
heading.
    Dr. Benishek.
    Mr. Benishek. Thank you, Mr. Chairman.
    Mr. Schoenhard, what is the average tenure of a director of 
a medical center?
    Mr. Schoenhard. Sir, I do not have that information, but we 
can provide that to you.
    Mr. Benishek. Mr. Weaver, would you happen to know in your 
VISN?
    Mr. Weaver. In my network it is not very long.
    Mr. Benishek. Ms. Berrocal, how long have you been the 
director of the Miami VA?
    Ms. Berrocal. It will be 4 years in March.
    Mr. Benishek. And you say you started just a year before 
this incident?
    Ms. Berrocal. Yes, sir.
    Mr. Benishek. Where were you before that?
    Ms. Berrocal. Before that--this is my sixth VA--before that 
I was in Los Angeles, California.
    Mr. Benishek. And how long were you there?
    Ms. Berrocal. About a year and a half or so.
    Mr. Benishek. And the place been that, how long were you 
there?
    Ms. Berrocal. I was in Loma Linda, California for roughly 
11 years or so.
    Mr. Benishek. But that was not as a director?
    Ms. Berrocal. No, I was the Associate Director there.
    Mr. Benishek. Mr. Schoenhard, this is the point of my 
questioning, is I worked at a VA hospital for 20 years and for 
that 20 years there was 10 directors, the director lasted 2 
years and then they went on that their next appointment, and in 
my opinion, you know, the director of a medical center it takes 
a while to understand the function of a medical center, and my 
impression of what was going on is that people were just biding 
their time and preparing for their next job, and I think that 
there is a structural problem in the fact that people turn over 
rapidly as a director of a medical center because they can't 
understand their own facility enough to delve into each and 
every problem like that because they are just preparing for 
their next job. And I think that that particularly is a problem 
in the way the VA is managed, not from the individual job, I 
mean I think people try to do the best they can, but you know, 
a year being there and then moving onto the next job it is a 
problem, and I think it is throughout the system. Can we fix 
that?
    Mr. Schoenhard. I might yield to Mr. Weaver to speak 
because he had previous responsibility for workforce and human 
resources at the central office and has more experience and 
perspective than I have, but I would agree, it takes time to 
turn the culture of a hospital.
    Mr. Benishek. But I mean it is not the hospital, it is the 
administrative people that are switching these people around on 
an every other year basis so that the person is not invested in 
that hospital and can't get to know that facility as well as 
they should to be the director.
    Mr. Schoenhard. Well, let me just clarify. We post openings 
and people are free to apply for those. We do not mandate turn 
over, we do not force people to transfer after a certain time.
    Mr. Benishek. But neither do you facilitate people staying 
in one facility.
    Mr. Schoenhard. Actually in this economy and with the 
situation on relocation there is more staying in position than 
we have----
    Mr. Benishek. All right, let me just go on because my time 
is limited.
    I have a question, Ms. Berrocal, about these logs. You 
know, I mean I fill out a log whenever I get colonoscopies at 
the VA and I don't understand what information was missing from 
the log, because usually they are quite complete. So you said 
they were unreliable, but why were they unreliable?
    Ms. Berrocal. Again, they were unreliable because it was 
incomplete information. It was----
    Mr. Benishek. What information was incomplete?
    Ms. Berrocal. Names were not spelled correctly, there was 
not exact information on the----
    Mr. Benishek. So people are not filling out their logs 
correctly, is that what you are telling me on a routine basis?
    Ms. Berrocal. Our official record is the electronic medical 
record.
    Mr. Benishek. But you already told us that that method of 
doing it doesn't work very well because you can't go back other 
than--you know, a paper log is permanent.
    Ms. Berrocal. No, we did no back . . . 
    Mr. Benishek. Well, but you couldn't find the people that 
you were looking for on the electronic medical records. Did the 
79 names occur on the paper record?
    Ms. Berrocal. We looked at--it was an electronic medical 
record----
    Mr. Benishek. Were the 79 names on the paper record, yes or 
no?
    Ms. Berrocal. Actually from the logs what we found was 12 
individuals. The 79 were from the letter that the patient 
wrote.
    Mr. Benishek. So those people, those 79 people were not in 
that paper log?
    Ms. Berrocal. The 12 individuals were not in the record--in 
the electronic record.
    Mr. Benishek. But in the paper log were those 79 people in 
that paper logbook?
    Ms. Berrocal. No, the 79 individuals came as a result of a 
letter that we received and were put back into the electronic--
--
    Mr. Benishek. So they were not in the log is what you are 
saying.
    Ms. Berrocal. No. Right. We went back into the electronic 
medical records and found those 79.
    Mr. Benishek. Mr. Schoenhard, I just wanted to express my 
problem with the electronic medical record as it exists, 
because obviously there is some sort of problem here where 
people cannot go back easily and find out what the deal is, and 
that to me is really frustrating, as is the fact that the log 
did not contain 79 names.
    I don't understand what is going on here, but you know, 
this kind of stuff doesn't happen where I work, and I mean I 
don't think it should be happening where you work.
    Mr. Schoenhard. Yes, sir, and I would just acknowledge, I 
think it is important for the Committee to know, that we have 
taken the Miami experience with the 79 and with the 12 and that 
has been gone into as part of the national AIB. There were a 
number of recommendations having to do with data collection and 
the rest.
    Part of the issue we learned in Miami is that the average 
medical center director maybe in their career will have one or 
two of these kind of instances that is involved with putting a 
data group together and making sure we mine the data and get it 
right the first time.
    The AIB included a number of recommendations at the 
national level to ensure we bring experts to bear when we have 
an incident like this, to ensure we get all of the veterans 
that we can get to in the first place.
    But let me urge this, I think it is important for veteran 
safety that we be always in discovery, always looking, did we 
miss anybody, always having our receptacles open to is there 
anybody that we might have missed? Because first and foremost 
is our responsibility to every veteran to ensure if we have any 
reason to believe they should be notified that they are 
notified.
    Mr. Benishek. Well, I just----
    Mr. Schoenhard. And that is what we would continue to urge 
in our culture.
    Mr. Benishek. Well, to tell you the truth, I like to have 
the paper record because then there is something actually 
written down, whereas, you know, like the electronic medical 
records sometimes things disappear and then you can't really 
find them afterwards, so I like to have this written document, 
so I would encourage that to be a part of it. And I think I am 
out of time. Thanks.
    The Chairman. Mr. Walz.
    Mr. Walz. Well, thank you, Mr. Chairman, and I want to 
thank all of you for being here and the work you have done.
    I think we do all know this is a zero sum proposition with 
our veterans, and I have said it and I will continue to say it, 
I am the staunchest supporter of the VA and because of that I 
am the harshest critic because the job is too important.
    I would like to say, Mr. Schoenhard, thank you as a naval 
officer for your service. I would also like to get your 
perspective earth first on this. Am I right that you were CEO 
of SSM Health care for 22 years?
    Mr. Schoenhard. No, I was the chief operating officer.
    Mr. Walz. Chief operating officer.
    Mr. Schoenhard. Yes, sir.
    Mr. Walz. Okay. What did they do?
    Mr. Schoenhard. Excuse me?
    Mr. Walz. What did SSM Health care do?
    Mr. Schoenhard. Very much like VA, it is a multi-state, but 
much smaller health care system. At the time I left we were in 
four states and it is a faith-based Catholic sponsored 
organization.
    Mr. Walz. How did SSM report their medical errors?
    Mr. Schoenhard. They came through the report similar to 
what we have here in VA through----
    Mr. Walz. Which is stricter in terms of every incident that 
happens, the private sector or the VA?
    Mr. Schoenhard. Well, I want to be careful to----
    Mr. Walz. The reason I ask is there is no error acceptable, 
but I want to be very clear on this, the requirements that this 
is not--and I am going to say this, and I appreciate you taking 
a macro position on this because trying to lump them all 
together I am going to stand firmly with the three that I 
supervise in Minneapolis and in Toma and in Sioux Falls of what 
is happening and try and get at the systemic cause of where 
this is at, that is the reason I ask this.
    Mr. Schoenhard. Let me say this. I do not want to cast 
aspersions on the private sector, but I can tell you after the 
years I have spent in the private sector our system is the most 
transparent, the most rigorous in VA, the most accountable for 
holding people accountable that I have seen.
    Mr. Walz. Well, I can back you up, I represent the Mayo 
Clinic and they would agree with you.
    And with that being said that doesn't remove from where we 
are at trying to figure this out systemically, but I do think 
we need to note that if we are starting to make changes I am 
very, very hesitant here that if this is systemwide we need to 
understand what happens because I do not want the quality of 
care being reduced at VA Minneapolis because of an incident at 
Miami or if that is the case if that is clear.
    Just a couple of things, I will move on. Mr. Weaver, I do 
think my colleagues are right, I think you used an unfortunate 
choice of words with Miami. I think one thing you said was is 
that Miami VA had challenges. No, the veterans there had 
challenges. You had some problems that needed to be addressed, 
so I think you--and saying we are making progress and feel good 
about it I think maybe again, and I am not going put words into 
your mouth, is a zero sum. If one veteran doesn't get the care 
they need I am sure you are not happen. I will let you speak on 
that.
    I will ask you though, Mr. Weaver, on this, how long have 
you served in the VA?
    Mr. Weaver. I have 32 years in.
    Mr. Walz. Are all VA medical centers created equal?
    Mr. Weaver. No.
    Mr. Walz. Okay. Is that important to keep in mind in your 
opinion?
    Mr. Weaver. I think it is.
    Mr. Walz. Okay. Ms. Berrocal, I am going to come to you on 
the specifics of running this. The endoscope issue. I am with 
my colleague's frustration on this one too because in 2009 I 
sat in that hearing and some of these folks were there too and 
we went through that trying to understand what happened, trying 
to be transparent, trying to make as my colleague said, someone 
accountable for this, but more importantly making sure that it 
never happened again.
    I had all of these folks, and you were right there were 11 
different contractors that provided these I believe, I had the 
folks come in and actually assemble and had me reassemble in my 
office an endoscope. We know the problem was a two-way valve 
amongst one of the contractors If I am not mistaken.
    So what I ask on this is, is at that point in time it 
became very clear to me, and we had a great commitment from our 
VA, that new processes would go out, because I made the 
statement at that time is my local quick trip convenient store 
has a little chart in a bathroom that shows who cleaned the 
damn toilet each hour, there was no such thing for this 
endoscope.
    So that being the case, did you adopt what others adopted 
that did not have a reoccurring problem? Did that happen?
    Ms. Berrocal. Yes. We have, you know, we haven't perhaps 
applied everything, I haven't seen all of the system, but we 
from a system perspective we did an after action review as a 
system to understand what others were doing.
    I will tell you that I don't stop at the endoscopy issue 
alone, I take the OIG reports that come from every facility in 
the system where they identify an issue and I have trended the 
problems that have been found and I issue that to my facility 
to ensure that those concerns are not concerns at the Miami VA.
    We have done consistent improvements as I mentioned before. 
My Nurse Exec, who the sterile and processing section reports 
to has gone above and beyond and she has gotten certified 
herself in this certification, which is an international 
certification that--on sterilization of instruments.
    In addition to that the nurse that oversees that section as 
well as the Nurse Educator for the sterile processing sections 
have received that certification as well and they are certified 
nurses in instrument sterilization.
    Mr. Walz. Okay.
    Ms. Berrocal. As well 80 percent and within the year 100 
percent of the individuals who we have hired in that area will 
have received the certification.
    Mr. Walz. That is international.
    Mr. Schoenhard, again, I don't want to put you in a 
position to be speaking for the private sector, you just have 
the most experience here is one of the reasoning I am asking, 
you have a foot in both camps.
    If there would have been a problem with an endoscope at the 
private hospital and I was due for my colonoscopy would there 
be a place I could find that easily to know that hospital had a 
problem?
    Mr. Schoenhard. I don't think as transparent as we have in 
the VA. And I would tell you, sir, we lead the industry and we 
are working with the FDA in this very area. We are making 
contributions not only to veterans care, but care to all 
Americans in this work.
    Mr. Walz. Okay. Well, I do want to make it clear that I am 
with my colleagues here on this accountability. I am with 
making sure that there is a sense that we are getting better, 
but I also understand, and I would leave with this, I think Mr. 
Schoenhard you had said--I am a systems analysis guy too by 
graduate training--but I also know I do believe in systems, but 
I understand that you are only as good as the people who are 
there, and I think we need to keep that in mind. And this might 
come back and I certainty don't want to speak for my colleagues 
that if there are people that there can't do it they need to 
move.
    Mr. Schoenhard. Let me just assure you, congressman, we 
will always put in place leadership that is in the best 
interest of our veterans.
    Mr. Walz. Well, I thank you all and thank you for coming 
today to help us understand this.
    I yield back and thank you for the extra time, Mr. 
Chairman.
    The Chairman. Yes, sir. Mr. Huelskamp. Hit your mic button.
    Mr. Huelskamp. Sorry for that, Mr. Chairman, I appreciate 
the time and opportunity to ask some questions.
    The first question would be for Mr. Schoenhard. What is the 
VA doing to promote transparency as well as providing 
protections for employees that would like to report misconduct?
    Mr. Schoenhard. Let me just again elude to what I mentioned 
in the opening statement, sir, regarding transparency. On our 
ASPIRE Web site, there is no other system that I am aware of 
anywhere that is putting out aspirational goals to improve care 
for our patients, and our performance to date in getting there, 
as we have seen under Secretary Shinseki's leadership in 
putting this kind of level of transparency forward, it is 
unprecedented.
    As it relates to ensuring that we have a safe culture where 
people can come forward let me mention a couple things, and if 
I could yield to Mr. Weaver who will talk at specifically what 
is being done in VISN 8, which we may adopt nationwide.
    First we hold all employee surveys, we have a good high 
return on that going forward and that is an indication of 
employees comfort in going forward with psychological safety.
    We have a program called CREW, which is civility, respect, 
and engagement in the workplace. We take teams like the OR 
teams and those that are in highly critical functions like an 
aircraft carrier flight deck crew might be and build comradery 
and ability to treat people with respect there. We are 
undertaking throughout all of VHA leadership appraisal teams.
    Part of what has become apparent where we have breakdowns 
in terms of people going forward and acting on information that 
requires improvement, is in that front office, the top 
leadership of the medical center. We want to get a good idea of 
how that team works together through a formal process and we 
are undertaking that now, because I am convinced it starts at 
the head of an organization in terms of the health with which 
even that senior team is able to effectively communicate with 
each other.
    Mr. Huelskamp. And what happens when that fails? I mean who 
is held accountable?
    Mr. Schoenhard. The medical center director is the captain 
of the ship would be responsible for the culture of the 
hospital as well as the front office.
    Mr. Huelskamp. And systemwide, and I am new this congress, 
I am a freshman, how many medical directors have been 
disciplined in any way or removed for failures in their sphere 
of responsibility?
    Mr. Schoenhard. Sir, if I could take that question and 
bring it back it would depend on the period of time that you 
are going back to. There have been a number of----
    Mr. Huelskamp. When was the last one removed or punished at 
that level?
    Mr. Schoenhard. Probably--I lose track of time, and I am 
doing this off the top of my head--but it would be several 
months ago a director was removed, and I can get you the 
specifics on that, I just--I want to give you the accurate 
information.
    Mr. Huelskamp. And I appreciate that and I appreciate the 
description of the model of how things would occur, but I have 
been in this position for about 9 months and other folks and my 
colleagues have talked about this incident.
    I would say I am particularly angry at what has occurred 
and I am angry about things that occurred in my district, 
complaints that have come to my attention and the absolute 
failure of the VA to respond to those complaints.
    The inability of members of Congress to get accurate 
information--it is just like pulling teeth. And I cannot 
imagine if a victim of a situation and the family was trying to 
get that information that I can't even get, it is one thing 
after another.
    There is not transparency in this particular situation, it 
is a very troubling incident and the idea that we can talk here 
about holding people accountable and responsible, but we can't 
even get accurate information, it certainly seems like an 
attempt to cover that up. I don't know how widespread it is, I 
don't know if it is in just one particular incident, but I am 
just very disappointed, and that is not the medical director's 
fault, it is the system, it is the folks at the top. It is your 
job to hold them accountable. And if I can't get the 
information what am I supposed to do? Just continue to ask 
after six, seven, 8 months of trying to get information and 
having, you know, apparently the response from the VA is we 
will give him enough to make him satisfied for 2 weeks and then 
he will call again and then we will give him just a little bit 
more. What am I supposed to do, Mr. Schoenhard?
    Mr. Schoenhard. First, Secretary Shinseki has made it very 
clear that we are to be transparent and accountable, and we 
would like to follow up with you in ensuring that we understand 
the root of where you are having problems getting information. 
I insist that we get good information from the medical center 
to the VISN to me and to VACO and then for the rest of the 
leadership of VA.
    If we are having difficulty getting information to your 
satisfaction in a timely fashion we need to work on that. I 
understand that sometimes it is the process of request--and I 
don't mean to describe this generally--but I think there is 
probably an area where we could improve in terms of what 
information requests, because I think at times we are not clear 
what is being asked and we probably could do a better job of 
clarifying that.
    In any case we both own the problem, and certainly VA owns 
the problem of ensuring if it is not clear what is being 
requested that we get timely clarification and we do the timely 
review and the release, because we honor and respect this 
committee's responsibility for oversight.
    Mr. Huelskamp. And I don't know as far as who owns the 
problem, all I know is there is a deceased veteran and some 
possibilities of failure of the system, and again, I don't want 
to start digging in there and find out it is a much broader 
situation than one particular individual, but I appreciate your 
willingness to help, but I will just say that it hasn't 
happened, it is no excuse, you know, we are going to help you 
sometime in the future, but this complaint and complaints 
related to that are again make me very angry.
    So we should call you directly if we want that information?
    Mr. Schoenhard. Yes, we work with our OCLA staffer office 
of Congressional Legislative Affairs, but I can assure you that 
we will work together with you. I would like to have us follow 
up with your office offline.
    Mr. Huelskamp. Absolutely, and I would appreciate later 
today or first thing tomorrow morning that you call my office 
and we will get started and maybe we can get over a few levels 
of bureaucracy.
    Mr. Schoenhard. Yes, sir.
    Mr. Huelskamp. Thank you. Sorry for taking too much time, 
Mr. Chairman.
    The Chairman. Thank you very much.
    Ms. Berrocal, let us go back to the veteran that escaped 
your facility. A root cause analysis has been done?
    Ms. Berrocal. Has been completed.
    The Chairman. How long did it take you to approve that root 
cause analysis?
    Ms. Berrocal. We have a 45-day window to complete these 
root cause analysis. We initiated the root cause analysis 
quickly. I don't have the exact information, you know, on hand, 
but I am happy to get it for you. We invited people from the 
network----
    The Chairman. But how long did it take for you to approve 
the RCA?
    Ms. Berrocal. As soon as the formal RCA was presented to me 
I signed it.
    The Chairman. Okay. Let us all go back to my opening 
statement about being open, honest, and transparent. Did you 
alter the text? Did you do anything to the root cause analysis 
that was presented to you prior to signing it?
    Ms. Berrocal. What happens in the root cause analysis is 
that I did not alter the text, but----
    The Chairman. You changed nothing in the root cause 
analysis?
    Ms. Berrocal. Not to my knowledge. What I--no. What happens 
in the root cause analysis is they--the team comes and presents 
and questions--they present to the whole executive leadership 
team and at that time we do ask questions, we ask 
clarification, and then the written document and 
recommendations are presented to me and I sign them.
    The Chairman. And here is why I am having a little bit of a 
problem, because we have asked Legislative Affairs to be 
provided every AIB and every root cause analysis from '08.
    Ms. Berrocal. Uh-huh.
    The Chairman. I think there have been 14 AIBs done, we have 
gotten 3. We haven't gotten any root cause analysis, none.
    Ms. Berrocal. At the facility level we have submitted 
everything that has been requested of us, and there is a 
vetting process.
    The Chairman. Well, since we are here in an open 
discussion, were there any management issues raised in the root 
cause analysis of the veteran that escaped your facility, 
walked out, shot a police officer, and was killed?
    Ms. Berrocal. I would like to recollect exactly all the 
recommendations.
    The Chairman. If it was pointed at you, you probably would 
know it wouldn't you?
    Ms. Berrocal. Yes.
    The Chairman. Was there anything in the root cause analysis 
that pointed at leadership at your facility?
    Ms. Berrocal. You know, I--honestly, I mean I am trying to 
be honest because that is what you have asked me to do and I am 
honestly not recalling a specific recommendation. You know, I--
--
    The Chairman. But I am asking now--I am asking you now to 
provide that root cause analysis to this Committee. Can you do 
that?
    Ms. Berrocal. Yes, sir.
    The Chairman. When?
    Ms. Berrocal. As soon as I get back to Miami.
    The Chairman. Can they transmit it before you get back to 
Miami?
    Ms. Berrocal. I will.
    The Chairman. Thank you.
    Ms. Berrocal. I will get that to you.
    The Chairman. What happens if a veteran presents at the 
facility with congestive heart failure?
    Ms. Berrocal. They are--you know, I rely on my clinicians 
to take care of the patients and they are--if they present to 
the ER they are taken care of in the ER.
    The Chairman. And for what reasons would a patient not be 
admitted if they had congestive heart failure?
    Ms. Berrocal. You know, I am not a clinician and I would 
have to defer to my clinicians in making toughs decisions. On a 
daily basis I must rely on my clinicians to make clinical 
decisions. Day in and day out our doctors are making decisions 
on our patients and I cannot possibly replace their judgment 
with mine.
    The Chairman. So would you know if a veteran had come to 
your facility, presented with a particular disease, returned 
home and then expired the next day? Would you have any way of 
knowing that?
    Ms. Berrocal. Usually what happens is we--any deaths we do 
review and there is where indicated we do peer reviews, where 
the death is not expected there are peer reviews that are done 
and we review to see what happened.
    The Chairman. There is a way that you would know if a 
veteran presented 24 hours prior to their death at your 
facility but was sent home, you would have a way of tracking 
that?
    Ms. Berrocal. Every morning we get a report on anything 
that is unusual that might have happened on that evening before 
or that day before, we get a report every single morning. I 
meet with my leadership, the staff in the ER presents their 
information, following that, you know, we stay with the 
leadership and discuss anything that we might need to follow up 
on.
    The Chairman. Is it unusual that a veteran would come to 
your facility, be discharged--not discharged, but just be sent 
home, not admitted, and would pass away the next day? Would you 
consider that unusual? And if you do consider that unusual, is 
that something that you would report then to the VISN that this 
has occurred?
    Ms. Berrocal. We would normally report deaths--unexpected 
deaths to the network, yes.
    The Chairman. So if an instance like this did occur it 
would have been reported to the VISN?
    Ms. Berrocal. It would be any expectation that it would be 
reported. If it is an unexpected death there are reports that 
go forward.
    The Chairman. Regardless----
    Ms. Berrocal. No, we don't independently like on an issue 
for something report every single death if it is an expected 
death.
    The Chairman. Regardless of what the peer review may have 
found you would still report it?
    Ms. Berrocal. The peer reviews focus specifically on the 
provider to determine whether it was something that didn't go 
the way it should be in that direction. So yes.
    The Chairman. Okay. Let us go inside the facility, now we 
have somebody who has been admitted to the facility and is 
having surgery. If there is a death on the operating table what 
would prevent that death from being reported to VISN?
    Ms. Berrocal. Those would be reported to the network.
    The Chairman. All deaths on an operating table are 
reported?
    Ms. Berrocal. Are reported. Should be reported. There is a 
system that we put through to report unexpected deaths.
    The Chairman. All deaths on the operating table are 
reported to the VISN?
    Ms. Berrocal. Yes, sir.
    The Chairman. All deaths?
    Ms. Berrocal. Unexpected deaths are reported.
    The Chairman. There is a difference now. Unexpected deaths 
or deaths? If a patient dies on the operating table is that 
reported? Regardless is that reported to the VISN? And if not, 
why not?
    Ms. Berrocal. It would be my expectation that it would be 
reported.
    The Chairman. Is there a root cause analysis on every death 
on an operating table?
    Ms. Berrocal. There would be a root cause analysis again if 
it is an unexpected death there would be a root cause analysis.
    The Chairman. What would be an expected death on an 
operating table? I would expect if I went in for surgery you 
wouldn't expect me to die, you would expect me to recover. Now 
what is an expected or an unexpected death? What is that?
    Ms. Berrocal. Again, it is--you know, I am not a clinician.
    The Chairman. You are the director of the medical center.
    Ms. Berrocal. Correct, not a clinician.
    The Chairman. For now.
    Ms. Berrocal. I am not a clinician, but I would expect 
that--I would--any unexpected death would be something where, 
you know, if they found something that they were not expecting 
to find I--you know, I believe that any deaths would be 
reported.
    The Chairman. Who makes the determination as to whether it 
is expected or unexpected?
    Ms. Berrocal. There are systems in place to report, and we 
have had a variety of groups come in look and determine, you 
know, that we have done things appropriately. All deaths are 
reported and they are investigated, but not necessarily through 
the RCA process. We do investigate. Again, we do peer reviews 
to determine----
    The Chairman. Is a peer review punitive?
    Ms. Berrocal. It could lead to be, but not necessarily. A 
peer review, there is a group of peers that review to see 
whether or not the care that was provided was adequate care.
    The Chairman. So if everybody just decides that the care 
was adequate and that it was an expected death you may not even 
report that to the VISN, correct?
    Ms. Berrocal. There is a committee that reviews after. You 
know, there is the peer review, it goes to a committee to 
review and then a determination is made. There is--there are 
rankings or scores that are provided determining whether or not 
it is a----
    The Chairman. Who makes the final determination as to 
whether or not it is sent to VISN?
    Ms. Berrocal. They are reported to the VISN. The deaths are 
reported to the VISN.
    The Chairman. All of them?
    Ms. Berrocal. No.
    The Chairman. Is there ever a death that is not reported to 
the VISN?
    Ms. Berrocal. We have, for example, deaths in hospice, 
these would be expected, you know.
    The Chairman. I am talking about on the operating table.
    Ms. Berrocal. I would expect----
    The Chairman. I will let you think on that.
    Mr. Johnson.
    Mr. Johnson. Thank you, Mr. Chairman.
    Mr. Schoenhard, you and I talked before the hearing 
started, we are both veterans, you know, and from your 
experience in the private sector, I agree that, you know, there 
is some good to be found anywhere, but I think based upon our 
mutual experience with the culture that we had where these 
veterans come from as a squadron commander if my moral factors 
were going down like VAMC in Miami is, if my customer service 
statistics were going south like theirs are, I can assure you I 
know what accountability would mean in that case.
    I am just curious, are you astutely hearing the responses 
to the questions that this Committee is asking and some of the 
answers that we are getting? Because you made a statement that 
you are prepared to hold leadership accountable, and I believe 
you, I am anxious to see the results of that. That is a 
statement, let me ask you a question.
    Mr. Schoenhard. Yes, sir.
    Mr. Johnson. Last month the Miami Herald reported that an 
administrative investigating board conducted by the VISN that 
they had obtained through a FOIA recommended disciplinary 
action for both Dr. Vara and Ms. Berrocal at the Miami VAMC. 
When asked for comment on whether these actions had taken place 
the VA had none.
    In documents submitted to us just last night by the VA only 
a draft, unsigned, and undated recommendation for action was 
provided.
    And then 30 minutes before today's hearing a notice of 
admonishment was provided that was dated in December of 2010 
with no specific day.
    Can you clarify and explain this discrepancy and how that 
fits into your we are going to hold leadership accountable?
    Mr. Schoenhard. Yes, sir. The AIB recommended 
administrative action. The one that I convened, the national 
IAB after the second disclosure of the veteran who had not been 
contacted, found that there was reason to take administrative 
action against the medical center director and the chief of 
staff.
    The way that works in VA then is that I shared that report 
with Mr. Weaver and he took the administrative action. He may 
want to speak to the process we use in VA and in government 
to----
    Mr. Johnson. What administrative action was taken?
    Mr. Schoenhard. An admonishment was issued against both 
individuals.
    Mr. Johnson. A veteran escapes the facility----
    Mr. Schoenhard. No, sir.
    Mr. Johnson [continuing]. And dies.
    Mr. Schoenhard. That was--this was predating this incident.
    Mr. Johnson. Okay. All right, so this admonishment that 
came through the Miami Herald incident from a previous AIB, 
correct? Have I got this right?
    Mr. Schoenhard. That is correct, sir.
    Mr. Johnson. Then the patient that escaped the center and 
subsequently committed suicide happened after that, correct?
    Mr. Schoenhard. That is correct, sir.
    Mr. Johnson. All right. So do you think the admonishment 
worked?
    Mr. Schoenhard. I think----
    Mr. Johnson. Next question. Next question. Can you provide 
to this Committee, Mr. Schoenhard or Mr. Weaver, a record of 
disciplinary actions from the Miami VAMC over the last 24 
months? I would specifically like to see, and with The 
CHAIRMAN's approval, I would like to see the incident. You 
don't have to give us names for privacy. I would like to see 
the incident and the action and what level of leadership and 
management that action was taken against.
    Ms. Berrocal, last week one of your employees was arrested 
for selling names of veterans. In the past 6 years it is 
estimated that more than 3,000 veterans information has been 
sold.
    Mr. Johnson. Have you alerted any veterans that their 
information may have been compromised? And if so, how have you 
done that?
    Ms. Berrocal. Actually this was an investigation that was 
done by the IG and it was a covert operation. I learned about 
it at the time shortly before they were going to be arresting 
the individual, and at the time what we knew was that there was 
information on 18 individuals that was compromised, and then 
on----
    Mr. Johnson. Have those veterans been notified?
    Ms. Berrocal. The----
    Mr. Johnson. Yes or no, have those veterans been notified? 
You talked earlier about a process for making sure that 
veterans are notified. I have heard that from various pieces of 
testimony this morning.
    Ms. Berrocal. We are in the process of notifying the 
individuals.
    Mr. Johnson. So they have not been notified. When was the 
guy arrested?
    Ms. Berrocal. This just happened in the last----
    Mr. Johnson. And you didn't know any about the 
investigation prior to his arrest?
    Ms. Berrocal. I knew that they were doing an investigation 
and they had some concerns. The individual----
    Mr. Johnson. So prudent leadership would be poised and 
ready to act if the investigation proved out, right, that you 
would then immediately begin to notify those veterans whose 
information had been compromised? And you are saying that as of 
today there still have been no veterans notified, you are only 
in the process of? Eighteen veterans, how long does that take? 
I can make 18 phone calls in 30 minutes.
    Ms. Berrocal. We have worked with our privacy officer to 
make sure the information is done and that we communicate to 
those veterans as we need to.
    Mr. Johnson. Okay. And have they been communicated with?
    Ms. Berrocal. I believe so.
    Mr. Johnson. You believe so.
    Ms. Berrocal. Yes, sir.
    Mr. Johnson. But you are not certain.
    Ms. Berrocal. The 18 have been communicated. The individual 
indicated that----
    Mr. Johnson. Well a few minutes ago you told me that you 
were in the process of notifying them, now you are saying that 
they have been notified?
    Ms. Berrocal. We have communicated with the privacy 
officer----
    Mr. Johnson. No, no, no.
    Ms. Berrocal [continuing]. Whose responsibility is to 
communicate----
    Mr. Johnson. I am not asking if you communicated with the 
privacy officer. Have the veterans whose information been 
compromised been notified that their information has been 
compromised and sold by an employee under your direction?
    Ms. Berrocal. I will have to get that information for you.
    Mr. Johnson. Okay. So now you don't know. First it was you 
got a process, then they have been notified, and now you don't 
know.
    Mr. Schoenhard, if I am the wing commander I am paying real 
close attention to these answers.
    Mr. Chairman, I yield back.
    Mr. Schoenhard. I can answer the question for you. 
According to the OIG last night they have not been contacted.
    The Chairman. Mr. McNerney.
    Mr. McNerney. Thank you, Mr. Chairman.
    Mr. Schoenhard, I thought it was interesting that you had 
assessment--your assessment was that the transparency at the VA 
hospitals is superior to the transparency in the private 
sector, and I actually do believe that, but in this particular 
case is the problem that we are seeing in Miami, is that a 
transparency issue or is something else going on that is 
causing this set of problems or what--what is going on here? I 
don't understand why this facility is having so many problems.
    Mr. Schoenhard. Well, sir, we have a culture which is in 
the process of improving, and I saw the chairman's bar graphs 
earlier in terms of the results, but what we are doing is 
holding people more accountable over time than has been done in 
the past, and that is what we expect a medical director to do. 
And there will be issues and concerns that arise what to----
    Mr. McNerney. So in prior years people weren't being held 
accountable.
    Ms. Berrocal.----
    Mr. Schoenhard. They were, sir. I want to be careful with 
the impression left there. But there is now increased sense of 
accountability.
    And the thing which I would also say that is beneficial 
here is that we have the support of our union partners and our 
veteran service organizations in making this change under Ms. 
Berrocal's leadership.
    Mr. McNerney. Ms. Berrocal, what is your assessment of why 
there are so many problems in Miami?
    Ms. Berrocal. Miami I think in part had--when I arrived 
Miami had a number of critical vacancies, including the nurse 
exec who had been selected for a previous position, the 
associate director who oversees the administrative part of the 
operation who had been--who left shortly after I arrived. There 
were at least ten vacancies at the time from senior leadership 
positions that would set the tone and lead the organization.
    I have had--at this point, and there have been----
    Mr. McNerney. Have these been filled now?
    Ms. Berrocal. Sir? Yes.
    Mr. McNerney. Have these vacancies been filled?
    Ms. Berrocal. I have spent whatever time I haven't been 
dealing with these kinds of situations I have spent trying to 
recruit a really incredible team of competent people to see 
this organization through this.
    Mr. McNerney. The thing is that in 2009 we had this 
institution in front of us because of the endoscopy issue, so--
and I take it Mr. Schoenhard's statement that it takes time to 
turn around, but 2 years it is a fair amount of time. I mean 
you can do a lot in 2 years.
    Ms. Berrocal. I am sorry?
    Mr. McNerney. So why are we seeing you again here in 2 
years? I don't understand why more hasn't happened in this one 
institution.
    Ms. Berrocal. I believe that, you know, we again had--I 
have spent these 3 years, the initial year assessing the 
organization and preparing the organization to face the 
challenges that we have with our Veterans and the ones coming 
up. I have had the opportunity to review the strengths and the 
weaknesses of our--of the staff and to not only fill the 
positions that were vacant, and that includes many of the 
service chief leadership positions, we have done almost a 
complete turn around there, and in addition to that, I have 
moved positions--individuals from previous positions to 
positions where their skills are enhanced.
    Mr. McNerney. So are these positions hard to fill? Are 
people not wanting these positions?
    Ms. Berrocal. Some of these positions are hard to fill.
    Miami has gone through, in the last three and a half years, 
through a tremendous amount of scrutiny, and unfortunately when 
these situations happen they--it takes a toll on the 
organization. It is difficult to recruit people to come to an 
institute that has this amount of oversight.
    Mr. McNerney. Well, let us talk about cost overruns for a 
little while. How does the facility run a $30 million deficit? 
I mean what does that mean? Does the money come from other 
facilities? Are other facilities being hurt because the Miami 
facility is running a deficit? Do bills not go paid? I mean how 
do you do that? How does that operate?
    Mr. Weaver. Sir, what happens at the--just to talk a little 
bit about the budget process. At the national level they 
allocate X dollars for each network and then the network 
through a collaborative effort partnership with the directors 
make a determination of what the budget should be for each 
medical center based on the unique number of patients that are 
there, the complexity of the patients, et cetera.
    During this past year--well, first of all the network holds 
a small amount of money in reserve for emergency situations 
like hurricanes, wild fires, et cetera, and we also hold some 
funds in reserve that the medical centers have agreed to have 
for high-tech/high cost and some other kinds of things.
    So as Miami moved forward, and we have other medical 
centers in the same situation, they--this past year they had 
some financial challenges that were not anticipated and they 
were also making some changes within their organization which 
creates--when you bring in--trying to meet the priorities of 
the agency we had to add some staff, and when you do that 
sometimes there is some overruns because you are waiting for 
people either to transition out or we have to move them from 
one program to another.
    So within that--those dynamics we were faced--Miami 
specifically was faced with a deficit, and the network worked 
with them to meet their needs.
    And I go back to one of my earlier statements, is that our 
focus is on quality of care, that cannot be compromised. We 
look at satisfaction and cost effectiveness.
    So this past year we were able to work with Miami and they 
ended the year with a balanced budget.
    Mr. McNerney. All right, I am going to have to yield back.
    The Chairman. Ms. Berrocal, I was going go another line of 
questions, but since we are talking about budgets and funding 
is it correct that--I think it may have recently been filled--
but is it correct that the public affairs position at your 
facility was vacant for 2 years and during that time basically 
it was filled by rotating service chiefs to fill those duties?
    Ms. Berrocal. The specific public affairs position at Miami 
has been vacant for quite some time, and during that period of 
time I had established a communications and protocol section. 
The chief of that section has responsibility for the media 
session, for the public affairs area, and for outreach section 
of the medical center.
    The Chairman. But there is a vacant public affairs position 
today?
    Ms. Berrocal. No, there is not a vacant position today.
    The Chairman. There was 2 years up til now. I mean this was 
an open position for 2 years.
    Ms. Berrocal. Approximately, that is correct.
    The Chairman. Okay. Where does the salary money for a 
position like that go when that position is unfilled?
    Ms. Berrocal. It goes into operations into what we might 
need to run the medical center.
    Our medical center, as I indicated before, has increased 
the number of veterans that we have seen, more--almost double 
the national average, so we are seeing a lot more patients.
    In addition to that we are a referral facility as Mr. 
Weaver had indicated for several of the other facilities within 
our Network, so we receive patients from the other facilities 
in the medical--in the Network to be able to address their 
needs and that also impacts on our budget.
    In addition to that we--fewer Veterans have insurance right 
now and so it impacts our ability to collect from insurance 
also to supplement our budget, which is also something we 
utilize.
    So those--in addition to that during this current year we 
have finalized a very robust budget briefing where each 
department received what money they would get and they were 
asked to review their programs to let us know how they were 
going to be accomplishing the work that needed to be done.
    So the budget briefings brought in every single one of the 
service chiefs to provide information as to how we were going 
to meet the budget moving forward, including efficiencies that 
we could create such as merging different departments under one 
leadership, working with other facilities to collaborate on 
workload, redesigning positions.
    The Chairman. Mr. Weaver, how many facilities within VISN 8 
ran a deficit this year?
    Mr. Weaver. We have approximately five out of our seven.
    The Chairman. Five ran a deficit out of seven.
    Mr. Weaver. Right.
    The Chairman. Who was the highest?
    Mr. Weaver. The highest--well, I am not going--I don't 
recall the highest. I don't remember if it was Tampa or--I 
don't recall, sir.
    The Chairman. Okay. Would you report back to us who has the 
highest?
    Mr. Weaver. I will. I will give you the deficits for each 
of the facilities. In fact I can probably get it now.
    The Chairman. How short was Miami? You said that number I 
think already. What kind of deficit did they run?
    Mr. Weaver. I have them here, sir.
    Miami at the end was 19.7 million, and our highest was 
Tampa at $28.4 million.
    The Chairman. Did you approve the two and a half million 
dollar executive suite renovation at Miami?
    Mr. Weaver. I am sorry?
    The Chairman. Did you approve the two and a half million 
dollars executive suite renovation in Miami?
    Mr. Weaver. That would have--I think that would have come 
through my office.
    The Chairman. It would have?
    Mr. Weaver. I think I had better get back with you on that. 
I want to be 100 percent sure that I am clear on that.
    The Chairman. Ms. Berrocal, did you suspend golf cart 
service for the veterans?
    Ms. Berrocal. Did I suspend what, sir?
    The Chairman. I am sorry. Did you suspend golf cart service 
for the veterans in the parking lot?
    Ms. Berrocal. We did. In the parking lot we did suspend 
the--that service. We--what we did was when----
    The Chairman. That is all.
    Ms. Berrocal [continuing]. At the Fisher House----
    The Chairman. I just wanted to know if you did. You did.
    Now how did you determine that the current office 
renovation of approximately $1 million to your executive suite 
wasn't sufficient and that two and a half million renovation 
was more important than golf cart escorts for the veterans 
trying to come into your facility?
    Ms. Berrocal. Sir, I would have to get back to you on that.
    The Chairman. Well, which one is more important, your 
office or golf carts for the veterans to get to the hospital?
    Ms. Berrocal. I would always put the Veteran first, sir.
    The Chairman. But you canceled the golf cart.
    Ms. Berrocal. The golf cart issue was canceled during this 
year. I would have to look at the information that you are 
giving me about the renovations, but----
    The Chairman. Have you renovated your office?
    Ms. Berrocal. My office is not renovated.
    The Chairman. Are you going to be renovating your offices?
    Ms. Berrocal. What we have done with the office was we 
painted the--I would have to look at the information that you 
have on hand.
    The Chairman. Are you going to be renovating your offices?
    Ms. Berrocal. No, sir.
    The Chairman. Okay. So if I produced a contract executed 
that said you were would you change your answer?
    Ms. Berrocal. I really would need to see what--I really 
would need to see what we are----
    The Chairman. We will produce it for you. We will show it 
to you. You are. You have contracted for that to be done.
    I just think it is egregious that you would stop golf carts 
from escorting veterans to the front door but you would sign a 
contract or somebody would sign a contract to expand the 
executive offices. Doesn't that sound odd?
    Ms. Berrocal. Yes, sir.
    The Chairman. Dr. Roe, welcome back. Took a trip to 
Afghanistan over the weekend, thank you very much. You and Mr. 
Walz I know went along with some other members, thank you for 
making that trip.
    You are recognized if you have some questions.
    Mr. Roe. Thank you, chairman, for recognizing me, and yes 
it was a great trip. Mr. Walz and I, along with other members 
of the Veterans Affairs Committee, had a great visit with our 
troops in Afghanistan.
    One of the problems I have as a health care provider when 
you look at some of the issues here, Ms. Berrocal, how would 
you--because I have had to do this my entire life--be able to 
sit down with a family of a patient that has had a mistake 
made, an error like the way these scopes were cleaned, and sit 
down and talk to them? That would be one thing. But how would 
you sit down and talk to the 79 who didn't get notified and 12 
others that were picked up by somebody else? How would you look 
them in the eye and say I am sorry, or would you look to have 
procedures that that could never happen again?
    Because whether the virus was transmitted or not is 
irrelevant, the fact is these people weren't notified that 
something could have happened to them, is inexcusable. I had to 
be the one that would sit down and say hey, I didn't get this 
lab test.
    Can you sit down eyeball to eyeball with that patient 
across the table from you and give them a correct answer about 
why that didn't happen? Why maybe their life was put at risk?
    Ms. Berrocal. I have always strived to be very patient 
centered, and precisely the reason why those patients were 
identified----
    Mr. Roe. Did you talk to any of them personally?
    Ms. Berrocal. Sir?
    Mr. Roe. Did you talk to any of them personally? Did you 
sit down yourself as basically the CEO responsible for patient 
care at that hospital and say this happened?
    Ms. Berrocal. What I did was I submitted an apology in the 
original letter of notification that was heart felt, and in 
addition to that I had my clinicians meet with them so that if 
there were any follow-up questions they had in terms of the 
clinical----
    Mr. Roe. How do you explain that that happened, I mean when 
there were so many that fell through the cracks? In other words 
how did that big a mistake happen?
    Ms. Berrocal. You know, as the AIB points out there were a 
series of areas that had problems for years, and the AIB 
identified them and I proceeded to address those issues.
    Mr. Roe. So there are no issues like that now?
    Ms. Berrocal. I don't have those issues right now.
    Now I--you know, I would like to point out that the 
additional members that were identified were identified because 
Miami did the right thing to--I personally did the right thing 
to report that there was a problem and that we should continue 
to look further, and my commitment to this committee and to 
anyone who will listen is that I will continue to look.
    Mr. Roe. I know you mentioned or Mr. Weaver mentioned that 
five of the seven VISNs were in a deficit, and I certainly 
understand from talking to my own VA at home in the VISN why 
that is correct is that they are collecting less private 
insurance dollars. But to go with The CHAIRMAN's questions a 
moment ago, if I were having problems buying food, which is 
pretty basic, I wouldn't go remodel the inside of my house.
    And the question is, if we are not providing basic health 
care needs for our veterans, why are we fixing up my office so 
it looks nice?
    Ms. Berrocal. You know, I would like----
    Mr. Roe. Wait, I want to ask Mr. Weaver that. Is that being 
done? I know you didn't answer the question the chairman asked 
a minute ago, maybe you couldn't and that is if you can't.
    Mr. Weaver. I think I misunderstood what he said. I thought 
he was saying emergency room and I was thinking about the 
trailers outside of the facility, so with my apology I just 
misunderstood that.
    As far as executive offices no, I think we have to take a 
look at what this contract has, and if that is indeed what it 
is then we need to take a look to see----
    Mr. Roe. I guess a question, let me ask it again. You can't 
buy food in your house, that is pretty basic.
    Mr. Weaver. Right.
    Mr. Roe. Would you be remodeling the bedroom?
    Mr. Weaver. No.
    Mr. Roe. No.
    Mr. Weaver. You are absolutely right, sir.
    Mr. Roe. You wouldn't, you would be spending that money on 
veterans, on their health care, the men and women that I went 
out to the forward operating base with Sergeant Major Walz and 
shook their hands and looked at them in the eye, that is who 
ultimately will be your client or your patient in the VA 
system.
    One other question, and they may not have this answer, Mr. 
Chairman, but because of this problem in Miami there have been 
numerous settlements in the legal system and it is not clear to 
me in the briefing we have here how much that has been. How 
much money have the taxpayers spent because of this error? And 
I certainly know in the private sector where I came from what 
would happen in that case who would pay that money, but how 
much money has been paid out? And so far it is not clear to me. 
It looks like it is in the millions, but I would like to know 
that number if anybody has it.
    Mr. Weaver. I did not submit that information, but I know 
we would have that information and we can get that from general 
counsel.
    Mr. Roe. Okay. But I would like to have that so the 
Committee would know through this error that was made how much 
the taxpayers were on the hook for, plus the risk that the 
patients had.
    I yield back my time, Mr. Chairman. Thank you.
    The Chairman. Mr. Walz.
    Mr. Walz. Well, thank you, Mr. Chairman, and again, as I 
said, this is a zero sum proposition we are at and I certainly 
take no pleasure, and I can assure all of you that it is not 
through collaboration that this hearing is taking a pretty 
direct turn in a very frustrating and quite honestly a very 
troubling manner for me.
    I will defend anyone's right on due process to the end of 
days, but I want to be very clear, and I have to say Mr. 
Schoenhard, Mr. Johnson might have given you some good advice 
to listen to the wing commander, I am going to speak now as the 
senior NCO and some recommendations, I am going to ask a couple 
things.
    Just some troubling decision-making that I have. Did we 
have a contract to replace locks on the doors?
    Ms. Berrocal. We currently have a contract to replace locks 
on the doors.
    Mr. Walz. What happened? Why did we do it twice for 
$24,000?
    Ms. Berrocal. Sir?
    Mr. Walz. Why did we have to do it twice for $24,000?
    Ms. Berrocal. The most recent contract has to do with the 
keys being lost.
    Mr. Walz. Who lost them?
    Ms. Berrocal. I was personally responsible for that. I 
don't recall the details of why I had--there was something 
happening at the medical center that evening and I took the 
keys out of the lock where I keep the keys in my office, they 
were in a single ring unidentified by anything else. I am 
currently raising a 9-year-old grandson and after addressing 
whatever it was that I had to pull the keys out for I was 
running late to pick him up at school, so I rather than going 
to my office and locking the keys again and leaving I left from 
the location and had the keys in my purse. The----
    Mr. Walz. But I would say, and don't want to cut you off, 
Ms. Berrocal.
    Ms. Berrocal. My car was broken into.
    Mr. Walz. I am certainly sympathetic, but it comes down to 
that accountability piece again in a very strong way.
    And next thing is we have police officer shortages, but are 
we paying police officers overtime to escort employees to their 
car?
    Ms. Berrocal. We are paying police officers overtime. We 
have a remote parking lot because we had to engage in that 
process because we had the Fisher House as well as the mobile 
hours, it took away most of our parking space.
    Mr. Walz. This is the best contract we could get? So we 
signed a contract for parking, it is in a bad neighborhood, we 
are paying 13,000 overtime to escort employees while we are 
shorting officers that are there in case of, and we know that 
VA hospitals can have problems with folks coming in and need to 
have that there. Could that contract have been better written?
    Ms. Berrocal. You know, we do have a contracting session 
that does take care of the contracting options, and we did 
listen to concerns from the employees about with the parking 
area, so we did go and check and it was a safe area.
    I will tell you that the medical center has received 
approval to purchase a piece of land to bring the parking 
closer to the medical center.
    Mr. Walz. Well, my moral is low and I don't work at Miami 
from the things I have heard. Again, perceived reality can be 
reality many times, Mr. Schoenhard, and I am going to leave, 
there is a few things on people removed, reinstated and that.
    I appreciate the candidness here, I will say that. I 
certainly appreciate your devotion, and I know this doesn't 
come from a desire to not provide for veterans at all, but at 
the end of the day outcomes, effectiveness have to be measures 
that we live by.
    And I have to tell you, I have been in numerous VA 
facilities and this is not the norm, it is certainly not there.
    And so again, I am very respectful of the due process and 
this was not meant to be--I can tell you I was hoping it 
wouldn't go this direction, but it is very obvious to me that 
the facts stand pretty strongly.
    So Mr. Chairman, I will yield back to your side for some 
follow up.
    The Chairman. Mr. Amodei, do you have any questions?
    Mr. Amodei. No, sir.
    The Chairman. Mr. Johnson.
    Mr. Johnson. Thank you, Mr. Chairman.
    Mr. Schoenhard, in your last few comments you talked about 
how you didn't want the wrong perception to be left here. You 
talked about how you thought when asked what the problems were 
what was the root cause of so many problems in Miami you talked 
about the cultural problems and the fact that you thought the 
culture was improving.
    Ms. Berrocal. has been there for 4 years. How much time do 
you give to see cultural improvement? I have a follow-up 
question so please answer that one quickly.
    Mr. Schoenhard. Sir, let me just again emphasize, and I 
appreciate the opportunity to respond. We will put in 
leadership that which is in the best interest of our veterans.
    Mr. Johnson. Great, great, I am glad you are going to do 
that, so then let me ask you the question. You were the COO of 
what company again?
    Mr. Schoenhard. SSM Health care.
    Mr. Johnson. Okay. How many locations, how many operating 
locations--I am not particular with them--but how many 
operating locations did you have?
    Mr. Schoenhard. We had about 20 hospitals.
    Mr. Johnson. Okay. All right. Did you know when you went 
into your staff meetings with your CEO--I set on the executive 
level of a company as well.
    Mr. Schoenhard. Uh-huh.
    Mr. Johnson. When you went into the meetings with your CEO 
did you know the operating parameters financially and otherwise 
of those 20 locations?
    Mr. Schoenhard. Yes, sir.
    Mr. Johnson. And you could speak to those details in that 
meeting, correct?
    Mr. Schoenhard. Yes, sir.
    Mr. Johnson. And yet you have a VISN director here who has 
seven and couldn't answer the chairman's question about which 
one had the highest deficit. Does that seem odd to you?
    Mr. Schoenhard. Well, sir----
    Mr. Johnson. In that same line of questioning the chairman 
asked repeatedly about a contract to renovate the executive 
office suite and somehow Mr. Weaver heard emergency room 
trailers.
    You know, I am not sure what is going on here, but I really 
hope that you are sincere about your comments about wanting to 
establish leadership accountability.
    I have a few more questions.
    Mr. Schoenhard. May I respond?
    Mr. Johnson. Yeah, please.
    Mr. Schoenhard. Thank you.
    Let me just emphasize again that leadership shapes a 
culture of any organization, you and I----
    Mr. Johnson. Starts at the top, you and I both know that.
    Mr. Schoenhard. That is correct, sir. And----
    Mr. Johnson. But what changes have been made at the top 
since you got there since these problems came to your 
attention, what changes at the top and how have you established 
accountability with Mr. Weaver and Mrs. Berrocal?
    Mr. Schoenhard. And we will continue to monitor all of what 
is going on. I can assure you----
    Mr. Johnson. Not monitor. Monitoring doesn't establish 
accountability.
    Mr. Schoenhard. By monitoring----
    Mr. Johnson. Are you denying any of these facts that are 
coming out?
    Mr. Schoenhard. No, but I will say this, we will make 
judgments regarding what is in the best interest of our 
veterans in service.
    Mr. Johnson. Well, I am going have to disagree that you are 
making those judgments up until now. I am going trust that you 
are going to make those because you have told this Committee 
that that is what you stand for.
    Mr. Schoenhard. Yes, sir.
    Mr. Johnson. I am going to hold you to your word. Those 
judgments have not been made thus far, that is what concerns 
me.
    Mr. Schoenhard. But could I----
    Mr. Johnson. Mr. Weaver, based on our investigation it 
appears that staff directly connected to the Miami VAMC 
director identified employees to be interviewed by the VISN 
during the administrative investigative board and that the VISN 
used those names for their interviews.
    Now I am not a rocket scientist, but to me this seems like 
a conflict of interest given that Miami leadership, if the 
people being interviewed about leadership works directly in the 
leadership team they can influence the investigation.
    Why would VISN seek such input from the people that are 
under investigation?
    Mr. Weaver. Which AIB was that?
    Mr. Johnson. I don't have a number right here in front of 
me. Leadership. The leadership administrative investigative 
board.
    Mr. Weaver. Okay. That would have been on the third one, 
the unanimous letter.
    The individuals who would have been interviewed would have 
been anyone who would have been cited in the letter, and then 
also we would ask the leadership to look at the letter and see 
if there was anything that we needed to include, plus the 
chairman of the AIB had latitude to chose who he--or his team 
wanted to interview. And his team was composed of people 
outside of the network, they were not members of Miami or VISN 
8.
    Mr. Johnson. Mr. Chairman, I think I am going to yield back 
any remaining time. And I am just going to summarize by saying 
this. You know, I am sort of at a loss for words with what I 
have heard here today and what I have read in the documents 
that have been provided to this Committee thus far.
    And Mr. Schoenhard, I don't envy your position because I 
think you have some tough decisions to make sir if you are 
going to stand firm on your commitment to establish leadership 
accountability.
    Mr. Schoenhard. Sir, I assure you and Members of the 
Committee and all veterans, we will provide the leadership that 
is in the best interest of your veterans.
    I just want to say also we have in Mr. Weaver and Ms. 
Berrocal two dedicated public servants who have given their 
lives to this mission. This is the most mission driven 
organization I have ever been a part of. We have executives 
like Mr. Weaver and Ms. Berrocal who have options to go to the 
private sector. They could make more money than they do, but 
they care about this mission.
    Mr. Johnson. You know, sir, I would recommend that you let 
them go. That would be my recommendation.
    I yield back, Mr. Chairman.
    The Chairman. I apologize, I was just given some numbers, 
and this came from VA and I don't know where the conflict is 
and we will try to research and see if the numbers that VA 
provided us are incorrect, but it says five medical centers in 
VISN 8 received additional funds at the end of fiscal year 
2011, those stations and the amounts they received are as 
follows, and the number one was Miami at 29.7 million. Now you 
said it was only 19 million. Where is the discrepancy?
    Mr. Weaver. The information I have is information that was 
prepared for me by my fiscal officer and we will see if there 
is some kind of correction that is needed.
    The Chairman. Okay. Ms. Berrocal, how many acting chiefs 
are there for physical medicine and rehabilitation services?
    Ms. Berrocal. Right now there would be one acting chief.
    The Chairman. Okay. I have a letter that you signed on 
September 1st of 2011, which would have been a month ago, 
effective August 1st until further notice two physicians are 
designated as acting chiefs. Why would that be and how are they 
being compensated and is this the same job?
    Ms. Berrocal. There would be one individual serving at a 
time as the acting chief. If there were two individuals it 
would be----
    The Chairman. This says instructions, effective August 1st 
until further notice doctor and doctor are designated as acting 
chiefs of physical medicine and rehabilitative service at the 
Miami VA health care system. Signed Mary D. Berrocal.
    Ms. Berrocal. As a general rule we would have one 
individual serve at a time being the leader of the section.
    In terms of their compensation at this time no additional 
compensation has been received to my knowledge. What we have 
done in the past is as individuals had served----
    The Chairman. So wait, so they are both being compensated 
as physicians----
    Ms. Berrocal. As physicians.
    The Chairman [continuing]. But not as----
    Ms. Berrocal. As acting.
    The Chairman [continuing]. As the chief.
    Ms. Berrocal. Correct.
    The Chairman. Okay. Where does that money go?
    Ms. Berrocal. Sir?
    The Chairman. Where does the chief's salary go then? If 
nobody is being paid that salary where is it going?
    Ms. Berrocal. Any money that is the result of vacancies 
would go back into operations.
    The Chairman. Okay. Let me see if I can jog your memory 
just a little bit about the executive office and relocation 
from the 2nd floor to the 12th floor A and B. Were you aware 
that you were moving from the 2nd to the 12th floor?
    Ms. Berrocal. Oh, okay, now I know what you are talking 
about. Yes, what we are doing--thank you for the clarification.
    What we are doing is Miami has had tremendous space issues 
because we are kind of like locked down by space, and----
    The Chairman. And let me also, I understand you are locked 
down by space, but I understand this renovation is going to 
take patient rooms in order to accomplish; is that correct?
    Ms. Berrocal. Well, what we are doing is actually we have a 
master space plan----
    The Chairman. Is it going to take patient rooms?
    Ms. Berrocal. What we are doing is shifting it. We are 
going to be trying to do the patient care services in the lower 
floors and consolidate so that we can gain some efficiencies. 
Right now we have individuals from different departments that 
are in different areas.
    So what I set up for that was a three-tier program to 
review the space needs of Miami. One of the issues was we had 
somebody from central office come and do an assessment of the 
physical plan to see moving into the future what the needs were 
going to be, and with that determined, for example, how much 
square footage we would need for different areas.
    Separate from that then I had a clinical group that is 
looking at patient flow to determine once we have that piece 
of----
    The Chairman. But I am looking specifically. So you are not 
expanding the size of your executive offices by your move, 
okay, they are going to be the same size or less.
    Ms. Berrocal. Sir, that is what I would anticipate, yes.
    The Chairman. Okay.
    Ms. Berrocal. The intent is to create more space----
    The Chairman. But when I asked you the question at a two 
and a half million dollar renovation why would you not have 
known? I mean if your whole offices are being moved ten floors.
    Ms. Berrocal. This is a very long-term plan that we have in 
place.
    The Chairman. This is actually a contract. And by the way, 
I have a service that tracks government contracts----
    Ms. Berrocal. Uh-huh.
    The Chairman [continuing]. So we have the ability to see 
all of this information, and the notice was on June 13th of 
2011.
    Ms. Berrocal. I believe that the idea of moving the 
executive office onto the 12th floor has been in the plans for 
quite some time. The idea was to be able to move the 
administrative functions to the higher floors and allow all the 
patient care functions to happen in the lower floors so that we 
can become more efficient and more patient centered.
    We have also done--as I said had a clinical group look to 
make sure that our space is fully utilized in the way that it 
is patient centered and that we do not have the patients going 
from one place to another to try to receive their care in a way 
that doesn't make any sense. So we are improving patient flow.
    The Chairman. Thank you, that is your explanation and I 
appreciate you being so candid with your explanation.
    Mr. Weaver, are bonuses for directors--is one of the facets 
of bonuses for a director tied to patient safety reports?
    Mr. Weaver. We take everything--when we do a recommendation 
for a bonus we look at the performance measures and then any 
other information that would be relevant, and then the 
recommendations go to central office.
    The Chairman. But are patient safety reports one of those 
facets?
    Mr. Weaver. That would be a factor.
    The Chairman. Did Ms. Berrocal receive a bonus in fiscal 
year 2011?
    Mr. Weaver. No, she did not.
    The Chairman. Did she receive one in 2010?
    Mr. Weaver. No, she did not.
    The Chairman. You are absolutely correct?
    Mr. Weaver. No bonus, she----
    The Chairman. You are sure?
    Mr. Weaver. Yes, but retention--now she has retention, that 
is not a bonus.
    The Chairman. Oh, she got retention money.
    Mr. Weaver. Right.
    The Chairman. Okay. And we need to keep Ms. Berrocal?
    Mr. Weaver. Well, my position is that in 2009--well, she 
came in 2008--but 2009 we had obviously some significant 
problems, we have been----
    The Chairman. You obviously still have significant 
problems.
    Mr. Weaver. Well, yes, sir.
    The Chairman. How much has she received in retention money?
    Mr. Weaver. Ten percent of----
    The Chairman. Both years?
    Mr. Weaver. Correct.
    The Chairman. So roughly 25,000?
    Mr. Weaver. Probably--I think it is----
    The Chairman. Ms. Berrocal, would you----
    Mr. Weaver [continuing]. $18,000 about, and so it would 
be----
    The Chairman. Per year.
    Mr. Weaver. Per year.
    The Chairman. Okay. So we are talking 36----
    Mr. Weaver. Correct.
    The Chairman. Okay. Ms. Berrocal, does the facility have 
all the supplies it needs to properly care for veterans?
    Ms. Berrocal. I believe at this point we do. We have looked 
at all of our equipment and I have requested information from 
the different departments to ensure that we have adequate 
supplies and equipment.
    The Chairman. Well, all of your labs or services are okay, 
they are not having any difficulty in getting any needed 
pharmaceutical supplies?
    Ms. Berrocal. Some of the things that we are receiving 
should be, you know, it is a process that goes on the whole 
year so some of the things that they identify that they need 
they submit them to us, we review through a committee, and then 
we allocate the money appropriately to ensure that we have the 
equipment.
    The Chairman. Are you aware of any service or lab having to 
cancel a service because of lack of the necessary items to 
perform that service?
    Ms. Berrocal. I am not aware of a specific instance, 
unless----
    The Chairman. Are you aware of any instance?
    Ms. Berrocal. Where we have canceled services for lack of--
--
    The Chairman. You didn't have the supplies to perform 
whatever the job was. Maybe you are just not aware. Could that 
be? I would hope that you would, but maybe you are just not 
aware.
    Ms. Berrocal. The service we have in place is that when 
services have a need that has not been met they submit those 
requests through the equipment committee and then it makes it 
to our level to make decisions. So anything that the services 
have requested would have been reviewed with the appropriate 
data and with the clinical input to determine whether or not 
that was something that we needed to get at the time.
    The Chairman. Are you aware of any equipment deficiencies 
or malfunctions that have impacted patient safety at your 
facility?
    Ms. Berrocal. Again, whenever there are, you know, 
equipment needs or equipment malfunctions or anything that 
needs repairs or anything of that nature I depend on the 
services to provide that information up through the process we 
have in place so that we are made aware and we can allocate the 
money to address the issues.
    The Chairman. Mr. Johnson.
    Mr. Johnson. Thank you, Mr. Chairman.
    The last line of questioning highlighted a couple of more 
questions for me.
    Mr. Schoenhard, it has been established here the results of 
the AIB investigations recommended disciplinary action. You 
have confirmed that admonishment has been the result. Does it 
seem odd to you that a retention bonus would be paid to someone 
that is not meeting their performance standards?
    Mr. Schoenhard. Sir, we take into account disciplinary 
action as it relates to retention incentives. There was 
disciplinary action taken. It was our judgment that in order to 
continue to turn the ship that it is important that the 
department have the ability to retain the executives that we 
think are turning the ship in the way that it needs to go. We 
do that very carefully.
    I want to convey to the Committee that this is done with a 
lot of care and concern, it is done with fiscal stewardship, 
and it is done in an effort to keep a highly qualified 
workforce in place.
    Mr. Johnson. Well, you have obviously got the patience of 
Job, because this has been a 4 year trail to lead us to where 
we are at today.
    You saw the performance metrics that the chairman showed 
earlier, they are headed south, and yet you are maintaining 
your steadfast support for the leadership that is in place.
    Back to your commercial experience. Would you have been 
able to recommend to your CEO performance incentives and 
bonuses for executives that were not meeting their performance 
standards? I can tell you what the answer was in my company.
    Mr. Schoenhard. Yeah. Sir, let me again clarify. There was 
no performance bonus paid.
    Mr. Johnson. No, retention bonus, yeah.
    Mr. Schoenhard. And that was based on performance.
    Mr. Johnson. What is a retention bonus?
    Mr. Schoenhard. A retention incentive is a tool that is 
available in government to keep highly qualified individuals.
    Mr. Johnson. Highly qualified.
    Mr. Schoenhard. Yes.
    Mr. Johnson. Which would insinuate that they are meeting 
their performance standards, correct? At least meeting their 
performance standards. Because again, I worked in the Federal 
Government so I know what the civilian employee performance 
standards are.
    Mr. Schoenhard. Sir, I think the thing that I would like to 
convey, and Mr. Weaver can speak to this and Ms. Berrocal in 
more detail, we are improving care at Miami. We are continuing 
to make progress with the performance measures and that is what 
is in the best interest of veterans to provide care. Are we 
there yet? No, sir, we are not.
    And when you stopped me earlier in terms of our continuing 
to evaluate, I can assure you we do a day-by-day valuation of 
our leadership.
    Mr. Johnson. Okay. Well, something that I think our 
veterans----
    Mr. Schoenhard. And I assure you we will make decisions 
that are in the best interest of care----
    Mr. Johnson. Well, I think our veterans are going to expect 
that. They have a right to expect that.
    Mr. Schoenhard. Yes, sir, they do.
    Mr. Johnson. How long does an admonishment stay in an 
employee's record?
    Mr. Schoenhard. Two years. I am sorry, I have to----
    Mr. Johnson. Is it punitive?
    Mr. Schoenhard. It is a form of disciplinary action, yes, 
sir.
    Mr. Johnson. Is it punitive? Does it cost them anything? Is 
there a suspension? Is there----
    Mr. Schoenhard. No, it is a level of----
    Mr. Johnson [continuing]. A reduction in salary?
    Mr. Schoenhard. No, it is an admonishment. There are 
different levels. And let me also explain the process by which 
the level of disciplinary action is rendered.
    When there is administrative action proposed that is in the 
hands of the person who has responsibility to that person. We 
go through a process whereby general counsel and the Office of 
Human Resource Management----
    Mr. Johnson. Uh-huh.
    Mr. Schoenhard [continuing]. Review the fairness and the 
justice and the supportability of the action and that was done 
in this case with the two people from the national AIB. And we 
monitor that continuously.
    We are looking at continued ways in which to improve that 
process, but it is done in a very deliberate way that trying to 
provide fairness and justice for the individual, but also holds 
the executive accountable for performance.
    Mr. Johnson. Did you initiate the letter of admonishment or 
who did that?
    Mr. Schoenhard. In the case of Ms. Berrocal that came from 
Mr. Weaver, it comes from the direct report, and in the case of 
Dr. Vara from the medical center chief of staff.
    Mr. Johnson. Okay. Well, like I have said, I think our 
veterans deserve better, I think they expect better, and we got 
a lot of questions that have been asked and answered here 
today.
    And Mr. Chairman, I am even more concerned leaving the 
hearing than I was before I came in. I yield back.
    The Chairman. Mr. Weaver and/or Ms. Berrocal, is the 
domiciliary facility still going to be built in Miami as was 
originally planned?
    Mr. Weaver. The answer to that is not as originally 
planned. We had difficulties with the county commissioners in 
Broward County, they had voted it down.
    What we have done as an alternative is to expand the scope 
of the dom--the domiciliary is going to be built in West Palm 
Beach on the campus there and we will be expanding that for 
southern Florida. Once we have that expanded then we can make 
an assessment of whether we need to go further into Miami to 
have a--or into Dade County to have a second domiciliary or 
some expansion for that.
    The Chairman. Can you tell me why there have already been 
employees hired for the domiciliary now that it is not going to 
be built in Miami but apparently in Palm Beach. Why were they 
hired and now what happens with those individuals?
    Mr. Weaver. Okay. First of all the reason they were hired 
is that as we were planning to open the domiciliary we--part of 
the rational working at central office they said that we needed 
to bring--we need to bring staff on so that when the 
domiciliary comes live that we would be able to move those 
employees into the domiciliary and have them start working. And 
Ms. Berrocal can talk about what they have been doing in the 
interim.
    The Chairman. Why don't we do that, because I would like to 
know since there is no domiciliary what have they been doing 
and what will they be doing?
    Mr. Weaver. Okay.
    The Chairman. And Ms. Berrocal?
    Ms. Berrocal. Certainly. We were asked to have the 
employees in place by the month of June I believe it was and so 
we proceeded to hire the individuals.
    Because a domiciliary would be a new program it required a 
lot of policy development and just determining how the program 
would run.
    Since the domiciliary--the area where we were going to 
build, the commissioners did not agree to allow the veterans 
to--the veterans program to be in their downtown area----
    The Chairman. I mean you didn't know beforehand? I mean we 
have hired people, we have done planning, we have done 
engineering and all of the things that are necessary and had no 
approval from the local governmental entity as to whether or 
not it met with zoning and codes?
    Ms. Berrocal. We had been requested to hire from the 
program office, so we have----
    The Chairman. Where is the program office?
    Ms. Berrocal. In central office.
    The Chairman. Okay. So it is up here.
    Ms. Berrocal. Sir?
    The Chairman. So it is in Washington.
    Ms. Berrocal. Yes, sir.
    The Chairman. All right. And it goes around the VISN, not 
through the VISN but around the VISN directly to you.
    Ms. Berrocal. No. Everything that we do pretty much goes 
through the Network and then to Washington and we have a very 
fluid communication between the three groups.
    So these individuals, what we have done at the time is the 
director of the dom is a social worker at our facility and he 
has been assisting with developing the new proposal that is 
being submitted to West Palm to have their domiciliary, and 
some of the other individuals that were hired I am able to 
absorb within our needs at the medical center.
    The Chairman. So you have one, but how many people have 
been hired?
    Ms. Berrocal. I don't remember the exact number. I don't 
remember the exact number, but it is probably like----
    The Chairman. Twenty-one?
    Ms. Berrocal. I don't remember the exact number; however, 
what I can tell you is that we have looked through the list and 
on the number of individuals that have been hired that we can 
absorb within vacancies of the medical center as opposed to 
going out and hiring wherever we had those needs, and some of 
the other individuals are continuing to help in the development 
of policies and that kind of thing so that the new proposal can 
go into place.
    The Chairman. Ms. Berrocal, I am going to ask a question 
and it involves a particular employee, but I think they are far 
enough out of somebody's reach that it should not create a 
problem.
    But I have gotten information regarding some email accounts 
that may have been confiscated, and I just want to know, have 
you ever confiscated somebody's email account, and if you did 
can you describe how you did it, what the policies are within 
VA?
    And you know, I just am concerned that policies continue 
even things like emails, even though they are on a government 
system, isn't there a policy in place as to how you lock 
somebody out of their system and don't allow them to have 
access again?
    Ms. Berrocal. I think you are referring specifically to the 
actions that might have been taken with a public affairs 
officer.
    The Chairman. So the question is----
    Ms. Berrocal. So that I can address it specifically.
    The Chairman. Yes.
    Ms. Berrocal. Are we talking about that?
    The Chairman. Yes.
    Ms. Berrocal. So at the time there were--this happened 
during the time of the endoscopies.
    The Chairman. Were you authorized to confiscate their email 
account? And if you did were they ever allowed to reaccess 
their email again?
    Ms. Berrocal. My recollection of the situation, the 
individual had compromised, you know, or it was our 
understanding at the time that they had compromised the medical 
center, and what we did was we did look into the emails. There 
is no--as a public officer there is no privacy in terms of the 
communication.
    The Chairman. That is not what I asked. I mean I 
understand, but is there not a procedure in which you can take 
over somebody's email account and you are saying it was because 
they had compromised the medical center's integrity?
    Ms. Berrocal. Sir, you know, this is approximately 3 years 
ago and what I would like to do if at all possible is request 
if I could speak offline with you at some time once I review 
that folder again.
    The Chairman. That would be fine, but in communications 
with this individual's attorney all 17--all 17 accusations have 
been proven false. All of them.
    Ms. Berrocal. The individual--there was a proposed action 
on this individual.
    What I can say is that the individual sought assistance 
from another individual to move at their choice, to move 
voluntarily outside of the Miami VA Medical Center and be 
transferred to another facility.
    So there was a proposed action and decision made on the 
proposed action and the individual consulted with another 
facility director to request a transfer into that facility 
prior to the actions being taken.
    The Chairman. So this person was accused and just left the 
facility?
    Ms. Berrocal. There was a proposed action----
    The Chairman. Proposed by?
    Ms. Berrocal. By myself, and I had made a decision based on 
the evidence that had been developed.
    The Chairman. And that proposal was to shift this 
individual to an off-site location totally stripping them of 
their original job and they have now been separated from their 
family for some two--or were separated for some 2 years from 
their family, all accusations as you know have been proven 
false, there has never been a shred of evidence.
    And my question is, how do you make an employee whole when 
you charge them with something and it doesn't hold up?
    Ms. Berrocal. Sir, there was--again, there was a proposal 
to an action, and then the evidence was--we had whatever 
evidence we had to support the action as they were proposed, 
and then as I reviewed the evidence then made a decision on the 
action.
    The individual had consulted with another facility director 
who then made the decision to transfer her prior to the 
decision being implemented. So it was a decision that was made 
outside of my scope, I was not aware of it, I did not transfer 
her to that facility, and as a matter of fact the----
    The Chairman. But if you were a trained public affairs 
officer and you were used to dealing with the public and you 
were stuffed somewhere inside of a closed office and not 
allowed to interact with the public, you were just making 
telephone calls, wouldn't you want to get out of that 
environment?
    Ms. Berrocal. What I indicated----
    The Chairman. Don't make it out like she did this because 
she just decided she wanted to transfer a long way away from 
her family.
    Ms. Berrocal. What I would like to say is every employee 
has the opportunity to present their side of the story before a 
decision is made and that due process is provided, and the time 
when the individual was moved from the facility was exactly 
during the time of the endoscopy. I had requested the 
individual to do certain things and they were not done. It was 
a very critical time for the medical center and I needed 
everybody on board and everybody following directions and doing 
what we needed to do to address things in the best interest of 
the veterans.
    The Chairman. So this has nothing to do with collaboration 
or anything, I mean she just didn't do what you wanted her to 
do.
    Ms. Berrocal. Sir?
    The Chairman. She just did not do what you wanted her to 
do?
    Ms. Berrocal. The individual was my direct report we were 
trying to handle a crisis at the medical center, I needed 
everybody to follow directions and not to go on their own 
direction. It was important to have everybody. As a leader of 
the organization it was important to me that everybody was 
following directions.
    The Chairman. So you took a leadership role, removed her 
from her position, put her in an environment that you knew she 
would not be able to do what she wanted to do, and then you 
represent to this Committee that she just decided to transfer 
on her own. No?
    Ms. Berrocal. No, that is not what I am proposing, but I 
really would like to vet the details of this situation.
    The Chairman. No, that is what this hearing is about. So 
offline, online, you know----
    Ms. Berrocal. Okay.
    The Chairman. Okay. We will do it offline at another time 
and--no, we will do it offline at another time and I am very 
appreciative of the candor.
    Mr. Schoenhard, I have great respect for you, you know I 
do, and I know the things that you have said today you mean, 
and I can appreciate that, but I am so saddened, I am so 
saddened by what I have heard today, things that are going on 
at the Miami VA Medical Center that are atrocious, and if it is 
better today I can only imagine--no ma'am, we are done--I can 
only imagine how bad it must have been if you think that it is 
moving in the right direction.
    Somebody has to be held accountable and it hasn't happened. 
People are scared to death of the director. They are scared to 
tell the truth. Why? Because they will be stuffed in a box 
somewhere in an office with no windows making phone calls to 
veterans in an attempt to get them to leave on their own so 
that it can't be said they were forced out.
    I intend to talk to some employees at the facility, and I 
can only imagine what I will find when I directly engage with 
rank and file at that facility. Because if there is even one 
shred of evidence that we have proposed to you today that is 
true the director should not be the director, much less be 
given a retention bonus.
    And by the way, on September 1st of this year I wrote a 
letter to the Secretary which it has not been responded to yet 
in regards to VA using this money for retention bonuses, 
especially for people who we know are going to be retiring in 
the future.
    And so I appreciate all of my colleague being here today to 
talk about a very important issue.
    And no, I don't use a broad brush to paint the entire VA 
system, because I know that there are dedicated, hard working 
individuals at every level of the VA that are taking care of 
our American heroes because we owe them nothing less, and I am 
sad today.
    With that we are adjourned.
    [Whereupon, at 12:57 p.m., the Committee was adjourned.]



                            A P P E N D I X

                              ----------                              

              Prepared Statement of Honorable Jeff Miller,
                Chairman, Committee on Veterans' Affairs

    Good morning. This hearing will come to order.
    Before we proceed, I would like to take care of an item of 
Committee business by welcoming our two newest members, Representatives 
Turner and Amodei, and adopting a resolution filling our Subcommittee 
rosters for the remainder of the 112th Congress.
    Representative Mark Amodei represents the second district of 
Nevada, which covers most of the state. Representative Amodei is also a 
veteran, having served as a J.A.G. officer in the United States Army. 
Before joining us here, he also served as a state senator in Nevada.
    I'd also like to welcome another Army veteran to the Committee. 
Congressman Bob Turner represents New York's ninth district, in New 
York City, where he has been a lifelong resident. He has also worked 40 
years in the television industry as a leader of both small and large 
companies.
    Should either of you like to say a few words, you are now 
recognized.
    For the purpose of creating Subcommittee vacancies for our new 
members, I first would like to ask unanimous consent of the Full 
Committee to accept the removal of Representative Flores of Texas from 
the Disability Assistance and Memorial Affairs Subcommittee and 
Representative Denham from the Economic Opportunity Subcommittee.
    Hearing no objection, so ordered.
    I thank Representatives Flores and Denham for their working with 
the Committee to accommodate our new members.
    The list is before the members and I ask Mr. Bilirakis for a motion 
on this resolution.
    Again, welcome to you both.
    That concludes our business meeting and I would now turn the 
Committee's attention to today's scheduled hearing titled ``Failures at 
Miami VAMC: Window to a National Problem''.
    Welcome to our witnesses. Because of some of the detail we will 
cover today I have thought long and hard about deviating from standard 
Committee practice by requiring each of you to be sworn in before 
giving your testimony. At this time, I do not think that is necessary. 
I trust that each of you would, and will, provide nothing but truthful 
answers to us. That said, we will be listening carefully to what you 
say and I reserve the right, at any moment, to put you under oath. Is 
everyone clear on that? Good, then let's proceed.
    Some of the issues plaguing the VA Medical Center in Miami are not 
new to this Committee.
    The facility came into the spotlight in 2009 when it was discovered 
and reported that endoscopes were not reprocessed correctly, placing 
over two thousand veterans at risk of exposure to disease.
    Nearly 2 years later, after the initial round of notifications, 12 
additional veterans were identified as being at risk of exposure.
    Putting veterans at risk is inexcusable.
    But failure to identify and notify everyone at risk because patient 
logbooks were locked away in a safe is nearly impossible to believe.
    I only say ``nearly impossible'' because that is what, in fact, 
happened.
    However, the issues we are discussing today extend well beyond 
sterilizing reusable medical equipment.
    At the heart of this issue is leadership at VA--at all levels and 
in all parts of the country.
    It is my belief that the failures in leadership and patient safety 
that were brought to light in 2009 are still occurring to this day.
    Multiple investigations have taken place, disciplinary 
recommendations put forth, new processes and procedures developed, new 
policies established- yet the problems are not fixed.
    Earlier this year, VA told this committee in a briefing that things 
were running smoothly in Miami.
    However, the VA Inspector General released a report in August 
detailing how, in one case, 50 percent of the facility employees still 
failed to properly sterilize reusable equipment.
    Recent news reports are also troubling.
    For example, this summer we read about, an Air Force veteran was 
brought to the Miami VAMC from neighboring Jackson Memorial Hospital.
    The veteran had been admitted to the hospital earlier by a friend 
after threatening suicide.
    Once it was realized she was a veteran, she was transferred to the 
Miami VAMC.
    The veteran then escaped and committed ``suicide by cop,'', just 
one day after she had been admitted to a system that should have 
protected her in her clearly fragile state of mind.
    In another troubling story released last month, the Miami Herald 
reported on its findings contained within one of several administrative 
investigation boards, or ``AIBs'', conducted at the Miami VAMC in the 
wake of the colonoscopy equipment cleaning problems and subsequent 
notifications to veterans.
    As the Herald noted, disciplinary action was recommended for a 
``lack of oversight'' by hospital leadership.
    The article also noted that the hospital's director was reinstated 
less than 2 months after the report's recommendations were completed, 
and that VA declined to comment on what actions were taken based on the 
recommendations.
    It is the Committee's desire that today's witnesses outline a clear 
process for VA's leaders in preventing and fixing failures that 
compromise the safety of our veterans.
    The Committee also needs to hear about how a stricter and 
comprehensive process can be put into place so that necessary 
information flows to all levels at VA, from the local level to the 
network level to Central Office.
    We know that currently there is much that goes unreported, and 
given the public, repeat offenses, a solution from VA is overdue.
    VA must also outline how compliance with department policies is 
enforced.
    If employees are circumventing patient safety policies, they must 
be held accountable.
    If policies made by Central Office can easily be circumvented, then 
policy makers at VA must be held accountable, and meaningful, 
enforceable policies put forth.
    A related expectation by the Committee is that existing VA policies 
in place can, and will, be followed by all employees.
    If policies are disregarded or willfully ignored, there should be 
enforcement mechanisms in place and the right people held accountable.
    Otherwise, policies become words on paper and little more.
    An important point to keep in mind throughout today's hearing, and 
moving forward, is that the problems we are discussing are not limited 
to Miami, or even VISN 8.
    The Committee is well aware of similar problems at VAMCs all across 
the country.
    More than once, VA has come before us and said problems at its 
facilities are fixed and ``all is well.''
    More than once, that has been shown not to be the case.
    The Miami facility is one glaring example of this national 
occurrence.
    Just as it should be unacceptable to Secretary Shinseki to be told 
one thing about how VA facilities are faring, only to subsequently be 
told otherwise, it is beyond unacceptable for that to occur before this 
Congressional oversight Committee.
    All of us must be vigilant in rooting out misleading or incomplete 
information that only serves to keep the truth from full view, and 
ultimately harms those we all serve in our common mission . . . the 
veterans of this country.
    Thank you. I appreciate everyone's attendance at this hearing and I 
now yield to the Ranking Member for an opening statement.

                                 
          Prepared Statement of Honorable Ileana Ros-Lehtinen

    Thank you Chairman Miller, Ranking Member Filner, and Members of 
the Committee here today. And once again, thank you for your leadership 
on this issue.
    It seems that each time I come to one of these hearings, I find 
myself saying the same thing: we continue to travel down the same path;
    Ever since this shameful failure by the Miami VA Health care System 
came to light over 2 years ago, we have been reassured time and time 
again, even in this very committee room, by the VA that appropriate 
actions were being implemented to prevent this from ever happening 
again.
    However, as of the latest report I have read, dated August 2011, 
there is still a widespread failure within the Miami facility in its 
handling of RME's, or Reusable Medical Equipment.
    While we were told in May of this year that the VA was making 
efforts to improve its procedures for handling RME's, the VA's Office 
of Inspector General was discovering a different story.
    Their review, which took place in April of this year, concluded 
that there was still a 50 percent failure rate for properly handling 
RME's;
    And that the Miami VA facility had still not implemented Standard 
Operating Procedures for sterilization, consistent with the 
manufacturer's instructions, for half of its RME's.
    These are not the only ongoing issues at the Miami VA Medical 
Center.
    This OIG review highlights many deficiencies within the facility in 
the areas of patient safety, cleanliness, as well as many others.
    What is going on in the Miami VA?
    I fear that this problem is not just isolated within Miami either.
    This is shameful.
    We owe our Veterans much more than this.
    They served our Nation bravely, and this is how we repay them?
    We need a drastic review of the processes in place.
    We need to make sure there are proper procedures in place; that we 
have qualified employees who have received all of the proper training; 
that we make sure that our veterans get the quality care they deserve--
and that they do not have to fear for their safety;
    We need to make sure that there is some oversight on how these 
changes are being effected; to ensure that all VA Medical Centers are 
compliant to these procedures;
    We need to make sure that we have the right kind of leadership in 
place that can manage these large facilities, with the right kind of 
experience; and we need to make sure that there is a clear line of 
communication, and those who are responsible for any shortcomings are 
held accountable.
    We need to make sure that we will not be back here in this 
committee room again in 6 months asking yet again: What went wrong?
    Again, I thank the Chairman and the Ranking Member for their 
leadership on this issue.
    Thank you.

                                 
        Prepared Statement of William Schoenhard, FACHE, Deputy
   Under Secretary For Health For Operations and Management Veterans
       Health Administration, U.S. Department of Veterans Affairs

    Mr. Chairman and Members of the Committee: thank you for the 
invitation to appear before you today to discuss the Bruce W. Carter 
Department of Veterans Affairs Medical Center (VAMC), in Miami, 
Florida. I am accompanied today by Mr. Nevin M. Weaver, FACHE, Network 
Director for Veterans Integrated Service Network (VISN) 8; and Ms. Mary 
D. Berrocal, MBA, Director, Miami VA Health care System.
    All of VA's facilities, including the Bruce W. Carter (Miami) VAMC, 
are committed to providing the best care for our Nation's Veterans. We 
want all Veterans who seek VA medical care to have a safe and positive 
experience. Among our ongoing actions to realize this objective, we 
have established a new model of patient-centered care, instituted more 
rigorous measures to ensure staff members are properly trained to 
handle patient needs, and developed enhanced protocols and policies to 
ensure compliance, verification, and confirmation with these standards 
so we deliver Veterans the very best care available. These efforts have 
produced significant results; last month, 20 VAMCs in 15 different 
states across the country were recognized by the independent Joint 
Commission as Top Performers on key quality measures in 2010. The Joint 
Commission recognized a total of 405 hospitals with this distinction, 
meaning that VA received a disproportionately large share of 
commendations for its health care system.
    VA has attained this success through a culture of continuous 
improvement, which is manifested in every one of the more than 1,400 
sites of care in the VA health care system. This is especially true of 
the Miami VAMC. Over the course of the past 2 years, the Miami facility 
has responded to concerns regarding the quality of patient care.
    Since VA identified concerns relating to reprocessing of reusable 
medical equipment in 2009, VA has taken aggressive action to inform, 
test, and support all patients who may have been potentially exposed to 
improperly reprocessed equipment. Additionally, we have increased our 
inspection and audits of reusable medical equipment reprocessing. My 
written statement will provide an overview of the Miami VAMC, describe 
efforts undertaken locally to improve patient safety through policy 
compliance, and review the facility's management of its budget. I will 
emphasize the role of leadership, performance measurement, and a 
culture of patient safety throughout.

Overview of the Miami VAMC

    The Miami VA Health care System serves an estimated 285,000 
Veterans in three counties in South Florida: Miami-Dade, Broward, and 
Monroe. This Health care System's parent facility is the Bruce W. 
Carter VAMC, which provides comprehensive medical, surgical, and 
psychiatric services. It is home to an AIDS/HIV Center, a Prosthetic 
Treatment Center, a Spinal Cord Injury Rehabilitative Center, and a 
Geriatric Research, Education and Clinical Center. The Miami VAMC 
operates 191 hospital beds and oversees six community-based outpatient 
clinics (CBOC) in Homestead (Miami-Dade), Key Largo (Monroe), Pembroke 
Pines, Hollywood, Deerfield Beach, and Coral Springs (Broward), in 
addition to two outpatient clinics in Sunrise (Broward) and Key West 
(Monroe).
    The Miami VA Health care System was recently approved as a kidney 
and liver Transplant Center, and these procedures will be performed in 
a state-of-the-art operating room scheduled to open in the third 
quarter of fiscal year (FY) 2012. The facility also conducts open heart 
surgery for other VA facilities in Florida. It is recognized as the 
Epilepsy Center of Excellence for the Southeast Region, as a Multiple 
Sclerosis Center of Excellence, and as a Center for Excellence in 
Spinal Cord Injury Research. In FY 2011, the Miami VA Health care 
System received the Silver Plus performance award from the American 
Heart Association/American Stroke Association for excellence in stroke 
care.
    The Miami VAMC has continued to improve its performance and 
management and has met VA's target for the ``fully successful'' level 
in 2010; it is on target to meet the same level in 2011. In FY 2010, 
the facility demonstrated overall improvement and sustained improvement 
for both critical and non-critical performance measures. For example, 
through aggressive efforts involving retraining of personnel on 
scheduling and new leadership in the Health Administration Service, 
Miami has continued to show substantial improvement in its access 
measures in the delivery of both primary and specialty care.
    In March 2009, in follow up to a national review of endoscopic 
equipment, the Miami VAMC's quality control staff identified concerns 
about reprocessing of reusable medical equipment. VA then initiated an 
intensive review of patient medical records for Veterans who had 
specific endoscopic procedures with specific types of equipment at the 
Miami VA Health care System between May 2004 and March 12, 2009. VA 
contacted Veterans identified during this review and offered screening 
for viruses that were potentially associated with reusable medical 
equipment that was not reprocessed according to manufacturer's 
instructions. In May 2010, the Miami VAMC discovered more potential 
Veterans who may have had procedures performed during this time period, 
and subsequently identified 91 additional Veterans, whom we also 
notified and offered testing. VA also convened a national Clinical Risk 
Assessment Advisory Board to make recommendations to the Principal 
Deputy Under Secretary for Health as to the clinical risk and whether 
larger-scale notifications or disclosures should be made to Veterans.
    The VISN 8 Network Director convened two Administrative 
Investigation Boards (AIB), and VA also convened a national AIB to 
review issues associated with this event. The national AIB conducted a 
thorough review, gathering facts and circumstances surrounding the 
procedures used to determine the patients in a potential risk pool and 
our notification requirements. This AIB made several recommendations to 
improve these procedures, particularly with regard to identifying 
patients potentially at risk. The AIB concluded that the Miami VA 
Health care System responded promptly upon finding that equipment 
tubing was not being reprocessed in accordance with manufacturers' 
instructions. The AIB further recommended that VA develop national, 
standardized processes to identify patients potentially at risk. 
Finally, the AIB credited the staff whose efforts made this process 
work as well as it did and commended them for their ethical practices 
and transparency in reporting this event. Miami has taken action to 
address all AIB recommendations.

Patient Safety

    The Miami VA Health care System has been recognized consistently by 
VA's National Center for Patient Safety through its Cornerstone 
Recognition Program, which was established in 2008. The Cornerstone 
Recognition Program recognizes the good work done at VA facilities and 
enhances the root cause analysis (RCA) process. The RCA process 
promotes patient safety by identifying the most fundamental reason a 
problem occurred. RCAs are focused on finding vulnerabilities in the 
system and remedying them to prevent a recurrence. The Miami VA Health 
care System received RCA Bronze awards in 2008 and 2009 and was 
recognized with the RCA Gold award in 2010. These awards signify that 
the Miami Patient Safety Program is meeting the RCA requirements as 
outlined in Veterans Health Administration (VHA) Handbook 1050.01 
(``VHA National Patient Safety Improvement Handbook,'' published March 
4, 2011).
    The number of RCAs conducted at Miami in the past year is 
comparable to the number performed at other facilities of a similar or 
higher complexity, and survey results indicate that Miami's scores are 
well within the normal range in VA for a culture of safety. VA 
conducted a total of 33 RCAs related to patient safety at the Miami 
VAMC between January 1, 2009, and September 23, 2011. The facility 
completed and approved all RCAs within the required 45 day time frame.
    Between August 2009, and August 2011, the Miami Patient Safety 
Program has demonstrated 100 percent compliance with responding to 
Patient Safety Alerts issued from VA's National Center for Patient 
Safety. The most recent Patient Safety Program review in 2009 
identified no issues or deficiencies in the Miami Patient Safety 
Program structure. A new report is pending and is scheduled to be 
published within the next month.
    The Miami VAMC has instituted a number of measures and processes to 
ensure compliance and user competence in reprocessing reusable medical 
equipment (RME). The Miami VAMC's RME Committee has an active RME 
Quality Management (QM) interdisciplinary team that conducts 
observations of processes related to set-up, use, pre-cleaning, 
cleaning, reprocessing, transport, and storage of RME. The QM Team 
performs an annual risk assessment, which considers frequency of use 
and risk factors to guide random selection for observation. These 
review processes also validate current equipment against the Equipment 
Inventory List and match standard operating procedures, manufacturers' 
manuals, and user competency assessments.
    The Miami VAMC has developed a ``double review'' process to ensure 
Sterile Processing Department standard operating procedures (SOP) 
accurately reflect the manufacturer's written instructions. These SOPs 
are reviewed by an independent expert and an Infection Control 
practitioner who concurs with the final draft.
    In response to an RCA action, Miami VAMC conducted a wall-to-wall 
RME instrument inventory in April 2011 to ensure that all RME was fully 
accounted for and properly documented. This review also verified that 
all RME reprocessing instructions are reflected in written SOPs and 
document user competence. The Sterile Processing Department obtained 
the services of a contracted company to conduct an inventory of 
surgical instruments so that a new computerized online count sheet 
system could be implemented. The Miami VAMC complies with the infection 
control reporting processes outlined in VHA Directive 2009-004 (``Use 
and Reprocessing of Reusable Medical Equipment (RME) in Veterans Health 
Administration Facilities,'' published February 9, 2009).
    The Associate Director for Patient Care Services is responsible for 
the RME process at the Miami VA Health care System and works with 
iternal organizations to ensure RME issues are reported and addressed 
at least once per month. The Miami VAMC has renovated and upgraded its 
Sterile Processing Department areas and those at the Broward County VA 
Outpatient Clinic to meet the standards established by the Association 
for the Advancement of Medical Instrumentation (AAMI). All rooms have 
traffic-controled doors and require proper attire, and temperature 
control, humidity, and pressure are managed by the Engineering Graphic 
Control. The Associate Director for Patient Care Services at the Miami 
VA Health Care System has completed a course for certification by the 
International Association of Health care Central Services and Material 
Management (IAHCSMM). Currently, 80 percent of technicians in the 
Sterile Processing Department at the Miami VAMC have attained IAHCSMM 
certification. All staff at the Miami VAMC will be certified within 6 
months of employment in the Sterile Processing Department.
    We are fully supporting the Sterile Processing Department's 
staffing with appropriate supervision, education, leadership, and 
program support. The Miami VAMC has either purchased or obligated funds 
to purchase equipment to support RME cleaning, reprocessing, and 
sterilization. The facility is using enzymatic spray to moisten debris 
on instruments and ensure their preparedness for the Sterile Processing 
Department's cleaning and disinfection. The Miami VAMC has replaced 
single layer aprons used by staff in the decontamination room with new 
chemical-resistant brands of impermeable gowns.
    In April 2011, VA's Office of the Inspector General conducted a 
Combined Assessment Program (CAP) review, which resulted in six 
recommendations relating to RME. We appreciate the OIG's 
recommendations, and the Miami VAMC has strengthened its processes to 
mitigate and prevent reoccurrence of the findings. All actions in 
response to the OIG's recommendations have been successfully completed 
with the exception of one that requires special construction; the Miami 
VAMC is installing air ducts, a new wall, and a custom made sink, per 
the OIG's recommendations, and these modifications will be complete 
within the next 120 days.

Budget Management

    For more than 14 years, VHA has used the Veterans Equitable 
Resource Allocation (VERA) model to allocate the majority of its 
appropriated resources to VISNs. This model captures medical care 
delivered at each VA site and weights more intensive or complex care to 
better align resources with the complexity of care provided. On 
average, VERA funds comprise 78 percent of the VISN's total operating 
budget, and another 14 percent of the VISN's budget comes from 
appropriations in the form of specific purpose dollars. The remaining 8 
percent of VISN budgets come from non-appropriated sources, such as 
Medical Care Cost Recovery funds.
    VHA employs a similar model to develop budgets for its medical 
centers. Beginning in FY 2011, VHA initiated a standardized funding 
distribution model that all VISNs use to distribute VERA funding to 
their facilities. This model is based on the same principles as the 
VERA model, but it aligns dollars with those stations that provide the 
greatest volume and the highest intensity of care. The model provides 
VISNs the flexibility to initiate new programs or strategies, such as 
providing funding for a new CBOC or shifting resources from one 
facility to another. When the national facility distribution model was 
released in FY 2011, preliminary results suggested a $4 million 
reduction in the Miami VAMC's VERA budget. Key drivers to that 
recommendation were 2 prior years of zero growth in unique patient 
workload in Miami. The facility's overall workload represented 10.5 
percent of the VISN's workload and was subsequently adjusted upward by 
$14 million at the beginning of FY 2011. This represented a 3 percent 
increase over FY 2010 levels. While final fiscal year data are not yet 
available, preliminary figures show the Miami VAMC's total operating 
budget from all funding sources was $453 million; an 8.3 percent 
increase over FY 2010 totals.
    Mindful of budget constraints, Miami leadership conducted a 
complete review of the organization and identified efficiencies that 
can be realized in many areas. These efforts will improve how the 
facility does business without compromising patient care or the quality 
of care; for example, some sections will combine administrative 
resources. Similarly, the facility will centralize the travel and 
overtime budget for better control, reduce non-emergency equipment and 
furniture purchases, and renegotiate or cancel non-critical contracts. 
Other efficiencies were realized in the area of beneficiary travel, 
records coding, monitoring of patients in the community, and increasing 
third party collections. The combined result of these actions yielded a 
cost avoidance of approximately $13 million in FY 2011.

Conclusion

    VISN 8 and the Miami VAMC have demonstrated considerable 
improvement over the past several years and have aligned resources, 
leadership, and emphasis to realize a better, safer, and more 
accountable environment for patient care. There has been notable 
progress, but there will always be challenges, and we will continue to 
work to overcome them so we can provide the best care to our Nation's 
Veterans. We appreciate the opportunity to discuss this facility's 
work, and we look forward to your recommendations. This concludes my 
prepared statement. My colleagues and I are prepared to answer your 
questions.
                                 
                   MATERIAL SUBMITTED FOR THE RECORD

                 Prepared Statement of Hon. Bob Filner,
                       Ranking Democratic Member

    Thank you, Mr. Chairman.
    Patient safety should always be the VA's top concern. Our veterans 
go to our hospitals because they are one of the best in this country, 
and obtaining optimal health care should not come, ironically, at the 
cost of veteran's health.
    Veterans trust their doctors but what they might not trust is the 
system, and when they get news that there has been a data breach and 
their personal information might have been stolen, or news that they 
are at risk of contracting diseases because staff did not properly 
sterilize Reusable Medical Equipment (RME), veterans rightfully lose 
trust.
    Even when these or other incidents come to light, we often find out 
that they could have been prevented IF hospital administrative 
officials (or Director or leadership?) would have implemented proper 
guidance or enforced protocols to avoid significant breakdowns of 
patient safety.
    What still fails to amaze me is how the VA neglects to effectively 
respond to these situations. We still have too many workplace assaults 
and alarming reports of veterans who may have been infected with 
diseases such as HIV or hepatitis.
    Many questions come to light with the many recent issues at the 
Miami VAMC, particularly the veteran suicide 2 months ago after the 
veteran was not held the mandatory ``72 hour'' VA-required evaluation 
period. Taxpayers are also curious to hear why this facility is running 
a $30 million budget deficit.
    While the Committee has examined these issues in both the 111th and 
112th congress, today we have the opportunity to hear from a hospital 
director who has witnessed this firsthand.
    I hope that the director will be able to provide us insight into 
her experience with delays in notifying individuals of contamination at 
the Miami VA medical center, such as what led to the delay in 
notification to 79 veterans, and what the Miami VAMC is doing to 
correct previous deficiencies and improve patient safety.
    Mr. Chairman, I look forward to this morning's testimony and I 
yield back the balance of my time.

                                 
               Prepared Statement of Hon. Russ Carnahan,
                           Democratic Member

    I want to thank the Chairman and Ranking Member for hosting this 
important hearing. Even though this hearing is focusing on one medical 
facility, Cochran Medical Center in my district has struggled with many 
of these same issues. Like Miami VAMC, Cochran had to notify veterans 
of possible exposure to disease after dental equipment was improperly 
sterilized. I have been working with Cochran throughout my time in 
Congress to make sure that there is never an incident like that again 
at Cochran, and I believe we are starting to see some signs of 
progress. It has not been easy, but through the leadership at Cochran 
changes are being made to ensure that this never happens to our 
veterans again.

                                 
          Post-Hearing Questions and Responses for the Record:
                     Letter from Hon. Bob Filner to
             Hon. Eric K. Shinseki, dated October 12, 2011

October 12, 2011
The Honorable Eric K. Shinseki
The Secretary
U.S. Department of Veterans Affairs
Washington, DC 20420

Dear Secretary Shinseki:

    In reference to our Full Committee hearing entitled ``Failures at 
Miami VAMC: Window to a National Problem,'' that took place on October 
12, 2011, I would appreciate it if you could answer the enclosed 
hearing questions by the close of business on November 24, 2011.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full 
Committee and Subcommittee hearings. Therefore, it would be appreciated 
if you could provide your answers consecutively and single-spaced. In 
addition, please restate the question in its entirety before the 
answer.
    Due to the delay in receiving mail, please provide your response to 
Carol Murray at [email protected], and fax your responses to 
Carol at 202-225-2034. If you have any questions, please call 202-225-
9756.
            Sincerely,

                                                         BOB FILNER
                                          Ranking Democratic Member

                               __________

   Department of Veterans Affairs (Deputy Under Secretary Schoenhard)
    1.  Mr. Scheoenhard, would you agree that there still is a problem 
within the Veterans Health Administration with compliance of 
established patient safety protocols, policies and procedures? If so, 
what are you doing about it?
    2.  Can you please explain to the Committee how the leadership has 
held directors and other managers accountable when these written 
policies and directives are clearly broken?

         a.  What specific actions were being taken to investigate and 
        fix the reported issues at the Miami VAMC ?
         b.  Why has it taken media reports and a recently released 
        Administrative Board of Investigation to bring these issues to 
        light?

    3.  Why has this facility been consistently running in a budget 
deficit--last reported at $30M for FY 11 and Tampa VAMC also running in 
a reported $27.5M deficit?

         a.  What specific action has the leadership at VACO taken to 
        deal with this enormous waste of money that could be spent on 
        our deserving veterans.

    4.  Where are we today with the external peer review program and 
how was that used for the Miami VAMC to assess the care provided?
         a.  What does the Secretary do with those reports?
         b.  The Veterans Integrated Service Network Directors are very 
        senior employees, how do these reports affect them?
    5.  In your testimony, yo mentioned that the AIB credited the staff 
for their efforts, but the AIB also recommended ``there should be 
appropriate administrative action regarding the Miami Director and the 
Chief of Staff for lack of adequate oversight''. The Miami Director was 
removed from her position for several weeks but was reinstated to her 
position. Your testimony does not match last month's AIB report--please 
explain?

                               __________

     Department of Veterans Affairs (VISN 8 Director, Nevin Weaver)
    1.  Why are two facilities under your watch consistently running 
$27 to $30M in the deficit? If you were running a private company that 
did this, what do you think would happen?
    2.  Where are we today with the external peer review program and 
how was that used for the Miami VAMC to assess the care provided? What 
do you do with those reports?
    3.  In May 2010, it was discovered there were 91 additional 
veterans identified as having endoscopic procedures performed between 
May 2004 and March 2009, Can you explain how these remaining veterans 
were identified and why did it take 6 years to discover the additional 
patients?
    4.  What specific disciplinary actions have you or will you take 
regarding the situation with the Miami VAMC?

                               __________

  Department of Veterans Affairs (Miami VAMC Director, Mary Berrocal)
    1.  Why are there so many issues at your facility? Also, from your 
perspective, why were you removed from your position and then 
reinstated?
    2.  Talk us through step by step the process of the delay in 
notifying the 79 veterans of possible contamination from Reusable 
Medical Equipment. Why did it take so long to let these veterans know?
    3.  Explain why your facility is running $30M in a deficit and what 
are your doing specifically to fix these metrics?
    4.  What is your plan to hold your staff accountable and improve 
this facility so it can provide our deserving veterans the patient 
safety and care they deserve?
    5.  Both the Inspector General and the Government Accountability 
Office have stated in separate reports that patient safety is at risk 
due to leadership failures and weaknesses in policies and oversight.

         a.  What are you doing to improve leadership quality and 
        management training?

                                 
           Department of Veterans Affairs Final Responses to
             Hon. Filner's 10-12-11 Post Hearing Questions,
                       Received December 1, 2011

        Prepared Statement of Post Hearing Questions for Deputy
        Under Secretary Schoenhard From the Honorable Bob Filner

    1.  Mr. Schoenhard, would you agree that there still is a problem 
within the Veterans Health Administration with compliance of 
established patient safety protocols, policies, and procedures? If so, 
what are you doing about it?

    Response: Compliance with safety protocols, policies and procedures 
must be continually monitored and violations quickly and fully 
addressed. Such compliance monitoring is a fundamental component of 
quality management, and a responsibility of every leader and employee 
within the Veterans Health Administration (VHA). VHA has consistently 
demonstrated a strong commitment to quality management across the 
Department of Veterans Affairs (VA) health care system--both before and 
after the shortfalls at the Miami VAMC. We are committed to continuous 
improvement, strong internal compliance monitoring, and decisive 
corrective actions at the source of any problem as well as throughout 
the health care system. Some recent VHA actions that demonstrate our 
focus on quality management include:
      The May 2010 launch of VA Hospital Compare, 
www.hospitalcompare.va.gov, a Web site-based dashboard that provides 
clinical outcome data for Congestive Heart Failure, Heart Attack and 
Pneumonia (comparing VA with non-VA facilities), and the creation of 
ASPIRE and LINKS transparency initiatives that are Web site-based 
dashboards with VHA goals for a wide variety of acute, intensive, and 
outpatient care process, outcome and safety measures. These sites 
provide Veterans, their families/significant others and the public with 
easy access to facility-specific performance data.
      The completion of the February 2011 national conference 
``Preventing Infection is Everyone's Job'' to relay a national sense of 
urgency, and set an expectation of increased awareness and vigilance 
for all leaders.
      Veterans Affairs Central Office (VACO), Veterans 
Integrated Service Network (VISN), and facility SPD staff and experts 
have been closely re-aligned, and frequent joint communication is now 
required. In addition, all three levels of staff now conduct routine 
and emergent inspections and action-oriented evaluations. Further, nine 
Field Advisory Committees have been charged to provide technical advice 
related to sterile processing and core facility activities (e.g., 
construction, environmental services, human resources, etc.).
      Creation of the Office of Clinical Consultation and 
Compliance (OCCC) in January 2010 to lead a rigorous, proactive, on-
site facility assessment of SPD systems, and roll out the International 
Standards Organization (ISO) 9001 nationally. In addition, OCCC is 
evaluating informatics software such as the Integrated Quality 
Management Systems (IQMS) and human-computer process aids such as a 
recent engineer-created innovation called ``Interactive Visual 
Navigator.''
      Each of these initiatives--transparent Web sites, 
education/awareness, expansion and alignment of SPD resources, and 
adoption of high reliability organization approaches--focus national, 
regional, and facility leadership attention on system-level concerns 
and goals, leading to the development of risk reduction strategies and 
safer, higher quality care.

    2.  Why has this facility been consistently running in a budget 
deficit--last reported at $30M for FY 2011 and Tampa VAMC also running 
in a reported $27.5M deficit?

    Response: The use of the term ``deficit'' is not accurate in 
describing the funding situation at the Miami and Tampa medical 
facilities. The funding adjustments for these two facilities were part 
of the VISN's fiscally responsible management actions to ensure that 
medical facilities are funded on a work-performed basis. The funds 
appropriated by Congress are allocated to the VISNs at the start of 
each year. Each VISN then allocates those funds to their medical 
facilities based on projected workload, and the VISN retains a small 
reserve to make necessary workload-based adjustments as the year 
progresses. In the case of Miami, the adjustment was related primarily 
to workload and staff increases and reduced collections. In the case of 
Tampa, the adjustment for the facility was directly related to workload 
changes and the activation of the new medical facility at Orlando. The 
Network was capable and prepared to fund fully both Miami VAHCS and 
Tampa VAH. As a result, neither the Miami nor Tampa medical facility 
had a funding ``deficit'' in FY 2011.

         a.  What specific action has the leadership at VACO taken to 
        deal with this enormous waste of money that could be spent on 
        our deserving Veterans?

    Response: VA is committed to ensuring that funds provided by 
Congress are executed in a fair and equitable manner to care for our 
Veterans through all of our medical facilities. The leadership at VACO 
constantly works to ensure that all Veteran patient needs are 
addressed, and allocates funds accordingly. Resource allocation is 
based on the number of Veteran patients served in each network and the 
complexity of the care required by these patients. This allocation 
process considers the actual cost of patients including those that are 
very high cost patients and where they are treated. The process also 
considers the geographic differences in the cost of care across the 
country.

    3.  Where are we today with the external peer review program and 
how was that used for the Miami VAMC to assess the care provided?

    Response: At the end of FY 2009, a national-level VA contract was 
awarded for external peer review, under which we currently audit over 
3,000 records per year and conduct an additional 600 facility-requested 
peer reviews annually. The audit reviews are secondary to the recurring 
peer review of episodes of care that are part of VA's internal process. 
The records are reviewed by contract providers to assess the quality of 
care using a three level rating system: (Level 1--Most experienced, 
competent practitioners would have managed the case in a similar 
manner; Level 2--Most experienced, competent practitioners might have 
managed the case differently; Level 3--Most experienced, competent 
practitioners would have managed the case differently).
    Once the external reviews are completed by the contractor, a 
secondary review of the external peer review is completed by staff in 
the Office of Quality, Safety and Value. Cases that are rated as Level 
3 are given special scrutiny for quality of care concerns. Quality of 
care concerns are brought to the immediate attention of VISN clinical 
leadership. Teleconferences are then scheduled to discuss the cases 
with VISN and facility clinical leadership. If the data review suggests 
a quality of care issue regarding the overall care being provided at 
the facility, site visits by VACO staff may be initiated.
    The external peer review program has been put in place to 
supplement and validate, not replace the local peer review program. The 
external peer review program serves the function of validating the 
effectiveness of local processes. The facility is still required to 
have a Peer Review Committee chaired by the Chief of Staff and 
consisting of senior members of key clinical disciplines, such as the 
Chief of Surgery. The local Peer Review Committee provides the first 
level of review to address quality of care concerns. Each facility is 
required to provide a roll-up of its local peer review data for review 
by VISN staff and VACO/VHA staff in the Office of Quality, Safety and 
Value.
    At the facility level, the Miami VAHCS is required to submit a 
random sample of 15 records per quarter for external review. The data 
from Miami is reviewed quarterly at the VACO level and reviewed monthly 
by the facility and VISN. The data is tracked to ensure there are no 
trends in specific areas (e.g., missed or incorrect radiologic 
diagnoses, adverse surgical outcomes, etc.) that would call for a more 
comprehensive focused review. Local data is also reviewed on a national 
level to ensure that the facility is assessing information in a timely 
manner and acts on concerns when appropriate. At the local level, 
concerns found during the peer review process are addressed through: 
discussion and recommendations of repeat findings from the Peer Review 
Committee; feedback from the clinical leadership to the individual 
provider; education; and systems changes. At the national level, data 
from the Miami VAMC is compared with that of other facilities of the 
same size and complexity level; this serves as another barometer of the 
quality of the care they provide. These results are discussed at the 
facility Peer Review Committee for final determination of level of 
care.
    In FY 2011, twelve cases were selected for randomized review by the 
contracted external peer review program at the Miami VAHCS. Of the 
twelve cases that were reviewed, nine of the cases were rated at the 
same level by both Miami and the external reviewer. In the remaining 
three cases, Miami rated the care more critically (at a higher level), 
than the external reviewers. This review, as well as local peer review 
data from the Miami VAHCS, has not identified any systematic or repeat 
findings that would suggest quality of care concerns.

         a.  What does the Secretary do with these reports?

    Response: The results of the national-level VA contract for 
external peer review are provided to the VHA Office of Quality, Safety, 
and Value (OQSV). VA's Under Secretary for Health (USH) has delegated 
responsibility to OQSV to provide consultation and oversight of this 
process. The results are reviewed and transmitted by OQSV to VISN 
clinical leadership to work with the medical centers on the data 
reconciliation process to address discordant findings. The contractor 
also provides a quarterly summary of their audit findings to OQSV. This 
data is shared with the Deputy Under Secretary for Operations and 
Management (DUSHOM), VISN clinical leadership, and medical center 
leadership. External peer review reports are managed by local medical 
center leadership. However, whencritical incidents or concerns are 
identified, VHA reviews these reports to determine if there is a 
specific provider or systems issue. Any evidence of quality of care 
concerns in the data would be shared with the VHA Principal Deputy 
Under Secretary for Health (PDUSH), the USH, and if needed, the 
Secretary of VA, along with the plan of action for resolution. Data and 
reports submitted by the external contractor and reviewed by OQSV and 
the DUSHOM through Q3FY 2011 have not required PDUSH and USH 
involvement other than as part of comprehensive quality and safety 
briefings to assist with VHA strategic decision-making. The data and 
report findings have not necessitated elevation to the Secretary of VA 
for intervention.

         b.  The Veterans Integrated Service Network Directors are very 
        senior employees, how do these reports affect them?

    Response: The report summaries from external peer review data are 
shared with the Chief Medical Officer (CMO) and the Quality Management 
Officer (QMO) at the VISN. The information is included in quality and 
safety briefings to assist in VISN level strategic planning decisions. 
The information provided by peer review data from the facilities in a 
VISN is just one of several parameters that are considered by the 
Network Director to ensure that senior officials are providing 
appropriate oversight of the clinical staff. Data from the peer reviews 
can be an early indicator to suggest that there may be concerns with 
leadership, staffing, and clinical competence. Based on feedback 
provided from data and routine on-site reviews to the facilities in a 
VISN, the Network Director is given information that is used to assess 
how the Medical Center Director is managing recommendations and needed 
improvements, and providing leadership in the facility. At the national 
level, local and external peer review data and other quality 
improvement data from each facility are rolled up at the VISN level and 
discussed in quarterly meetings with VISN leadership. In addition, this 
is another information source for the DUSHOM to consider in 
comprehensively assessing the effectiveness of the VISN Director's 
leadership and determining if consultative site visits and staff 
assistance are needed from VHA program offices and/or other facilities 
to provide mentoring to improve the quality of a local peer review 
program.

                                 
        Post Hearing Questions for Network Director Nevin Weaver
                     From the Honorable Bob Filner

    1.  Why are two facilities under your watch consistently running 
$27 to $30M in the deficit? If you were running a private company that 
did this, what do you think would happen?

    Response: I want to reemphasize that the use of the word 
``deficit'' is not accurate in this circumstance. Network funding was 
sufficient to fund fully the shortfalls experienced by Miami VAHCS and 
Tampa VAH. For a more detailed response, please see the response to 
question ``2'' for Deputy Under Secretary for Health for Operations and 
Management William Schoenhard. I cannot speculate as to what would 
happen in a private company.

    2.  Where are we today with the external peer review program and 
how was that used for the Miami VAMC to assess the care provided? What 
do you do with those reports?

    Response: Please see response to question ``3'' for Deputy Under 
Secretary for Health for Operations and Management William Schoenhard. 
The results of individual peer reviews are not reported up to the 
Network. As the Network Director, I ensure that senior leaders at the 
facility level provide appropriate oversight of the clinical staff. I 
use feedback provided from data and routine on-site reviews of the 
facilities to assess how the Medical Center Director is managing 
recommendations and needed improvements and providing leadership in the 
facility.

    3.  In May 2010, it was discovered there were 91 additional 
Veterans identified as having endoscopic procedures performed between 
May 2004 and March 2009. Can you explain how these remaining Veterans 
were identified and why did it take 6 years to discover the additional 
patients?

    Response: The Miami VAHCS did not take 6 years to identify the 
additional patients. VHA facilities and individual VHA providers have 
an ethical obligation to disclose to patients adverse events that have 
occurred in the course of their care, including cases where the adverse 
event may not be obvious or severe, or where the harm may only be 
evident in the future. Below is a chronology of what took place from 
the initial patient safety alert.
    VHA issued Patient Safety Alert (AL09-07) across the entire VA 
system on
    December 22, 2008. This alert requested that all facilities 
determine they were using the correct valve and also stressed that the 
manufacturers' instructions for all endoscopes were to be exactly 
followed regardless of the brand. All facilities were directed to 
determine if manufacturers' instructions were followed in the use or 
reprocessing of flexible endoscope tubing and accessories and to report 
any deviations to VA Central Office by January 7, 2009.
    On March 4, 2009, Miami VAHCS staff found that the water irrigation 
tubing was not correctly reprocessed and that it was not consistently 
primed and flushed prior to the start of the patient examination. While 
either one of these omissions by themselves would not have resulted in 
increased risk to patients, both practices together created a slightly 
increased potential for cross contamination between patients.
    In March 2009, Miami VAHCS staff conducted an intensive review of 
patient medical records for Veterans who were seen between May 1, 2004 
and March 12, 2009 and had specific endoscopic procedures with certain 
types of equipment at the Miami VAHCS. Identification strategies 
utilized in 2009 included electronic medical record search using 
procedure codes and note titles pulling up VistA images containing 
procedure notes and scope numbers. Miami VAHCS staff contacted Veterans 
identified during this review and offered screening for viruses that 
were potentially associated with reusable medical equipment (RME) that 
was not reprocessed according to manufacturer's instructions.
    This identification strategy was ultimately refined to a 
standardized intensive chart review by a team of specially trained 
nurses and physicians. In 2010 all records originally pulled in 2009 
were subjected to a re-review using standardized chart review including 
capturing dual CPT codes on same day. A series of extended 
methodologies was also employed, which included looking at additional 
procedure codes; Delphi Invasive Procedure software list of 
colonoscopies; pathology codes; additional VistA Imaging titles and 
consents. The identification process used in 2010 included a validation 
study that verified all patients identified were found on at least one 
of the combined methodologies utilized. As a result, Miami VAHCS staff 
then identified 79 additional patients as a result of a patient concern 
(who was not previously identified) in May 2010. These additional 
patients were identified through an extensive manual review of patient 
records using the methodologies described above (approximately 11,000) 
in an effort to ensure that no patients were missed.
    In August 2010, the U.S. Attorney's office, while gathering 
information related to patients who had filed tort claims on this 
issue, asked the Miami VAHCS to review a record source of log books 
containing information about endoscopic procedures. The review was to 
identify potential Veterans who may have been affected in the original 
2009 look back event. These log books were not reviewed in their 
entirety as part of the original 2009 look back because the Miami VAHCS 
was advised by internal and external experts that the log books may be 
an incomplete source of information.
    When reviewing the log books in August 2010, the Miami VAHCS 
identified a patient who had not been identified in the previous look 
backs. Miami conducted an exhaustive, manual review of the log book 
entries for the specific time period in question to ensure all possible 
patients were identified. As a result, Miami VAHCS staff identified 12 
Veterans who underwent endoscopic procedures during the specified time 
frame who were not previously notified, and offered these Veterans 
testing.

                                 
      Post Hearing Questions for Miami VA Health System Director,
              Mary Berrocal From the Honorable Bob Filner

    1.  Why are there so many issues at your facility? Also, from your 
perspective, why were you removed from your position and then 
reinstated?

    Response: Miami VAHCS is a complex Health Care System that provides 
Veterans a comprehensive array of quality health care services. The 
facility is staffed with hard-working and competent employees who are 
very proud of the care and service they provide to Veterans and their 
families. Despite the tremendous good work that is done here at the 
Miami VAHCS, there will always be challenges in a system this large and 
complex. There are thousands of correct decisions and actions taken by 
compassionate and competent employees every day. On a larger scale, 
over the past several years, the Miami VAHCS has continued to align 
resources, leadership, and focused emphasis to realize a better, safer, 
and more accountable environment for patient care. As is the case with 
every organization, there is always room for continued improvement. 
However, there have been many positive accomplishments worth 
highlighting. These examples of achievement are evidence that the 
facility is both providing quality care and services to Veterans and 
engaging in continuous performance improvement to identify and address 
concerns when they occur:
     Since 2009, there has not been a single reusable medical 
equipment- (RME) related incident where a patient has been placed at a 
potential risk at the Miami VAHCS. Since 2009, the Miami VAHCS has won 
awards or has been independently recognized for excellence in stroke 
care, epilepsy treatment, surgical services, spinal cord injury care, 
and mammography imaging.
    ``Get With The Guidelines'' Silver plus award on February 10, 2010. 
Dr. Yolanda Reyes, Chief of Neurology and Stroke Specialist accepted 
the Silver Plus Award along with Raquel Pastor-Rojas Stroke Coordinator 
from Dr. Gregg C. Fonarow, Immediate Past Chair Get With The 
Guidelines' by the American Heart Association/American 
Stroke Association.
    On July 22, 2009, the Miami Medical Center was selected to be 
included in the VHA Epilepsy Centers of Excellence Network. This 
network was established as the VHA response to the section 404 of the 
Veterans' Mental Health and other care Improvements Act of 2008, Public 
Law (PL) 110-387. There was a need to enhance epilepsy care to treat 
existing numbers of veterans with epilepsy and to provide care for 
veterans who would develop epilepsy as consequence of traumatic brain 
injury.
    Mammography Imaging:

           Miami ACR Inspection--2/23/2011 (every 3 years)
           Miami FDA Inspection--7/22/2011 (yearly)
           Broward ACR Inspection--3/10/2009 (every 3 years)
           Broward FDA Inspection--8/12/2011 (yearly)

      Miami VAHCS leadership chartered a work group on April 
13, 2010, to redesign the pharmacy system to reduce wait times to be 
less than an average of 30 minutes. Following the implementation of the 
redesign on November 22, 2010, patient satisfaction improved 96 
percent, and pharmacy cycle time improved 28 percent.
      Miami VAHCS leadership chartered a work group on October 
20, 2010, to reduce the average wait time for compensation and pension 
(C&P) examinations. Following the implementation of the workgroup's 
recommended changes in November and December of 2010, Miami VAHCS 
leadership reduced the average wait time for C&P examinations by more 
than 30 days to an average of less than 25, improved access to primary 
care and specialty care clinics, and increased performance in clinical 
measures such as diabetes care, tobacco cessation, and surgical 
quality.
      Since 2009, leadership at the Miami VAHCS oversaw the 
opening of a Fisher House for families of severely ill or injured 
Veterans, a new medical ward, five state-of-the-art surgical suites, an 
outpatient clinic in Broward that served over 21,000 Veterans in FY 
2011, a new hospice and palliative care service, and general 
refurbishments to the medical center to ensure the facility will better 
withstand natural disasters such as hurricanes.
      From 2008 to October 31, 2011, 424 previously homeless 
Veterans were provided housing through HUD VASH. Of those, 389 were 
male and 35 were female Veterans. 42 families are included in this 
number. An additional 200 or more receive services each year as part of 
the medical center's annual stand down events. Listed below are the 
events the Miami VAHCS leadership team has coordinated since the 
homeless effort began:

           C.H.A.L.E.N.G. Meetings--Miami-Dade and Broward 
        Counties--May 26, 2009, August 3, 2010, August 15, 2011. (A 
        separate meeting was held in Monroe County each year.)
           Stand Downs--June 27, 2009, September 18, 2010, and 
        November 19, 2011 in Broward County. September 17, 2011 in 
        Miami-Dade County.
           Homeless Summit--February 2, 2011.
           Homeless Veterans Outreach Kick-Off Event--October 
        21, 2011.
           Coordinated Outreach Team--Miami-Dade County--
        Identifies chronically homeless Veterans in coordination with 
        non-VA homeless outreach teams.
           Miami-Dade County Veterans Services Representatives 
        come to the Health Care for Homeless Veterans (HCHV) office 
        every other week to assist Veterans in applying for VA 
        benefits.
           One Stop Services including:
           Social Security Administration
           Florida Department of Motor Vehicles
           Volunteers of American
           The ELKS Lodge funds a laundry program for homeless 
        veterans so that they can wash clothes on a weekly basis.
           The American Veterans Food Assistance Program 
        provides large quantities of food on a monthly basis that are 
        distributed to veterans in the HUD-VA Supportive Housing (HUD-
        VASH), GPD and homeless walk-in clinic.
           St. Stephens Episcopal Church provides veterans with 
        funds for birth certificates, I.D.'s.
           Donations of household goods and furnishings are 
        coordinated through HCHV to assist Veterans in furnishing their 
        HUD-VASH apartments.
           Supportive Services for Veterans Families grantees 
        provide services to Homeless Veterans daily at the HCHV office.
           Carrfour Supportive Housing representatives are 
        available weekly at the HCHV office to process applications for 
        subsidized housing.

    These improvements, combined with cost saving initiatives begun 
under my leadership, saved more than $13 million, including one 
initiative that eliminated the need for a coding contract. Miami's All 
Employee Survey (AES) has sustained satisfactory levels of employee 
satisfaction over the last few years. While there were some drops in 
AES scores on specific questions from 2009 to 2011, they were defined 
by the National Center for Organizational Development (NCOD) as 
``significant, but not meaningful.'' What NCOD meant was that although 
there were noticeable drops in AES Scores on specific questions from 
2009 to 2011, overall, Miami VAMC scored higher than the VHA Average 
(excluding VA Central Office) in the 2011 survey cycle on the following 
measures: Job Satisfaction--Coworker, Supervision, Senior Management, 
Promotion Opportunity and Satisfaction Organizational Assessment--
Conflict Resolution, Diversity Acceptance, Customer Service, 
Innovation, Leadership, Rewards, Employee Development, Job Control and 
Engagement, Culture--Group, Entrepreneurial, Rational and Enabling.
     Finally, it should be noted that Miami VAHCS leaders have expanded 
relations with the greater Miami community in honoring Veterans, to 
include such activities as participating in Wounded Warrior ``Soldier 
Rides,'' rescuing beached whales with the help of Veterans in the 
community, working with a local restaurant to feed more than 700 
Veterans families at Thanksgiving, hosting a Valentines for Veterans 
concert that provided live entertainment for more than 1,000 attendees, 
and hosting Yellow Ribbon events for returning troops that resulted in 
more than 500 new enrollees to the Miami VAHCS.
    It is not unusual for a person to be removed from a position during 
an investigation. This is considered an administrative action. Transfer 
of leadership away from the facility pending such an investigation is 
standard practice in the Department; it ensures the integrity of the 
process. I was detailed to the VISN 8 Network Office while an 
investigation was conducted to review how the RME incident and 
subsequent notification of patients at the Miami VAHCS was managed. I 
returned to my post as Director, Miami VAHCS, after the investigation 
concluded. The report found that I should have exercised more effective 
leadership over the patient notification process. While I was 
disciplined, the Network Director and VACO leadership did not determine 
removal from my position as medical center director was warranted at 
that time. However effective November 17, 2011, I was removed from the 
position as Director of the Miami VAHCS.

    2.  Both the IG and GAO have stated in separate reports that 
patient safety is at risk due to leadership failures and weaknesses in 
policies and oversight.

    Response: The findings and recommendations of the cited OIG and GAO 
reports were not specific to the Miami VAHCS but reference the 
importance of the role of leadership and oversight to ensure patient 
safety. The Miami VAHCS provides Veterans with safe, high quality care. 
Since we were alerted to the RME issue in 2008, Miami has continued to 
improve its health care quality performance metrics. The Miami VAHCS 
met the performance measure for Effective and Safe Clinical Care which 
requires facilities to continually monitor facility performance on key 
indicators of quality and safety for both inpatient and outpatient 
care. The last Joint Commission Survey at the Miami facility occurred 
in 2010, resulting in full accreditation for the health care system.
    The OIG Combined Assessment Program (CAP) reviews are recurring 
assessments of selected health care facility operations, which focus on 
patient care administration and Quality Management (QM). The most 
recent FY 2011 OIG CAP review conducted at Miami VAHCS consisted of a 
review of the following nine elements:

      Coordination of Care **
      Enteral Nutrition Safety **
      Environment of Care
      Management of Workplace Violence
      Medication Management **
      Physician Credentialing and Privileging **
      QM
      RME
      Registered Nurse Competencies
    ** no recommendations made in these areas

    Recommendations for improvement were noted in five areas. Overall, 
the types of findings in these areas were similar to the types of 
findings from CAP reviews at other medical centers. Miami had one (1) 
repeat finding related to patient privacy, however there were no 
findings related to leadership or patient safety. All of the 
recommendations in this report have been addressed and completed except 
those having to do with construction or physical environment.
    GAO visited six VA Medical Centers, including the Miami VAMC, to 
examine VA reprocessing requirements for reusable medical equipment. At 
each site, GAO examined the adequacy of the selected reprocessing 
requirements to help the facilities ensure the safety of Veterans who 
received care at these facilities. Miami was not specifically 
identified in the report; however, the overall findings related to 
weaknesses identified in VA's process for tracking expendable medical 
supplies and reprocessing RME have been taken very seriously.
    The plans for recommended actions have been implemented as directed 
by the Under Secretary for Health. The National Program Office for 
Sterile Processing has oversight responsibility for the reprocessing of 
all critical and semi-critical reusable medical equipment in the VHA. 
The program office develops and reviews policies and procedures related 
to sterile processing, tracks and trends data reporting related to 
sterile processing, and provides subject matter expertise to sterile 
processing services in VHA facilities.
    The National Program Office for Sterile Processing is responsible 
for reviewing multiple annual inspections of sterile processing 
functions in VHA facilities. These inspections specifically address 
compliance with protocols, policies, and procedures that directly 
impact patient safety. Inspections are conducted by National Program 
Office staff, VISN leadership, and facility leadership.
    Among the areas these inspections address are:

      Staff compliance of sterile processing with nationally 
established guidelines for the reprocessing of critical and semi-
critical reusable medical equipment (use of cleaning agents, length of 
cycles, temperatures, documentation of sterilization process, etc.).
      Documentation of training and competency of staff 
performing cleaning, assembly, sterilization or high level disinfection 
tasks.
      Adherence to VHA policies regarding storage, 
environmental conditions, use of personal protective equipment (PPE), 
and the cleaning of sterile processing areas.
      Availability of standard operating procedures and 
manufacturer's instructions for use for the reprocessing of critical 
and semi-critical reusable medical equipment.
      Documentation and review of sterilization and high level 
disinfection records relating to the reprocessing of critical and semi-
critical reusable medical equipment performed in the facility.

    In addition to regular inspections, the National Program Office for 
Sterile Processing immediately responds to emergent issues related to 
the reprocessing of critical and semi-critical reusable medical 
equipment. Emergent issues may be related to equipment malfunction, 
environmental service issues, or reprocessing errors. Within 48 hours 
of an assignment, National Program Office staff review and provide 
recommendations to VHA leadership on the level of risk an event poses, 
develops action plans to address the issue, and advises on service 
disruptions and resumption of services.
    The National Program Office for Sterile Processing has convened 
nine Field Advisory Committees (FACs) chaired by subject matter experts 
to advise the Program Office on concerns that intersect with sterile 
processing. These areas include leadership with expertise in 
construction, logistics, environmental services, biomedical 
engineering, human resources, education and compliance issues, incident 
response, as well as clinical end-users of RME. These FACs ensure that 
all sterile processing-related policies and procedures are developed, 
implemented, and evaluated with the appropriate subject area expertise.
    All VISNs and facility officials have conducted numerous 
inspections to ensure proper reprocessing of RME and track the results 
of these inspections. Purchasing guidelines are being adhered to and 
facilities are being held accountable for the device specific training 
requirements.

    a.   What are you doing to improve leadership quality and 
management training?

    Response: Recognizing the importance of leadership in the delivery 
of patient-centered care, all managers are required to regularly attend 
leadership training and participate in developmental opportunities.
    New supervisors are required to complete approximately 60 hours of 
training during their first year. In order to complete this 
requirement, new supervisors complete a pre-test, 14 modules of 
required training, and a post-test. They are also required to complete 
approximately 20 hours of elective type training every year offered by 
Franklin Covey and Booz Allen Hamilton, such as ``The Seven Habits of 
Highly Effective People'', crucial conversations coaching, and 
mentoring. VA's Talent Management System (TMS) offers about 35 courses 
including Leadership Skills for VA Supervisors and VHA Supervisory 
Training Evaluation. There are also many training opportunities that 
address quality and safety. These are in the form of sharing strong 
practices (that address quality and safety) across the VISN, training 
through consultants, Quality Council and improvements forums held at 
the Network level that are attended by senior leaders and quality 
managers that shares strong practices (presented by facilities) in 
quality, safety and systems redesign. In addition, the VISN 8 Deputy 
Network Director, a workforce management expert, is engaged in 
designing a plan for leadership and management training in FY 2012.
    Leadership at the facility continually monitors quality of care and 
awareness of quality by leadership. As evidence of this, the Miami 
VAHCS has been recognized consistently by VA's National Center for 
Patient Safety (NCPS), Annual Cornerstone Recognition Program, since 
the award was first established in 2008. The Cornerstone Recognition 
Program enhances the root cause analysis (RCA) process and recognizes 
the good work done to promote patient safety at the facility level. 
RCAs are used to identify the most fundamental reason a problem 
occurred; they are focused on finding vulnerabilities in the system and 
remedying them to prevent a recurrence.
    Patient Safety Culture Surveys occur approximately every 3 years. 
Results of this Survey for the Miami VAMC are as follows:

      FY 2000: Overall, there were no significant differences 
in Miami's scores as compared to other facilities.
      FY 2005: Overall, the Miami VAMC was above the Normal VA 
Range.
      FY 2009: Overall, the Miami VAMC was within the National 
VA Range.
      FY 2011: This survey was recently conducted in July/
August 2011 by the NCOD & NCPS through the Voice of VA Survey process. 
The final results of this survey are still pending.